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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/practiceofmedici1903tyso 


THE 

PRACTICE 


OF 


VIEDICINE 


/TEXT-BOOK  FOR  PRACTITIONERS  AND  STUDENTS 
WITH  SPECIAL  REFERENCE  TO  DIAG- 
NOSIS AND  TREATMENT 


BY 


JAMES  TYSON,    M.D. 


lOFESSOR  OF  MEDICINE  IN  THE   UNIVERSITY  OF   PENNSYLVANIA  AND   PHYSICIAN    10  THE    HOSPITAL 
OF    THE    UNIVERSITY;    PHYSICIAN  TO    THE  PENNSYLVANIA  HOSPITAL ;    FELLOW    OF 
THE  COLLEGE  OF  PHYSICIANS  OF  PHILADELPHIA  ;     MEMBER  OF  THE 
ASSOCIATION   OF    AMERICAN    PHYSICIANS,    ETC. 


THIRD   EDITION 

THOROUGHLY    REVISED   AND    IN -PARTS   REWRITTEN 


lUitb  134  lillU5tration5 

INCLUDING    COLORED    PLATES 


PHILADELPHIA 

P.   BLAKISTON^S  SON   &  CO 

I  0  I  2    WALNUT    STREET 
1903 


GIPT 

Copyright,  1903,  by  P.  Blakiston's  Son  &  Co. 


^. 


Q^ci^-i^^AAXi^ 


THE   MERSHON   COMPANY    PRESS, 
RAH  WAY,    N.    J. 


PREFACE    TO   THE   FIRST   EDITION. 


I  HAVE  no  apology  to  make  for  preparing  this  book.  I  have  long  con- 
templated it,  and  have  finished  it  after  several  years'  labor.  It  has  taken 
some  time,  because  it  represents  almost  purely  personal  work,  which  has  been 
frequently  interrupted.  It  does  not  pretend  to  be  based  on  my  personal  prac- 
tice only.  In  these  days  of  specialized  work  this  would  be  impossible, 
though  with  most  of  even  the  rare  forms  of  disease  in  every  section  I  have 
had  some  experience.  To  fill  in  the  gaps  of  my  own  knowledge  I  have  used 
that  of  others,  but  have  always  sought  to  make  suitable  acknowledgment  to 
the  proper  source,  and  if  this  has  not  been  done  in  any  case,  it  has  been  a 
matter  of  oversight. 

I  had  not,  at  the  outset,  expected  to  illustrate  the  work,  but,  as  it  pro- 
gressed, a  certain  number  of  illustrations  seemed  necessary,  not  only  to 
explain  the  text,  but  also,  in  a  few  instances,  to  render  clearer  the  treatment 
described.  Thus  the  number  of  charts  and  other  drawings  has  grown  to 
nearly  a  hundred,  all  of  which,  it  is  hoped,  will  be  found  useful.  In  expec- 
tation of  the  ultimate  adoption  of  the  metric  system  for  the  measuring  of 
doses,  these  have  been  indicated  throughout  the  book  in  the  metric  and  Eng- 
lish measures. 

Acknowledgment  is  due  to  Dr.  Joseph  P.  Walsh  and  Mr.  M.  A.  Morin 
for  suggestions  after  reading  the  text,  to  Dr.  William  Schleif  for  material 
assistance  in  Section  XV,  and  to  my  son,  Dr  T.  Mellor  Tyson,  for  assistance 
throughout  the  work  and  especially  in  preparing  the  index. 

1506  Spruce  St.,  Philadelphia,  October  i,  1896. 


PREFACE    TO    THE   THIRD    EDITION. 


In  preparing  the  third  edition  of  the  Text-Book  of  Medicine,  I  have 
sought  to  make  its  contents  represent,  as  far  as  possible,  the  present  state  of 
modern  medicine.  The  subject  is  an  extensive  one  and  it  may  be  that  some 
important  points  have  escaped  notice,  and  I  will  be  indebted  to  readers  who 
may  call  my  attention  to  them. 

It  is  not  easy  to  point  out  the  sections  in  which  additions  and  changes 
have  been  most  numerous,  but  as  the  infectious  diseases  are  those  of  which 
our  knowledge  is  being  most  enlarged  and  modified,  a  good  many  alterations 
and  additions  will  be  found  in  the  pages  devoted  to  them.  So  numerous  have 
they  been  in  all  parts  that  the  entire  book  has  been  reset. 

I  have  again  had  the  advantage  of  a  careful  revision  of  the  Section  on 
Nervous  Diseases  by  Dr.  W.  G.  Spiller  and  I  believe  it  will  be  found  fully 
abreast  of  the  times.  The  subject  of  Dysentery  has  been  carefully  revised 
and  partly  rewritten  by  my  colleague.  Dr.  Simon  Flexner,  whose  studies  on 
this  subject  have  made  him  an  acknowledged  authority. 

I  have  had  much  valuable  assistance  from  my  son,  Dr.  T.  Mellor 
Tyson,  in  various  ways. 

1506  Spruce  St.,  Philadelphia,  September,  1903. 


CONTENTS 


SECTION  I. 


INFECTIOUS  DISEASES. 


Typhoid  Fever,     . 
Paratyphoid  Fever, 
Mountain  Fever, 
Typhus  Fever, 
Relapsing  Fever, 
Malta  Fever, 
The  Malarial  Fevers, 

Clinical  Varieties,    .... 

Intermittent   Fever, 

Remittent       Fever  —  Estivo-au- 

tumnal  Fever,     .        .        ■        • 

Pernicious   Malarial   Fever— The 

Congestive    Chill, 
Irregular     Forms     of     Malarial 

Fever, 

Malarial    Hematuria    or    Hemo- 
globinuria     o  r      Intermittent 
Hematuria — Blackwater  Fever, 
Malarial    Cachexia    or    Chronic 
Malaria, 
Yellow   Fever, 
Dengue, 
Cholera, 

Dysentery,      .        .        .        - 
Acute  Catarrhal  Dysentery, 
Amebic  or  Tropical  Dysentery 
Bacillary  Dysentery, 
Chronic    Dysentery, 
The  Plague,  . 
Measles, 
Rubella,  . 
Scarlet  Fever, 
Diphtheria,     . 
Smallpox, 
Vaccine  Disease,  . 
Chicken-pox, 
Whooping-cough, 
Mumps, 
Influenza, 

Cerebrospinal  Fever, 
Erysipelas, 

Septicemia  and  Pyemia, 
Hydrophobia, 
Tetanus, 
Anthrax, 

Glanders  and  Farcy, 
Actinomycosis, 
Foot  and  Mouth  Disease, 
Milk  Sickness. 
Syphilis, 

The  Gonorrheal  Infection, 
Gonorrheal    Arthritis, 


17 
54 
54 
55 
59 
63 
65 
7Z 
72, 

76 

77 
78 


79 

79 
83 
90 

91 
104 
104 
109 
106 
113 
114 
118 
122 
124 
132 
145 
152 
156 
157 
161 
162 
167 

177 
181 
184 
190 
194 
197 
198 
200 
201 
202 
210 
210 


PAGE 

Croupous    Pneumonia,         .        .        .  212 

Bronchopneumonia,      ....  228 

Chronic  Interstitial  Pneumonia,         .  22,z 

Embolic  Pneumonia,     ....  235 

Embolic  Non-septic  Pneumonia,      .  235 

Embolic  Septic  Pneumonia,     .        .  237 

Tuberculosis, 238 

I.  General   Etiology   and  Invasion, 
Morbid   Anatomy,         .        .        .  238 

II.  Acute  Tuberculosis,    .        .        .  244 

1.  General  or  Typhoid  Form,  .  245 

2.  Pulmonary  Form,  .         .         .  247 

3.  Meningeal  Form.     Tubercu- 
lous  Meningitis,      .         .         .  249 

III.  Chronic  Tuberculosis,  .  .  252 
Pulmonary  Tuberculosis,  .  252 
Chronic  Ulcerative  Phthisis,  .  254 
Fibroid  Phthisis,  .  .  .  265 
Treatment  of  Tubercular 

Phthisis,           .         .         .         .  266 

IV.  Tuberculosis     o  f     Lymphatic 
Glands, 279 

V.  General     Tuberculosis     of     the 

Serous  Membranes,    .        .        .  281 
Tuberculosis   of   the    Pleura,     .  281 
Tuberculosis      of      the      Perito- 
neum,        .          ...  282 

VI.  Tuberculosis    of    the    Genito- 

urinary Organs,      .        .        .  283 

Tuberculosis  of  the  Kidney,     .  283 
Tuberculosis    of   the    Pelvis    of 

the     Kidney,     Ureters,     and 

Bladder, 284 

Tuberculosis     of    the    Ovaries, 

Fallopian  Tubes,  and  Uterus,  285 
Tuberculosis     of     the      Testes, 

Prostate  Gland,  and   Seminal 

Vesicles 285 

VII.  Tuberculosis     of    the     Mam- 

mary Glands 286 

VIII.  Tuberculosis    of    the    Heart 

and  Blood-vessels,  .        .        .  286 

Leprosy, 287 

Rheumatic     Fever,       ....  289 
Infectious  Diseases  of  Doubtful  Na- 
ture   ^97 

Ephemeral  Fever— Febricula,  .        .  297 
Protracted    Simple    Continued    Fe- 
ver   298 

Weil's    Disease 300 

Miliary  Fever 30i 

Glandular  Fever,       .        .        .        •  302 


Vlll 


CONTENTS. 


SECTION  II. 
DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Diseases   of   the    Mouth, 
The    Coated   Tongue, 
Dc-angement  Due  to  Dentition, 
Stomatitis,  .... 

Simple  Acute   Catarrhal    Stoma 

titis 

Aphthous   Stomatitis     .     . 
Mycotic   Stomatitis. 
Ulcerative  Stomatitis, 
Treatment   of  Different   Forms  of 

Stomatitis,  .... 
Cancrum  Oris, 
Glossitis, 

Glossitis  Desiccans,    . 
Eczema  of  the  Tongue,     . 
Leukoplakia   Buccalis. 
Mucous  Patches. 
Diseases  of  the  Salivary  Glands, 
Functional   Derangements, 
Inflammation      of      the      Salivary 

Glands,        .... 
Angina  Ludovici, 
Diseases  of  the  Tonsils  and  Pharynx 

Quinsy, 

Follicular  Tonsillitis, 
Chronic     Tonsillitis     and     Hyper- 
trophy of  the  Adenoid  Tissue 
of  the  Pharynx, 
Simple    Circulatory    Derangements 

of  the  Pharynx, 
Acute  Catarrhal  Pharyngitis, 
Chronic  Catarrhal  Pharyngitis 
Ulceration  of  the  Pharynx, 
Phlegmonous  Pharyngitis, 
Postpharyngeal  Abscess, 
Diseases  of  the  Esophagus, 

Exploration  of  the  Esophagus  with 

;he  Bougie, 
Esophagitis, 

Spasm  of  the  Esophagus, 
Cancer  of  the  Esophagus, 
Stricture  of  the  Esophagus, 
Dilatation  of  the  Esophagus, 
Diseases  of  the  Stomach,    . 
Diagnostic  Technique. 
External  Examination. 
Internal   Examination   or   Chem- 
ical    Examination     of    Gastric 
Contents. 
Acute  Catarrhal  Gastritis. 
Chronic  Catarrhal  Gastritis 

Phlegmonous      or      Suppurative 

Gastritis,   .  ... 

Traumatic  and  Toxic  Gastritis, 
Diphtheritic  Gastritis, 
Mycotic  Gastritis, 
Nervous  Dyspepsia, 
Atonic  D^'spepsia, 
Gastralgia. 
Hyperchlorhydria. 
Anorexia   Nervosa.   . 
Nervous    Vomiting-. 
Gastric  and  Duodenal  Ulcers 
Cancer  of  the  Stomach, 
Dilatation  of  the  Stomach, 
Visceroptosis,     . 


PAGE 

304 
304 

304 
306 

306 
307 
307 
308 

310 
311 
311 
312 
312 
312 
313 
313 
313 

3^3 
314 

315 
315 
316 


317 

320 
320 
321 
322 
322 
323 
323 

323 
324 
324 
325 
326 
326 
329 
329 
329 


332 
342 
343 

349 
349 
350 
350 
350 
352 
353 
354 
357 
357 
359 
366 
373 
376 


Diseases  of  the  Intestines, 

Simple   Acute   Catarrhal   Enteritis, 
Chronic  Catarrhal  Enteritis,    . 
Cholera  Morbus, 
Diarrheas  of  Children, 
Acute  Dyspeptic  Diarrhea,  . 
Acute    Entero-colitis, 
Cholera   Infantum, 
The  Celiac  Affection  in  Children 
Pseudo-membranous    Enteritis, 
Phlegmonous   Enteritis,    . 
Hemorrhagic  Infarct  of  the  Bowel 
Ulceration    of   the    Bowel, 
Tubercular  Ulcer, 
Embolic  Ulcer, 
Syphilitic   Ulcer, 
Appendicitis,      .... 
Recurring  and  Relapsing  Appen 
dicitis  —  Chronic   Appendicitis 
Intestinal  Obstruction,  . 

I.  Internal    Strangulation, 
II.  Intussusception  —  Invagina 
tion,      .... 

III.  Twists    and    Knots — Volvu 

lus,        .... 

IV.  Obstruction     by     Abnormal 

Contents     or     Foreign 
Bodies,  .        .        .        . 

V.  Strictures   and    Morbid 
Growths, 
VI.  Fecal  Obstruction, 
Constipation,      .... 

Dilatation  of  the  Colon, 
Nervous  Affections  of  the  Bowel, 
I.  Derangements     of     Motion, 
II.  Derangements    of    Sensibil- 
ity, 
III.  Secretion  Neuroses, 
Carcinoma   of  the   Bowel, 
Hemorrhoids, 
Diseases   of  the  Liver, 
Abnormalities    in    the    Shape    and 
Position  of  the  Liver, 
Diseases    of   the    Bile    Passages   and 
Gall-bladder,       . 
Jaundice,  or  Icterus, 
Icterus  Neonatorum, 
Simple  Catarrhal  Jaundice, 
Cholelithiasis,     . 
Acute  Impaction, 
Chronic  Impacted, 
Acute  Infections,  . 
Cancer  of  the  Gall-bladder, 
Carcinoma, 
Stenosis, 

Cicatricial  Contraction, 
Parasites, 

Diseases  of  the  Blood-vessels  of  the 
Liver. 
Hyoeremia, 

Passive      Hj-peremia — Red      At- 

rophj". 
Active  Hyperemia. 
Thrombosis  and  Embolism, 
Pylethrombosis, 
Pylephlebitis, 


CONTENTS. 


IX. 


Diseases  of  the  Blood-vessels  of  the 
Liver : 
Fatty  Liver,       .... 

Fatty  Infiltration, 

Fatty  Metamorphosis, 
The  Amyloid  Liver, 
Cirrhosis  of  the  Liver,   . 
Suppurative  Hepatitis, 
Perihepatitis,      .... 

Glissonian  Cirrhosis, 
Acute     Yellow     Atrophy     of     the 

Liver,  .... 

Morbid  Growths  of  the  "Liver, 

Carcinoma  of  the  Liver, 

Sarcoma,         .... 
Syphilis  of  the  Liver, 
Parasites  of  the  Liver, 

Echinococcus    Disease    or    Hyd 
atid  Cyst  of  the  Liver, 

Other  Parasites  of  the  Liver, 
Diseases  of  the  Pancreas,    . 
Acute   Pancreatitis, 
Chronic   Pancreatitis, 


Diseases  of  the   Pancreas: 
Cancer  of  the  Pancreas,  . 

455  Sarcoma  of  the  Pancreas, 

456  Cysts  of  the  Pancreas, 

457  Pancreatic   Cellulitis, 

457  Diseases  of  the  Spleen, 

458  Splenitis,     ..... 
465  Perisplenitis,       .... 

468  Abscess  of  the  Spleen, 

469  Rupture  of  the  Spleen, 
The  Amyloid  Spleen, 

469  Atrophy  of  the  Spleen, 

471  Hemorrhagic  Infarct  of  the  Spleen 

471  Neoplasms  of  the  Spleen, 

471  Echinococcus  of  the  Spleen,    . 

475  Wandering  Spleen,    . 

477  Diseases  of  the  Peritoneum, 

Acute  Peritonitis, 
477  Chronic  Peritonitis, 

481  Local,  Circumscribed,  or  Chronic 

481  Adhesive  Peritonitis, 

482  Diffuse  Chronic  Peritonitis,     . 

483  Cancer  of  the  Peritoneum, 
Ascites,       .        .        .        . 


483 

484 

484 

485 

485 

485 

485 

485 

485 

486 

486 

486 

486 

486 

486 

487 

487 

491 

491 
492 
492 
495 


SECTION  III. 
DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


PAGE 

Diseases  of  the  Nose,         .        .        .  497 

Rhinitis, 497 

Chronic  Nasal  Catarrh,           .        .  498 

Hay-fever, 501 

Diseases  of  the  Larynx,     .        .        .  503 

Examination  of  the  Larynx,    .        .  503 

Acute  Catarrhal  Laryngitis,      .        .  505 
Spasmodic,     Catarrhal,     or     False, 

Croup 506 

Simple    Chronic   Catarrhal   Laryn- 
gitis,       508 

Tubercular  Laryngitis,     .        .        ■  SH 

Syphilitic  Laryngitis,        .        .        .  513 
Edema  of  the  Glottis,      .        .        .513 

Paralysis  of  the  Laryngeal  Muscles,  514 

Diseases  of  the  Trachea  and  Bron- 
chial  Tubes 517 

Acute  Bronchitis 5^7 

Chronic  Bronchitis,           .        •        .  5i9 
Bronchiectasis,  or  Bronchial  Dila- 
tation,             524 


Diseases  of  the  Trachea  and  Bron 
chial  Tubes : 

Bronchial   Asthma,   . 

Plastic  or  Fibrinous  Bronchitis, 
Diseases  of  the  Lungs, 

Emphysema,       .... 
Vesicular    Emphysema — Pseudo 
hypertrophic  Emphysema, 

Tumors  of  the  Lung, 
Diseases  of  the  Pleura, 

Acute    Pleurisy,         .         .         . 

Chronic  Pleurisy, 

Hydrothorax  and  Hematothorax, 

Pneumothorax, 

Morbid  Growths  of  the  Pleura, 
Mediastinal  Disease,     . 

Mediastinal  Tumors, 

Mediastinal  Abscess, 

Simple  Lymphadenitis, 


526 
530 
531 
531 

532 
537 
539 
53^ 
547 
548 
54^ 
551 
.551 
553 
556 
557 


SECTION  IV. 
DISEASES  OF  THE  HEART  AND  BLOOD-VESSELS. 


General   Symptomatology  of  Cardiac 

Disease,       .... 
Cardiac  Asthma. 
Di=;eases  of  the  Pericardium, 
Pericarditis,        .... 
Other  Pericardial  Affections, 
Hydropericardium, 
Hemopericardium, 
Pneumopericardium, 


'AGE  PAGE 

Diseases  of  the  Endocardium,     .        .  507 

558             Endocarditis, 567 

558  The    Mild    or    Simple    Form    of 

559  Acute  Endocarditis,  .        -  568 
559  The  Severe  or  Malignant  Form 

566  of  Acute  Endocarditis,      .         .  570 

566  Chronic  Valvular  Defects,        .         .  574 

566              Mitral  Insufficiency 57» 

566  Mitral    Stenosis,        .        .        .        •  57^ 


CONTENTS. 


Diseases  of  the  Endocardium : 

Mitral  Insuflficiency  and  Stenosis, 

Aortic    Insufficiency    or    Incompet- 
ency, .... 

Aortic  Stenosis  and  Insufficiency, 

Tricuspid  Regurgitation, 

Tricuspid  Stenosis,  . 

Pulmonary  Insufficiency  or  Incom 
petency,        .... 

Pulmonary  Stenosis, 

Congenital  Defects,  . 

Relative     Frequency     of    Valvular 
Defects,        .... 

Associated   or   Combined  Valvular 
Lesions,       .... 
Diseases  of  the  Myocardium, 

Hypertrophy  and  Dilatation — Atro 
phy, 

Hypertrophy  of  the  Heart, 

Dilatation    of   the    Heart, 

Atrophy  of  the  Heart,     . 

Brown  Atrophy, 

Degenerations  of  the  Cardiac  Mus- 
cle,         


Diseases  of  the  Myocardium  : 
582  Parenchymatous    or    Albuminoid 

Degeneration, 
582  Fatty     Degeneration     or      Fatty 

587  Metamorphosis, 

588  Fatty  Infiltration  or  Fatty  Over 

589  growth,        .... 
Amyloid  Infiltration, 

589  Calcareous    Infiltration, 

590  Myocarditis,        .... 

590  Chronic    Myocarditis    or    Fibro 

myocarditis, 

591  Acute    Suppurative   Myocarditis. 
Aneuryism  of  the  Heart, 

592  Rupture  of  the  Heart, 
599          Neuroses  of  the  Heart, 

Nervous    Palpitation, 

599  Tachjxardia   and   Bradycardia, 

600  Irregular    Pulse, 

603  Angina  Pectoris,  or  Stenocardia, 

608  Diseases  of  the  Blood-vessels, 

608  Arteriosclerosis. 

Aneurysm,  .... 

608  Aneurysm  of  the  Thoracic  Aorta, 


608 

608 

609 
610 
610 
610 

610 
612 
613 
613 
614 
614 
615 
616 
620 
624 
624 
627 
628 


SECTION  V. 
DISEASES  OF  THE  BLOOD  AND    BLOOD-MAKING   ORGANS. 


PAGE 

Diseases  of  the  Blood,         .        .        .  641 

Minute  Structure  of  the  Blood,      .  641 

The   Anemias, 644 

Secondary    or    Symptomatic    Ane- 
mia,        645 

The  Primary  or  Essential  Anemias,  648 
I.  Chlorosis,            ....  648 
II.  Progressive    Pernicious    Ane- 
mia,            652 


The   Primary  or  Essential  Anemias : 

III.  Leukemia,  .... 

IV.  Lymphatic    Anemia  —  Pseudo- 

leukemia —  Hodgkin's     Dis- 
ease, ..... 
Status  Lymphaticus, 
V.  Splenic     Anemia,     or     Splenic 
Pseudoleukemia, 


658 


664 
667 

668 


SECTION  VI. 
DISEASES  OF  THE  THYROID  GLAND. 


Goitre, 

Simple  Goiter,  or  Struma, 
Exophthalmic  Goitre, 
Myxedema,    .... 
Congenital  Cretinism, 


PAGE 

670 
670 
672 
676 
678 


Sporadic   and   Endemic   Cretinism, 
Neoplasms  of  the  Thyroid. 
Diseases  of  the  Suprarenal  Capsules, 

Addison's  Disease,    .... 


PAGE 

678 
680 
681 
681 


SECTION   VII. 
DISEASES  OF  THE  URINARY  ORGANS. 


General  Remarks  on  Albuminuria, 
Extrarenal  Albuminuria, 
Renal  Albuminuria, 


General  Remarks  on  Albuminuria : 
Physiological   or   Functional   Al- 
buminuria, .... 


CONTENTS. 


XI 


General  Remarks  on  Albuminuria : 
Tests  for  Albumin  and  Globulin, 

Renal   Dropsy, 

Uremia, 

Tube-casts,         .... 
Diseases  of  the  Kidney, 

Derangements  of  Circulation, 

Active  Congestion, 

Passive   Congestion   of   Cyanotic 

Induration,  .         .         .         . 

Acute    Parenchymatous    Nephritis, 

Chronic    Parenchymatous    Nephri- 
tis,         

Chronic  Interstitial   Nephritis, 

Lardaceous  Kidney, 

Suppurative    Interstitial    Nephritis, 
and  Pyelonephritis,     . 

Abscess  of  the  Kidney, 

Paranephritis    or    Perinephric    Ab- 
scess,     

Nephrolithiasis  (Stone  in  the  Kid- 
ney), .        . 

Tumors  of  the  Kidney, 

Cysts  of  the  Kidney, 

Anomalies  of  Form  and  Position  of 
the    Kidney 


686 
687 
688 
690 
693 
693 
693 


696 

707 
716 
726 

730 

735 

735 

736 
742 

744 

746 


Diseases  of  the  Kidney : 

Normal  Situation  of  the  Kidney,  746 
Congenital  Absence  of  the  Kid- 
ney,        746 

Congenital  Absence  of  One  Kid- 
ney,        746 

Lobulated  Kidney,         .         .         .  747 
Horse-shoe  Kidney,       .        .        .  747 
The   Movable   or   Floating   Kid- 
ney,     ......  747 

Idiopathic  Hematuria,       .        .        .  749 

Hemoglobinuria,        ....  750 

Toxic  Hemoglobinuria,         .        .  751 

Paroxysmal  Hemoglobinuria,       .  751 

Chyluria,  752 

The  Relation  of  Heart  Disease  to 

Kidney  Disease,  .        .        .  753 

Diseases  of  the  Bladder,      .        .        .  759 

Cystitis, 759 

Stone  in  the  Bladder,  .  .  .  765 
Neuroses  of  the  Bladder,  .  .  765 
Paralysis  of  the  Bladder,  .  765 
Muscular  Spasm  of  the  Bladder,  .  766 
Hemorrhoidal  Veins  of  the  Blad- 
der,         769 

Morbid    Growths    of   the    Bladder,  769 


SECTION  VIII. 


CONSTITUTIONAL    DISEASES. 


PAGE 

Rheumatism, 771 

Muscular  Rheumatism,     .        .         .  771 

Chronic  Articular  Rheumatism,       .  77^ 

Joint  Affections  Simulating  Rheuma- 
tism,       775 

Arthritis  Deformans,        .        .        .  775 

1.  Multiple  Arthritis  Deformans,  777 

2.  The    Partial    or    Monarthritic 
form, 778 

Gout, 780 

Lithemia, 793 

Diabetes  Mellitus,         .        .        .        -795 

Diabetes  Insipidus,       ....  817 


Obesity,          .... 

.      821 

Rickets,           .... 

.      824 

Osteomalacia, 

.      829 

Purpura 

.      831 

Symptomatic  Purpura, 

-      831 

Scurvy,        .... 

.      832 

Infantile  Scurvy, 

.      834 

Arthritic  Purpura,     . 

.      834 

Purpura  Hsemorrhagica,   . 

•      835 

Hemorrhagic  Diseases  of  the 

^lew- 

born 

.      836 

Hemophilia, 

.      837 

SECTION   IX. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


General  Introduction,  .... 
Histology  of  the  Nervous  System, 
General   Symptomatology   (Investi- 
gation of  a  Case  of  Nervous 

Disease, 

I.  Phenomena  of  Motion,     . 
II.  Sensory   Phenomena, 

III.  Sensory  Motor  Phenomena,     . 

IV.  Vasomotor  and  Trophic   Phe- 

nomena  

V.  Mental  Phenomena, 


PAGE 
840 

General  Introduction : 

PAGE 

840 

VI.  Alterations      in      Vision 

and 

Hearing, 

865 

VII.  Alterations    in    Breathing 

and 

843 

Pulse,        .... 

866 

843 

Affections  of  the  Peripheral  Nerves, 

867 

860 

Neuritis 

867 

86s 

Localized  Neuritis, 

867 

Sciatica,           .... 

870 

863 

Multiole  Neuritis,      . 

872 

865 

Endemic   Neuritis, 

878 

xu 


CONTENTS. 


Afltections  of  the  Peripheral  Nerves: 
Malarial   Neuritis, 
Beri-Beri.    the    Kakke   of   Japan, 
Leprous  Neuritis, 

Neuralgia, 

Varieties    Depending    upon    the 

Nerves   Involved, 

Tumors  of  Nerves,  .        .        .        . 

Affections  of  the  Spinal  Cord,    . 

Localization    of   the    Functions   of 

the     Segments    of    the     Spinal 

Cord, 

Affections  of  the  Membranes  of  the 

Cord, 

Spinal   Pachymeningitis, 
Spinal   Leptomeningitis.   . 
Hemorrhage  into  the  Spinal  Mem- 
branes,        .... 
Affections   of  the    Substance   of  the 
Cord,  .... 

Secondary     Systematic     Degenera- 
tions of  the  Spinal  Cord.  . 
Acute     Affections    of    the     Spina 

Cord, 

Disturbances  of  the  Circulation  of 

the   Spinal  Cord, 
Hemorrhage  into  the  Substance  of 

the  Cord,    .... 
Caisson  Disease, 
Diffuse       Myelitis       (Acute      and 

Chronic), 

Myelitis    of    the    Anterior    Horns 
(Acute     Poliomyelitis     Anteri- 
or),      .        .        .        .        . 
Acute  Poliomyelitis  in  Adults, 
Subacute  and  Chronic  Poliomveli- 

tis, ' 

Acute  Ascending  Spinal  Paralysis 
Chronic    Affections    of   the    Spinal 

Cord 

Spastic  Spinal  Paralysis, 
Tabes  Dorsalis,  ... 

Hereditary   Ataxia,   . 
Cerebellar  Hereditary  Ataxia, 
Progressive    Interstitial    Hypertro 

phic   Neuritis  of  Childhood, 
Toxic  Sclerosis, 
Ataxic  Paraplegia,     . 
Syringomyelia,  .... 
Morvan's  Disease,     . 
Compression  of  the  Spinal  Cord, 
Tumors   of   the    Spinal    Cord    and 

Membranes, 
Lesions  of  the  Cauda  Equina  and 
Conus  Medullaris, 

Spina  Bifida 

Progressive  Bulbar  Palsy, 
Acute  Bulbar  Palsy, 
Pseudoparalytic  Mayasthenia, 
Amytropic  Lateral  Sclerosis,  . 
Progressive  Spinal  Muscular  Atro- 
phy,     .         .         . 
Diseases  of  the  Brain, 

Localization  of  Cerebral  Disease, 
I.  The  Motor  Areas  of  the  Cor 
tex,  .... 

II.  Sensory  Areas  of  the   Cortex 
and   Sensory  Paths, 
Cortical  Areas  Covering  Speech, 
The    Various    Forms    of    Aphasia 
and  their  Anatomical  Lesions, 


878 
879 


«8i 
886 


900 
901 

903 
904 

90.5 

908 

908 

908 
910 

911 

918 
921 

921 
922 

924 
924 
926 

937 
938 

938 
939 
939 
941 

943 
943 

946 

949 
950 

951 
954 
954 
956 

958 
963 
963 

964 

970 
972 

972 


PAGE 

Diseases  of  the  Brain  : 

The   Physical   Basis  of  Thought — 

Apraxia, 973 

Aphasia,  or  Loss  of  the  Faculty  of 

Speech, 975 

Derangements  of  Speech  of  Irrita- 
tive Origin 980 

Cortical  Areas  Whose  Function  is 

Unknown  or  Uncertain,        .         .       981 

Tracts  Within  the  Brain — Centrum 
Ovale,  Internal  Capsule,  Cen- 
tral Ganglia,  Corpora  Quadri- 
gemina, 983 

Cerebellar  Disease 984 

Diseases  of  the  Cranial  Nerves,        .      987 

Olfactory   Nerve,       ....       987 

Optic  Nerve  and  Tract,  .        .      987 

1.  Affections  of  the   Retina,        .      987 

2.  Affections  of  the  Optic  Nerve,      989 

3.  Lesions    of    the    Chiasm    and 

Tract, 992 

4.  Lesions  of  the  Tract  and  Cen- 

ters,   994. 

Symptoms  of  Lesions  of  the  Optic 
Nerve     Chiasm,     Tract,     and 
Optic  Cortex,      ....      995 
Lesions  of  the  Motor  Nerves  of  the 

Eyeball, 998 

Third  Nerve,  ....      998 

Fourth   Nerve,       ....     looa 
Sixth   Nerve,        ....       lOOi 
Phenomena  in  General  of  Paral- 
ysis  of   Motor   Nerves  of  the 

Eye), looi 

Ophthalmoplegia,   ....     1002 
Treatment  of  Ocular  Palsies.  1003 

Lesions    of    the    Trifacial,    or    Fifth 

Nerve,  (Trigeminus),        .         .     1004 
Lesions  of  the  Facial  Nerve  or  Sev- 
enth Pair, 1006 

Lesions   of  the  Auditory  or   Eighth 

Nerve, 1013; 

Diseases  of  the  Crariial  Nerves — Le- 
sions of  the  Auditory  or 
Eighth  Nerve: 

1.  Loss  of  Function;  Nervous 
Deafness, 1013 

2.  Auditory  Hyperesthesia,  .         .     1015 

3.  Irritation  of  the  Auditory 
Nerve — Tinnitus   Aurium,         .     1016 

4.  Disturbance  of  Equilibrium 
Associated  with  Defect  of 
Hearing,  Labyrinthine  Verti- 
go,   Meniere's   Disease,     .         .     1017 

Lesions  of  the  Ninth  or  Glossophar- 
yngeal   Nerve,      '.        .        .     .     1018 
Lesions     of     the      Pneumogastric 
or    Vagus    Nerve,    the    Tenth 
Pair, 1019 

Lesions  Involving  the  Nucleus 
and  Trunk  of  the  Pneumogas- 
tric and  Branches,     .         .         .     1019 

Lesions   of   the    Pharyngeal 

Branches 102a 

Lesions  of  the  Laryngeal 
Branches 1020 

Spasm  of  the  Larynx.    .         .         .     1023 

Lesions  of  the  Cardiac  Branches,     1024 

Lesions  of  Gastric  and  Esopha- 
geal Branches 1024 

Lesions  of  Pulmonary  Branches,     1024 


CONTENTS. 


xiu 


Lesions  of  the  Eleventh  Pair  or 
Spinal  Accessory  Nerve,    . 

Symptoms  of  Paralysis  of  the 
External  Branch  of  the  Spinal 
Accessory, 

Symptoms  of  Accessory   Spasm, 

1.  Congenital  Torticollis,  or 
Fixed  Wry-neck,        ... 

2.  Spasmodic    Wry-neck, 
Lesions  of  the  Twelfth  Pair  or  Hy 

poglossal  Nerve, 
Diseases  of  the  Spinal  Nerves,    . 
Cervical    Plexus,       .... 
Affections  of  the  Phrenic  Nerve,    . 
Lesions  of  the  Brachial  Plexus,     . 

Of  the  Combined  Plexus,     . 
Lesions  of  Individual  Nerves, 
Of   the    long   Thoracic   or    Pos- 
terior Thoracic — Serratus  Pal- 


sy, 


Nerves  of  the  Arm, 
Lumbar  and  Sacral  Plexuses 
Diseases   of  the   Membranes    of   the 
Brain,  .... 

Pachymeningitis,        .   _     .  _     . 
External    Pachymeningitis, 
Internal  Pachymeningitis,     . 
Purulent    and    Pseudomembran 

ous    Pachymeningitis, 
Hemorrhagic  Pachymeningitis, 
Leptomeningitis, 
Affections  of  the  Blood-vessels  of  the 
Brain, 
Hyperemia, 
Anemia, 
Edema, 
Apoplexy,   . 

I.  Cerebral  Hemorrhage, 

II.  Embolism     and     Thrombosi; 
of  the  Cerebral  Vessels,    . 

Morbid    Changes    due    to    Throm 

bosis  and  Embolism,         .     • 
Affections  of  the  Blood-vessels  of 

the  Brain : 
Thrombosis   of  the    Cerebral    Sin- 
uses   and    Veins, 
Intracranial  Aneurysms, 
The  Cerebral  Palsies  for  Children, 

Infantile  Hemiplegia,     .         . 
Bilateral  Spastic  Hemiplegia,  . 

Spastic    Paraplegia, 
Sclerosis  of  the  Brain,     . 


PAGE 
1026 

1026 
1027 

1027 
1028 

1030 
IO3I 
IO3I 
1031 
1032 
1032 
1032 


1032 

1033 
1036 

1038 
1038 
1038 
1038 

1038 
1038 
1040 

1045 
1045 
1046 
1047 
1048 
IQ48 

1056 
1057 


1 061 
1062 
1062 
1063 
1066 
1067 
1069 


Intracranial    Aneurysms : 

Multiple   Sclerosis   of  the   Brain 
and    Spinal    Cord, 
Dementia  Paralytica,    .... 

Tumors   of  the   Brain, 

Suppurative  Encephalitis, 
Encephalitis  without  Abscess,     . 

Chronic  Hydrocephalus,  . 
General  and  Functional  Diseases : 

Neuroses,    . 

Acute    Delirium, 

Paralysis  Agitans,     . 

Other  Forms  of  Tremor, 

Acute  Chorea,  . 

Choreiform  Affections, 

I.  Simple  Tic, 

II.  Tic  with  Explosive  Utter- 
ances, Coprolalia,  Echolalia, 
etc., 

III.  Complex  Co-ordinated  Tic,  . 

IV.  Spasms  of  the  Muscles  of 
Respiration  and  Deglutition,    . 

V.  Chronic   Progressive   Chorea, 
General   and   Functional   Diseases: 

VI.  Chorea  Major, 

VII.  Postchoreal  Paralysis  and 
Postparalytic  Chorea, 

Epilepsy, 

Reflex  Convulsions  of  Children,    . 

Migraine, 

Occupation  Neuroses, 

Writers'  Cramp,     .... 

Athetosis, 

Tetany, 

Hysteria,     ...... 

Neurasthenia,             .        . 
Traumatic  Neuroses, 
Other  Forms  of  Functional  Paraly- 
sis,         

Abasia-atasia,  .        .      _  . 

Family  Periodical  Paralysis, 
Vasomotor  and  Trophic  Derange- 
ments, .        •        • 

Acute    Angioneurotic   Edema,     . 

Raynaud's    Disease, 

Progressive  Facial  Hemiatro- 
phy,       

Acromegaly, 

Scleroderma,  .        .        .        . 

Morphea,         .         .         . 

Ainhum, 

Syphilis  of  the  Nervous  System,    . 


1069 
1070 
1074 
1081 
1083 
1084 

1087 
1087 
1088 
1091 
1091 
1097 
1097 


1098 
1099 

1099 
1099 

IIOI 

1 102 
1 102 
iiii 
1112 
1115 
1115 
1119 
1119 
1121 
1 129 
1 132 

1133 
1133 

1 136 
1 136 
1 136 

1138 

1 139 
1141 
1 142 

1143 
1144 


SECTION  X. 
DISEASES  OF  THE  MUSCULAR  SYSTEM. 


Myositis, 

Rheumatic    Myositis     (Acute    and 

Chronic),     .         . 
Infectious    Myositis, 
Progressive  Ossifying  Myositis.     . 
Idiopathic  Muscular  Atrophies.     Pri- 
mary    Myopathic     Forms     of 
Muscular  Atrophy, 
L  Pseudohypertrophy     of     Mus- 
cles,       


PAGE 
1 150 

iiSo 
1 150 
1 150 


II5I 


II?,I 


Idiopathic  Muscular  Atrophies: 

Erb's  Form  of  Juvenile  Hered- 
itary Atrophy 

HI.    The     Facio-scapulo-humeral 

Tyoe  of  Juvenile  Palsy,     . 
IV.  The  Peroneal  Type  of  Pro- 
gressive   Atrophy, 
Myotonia    Congenita     (Thomsen's 
Disease),    .        .        ^        •        ■ 


PAGE 


1152 
1153 
IIS3 
IIS3 


XIV 


CONTENTS. 


SECTION   XI. 
THE   INTOXICATIONS. 


Alcoholism, ii55 

Acute  Alcoholism,     .        .        .        •  ii55 

Chronic     Alcoholism,       .        .        .  ii55 
Delirium     Tremens,    or    Mania    a 

Potu 1158 

The  Morphin  Habit— Morphinism.     .  1161 

Chloralism, 1163 

Cocainism, 1163 

The  Tobacco  Habit,     .        .        •        .1164 


PAGE 

Bisulphide  of  Carbon  Poisoning,          .  1164 

Lead  Poisoning 1171 

Arsenical  Poisoning,     ....  1170 

Ptomain   and   Leukomain    Poisoning,  11 71 

Grain  Poisoning,           ....  1173 

1.  Ergotism, 1173 

2.  Pellagra.         .        .        .        .        .  1174 

3.  Lathyrism,  or  Lupinosis,     .        .  1174. 


SECTION  XII. 


EFFECTS  OF  EXPOSURE  TO  HIGH  THOUGH  BEARABLE 

TEMPERATURE. 


Heat  Exhaustion, 


PAGE 
II75 


Thermic  Fever — Sunstroke,  Coup  de 

Soleil, 1 176 


SECTION    XIII. 


ANIMAL  PARASITES  AND   THE  CONDITIONS  CAUSED 

BY  THEM. 


or        Flat 


I.  Protozoa, 
II.  Platyhelminthes, 

Worms,        .         .         .         .         . 

A.  Trematodes  or  Flukes',    . 

B.  Cestodes,    or    Tape-worms,     . 
IIL  Nematodes,  or  Round  Worms,    . 

A.  The   Ascarides, 

B.  Trichiniasis,       .         .         .         . 

C.  Anchylostomiasis       Uncinari- 

asis,        .         .         .         .         , 


PAGE 
II79 

1 180 
1 180 
II81 
1 189 
1 189 
II9I 

1 193 


III.  Nematodes,   or  Round  Worms : 

D.  Filariasis,  ....  1194 

E.  Other  Nematode  Worms,       .  1198 

IV.  Acanthocephali — Thorn-head 

Worms 1 198 

V.  Arthropoda, 1199 

A.  Arachnoidea,     ....  1199 

B.  Insecta, 1200 


SECTION  XIV. 


Summary  of  Symptoms  Following  Overdoses  of  Poisons,  and  the  Treatment 
OF  their  Effects.  To  which  is  Added  a  Table  of  Minimum  Dose  which 
HAS  Caused  Death  and  Maximum  Dose  Followed  by  Recovery,  .        .        .     1204 


APPENDIX. 


Tables  for  the  Con\t:rsion  of  the  English  Into  Metric  System,  and  the 

Reverse, ^-^^ 


INDEX. 


1219 


CHARTS   AND    ILLUSTRATIONS 


FIG. 
I. 


PAGE 


Temperature  Chart  of  a  Typical  Case  of  Typhoid  Fever  Uninfluenced  by 

Treatment, -r  '        •'    i  tV        "    u  '         '         o^ 

2.  Chart  Showing  Drop  in  Temperature  Incident  to  Intestmal  Hemorrhage  27 

3.  Chart  Showing  Anemia  of  Typhoid  Fever,  /    -,  ^    t,'    ,    ^Colored)         30 
4    Chart  Contrasting  the  Drop  in  Temperature  after  the  Bath  Early  and  Later 


m 


...   the  Disease, 43 

5.  Burr's  Portable  Bath-tub, 44 

6.  Temperature  Chart  in  Typhus  Fever,         •      .  ■     ^\ §; 

7    Temperature  Chart  of  Relapsing  Fever,  Showmg  Relapses      .         ■         ■        ■  Oi 
8.  Chart  Showing  Morning  and  Evening  Temperature  m  Malta  Fever— 1  wo 

Distinct  Relapses  are  Shown,     .         .         ....         •.,-.•  "4 

Q    Plate  Illustrating  Different  Forms  of  the  Malarial   Organism  with  Their 

Stages  of  Development,       .        .        ■        ■       .•        :       ^  {Colored)  68 

10.  Temperature   Chart   in   Intermittent   Fever,    Showing   the    Paroxysms   and 

Intermission,  .         •         •         •         '      r.,'       • '        /      t."         '         'a 

11.  Temperature   Chart   in   Intermittent   Fever,    Showing  the    Paroxysms   and 

Intermission,  ...••• 75 

12.  Fountain  Syringe  for  Hypodermoclysis, joi 

n.  Temperature  Chart  of  Measles,    .        •        •        '    ,^  •    .,  ,•   c    \  %  '      v     ■    '  IJi 

Plate  Showing  Pathognomonic  Sign  of  Measles  (Koplik  s  Spots),  .     Facmg  1^0 

14.  Temperature  Chart  of  Scarlet  Fever, 127 

15.  Temperature   Chart   of    Smallpox, '(Colored)  163 

16.  Chart  of  a  Case  of  Influenza,        :^ {Colored)  03 

17.  Method  of  Puncture  for  Spinal  Drainage,         . ^/^ 

18.  19-  Syphilitic    Teeth,      _.        .        • •        •        '        •        '217 

20.  Chart   Showing  Crisis  m  Pneumoma,  _      .        •        •  p  ;        •^.     Succeeding 

24.  Tempfrature'chart'of  a  Case  of  Tubercular  Consumption  without  Fever,     .  262 

25.  Pasteboard    Spit-cup,      .        •        ^        '  r^.     [, ^o"; 

26.  Diagram   Showing  Eruption  of  Milk   Tee  h .         .  305 

%:  |l;l"p\tir„?F^irTeTrSra°{.fy:terF..een,  Who  Had  Ta.en  kucH  ' 

Mercury  in  Infancy, :^  g 

20    Arrangement   for   Auto-lavage,     .         .         •         •.        ■         '    c'        i        '         '  iln 

S'  Oppler  Boas  Bacillus  from  Contents  of  a  Carcinomatous  Stomach       .        .  369 
3?"  Temperature  Chart  of  Appendicitis,   Showing  Temperature  Maintained  by 

32.  Chart^on^Vn^Sti^ShL?^^^^                                 to    Normal,    Incident  to 
Perforation,  


33   Vertical  and  Transverse  Sections  of  an  Intussusception 411 

34.  Giant   Congenital   D^'-^-^'-"    ^^   Human    Colon 423 

35.  The  Cystic  Duct  in 


iA    Giant  Coneenital  Dilatation  of  Human  Colon.         .        .        •        • 

35:  The  Cystic  Duct  in  Section,  with  Part  of  the  Gall-bladder  and  Hepatic  and 

Common  Bile-ducts,     .        .        ■        •        •        •        •        '    ,     '  T>>-£r'        I  '^'^^ 
36    Comparative   Enlargements  of  the  Liver,    Corresponding  to   the   Different 

Morbid    Growths, "  "^Js 

37.  Tenia    Echinococcus,      .        .        •        •       .-,   ^-     ,■        \      '        "        '        '  1^^ 

38.  Section  through  an  Echinococcus  Cyst    with  Brood  Capsules 479 

39^  So-called  "  Ovarian  Cells,"  -  _       .- 495 

40.  Technique   of  Rhinoscopic  Examination 49^ 

41.  Technique   of   Laryngoscopic    Examination, 504 

42.  Natural  Size  of  Image  of  the  Vocal  .Apparatus, 505 

43.  Cadaveric  Position  of  the  Left  Vocal  Cord      .        .        •.        •   .     •        •      .  •  ^'^ 

44.  Complete  Both-sided  Abductor  Paralysis  of  the  Posterior  Cnco-arytenoid 

45.  Paralysis   of  'the    Internal    thyro-arytenoid    Muscles, 5i6 


XV 


xvi  CHARTS  AND  ILLUSTRATIONS 

TIG.  PAGE 

46.  Paralysis   of  the    Transverse   and    Oblique    Interarytenoid   Muscles,      .         .  516 

47.  Bilateral  Paralysis  of  the  Thyro-arytenoids  Combined  with  Paresis  of  the 

Arytenoid 5i6 

48.  Curschmann's   Spirals, 528 

49.  Section   through   Frozen   Thorax   at    Second    Interspace   in  Front,   Looking 

from   Above   Downward, 552 

50.  Section  through  Frozen   Thorax  at  Second  Interspace  in   Front,   Looking 

from    Below    Upward. .         .  552 

51.  Pulsus  Paradoxus, 562 

52.  Temperature    Chart.    Malignant   Endocarditis, 572 

53.  Tracing  of   Pulse   of   Mitral   Insufificiency, 578 

54.  Tracings   of   Pulse   of   Mitral    Stenosis 580 

55.  Tracings  of  Pulse  of  Aortic   Regurgitation, 583 

56.  Pulse-tracing    of    Aortic    Stenosis, 586 

57.  Normal    Pulse-tracing, 618 

58.  Pulsus    Bisferiens. •         •         •         •  619 

,   59.  Tracing  of  Pulse  of  High  Arterial  Tension .        .  619 

60.  Sphygmogram   of  an   Atheromatous   Vessel, 626 

61.  Aneurysm  of  the  Aorta.  Showing  Sites  of  Election,  .        .         •        .        .        .  629 

62.  Chart.^Showing  the- Blood  in  Simple  Anemia {Colored)  646 

63.  Chart,  Showing  Blood  in  Chlorosis {Colored)  650 

64.  Liver  Lobules  in  a  Case  of  Pernicious  Anemia,       .        .        .        {Colored)  653 

65.  Cells  from  Liver  in  Pernicious  Anemia, {Colored)  654 

66.  Chart.  Showing  Blood  in  Pernicious  Anemia,      ....        {Colored)  655 

67.  Colored  Plate,  Showing  the  Different  Forms  of  Colorless  Corpuscles  in  the 

Blood  of  Leukemia {Colored)  661 

Plate  Showing  Degeneration  of  Blood  Corpuscles  in  Leukemia,        .      Facing  662 

68.  Epithelial    Casts   and    Compound    Granule    Cells 691 

69.  Pus    Cast, 691 

70.  Blood  Casts,            661 

71.  Hyaline    Casts,                 691 

72.  Hyaline  and  Granular  Casts,  Illustrating  the  Formation  of  the  Former,        .  691 

73.  Dark    Granular    Casts,    Casts    Partly    Hyaline,    Containing    Oil-drops    and 

Granular    Matter, 693 

74.  Waxy    Casts, 692 

75.  Oil  Casts  and  Fatty  Epithelium, 693 

76.  Cylindroid    or    Mucus-casts, 693 

77.  Hilus  of  Kidney  with  a  Large  and  Small  Renal  Calculus,   Showing  How 

Precipitation  and  Aggregation  Take  Place, 738 

78.  Diagram  Showing  Probable  Plan  of  the  Center  for  Micturition,      .        .        .  766 

79.  Heberden's  Nodosities, yyj 

80.  Tophacious  Gout,            786 

81.  Deformed  Skeleton  from  a  Case  of  Rickets, 825 

82.  Outline  of  Rickety  Chest, 826 

83.  Diagram  of  an  Element  of  the  Motor  Path, 841 

84.  Diagram  Illustrating  Crossed  Paralysis, 844 

85.  Diagram  Illustrating  the  Possibility  of  Paralysis  of  Arm  on  one  Side  and 

Leg  on  the  other, 845 

86.  Diagram  Showing  Probable  Plan  of  the  Centre  for  Micturition,    .        .        .  848 

87.  Motor  Nerve  Points  on  Face  and  Neck 853 

88.  Motor  Nerve  Points  on  Upper  Limb,  Flexor  Surface,     .....  854 

89.  Motor  Nerve   Points   on  Upner   Limb,   Extensor   Surface,     ....  855 

90.  Motor  Nerve  Points  on  ThigTi.  Anterior  Surface, 856 

91.  Motor  Nerve  Points  on  Lower  Limb,   Posterior  Surface 858 

92.  Motor  Nerve  Points  on  Leg,  External   Surface.       .         .         .         .         .         .  859 

93.  Diagram  Showing  Relation  of  Vertebral  Spines  to  their  Bodies  and  to  the 

Nerve-roots,              889 

94.  Diagram  Showing  Relative  Size  and  Shape  of  the  Cord  and  Gray  Matter  at 

Different  Levels 889 

95.  Section  of  Spinal  Cord  in  the  Cervical  Region, 890 

96.  Diagram  of  Sensory  Skin  Areas  Corresponding  to  the  Different  Spinal  Seg- 

ments, Anterior   Surface 891 

97.  Diagram  of  Lesion  Showing  Brown-Sequard's    Paralysis.           ....  895 

98.  Schema  Showing  Chief  Symptoms  in  Left  Unilateral  Lesion  of  the  Dorsal 

Cord, 895 

99-100.  Diagram  of  Sensory  Skin  Areas  Corresponding  to  the  Different  Spinal 

Segments,   Posterior   Surface .        896-897 

loi.  Secondary  Descending  Degeneration  of  the  Pyramidal  Tracts  in  a  Primary 

Lesion  of  the  Left  Half  of  the  Cerebrum, go5 


CHARTS  AND  ILLUSTRATIONS  xvii 

FIG.  PAGB 

102.  Diagram   of  Descending  Degeneration   of  the   Pyramidal   Tracts   due  to  a 

Lesion  in  the  Left  Internal  Capsule,         .             907 

103.  Secondary  Ascending  and  Descending  Degeneration  in  a  Transverse  Section 

of  the  Upper  Dorsal  Region, 907 

104.  Section  through  the  Cervical  Enlargement  in  Anterior  Poliomyelitis,      .         .  919 

105.  Transverse  Section  through  the  Lumbar  Region  in  Tabes  Dorsalis,         .         .  927 

106.  Transverse  Section  through  the  Thoracic  Region  in  Tabes  Dorsalis,       .         .  928 

107.  Transverse  Section  through  the  Cervical  Region  in  Tabes  Dorsalis,        .         .  929 

108.  Transverse    Section    through    the    Lumbar    Region    in    Beginning    Tabes 

Dorsalis.                    930 

109.  Sarcoma  of  the  Lower  Cervical  Cord, 946 

no.  Sarcoma  Compressing  the  Cervical  Cord,            946 

111.  Situation  of  the  Cranial  Nerves, 951 

112.  Bird-Claw  Hand.             959 

113.  Lateral  Aspect  of  the  Brain, 964 

114.  Aspect  of  the  Median  Surface  of  the  Cerebrum  as  it  Appears  when  the  Two 

Hemispheres  are  Separated, 965 

115.  Lateral  Aspect  of  the  Brain, 966 

116.  The  Motor  Tract, 967 

117.  Sensory  and  Motor  Paths  in  the  Spinal  Cord,          .        .        .        {Colored)  968 

118.  Primitive  Speech  of  the  Child  in  Mechanical  Repetition  of  Words,      .        .  973 

119.  Wernicke's  Schema,  Showing  the  Association  of  the  Various  Partial  Con- 

ceptions to  Form  the  Whole  Conception  or  Word  Image  of  an  Object,  974 

120.  Simplification  of  the  Schema  of  Voluntary  Speech, 975 

121.  Diagram  of  Seats  of  the  Lesions  of  Word-deafness,  Word-blindness,  Motor 

Aphasia,  and  Agraphia, 976 

122.  The  Left  Hemisphere,  with  the  Fissure  of  Sylvius  Drawn  Apart  in  Order 

to   Show   the   Convolution   in   Island  of   Reil, 977 

123.  Simplification  of  Wernicke's  Schema  of  Voluntary  Speech,      ....  980 

124.  Transverse  Section  through  the  Crura  Cerebri  in  Secondary  Degeneration 

of  the  Right  Pyramidal  Tract, 983 

125.  Commencing  Optic  Neuritis  from  a  Case  of  Caries  of  the  Sphenoid  Bone 

with   Secondary  Meningitis, qqq 

126.  Diagram  Showing  Course  of  Optic  Nerve-Fibers, 993 

127.  Situation  of  the  Cranial  Nerves, (Colored)  1000 

128.  Schema  for  Central  Innervation  of  the  Facial  Nerve,      .....  1007 

129.  Simplified     Drawing     of     the     Peripheral     Distribution     of     the     Facial' 

Nerve,  .,.•..„.. {Colored)  1009 

130.  Wnst-arop  m  Musculospmal  Paralysis, 1034 

131.  Position  of  Wrist,  Hand,  and  Fingers  in  Ulnar  Paralysis,      ....  1035 
Circle  of  Willis  and  Arteries  of  Brain, Facing  1046 

132.  Focal  Symptoms  of  Brain  Tumor, 1077 

133.  Left  Facial  Hemiatrophy, 113Q 

134.  Temperature  Chart  from  a  Case  of  Sunstroke  Treated  by  Ice-water  Baths 

and  Frictions.     Recovery,      .        ,        .        . jj^^ 


PRACTICE   OF  MEDICINE. 


SECTION    I. 

INFECTIOUS  DISEASES. 
TYPHOID   FEVER. 

Synonyms. — Typhus  abdominalis ;  Enteric  Fever;  Pythogenic  Fever;  Gas- 
tro-enteric  Fever;  Nervous  Fever;  Autumnal  Fever;  Slow  Nervous 
Fever. 
Definition. — Typhoid   fever   is   an  acute   infectious   fever  due  to  the 

implantation  and  proHferation  of  the  typhoid  bacillus — the  bacillus  of  Eberth. 

It  is  especially  characterized   anatomically  by  hyperplastic   and   ulcerative 

lesions  of  the  lymph-follicles  of  the  intestine,  of  the  mesenteric  glands,  and 

by  enlargement  of  the  spleen. 

Historical. — The  disease  is  probably  coeval  with  civilization,  and  is  easily  recog- 
nizable in  the  descriptions  of  Hippocrates  (B.  C.  460-357)  and  Galen  (A.  D.  130-200); 
and  in  more  modern  times  in  those  of  Adrianus  Spigelius  (1624),  Thomas  Willis  (1659), 
N.  Hoffmann  (1699),  Thomas  Sydenham  (1685),  and  others  in  the  seventeenth  century 
and  in  the  next.  Noteworthy  are  the  writings  of  E.  Gilchrist  (1734),  John  Huxham 
(i739)>  J- C.  Riedel  (1748),  and  R.  Manningham  (1746).  Doubtless  Huxham's  "slow 
nervous  fever,"  described  in  his  "Essays  on  Fevers,"  was  the  typhoid  of  the  present 
day,  and  his  "putrid  malignant"  the  rarer  typhus  of  to-day.  But  Huxham  regarded 
typhoid  as  a  variety  of  continued  fever  rather  than  as  a  distinct  and  separate  fever, 
and  it  was  not  until  1813  that  Pierre  Bretonneau,  of  Tours,  described  it  under  the 
name  dothieninterite  and  Petit  and  Serres  as  fievre  etitero-rndsentirique.  It 
was,  however,  the  writings  and  teachings  of  the  great  French  physician,  Louis,  which 
did  most  to  disseminate  a  knowledge  of  the  true  nature  of  typhoid  fever — to  which  he 
gave  the  name  it  bears.  His  great  work  was  published  in  1829.*  Among  his  pupils, 
who  came  from  every  country,  was  a  coterie  of  brilliant  young  Americans,  including 
William  W.  Gerhard  and  C.  W.  Pennock,  of  Philadelphia,  and  James  Jackson,  Jr.,  of 
Boston.  The  first,  after  his  return  to  America,  had  the  opportunity,  in  conjunction 
with  Pennock,  of  studying  the  disease  in  the  wards  of  the  Philadelphia  Hospital  in  the 
spring  and  summer  of  1836,  and  of  contrasting  it  with  typhus  fever,  of  which  there  was 
an  epidemic  then  prevalent  in  Philadelphia.  These  two  observers  were  the  first  to 
point  out  the  difference  between  the  two  diseases.  This  they  did  in  the  "American 
Journal  of  the  Medical  Sciences"  in  1837.  Their  publications  were  followed  in  1838 
by  a  paper  by  James  Jackson,  Sr.,  entitled  "  Report  on  Typhoid  Fever,"  and  another 
Tjy  Enoch  Hale  "  On  the  Typhoid  Fever  of  New  England,"  which  probably  had  their 
impulse  in  the  information  furnished  by  the  younger  Jackson  to  his  father  on  his  re- 
turn from  Paris.  Thus  it  came  to  pass  that  Elisha  Bartlett's  work  on  the  "  Diagnosis 
and  Treatment  of  Typhus  and  Typhoid  Fevers,"  an  American  text-book  published  in 
1842,  contained  the  first  separate  description  of  the  diseases.  For  up  to  1838  only 
typhoid  fever  was  known  in  Paris.  At  this  time  Alfred  Stille,  who  had  been  the  house 
physician  of  Gerhard  and  Pennock  in  the  Philadelphia  Hospital,  and  had  learned  there 
the  distinctive  features  of  typhus  and  typhoid,  went  to  Paris,  and  in  1838  read  a  paper 
Taefore  the  Societe  M6dicale  d'Observation  pointing  out  the  differences  between  them. 
George  C.  Shattuck  had  been  similarly  trained  in  Boston,  and  contributed  a  paper  to 
the  same  society.  Shattuck  also  went  to  London  at  Louis'  request,  and  at  the  Fever 
Hospital  there  saw  the  two  distinct  affections,  on  which  he  reported  to  the  Society  on 
bis  return  to  Paris, f     He  insisted  on  the  existence  of  two  fevers  in  Eneland 

*  Louis,  P.  C.  A.,  "  Recherch.  anatom.,  patholog.,  et  therapeutiques  sur  la  maladie  connue  sous 
lesnoms  gastro-enterite,  fievre  putride,"  etc.,  Paris,  1829. 
t  "  Amer.  Med.  Examiner,"  February  i,  March,  1840. 


I8  INFECTIOUS  DISEASES. 

In  Germany,  J.  V.  Hlldenbrand  had  pointed  out  differences  between  typhoid  and 
typhus  as  early  as  iSio,  but  also  regarded  them  as  varieties  of  the  same  disease,  and 
not  distinct  diseases.  These  views  were  maintained  for  many  years  in  Germany,  but 
since  1S59,  at  least,  correct  notions  have  prevailed.  In  Great  Britain,  in  1835,  Peebles, 
of  Glasgow,  who  had  observed  the  rubeoloid  eruption  in  the  contagious  typhus  of 
Italy,  pointed  it  out  to  Drs.  R.  Perry  and  A.  P.  Stewart.  The  former,  according  to 
Stewart,  was  the  tirst  to  contend  for  the  difference  between  the  eruptions  of  typhus 
and  typhoid.  His  writings,  as  quoted  b}'  Murchison,  do  not  show  this.  Stewart,  how- 
ever, separated  the  two  affections  in  a  paper  published  in  1840.*  In  England  it  was 
not  until  1849-51  that  Sir  William  Jenner,  f  by  his  experiments  and  observations, 
clearly  demonstrated  their  difference,  and  about  the  same  time  definite  ideas  were 
arrived  at  in  France.  Since  1S50  the  two  diseases  have  been  everywhere  recognized 
and  described  as  distinct  and  separate,  except  in  German^',  where  the  recognition  came 
a  few  years  later.  ^ 

Etiology. — The  bacillus  typhosus,  to  which  prevaiUng  views  ascribe 
typhoid  fever,  was  discovered  by  Eberth  in  1880  in  the  intestine  of  a  case  of 
the  disease.  This  observation  was  promptly  confirmed  by  Klebs,  Eppinger, 
Koch,  V.  Meyer,  Friedlander,  Gaffky,  and  others,  who  found  it  in  the 
intestines,  lymphatic  system  including  the  mesenteric  glands  and  spleen,  in 
the  liver  and  the  kidneys,  the  blood  and  bone-marrow,  and  even  in  bile  and 
urine,  as  well  as  in  the  rose-colored  spots.  It  was  secured  in  pure  culture 
from  the  spleen  and  infected  lymphatic  glands  by  Gafifky  in  1884.  The 
bacillus  is  described  as  a  short,  rod-like  bacterium,  whose  length  is  three 
micromillimeters,  breadth  one  micromillimeter.  Thus  its  length  is  about 
one-third  the  diameter  of  a  red  blood-disc,  and  its  width  one-ninth  of  the 
same,  though  its  size  and  shape  vary  somewhat  with  the  culture-medium  and 
the  age  of  the  bacillus.  Its  ends  are  rounded,  and  sometimes  there  can 
be  seen  toward  them,  dark,  glistening,  round  bodies.  These  were  at  one 
time  believed  to  be  spores,  but  recently  this  germ  has  been  classed  among 
those  that  do  not  produce  spores.  § 

Early  observations  have  been  rendered  somewhat  unreliable  by  the  very 
close  resemblance  of  this  bacterium  to  the  bacterium  coli.  Several  methods, 
all  more  or  less  successful,  have  superseded  that  suggested  by  Eisner  ||  for 
differentiating  the  two  bacilli. 

The  bacillus  stains  readily  in  a  saturated  watery  solution  of  methyl- 
blue.  Cultures  may  be  made  from  the  lecal  discharges  on  the  tenth  day  of 
the  disease  or  later,  but  with  difficulty,  and  are  often  negative ;  probably 
because  the  bacilli  are  not  numerous.  E.  Frankel  and  ]\I.  Simmonds*'  early 
injected  pure  cultures  of  the  typhoid  fever  bacillus  into  the  blood  of  mice, 
rabbits,  and  guinea-pigs,  with  fatal  results,  which  are  now  ascribed  to  toxins 
thus  introduced.  By  introducing  the  cultures  into  the  duodenum.  Klem- 
perer.  Levy,  and  others  caused  lesions  similar  to  those  of  typhoid  fever, 
though  more  recently  similar  intestinal  lesions  have  been  produced  by  other 
bacteria,  including  the  bacterium  coli  commune. 

The  resisting  powers  of  the  typhoid  bacillus  are  very  great.  It  thrives 
at  room-temperature.  The  thermal  death-point  is  given  by  Sternberg  at 
156°  F.  (69°  C).  According  to  Klemperer  and  Levy,  the  bacilli  remain 
vital  for  three  months  in  distilled  water,  though  in  ordinary  water  the  com- 
moner and  more  vigorous  saprophytes  consume  them.  When  buried  in  the 
upper  layers  of  the  soil,  they  retain  their  vitality  for  nearly  six  months.    Cold 

♦"Edinburgh  :\Ied.  and  Surg.  Jour.,  ■  April,  1840.  „       ,     • 

t  Jenner,  "Med.  Chir.  Trans.,"  vol.  xxxiii.;  "  Edinburgh  Mo.  Jour,  of  Med.  Sci.,  vols.  ix.  and 
X.,  1840-31  ,  "  Med.  Times,"  vols,  xx-xxiii.,  November.  1840.  to  ]March,  1851. 

JFor  an  interesting  and  verv  much  more  complete  historical  sketch  of  the  development  of  our 
knowledge  of  typhoid  fever,  see  Murchison's  treatise  on  the  "Continued  Fevers  of  Great  Britain," 
?d  ed..  London.'  18S4. 

§  Sternberg.  "Tour,  of  Am.  >red.  Assoc,"  August  22,  t8qi,  p.  sqo. 

1  "  Zeitschrift  fiir  Hygiene  und  Infectionskrankheiten,"  January,  i8g6. 

5  Von  laksch,  ''  Kiinische  Diagnostik,"   1892,  S.  213. 


TYPHOID  FEVER.  19 

has  no  effect  upon  them,  for  repeated  freezing  and  thawing  fail  to  kill  them. 
They  have  lived  upon  linen  for  from  sixty  to  seventy-two  days,  and  on  buck- 
skin from  eighty  to  eighty-five  days.  Sternberg  has  si^ceeded  in  keeping 
alive  hermetically  sealed  bouillon  cultures  for  more  than  one  year.  John 
S.  Billings  and  Adelaide  Ward  Peckham,  in  some  experiments  in  the  Labo- 
ratory of  Hygiene,  University  of  Pennsylvania,  dried  bouillon  cultures  on 
threads  and  found  that  typhoid  bacilli  lived  in  a  vacuum  two  hundred  and 
seven  days ;  in  a  desiccator  over  sulphuric  acid,  two  hundred  and  three  days ; 
in  a  closet,  two  hundred  and  twenty-eight  days,  and  proved  more  resistant 
than  the  bacillus  coli  communis  or  staphylococcus  aureus.  One-tenth  to 
0.2  of  one  per  cent,  carbolic  acid  added  to  a  culture-medium  is  without 
effect  upon  the  growth  of  the  bacillus ;  0.5  of  one  per  cent,  strength  of  car- 
bolic acid  and  0.05  of  one  per  cent,  corrosive  sublimate  solutions  are,  how- 
ever, fatal  to  it.  Of  all  agents  except  high  heat,  sunlight  seems  to  be  among 
the  most  powerful  to  destroy  it.  The  experiments  of  Billings  and  Peckham,* 
just  alluded  to,  go  to  show  that  insolation  for  two  hours  destroys  98  per 
cent,  of  the  germs,  and  in  three  to  six  hours  kills  all.  This  very  important 
observation,  made  first  by  Janowski  in  i890,f  has  been  confirmed  by  Dieu- 
donne.ij: 

L.  Brieger  announced  in  1885  that  the  pathogenic  action  of  the  typhoid 
bacillus  was  due  to  a  specific  product  of  the  bacillus,  a  soluble  toxin,  but 
later  studies  led  by  R.  Pfeiffer  have  shown  that  these  bacteria  do  not  yield 
a  soluble  toxin,  but  store  up  the  poison  in  their  bodies,  whence  it  goes  over 
in  very  small  quantities  into  the  fluids  in  which  the  bacilli  are  cultivated. 

The  bacillus  itself  most  frequently  enters  the  blood  through  the  stomach 
in  drinking-water  or  milk,  in  both  of  which  it  has  been  found  during  epi- 
demics. There  is  reason  to  believe  also  that  it  may  be  inhaled.  It  has 
been  found  in  water-filters  by  Harold  C.  Ernest  and  T.  M.  Prudden.  It  is 
quite  well  settled  that  the  bacilli  find  their  way  into  food  and  drink  through 
the  careless  disposition  of  alvine  discharges  from  typhoid  fever  patients, 
and  more  than  likely  that  food  may  be  contaminated  by  contagion  conveyed 
from  these  discharges  by  the  common  house-fly.  An  oyster  bed  may  be 
infected  by  sewage ;  green  vegetables,  by  polluted  water  sprinkled  upon 
them. 

Whether  the  bacilli  multiply  outside  the  body  in  the  water  of  wells  or 
rivers  to  which  they  have  obtained  access  is  not  well  settled,  but,  judging 
from  the  large  number  of  persons  sometimes  infected  from  those  sources,  it 
is  not  unreasonable  to  conclude  that  such  multiplication  can  take  place.  A 
most  noteworthy  instance  was  the  epidemic  of  1885  at  Plymouth,  Penna., 
U.  S.  A.,  where  1200  persons  were  attacked  and  130  died,  all  the  cases 
starting  from  a  single  subject,  whose  discharges  contaminated  the  water- 
supply.  The  recent  epidemic  (1897)  at  Maidstone,  England,  furnishes 
another  illustration  of  the  effect  of  contaminated  water-supply.  Within  two 
weeks  after  the  outbreak,  about  the  middle  of  September,  509  cases  were 
reported;  by  October  2y,  1748  cases;  November  17,  1848  cases;  in  all, 
about  1900  in  a  population  of  3=^,000.  The  bacilli  develop  rapidly  in  milk 
and  in  the  soil.  The  relatively  infrequent  communication  of  tvphoid  fever 
to  physicians,  nurses,  and  others  in  close  communication  with  the  disease  is 
explained  by  the  fact  that  the  contagion  escapes  from  the  patient  in  the 

*  "Influences  of  Certain  Agrents  in  Dei5troying  the  Vitality  of  the  Typhoid  and  Colon  Bacillus," 
"  Science,"  February  !■;.  iSo";. 

+  "  Zur  Biologic  des  Tvphus-Bacillus."  "Centralbl.  f.  Bakteriol.,"  viii.,  i8qo. 

t  "  Reitraere  zur  Benrtheilunp  der  Einwirkung-  des  Lichtes  auf  Bacterien,"  "  Arbeiten  aus  dem 
kaiserlichen  Gesundheitsamte,"  Band  ix. ,  S.  405,  1894. 


20  INFECTIOUS  DISEASES. 

stools  alone,  and  as  these  are  commonly  promptly  disposed  of,  the  chances 
for  the  dissemination  of  the  poison  are  correspondingly  few.  Carelessness 
in  the  disposition  of  these  discharges,  as  the  result  of  which  they  are 
allowed  to  dry  on  linen,  whence  the  bacilli  pass  into  the  air  of  the  room, 
does  sometimes  occasion  the  infection  of  nurses  and  physicians  and  others 
attending  on  typhoid  cases.  The  inadvertent  drinking  of  water  from  a  bath 
used  in  tubbing  typhoid  fever  cases  is  said  to  have  caused  the  disease  in 
a  nurse. 

Predisposing  Causes. — Experience  fails  to  establish  definite  pre- 
disposing causes  of  typhoid  fever,  but  new-comers  are  more  likely  to 
be  attacked  than  old  residents,  as  early  shown  by  the  French  physicians  in 
Paris.  It  certainly  often  attacks  the  strong  and  healthy  as  fiercely  as  the 
feeble  and  delicate,  while  allowance  must  be  made  for  the  more  frequent 
exposure  of  the  healthy.  Thus  caused,  typhoid  fever  is  unlimited  in  its 
distribution  by  climate  or  civilization,  but  it  may  be  complicated  by  disease 
peculiar  to  certain  localities,  pre-eminently  malaria. 

Typhoid  fever  is  a  disease  of  adolescents  and  adults  under  thirty, 
although  it  may  occur  at  any  age.  Less  common  in  children,  perforation 
has  been  found  in  a  child  five  days  old,  while  not  a  few  cases  have  been 
reported  in  sucklings.  Infection  in  utero  is  claimed  as  possible  because  of 
successful  cultures  of  bacilli  from  the  fetus.  In  the  young  the  duration 
of  the  disease  is  short  and  the  prognosis  singularly  favorable.  It  has  oc- 
curred at  the  age  of  seventy-five,  eighty-six,  and  even  ninety.  More  men 
than  women  have  typhoid  fever  (71  per  cent,  of  444  cases  collected  by 
Reginald  H.  Fitz),  probably  because  of  their  more  frequent  exposure.  The 
assertion  that  the  pregnant  state  seems  to  protect  against  typhoid  fever  is 
not  substantiated  by  experience  in  Philadelphia,  in  evidence  of  which  I  may 
state  that  within  two  months  there  were  received  in  my  wards  at  the  Hos- 
pital of  the  University  of  Pennsylvania  three  pregnant  women  with  typhoid 
fever. 

Typhoid  fever  is  more  common  in  the  late  summer  and  autumn 
months  than  at  any  other  time  of  the  year,  whence  one  of  the  names, 
"  autumnal  fever."  Heat  has  probably  to  do  with  the  ripening  of  the  cause, 
but  the  relation  of  moisture  to  such  maturing  is  not  so  well  settled.  It  has, 
however,  been  observed  that  hot  and  dry  summers  are  followed  by  more 
cases  than  hot  and  moist  summers.  Buhl  and  Pettenkofer  have  shown  that 
more  cases  succeed  seasons  when  the  ground  water  is  low — that  is,  when 
the  springs  are  low  and  the  upper  layers  of  the  soil  comparatively  dry — than 
when  the  ground  water  is  high  and  the  soil  is  saturated  with  moisture  to  a 
point  nearer  to  the  surface.  Under  the  latter  condition  of  high  ground 
water  the  germs  are  retained  in  situ.  When  the  ground  water  is  low,  on 
the  other  hand,  the  constant  circulation  between  the  air  in  the  loose  soil 
and  that  above  it  conveys  the  germs  upward,  and  they  pervade  the  air  accord- 
ingly. The  hot  and  dry  summer  furnishes  identical  conditions.  While  it 
is  not  impossible  that  the  germs  may  be  transmitted  through  the  air,  and 
the  disease  acquired  by  inhalation,  it  is  scarcely  likely  that  this  is  a  frequent 
occurrence,  since  it  has  been  shown  by  German©  that  in  completely  dried 
air-currents  the  bacillus  soon  dies.  Liebermeister  prefers  to  explain  the 
relation  of  typhoid  to  the  hot  and  dry  season  by  the  fact  that  at  this  season 
the  Quantity  of  solid  matter  in  springs  is  relatively  larger;  that  the  poison, 
in  other  words,  is  more  concentrated,  and  therefore  more  virulent.  Special 
epidemics  may  occur  at  any  season.     Thus  the  epidemic  of  typhoid  fever  at 


TYPHOID  FEVER.  21 

Plymouth,  Penna.,  alluded  to,  began  April  10  and  raged  with  greatest  fury 
during  May  and  June.     Other  epidemics  illustrate  the  same  truth. 

Morbid  Anatomy. — The  characteristic  morbid  anatomy  of  typhoid 
fever  includes  the  changes  in  the  lymphatic  structures  so  constantly  asso- 
ciated with  the  disease.  These  are  more  striking  in  the  solitary  glands  of 
the  ileum  and  their  agminations  known  as  Peyer's  patches.  The  glands 
are  enlarged  by  the  accumulation  of  outwandering  and  proliferated  leuko- 
cytes that  develop  to  the  stage  of  epithelioid  cells,  when  they  become  necrotic 
and  disintegrate.  The  acme  of  this  process  prior  to  disintegration  is  known 
as  medullary  infiltration,  and  is  reached  from  the  eighth  to  the  tenth  day 
of  the  disease.  In  a  recent  autopsy  made  after  death  on  the  eleventh  day 
typical  medullary  infiltration  was  found.  The  disintegration  is  either  molec- 
ular or  massive.  The  former  is  followed  by  a  corresponding  absorption ; 
the  latter,  by  a  massive  discharge  of  the  dead  cells  into  the  bowel,  resulting 
in  the  well-known  typhoid  ulcer.  This,  when  it  represents  a  single  follicle, 
is  small  and  circular,  not  more  than  from  three  to  six  millimeters  (1-8  to 
1-4  inch)  in  diameter;  large  and  elliptical  when  an  entire  Peyer's  patch  is 
involved.  Such  a  patch  is  usually  opposite  the  mesenteric  attachment,  has  its 
longest  diameter  parallel  with  the  length  of  the  bowel  and  its  shorter  trans- 
verse, thus  reversing  the  relations  of  the  tubercular  ulcer.  Much  larger  ulcers 
are  sometimes  formed  by  the  union  of  others,  especially  toward  the  lower 
end  of  the  bowel.  The  borders  are  commonly  raised.  The  floor  of  the  ulcer 
is  usually  the  submucosa,  or  the  muscular  coat  of  the  bowel,  but  it  may  be 
the  peritoneum,  and  even  this  is  sometimes  sphacelated,  appearing  as  an 
opaque  white  membrane  that  sooner  or  later  breaks  and  the  bowel  is  per- 
forated. The  discharge  of  its  contents  into  the  peritoneal  cavity  is  followed 
by  peritonitis,  usually  fatal.  More  commonly,  the  ulcer  heals,  and  the  patient 
recovers,  but  the  normal  glandular  structure  of  the  gut  at  the  seat  of  the 
ulcer  is  not  restored.  Necropsy  discovers  ulcers  in  different  stages  of  healing, 
sometimes  all  healed  except  the  single  fatal  spot  that  has  become  the  seat 
of  perforation.  The  large  intestine  is  also  invaded  in  probably  one-third 
of  the  cases,  and  the  process  may  terminate  here  also  in  perforation.  Ulcer- 
ation may  extend  to  the  appendix,  where,  too,  perforation  sometimes  takes 
place. 

Similar  infiltration  of  the  lymph  nodules  and  lymph  cords  of  the 
mesenteric  glands  and  of  the  spleen  may  occur,  contributing  to  the  enlarge- 
ment of  these  organs.  In  the  spleen  it  is  associated  with  an  active  hyperemia 
that  contributes  to  further  enlargement,  generally  recognizable  during  life. 
The  organ  may  reach  twice  or  three  times  its  normal  size — i.  e.,  435  to  650 
gm.  (14  to  20  ounces).  There  has  even  been  rupture  of  this  organ.  Hemor- 
rhagic infarcts  have  been  found  in  the  spleen  in  from  four  to  seven  per 
cent,  of  cases  coming  to  autopsy.    Abscess  of  the  spleen  has  been  found. 

Perforation  has  been  noted  at  necropsy  in  5.7  per  cent,  of  cases — that 
is,  114  out  of  2000  autopsies  in  Munich;  by  Osier,  in  2.48  per  cent,  of  685 
cases.  Schultz  found  peritonitis  from  intestinal  perforation  in  1.2  per  cent, 
of  3680  cases  in  Hamburg  in  1886-87 '  Liebermeister  found  perforation  in 
1.3  per  cent,  of  over  2000  cases  at  Basle  between  1865-72;  Holscher,  in 
6  per  cent,  of  2000  cases;  and  Murchison,  11.38  per  cent,  of  1721  cases.  In 
4680  cases  collected  by  R.  H.  Fitz  the  deaths  from  perforation  were  6.58 
per  cent.,  which  may  be  said  to  represent  about  the  proportion  actually 
occurring,  since  up  to  the  date  of  his  report  nearly  all  died.  It  occurred  in 
only  one   of    105   soldiers   treated   at  the   University   Hospital   in   the   fall 


22  INFECTIOUS  DISEASES. 

of   1898.     The  range  of  percentage  of  perforation  may,  therefore,  be  put 
down  at  from  1.2  to  11.38  per  cent. 

As  to  the  location  of  perforation,  Hawkins  found  it  in  61  of  y2  cases 
in  the  ileum,  3  in  the  cecum,  3  in  the  appendix,  and  5  in  the  colon,  most 
of  the  latter  being  in  the  sigmoid  flexure.  In  167  cases  collected  by  Fitz 
the  ileum  was  perforated  in  136,  the  large  intestine  in  20,  the  appendix  in 
5,  Meckel's  diverticulum  in  4,  the  jejunum  in  2.  The  number  of  perfora- 
tions is  usually  i,  but  Fitz  reports  out  of  167  cases,  2  in  19,  5  in  3,  4  in  i, 
several  (sic)  in  4,  and  25  to  30  in  2.  The  accident  is  most  frequent  in  the 
third  week,  or  close  to  the  third  week.     It  is  more  frequent  in  men. 

The  liver,  among  organs  more  rarely  affected,  shows  cloudy  swelling, 
granular  and  fatty  degeneration  of  its  cells,  lymphatic  nodular  areas,  and 
even  liver  abscess  with  pylephlebitis,  and  acute  yellow  atrophy.  Abscess  of 
the  liver  was  found  12  times  in  the  Munich  necropsies,  and  acute  yellow 
atrophy  3  times.  Pylephlebitis  has  followed  abscess  of  the  mesentery  and 
perforation  of  the  appendix.  Typhoid  bacilli  are  often  found  in  the  gall- 
bladder in  fatal  cases;  in  Chiari's  reports*  19  out  of  22;  in  Simon  Flex- 
ner's,  7  out  of  14.  Perforation  of  the  gall-bladder  is  sometimes  met,  and 
Keen  has  collected  30  cases  in  his  book  on  the  "  Surgical  Complications  and 
Sequels  of  Typhoid  Fever,"  1898.  .Nine  cases  of  abscess  of  the  spleen  were 
collected  by  Keen,  who  also  reports  a  leukemic  spleen  that  seems  to  have 
been  caused  by  typhoid  fever. 

In  the  kidneys  there  may  be  cloudy  swelling  and  granular  degenera- 
tion of  renal  cells,  more  rarely  acute  nephritis,  which  may  even  be  hemor- 
rhagic ;  also  miliary  abscesses  in  which  typhoid  bacilli  have  been  found. 
Diphtheritic  and  catarrhal  inflammation  of  the  pelvis  of  the  kidney  and 
catarrhal  inflammation  of  the  bladder  are  occasionally  present. 

Changes  in  the  respiratory  organs  are  often  found.  Among  the  rarer 
of  these  are  edema  of  the  glottis,  ulceration  of  the  larynx,  and  even  necrosis 
of  the  laryngeal  cartilages.  Hypostatic  congestion  of  the  lungs  is  quite 
common ;  pneumonia  is  more  infrequent.  Even  gangrene  of  the  lungs  was 
found  in  40  of  the  Munich  cases ;  abscess,  in  14 ;  and  hemorrhagic  infarction, 
in  129.  Pleurisy  and  empyema  are  rare  events.  Dr.  Arthur  V.  Meigs f 
has  described  changes  of  a  hemorrhagic  character  in  the  lungs,  and  others 
in  the  muscular  and  nervous  systems,  the  essential  relation  of  which  to 
typhoid  fever  remains  to  be  demonstrated. 

In  the  circulatory  system  there  may  be  thrombosis  of  veins,  especially 
of  the  femoral,  causing  the  not  very  rare  symptom  of  milk  leg ;  more  rarely 
there  is  thrombosis  of  the  femoral  artery,  which  may  be  preceded  by  embo- 
lism. Endocarditis  and  myocarditis  may  be  present.  The  latter  condition  is 
attested  by  a  yellow,  soft,  and  flabby  muscle  seen  after  death. 

As  to  the  nervous  system,  notwithstanding  the  intensity  of  the  nervous 
symptoms  at  times,  meningitis  is  a  rare  event,  though  both  serious  and 
purulent  forms  have  been  met,  typhoid  bacilli  being  found  in  loco  as  the 
apparent  cause ;  also  thrombosis  of  cortical  veins  and  parenchymatous 
changes  in  nerve-trunks,  even  when  there  have  been  no  symptoms  of  neuritis. 
Abscess  of  the  brain  has  also  been  found  with  the  bacillus  typhosus  in  loco. 
In  the  muscular  system  granular  and  hyaline  transformation  of  voluntary 
muscle  may  occur,  as  in  other  fever  processes. 

Abscesses  in  the  parotid  gland  are  a  familiar  complication ;  more  rarely, 
abscesses  in  the  intermuscular  tissue.     General  invasion  of  all  organs  and 

*  •  Prager  medicinische  Wochenschrift,"  i8q^.  No.  22. 

t  "Proceedings  of  the  Pathological  Society  of  Philadelphia,"  1890. 


TYPHOID  FEVER. 


23 


of  the  blood  by  the  typhoid  bacillus  was  found  once  in  William  Osier's 
wards  at  the  Johns  Hopkins  Hospital  by  Simon  Flexner. 

Typhoid  Fever  unthout  Enteric  Lesions. — A  few  years  ago  typhoid 
fever  without  enteric  lesions  would  have  been  considered  an  impossibility. 
This  can  no  longer  be  claimed.  Cases  have  been  reported  by  Sidney  Philips, 
J.  W.  Moore,  Simon  Flexner,  and  others,  without  these  lesions.  In  doubt- 
ful cases  the  Widal  reaction  and  the  presence  of  bacilli  as  determined  by 
cultures  must  be  appealed  to,  such  examinations  being  suggested  by  other 
symptoms. 

Symptoms  and  Course. — A  certain  period  of  incubation  is  necessary 
after  the  successful  implantation  of  the  bacillus  before  typhoid  fever  arises. 
This  varies  from  a  week  to  two  weeks  and  even  longer.  The  period  of 
incubation  is  usually  without  symptoms,  but  a  sense  of  weariness  and  indis- 
position to  exertion,  the  latter  often  overcome  by  force  of  will,  may  be 
present ;  so  may  a  want  of  appetite  and  a  slight  coating  of  the  tongue.  These 
symptoms,  more  strictly  speaking,  belong  to  the  prodrome,  and  are  in  turn 
not  sharply  separated  from  those  of  the  disease  itself,  which  usually  sets 
in  very  gradually,  and  is  often  quite  advanced  before  suspected, — indeed, 
sometimes  well  advanced,  constituting  the  "  walking  ""  or  ''  ambulatory " 
typhoid.  In  children  the  onset  is  less  gradual.  There  may  be  headache, 
anorexia,  a  furred  tongue,  nausea,  chilliness,  but  only  rarely  a  decided  rigor. 
The  disease  may  be  ushered  in  by  pain  in  the  back  or  legs  or  muscles  and 
nosebleed.  The  latter  has  always  been  considered  characteristic,  and  yet 
I  meet  it  less  frequently  than  might  be  expected  from  the  text-book  state- 
ments, yiore  common  is  looseness  of  the  bozvels.  All  this  time  there  is 
slight  fever,  and  the  patient  feels  wretched.  The  fever  and  the  discomfort 
increase,  and  finally  he  goes  to  bed.  The  tendency  to  looseness  of  the  bowels 
and  epistaxis,  more  than  any  other  symptoms  of  this  group,  justify  strong 
suspicion  of  the  existence  of  typhoid  fever.  Yet  one  or  both  are  quite  often 
absent.  Certain  epidemics  are  more  apt  to  be  attended  by  diarrhea  than 
others.  The  abdomen  soon  becomes  slightly  distended  and  tympanitic,  and 
pressure  in  the  right  iliac  fossa  will  usually  elicit  tenderness  with  gurgling. 
At  times  there  is  colicky  pain  of  varying  severity  independent  of  pressure ; 
at  others  the  gastric  symptoms  are  marked  and  there  are  nausea  and  zvni- 
iting. 

Usually  about  the  eighth  day,  rarely  later  and  sometimes  a  little  earlier, 
rose-colored  spots  make  their  appearance  on  the  skin  of  the  abdomen  and 
chest,  more  rarely  elsewhere  on  the  body.  These  call  for  further  description. 
They  are  usually  bright  red  in  color,  and  are  well  compared  to  a  fleabite. 
They  are  very  slightly,  if  at  all,  raised  above  the  surface  and  disappear  on 
pressure,  to  return  instantly  after  its  removal.  Their  number  varies  greatly. 
Sometimes  they  are  very  numerous,  oftener  there  are  four  or  five  to  ten. 
again  one  or  two,  most  rarely  none.  When  numerous,  they  occur  in  suc- 
cessive crops,  each  crop  lasting  from  two  to  four  days.  Histologically,  they 
are  circumscribed,  actively  hyperemic  areas,  the  hyperemia  being  excited 
by  some  irritant,  which  may  be  the  typhoid  bacillus  itself,  since  it  has  been 
found  in  the  spots.  Only  in  the  most  malignant  cases  is  there  any  blood 
found  outside  of  the  vessels,  and  when  this  occurs,  the  spots  can  be  made 
to  disappear  but  partially  on  pressure.  The  association  of  roseolar  spots  is 
so  intimate  with  the  disease  that  they  have  been  regarded  as  pathogno- 
monic.    Rose-colored  spots  are  much  more  uncommon  in  children. 

In  addition  to  rose-colored  spots,  sudauiina  are  often  present  in  large 


24 


INFECTIOUS  DISEASES. 


numbers  on  the  skin,  especially  when  the  disease  is  associated  with  much 
sweating,  but  their  occurrence  is  by  no  means  constant,  and  their  association 
with  Other  diseases  in  which  there  is  perspiration  is  well  known.  More 
rarely,  petechia:  and  t'ibices  are  noted  in  adynamic  forms  of  the  disease.  An 
erythema  is  quite  often  found  on  the  skin  of  the  chest  and  abdomen. 
Peliomatous  patches — the  tache  hleuatre — sometimes  are  found  on  the  skin 
of  the  thorax,  abdomen,  and  thighs ;  also  the  tache  ccrebrale — a  red  line, 
produced  on  drawing  the  finger-nail  over  the  skin, — but  neither  have  any 
symptomatic  significance.  Herpes  is  so  rare  that  it  is  often  spoken  of  as. 
negatively  pathognomonic.  Jaundice  is  occasionally  seen,  and  may  be  the 
result  of  an  obstructive  cholangitis  excited  by  the  bacillus. 

Enlargement  of  the  spleen  is  an  almost  constant  clinical  feature  of 
typhoid  fever.  If  the  vertical  dullness  exceeds  the  depth  of  two  ribs  and  an 
interspace,  enlargement  is  present.  Not  only  may  such  enlargement  be 
recognized  by  percussion,  but  by  palpation  as  well.  Clinicians  generally 
lay  great  stress  on  palpation,  and  enlargement  may  sometimes  be  detected 
by  it  when  the  organ  eludes  percussion  by  reason  of  tympany.  Hermann 
Eichhorst  advises  the  following  method  of  examination :  Put  the  patient  in 
the  right  diagonal  position,  and  lay  the  finger  gently  between  the  anterior 
ends  of  the  eleventh  and  twelfth  ribs,  when  the  enlarged  organ  can  almost 
always  be  felt  with  every  deep  inspiration  of  the  patient,  in  spite  of  meteo- 
rism.  At  times  the  outline  is  indistinct,  at  others  both  the  tip  and  anterior 
edge  of  the  organ  can  be  distinctly  located.  Strong  pressure  should  not  be 
exerted  by  the  fingers,  for  in  this  way  the  spleen  may  be  insensibly  pressed 
backward  into  the  excavation  of  the  left  hypochondrium.  Enlargement  can 
generally  be  detected  at  the  end  of  the  first  week  or  in  the  first  half  of  the 
second  week,  when  the  organ  may  reach  twice  or  three  times  its  normal  size. 
By  the  end  of  the  third  week  it  begins  to  diminish  in  size.  The  enlargement 
may  be  accompanied  by  tenderness.  Enlargement  of  the  spleen  is  less  fre- 
quent in  cases  occurring  late  in  life. 

Early,  too,  in  the  disease  the  patient  may  have  a  slight  cough,  unasso- 
ciated  with  physical  signs,  or  at  most  those  of  a  mild  bronchial  catarrh. 

The  fever  is  at  once  the  most  important  and  characteristic  symptom, 
and  from  the  temperature  alone  a  diagnosis  can  be  made.  During  the 
increment  of  the  disease  it  exhibits  a  peculiar,  tide-like  evening  rise  and 
morning  fall,  while  the  temperature  of  each  morning  and  evening  is  from 
one  and  a  half  to  three  degrees  higher  than  that  of  the  previous  morning 
and  evening.  The  patient  isjarely  seen  at  the  very  beginning  of  this  first 
stage,  but  should  he  be,  it  will  be  found  to  last  commonly  a  week.  Fre- 
quently it  is  succeeded  at  the  end  of  four  or  five  days  by  the  acme  or 
fasti gium,  in  which  are  continued  the  evening  rise  and  the  morning  fall, 
but  the  evening  and  morning  difterence  is  less  marked,  the  tidal  character 
is  no  longer  present,  and  the  temperature  is  high  throughout.  The 
average  duration  of  the  fastigium  is  five  to  eight,  rarely  ten  days,  being 
longer  in  severe  cases  and  shorter  in  milder  ones.  It  is  during  it  that  we 
meet  the  maximum  temperature,  quite  often  105°  F.  (40.5°  C.)  or  a  little 
above,  more  rarely  106°  F.  (41.1°  C).  A  temperature  of  106°  F.  is  not  infre- 
quently followed  by  recovery,  but  while  107°  F.  (41.6°  C.)  and  108°  F. 
(42.2°  C.)  and  even  109°  F.  (42.7°  C.)  are  met,  such  cases  have  invariably, 
in  my  experience,  terminated  fatally. 

The  fastigium  is  succeeded  by  the  third  stage,  or  period  of  decrement  or 
decline,  in  which  the  reverse  of  the  initial  stage  is  shown  by  an  evening 


TYPHOID  FEVER. 


25 


temperature  lower  than  that  of  the  previous  evening,  and  the  morning 
temperature  lower  than  that  of  the  previous  morning,  but  with  the  evening 
temperature  still  higher  than  that  of  the  morning  of  the  same  day.  This 
decline  continues  until  the  normal  is  reached,  and  from  one  to  two  weeks  are 
consumed  before  that  is  attained.  The  whole  is  much  better  shown  and 
more  easily  understood  from  a  chart  than  from  a  description  in  words. 
Such  a  chart  of  the  temperature  uninfluenced  by  treatment  is  seen  in  figure 
I,  although  the  rise  and  fall  are  not  always  as  regular  as  indicated.  In  a 
typical  case  one  might  safely  place  the  first  stage  at  four  days  to  a  week ;  the 
second,  or  fastigium,  at  seven  to  ten;  and  the  third,  about  as  long  as  the 
second,  the  shorter  period  corresponding  to  a  mild  case  and  the  longer  to  a 
severe  one.     The  fever  does  not  always  reach  the  higher  temperature  shown 


1ST  WEEK 


2D  WEEK 


3RD  WEEK 


4TH  WEEK 


I 


s; 


1: 


i 


Fig.  I.— Temperature  Chart  of  a  Typical  Case  of  Typhoid    Fever 
Uninfluenced    by   Treatment. 

in  the  chart,  and  sometimes  the  maximum  never  reaches  102°  F.  (38.9°  C). 
On  the  other  hand,  there  is  sometimes  a  difference  of  three  or  four  degrees 
in  the  morning  and  evening  temperature,  and  the  latter  may  drop  to  the 
normal.  In  ordinary  cases  the  evening  temperature  falls  to  the  normal  in 
the  course  of  the  fourth  week,  but  in  severe  cases  the  temperature  keeps  up 
during  the  fifth  and  even  sixth  week,  these  cases  having  almost  invariably 
extensive  ulceration  with  great  tenderness  of  the  abdomen  and  meteorism. 
Many  of  them  terminate  unfavorably  by  hemorrhage  or  perforation. 

When  the  disease  begins  with  a  chill, — a  rare  event, — the  temperature 
rises  more  rapidly  in  the  beginning.     Sudden  falls  of  a  decided  character 


26  INFECTIOUS  DISEASES. 

may  occur  in  consequence  of  hemorrhage  from  the  bowels  or  the  nose  or 
from  collapse  after  perforation  of  the  bowels.  Sudden  rises  are  produced  by 
indiscretion  in  diet  and  overexertion  or  the  supervention  of  some  acute  in- 
flammatory affection,  as  pneumonia,  or  ptomain  absorption. 

Copious  szi'catiiig  characterizes  some  cases  of  typhoid  fever,  though  the 
skin  is  more  commonly  dry.  Sometimes,  during  the  reaction  after  a  cold 
bath,  there  is  perspiration.  The  profuse  sweats  first  alluded  to  are  not 
attended  by  a  reduction  of  temperature.  On  the  other  hand,  they  are  some- 
times present  when  the  temperature  is  highest.  Cases  of  recurring 
paroxvsms  of  chill,  fever,  and  sweat  are  reported,  which  simulate  intermittent 
fever,  and  may  reasonably  be  mistaken  for  it. 

The  pulse  is  only  moderately  frequent,  90  to  120  being  the  usual  range, 
while  a  proximity  to  100  is  quite  frequently  maintained.  In  grave 
cases  it  becomes  more  frequent.  14c  or  more;  when,  if  maintained,  it  is  a 
rather  unfavorable  symptom,  due  to  high  temperature  or  complications. 
Temperature  and  pulse  do  not  always  increase  pari  passu.  Dicrotism  may 
occur  with  frequent  pulse,  but  dicrotism  also  occurs  in  the  early  stage,  when 
it  is  regarded  by  some  as  diagnostic.  During  convalescence  the  pulse  gradu- 
ally resumes  its  normal  character,  and  sometimes  becomes  abnormally  slow, 
falling  to  30  or  less.  I  have  recently  had  a  case  in  which  the  pulse  fell  as 
low  as  18,  and  continued  for  one  day  between  20  and  36. 

The  breathing  rate  commonly  advances  with  the  rate  of  the  pulse,  but  is 
sometimes  increased  in  frequency  by  temporary  causes  and  rarely  is  dispro- 
portionately slow.  In  a  very  striking  case  of  my  own  at  the  University  Hos- 
pital the  rate  fell  to  twelve  in  a  minute,  and  continued  thus  for  an  hour. 

The  heart-sounds,  at  first  natural,  grow  less  loud  as  adynamia  pro- 
gresses, and  the  first  sound  may  even  disappear  in  grave  cases.  Sometimes 
a  soft  systolic  murmur  develops  at  the  apex,  usually  at  the  end  of  the  second 
week.  Sometimes  it  acquires  greater  intensity.  It  has  been  especially 
studied  by  M.  G.  Hayem,*  who  ascribes  it  not  to  an  endocarditis,  but  to  a 
relaxation  of  the  muscle  which  results  in  imperfect  apposition  of  the  valves 
and  a  consequent  regurgitation.  This  murmur  disappears  as  recovery  takes 
place,  and  the  heart-muscle  growls  strong. 

As  the  disease  advances,  the  tongue,  previously  furred,  tends  to  become 
dry  and  brown,  clearing,  however,  at  the  edges  and  tip  as  the  case  improves. 
In  severe  cases,  especially  if  the  mouth  is  not  kept  clean,  stomatitis  with 
fissures  and  bleeding  may  occur,  and  sordes  may  collect  on  the  teeth,  while 
the  lips  become  covered  with  black  crusts,  constituting  the  "  fuliginous  coat- 
ing." These  phenomena  are  almost  unknown  with  the  bath  treatment. 
Mild  grades  of  pharyngitis,  producing  difficulty  in  swallowing,  sometimes 
usher  in  the  attack,  more  particularly  in  certain  epidemics. 

The  diarrhea  of  typhoid  fever  has  been  alluded  to.  Usually  correspond- 
ing in  severity  with  the  extent  of  the  local  lesion,  it  is  seldom  troublesome  or 
difficult  to  control,  and  is  sometimes  absent  throughout.  The  stools  may 
be  grayish  yellow,  and  about  the  consistence  of  pea  soup. 

Meteorisiii  in  moderate  degree  is  an  almost  constant  symptom.  The  dis- 
tention by  gas  is  commonly  ascribed  to  atony  of  the  bowels.  Its  presence  in 
high  degrees  adds  to  the  seriousness  of  the  case,  since  it  corresponds  usually 
with  the  extent  of  bowel  lesion,  and  soon  succeeds  perforation. 

Hemorrhage  from  the  bowels,  also  a  consequence  of  intestinal  ulceration 

*M.  G.  Hayem.  "  Des  manifestations  cardiaques  de  la  fievre  typhoid,"  "  Le  Proyres  Mfedical," 
17  Juillet,  1875,  p.  401  et  seq. 


TYPHOID  FEVER. 


27 


and  the  separation  of  sloughs,  is  a  serious  symptom,  but  by  no  means  always 
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The  occurrence  of  such  hemorrhage  is  followed  by  a  rapid  reduction  of  the 
temperature,  as  shown  in  the  appended  chart,  and  a  pallor  and  faintness  such 


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as  are  common  to  large  hemorrhages  elsewhere.  As  stated,  very  profuse 
hemorrhages  may  be  followed  by  recovery,  and  it  is  barely  possible  that  a 
favorable  influence  may  sometimes  be  exerted  by  them.  Very  rarely  a 
patient  will  bleed  to  death.  Hemorrhage  was  a  cause  in  1 1  out  of  56  deaths  In 


28  INFECTIOUS  DISEASES, 

Osier's  685  cases.     It  occurred  99  times  in  2000  cases  in  Munich,  and  8  times 
in  105  soldiers  under  my  care  after  the  Spanish-American  war. 

Perforation  is  attended  by  sudden  acute  pain  in  the  abdomen,  and  symp- 
toms of  collapse.  The  pain  is  rarely  circumscribed,  but  radiates  through  the 
abdomen ;  and  I  well  remember  a  case  when  it  was  so  high  up  that  it 
seemed  in  the  thorax  and  I  mistook  it,  for  a  time,  for  that  of  pleurisy.  It 
occurs  most  frequently  in  my  experience  in  the  third  or  fourth  week,  but  it 
has  happened  as  early  as  the  eighth  day  and  as  late  as  the  sixth  week.  In 
Fitz's  cases  it  occurred  in  the  third  or  fourth  week  in  46.5  per  cent. ;  in  four 
cases  in  the  first  week  and  one  in  the  sixteenth  week.  (See  also  Morbid 
Anatomy.) 

Delirium  is  less  constantly  present  in  typhoid  fever  than  in  typhus,  and 
may  be  absent  throughout.  It  may,  however,  be  very  active,  requiring  the 
patient  to  be  carefully  watched  to  prevent  him  from  leaving  his  bed  and  seri- 
ously endangering  his  life.  More  than  one  victim  has  leaped  from  a  window 
with  fatal  results  under  such  circumstances.  In  certain  cases,  especially 
when  the  initial  headache  is  very  intense,  this  symptom  continues,  and  to  it 
are  added  fever  and  delirium  so  extreme  that  meningitis  is  simulated,, 
though  the  true  form  of  this  disease  rarely  occurs.  Such  cases  illustrate  the 
"  nervous  form  "  of  the  disease.  A  tendency  to  drowsiness,  and  even  to 
stupor,  suggested  the  common  name  "  typhoid,"  but  it  is  less  character- 
istic than  in  typhus. 

Muscular  tremor  is  a  symptom  in  severe  cases,  when  it  would  seem  to 
indicate  a  muscular  weakness  or  exhaustion,  which  may  be  an  effect  of  high 
temperature  or  of  the  specific  poison  of  the  disease.  Carphologia,  or 
"  picking  at  the  bedclothes,"  is  a  symptom  of  which  the  unfavorable  import 
has  been  somewhat  exaggerated,  probably  because  of  the  popular  familiarity 
with  Dame  Quickly's  interpretation  in  Falstaff's  illness.  Concurrently  with 
these  "  typhoid  "  symptoms,  the  tongue  reaches  its  maximum  dryness,  and 
may  be  dark  and  leathery  in  appearance,  while  sordes  may  collect  on  the 
teeth. 

Bed  sores  are  among  the  dangers  of  protracted  cases. 

Hiccough  is  an  infrequent,  but  sometimes  obstinate  symptom. 

Apart  from  an  initial  bronchial  catarrh,  which  sometimes  ushers  in  the 
disease,  the  typhoid  patient  sooner  or  later  acquires  a  slight  cough,  due  to 
hypostatic  congestion  of  the  lungs,  but  it  is  easily  kept  within  bounds  by  fre- 
quent changes  in  the  position  of  the  patient.  Occasionally,  the  cough  is 
quite  severe,  but  seldom  requires  more  active  treatment  than  this.  The 
initial  bronchial  catarrh,  too,  sometimes  assumes  severity,  while  more  rarely 
the  symptoms  and  signs  of  pneumonia  usher  in  the  disease. 

Changes  in  the  Urine. — The  urine  is  always  dark-hued  and  concentrated, 
with  a  correspondingly  high  specific  gravity.  Often  when  the  fever  is  high 
the  urine  contains  a  small  amount  of  albumin.  When  complicated  with 
nephritis,  there  is  more  albumin,  and  tube-casts  are  present.  Recent  French 
statistics  place  albuminuria,  regardless  of  its  cause,  at  over  twenty  per  cent. 
While  such  albuminurias  are  found  in  grave  cases,  they  do  not  appear  to  add 
greatly  to  the  seriousness  of  the  case,  and  recovery  is  by  far  the  more  usual 
termination.  More  rarely,  nephritis  in  a  mild  form  may  develop  during  con- 
valescence. Most  rarely,  it  may  be  the  initial  symptom  of  the  disease,  con- 
stituting a  nephrotyphoid  analogous  to  the  pneumotyphoid,  when  it  may  even 
mask  the  true  disease  by  the  severity  of  its  symptoms.  It  is  well  named  by 
the  French — fievre  typhoide  a  forme  renale.     Only  the  Widal  test,  the  intes- 


TYPHOID  FEVER.  .  29 

tinal  symptoms,  and  the  spots  clear  up  the  diagnosis.  Such  nephritis  may 
rarely  be  hemorrhagic.  The  toxic  properties  of  urine  are  said  to  be  in- 
creased during  typhoid  fever,  especially  while  the  cold  baths  are  being  used. 

The  urine  may  contain  bacilli  of  typhoid  fever,  generally  associated 
with  albumin.  The  following  summary  from  Norman  B.  Gwyn's  paper  in 
the  "  Johns  Hopkins  Bulletin,"  June,  1899,  condenses  our  present  knowledge. 

"  I.  In  quite  a  high  percentage,  perhaps  from  twenty  to  thirty  per  cent., 
■of  all  cases  of  typhoid  fever  typhoid  bacilli  may  be  present  in  the  urine. 

"  2.  When  present,  they  are  usually  in  pure  culture,  often  so  numerous 
as  to  make  the  freshly  voided  urine  turbid,  and  may  then  be  detected  by  a 
cover-slip  examination, 

"  3.  Appearing  generally  in  the  second  and  third  week  of  illness,  the 
•organisms  may  persist  for  months  or  years,  probably  multiplying  in  the 
bladder,  the  urine  being  apparently  a  suitable  medium  for  their  growth. 

"  4.  Though  often  showing  evidences  of  cystitis  and  marked  renal  in- 
Tolvement,  the  urine  containing  bacilli  has  usually  only  the  characteristics  of 
an  ordinary  febrile  urine;  the  presence  of  bacilli  has  no  prognostic  impor- 
tance, and  their  disappearance  or  persistence,  without  having  induced  local 
change,  is  the  rule. 

"5.  Lastly,  as  shown  by  Richardson,  irrigation  of  the  bladder  with 
"bichlorid  of  mercury  and  the  internal  administration  of  urotropin — a  com- 
pound of  ammonia  and  formaldehyde — seem  to  be  safe  methods  of  remov- 
ing the  bacilli ;  thirty  to  sixty  grains  of  the  latter  quickly  removing  all  bacilli 
in  six  cases." 

The  so-called  diazo  reaction  of  urine,  to  which  attention  was  first  called 
"by  Ehrlich  in  1882,  is  so  constant  in  this  disease  as  to  be  deservedly  regarded 
as  a  symptom.  It  was  found  by  John  Hewetson  in  136  out  of  196  cases, 
and  by  Arthur  R.  Edwards  in  128  out  of  130  cases,  and  by  Simon  in  22  out  of 
26  cases.  I  have  never  found  it  absent  when  the  test  was  made  sufficiently 
early. 

Three  solutions  are  kept  in  separate  bottles : 

1.  A  five  per  cent,  solution  of  hydrochloric  acid  saturated  with  sul- 
phanilic  acid.     This  solution  should  be  fresh. 

2.  A  half  of  one  per  cent,  solution  of  sodium  nitrite. 

3.  Ammonium  hydrate. 

When  it  is  desired  to  make  the  test,  40  c.c.  of  (i)  andc.c.  of  (2)  are 
mixed.  The  hydrochloric  acid,  acting  on  the  sodium  nitrite,  liberates 
nitrous  acid,  which  in  its  nascent  state  combines  with  the  sulphanilic  acid, 
producing  diazo-benzine-sulphonic  acid.  Equal  parts  of  this  mixed  solution 
and  urine  are  thoroughly  shaken ;  enough  of  the  ammonia  is  then  allowed  to 
flow  carefully  down  the  side  of  the  tube  to  form  a  colorless  zone  above  the 
urine  mixture.  At  the  junction  of  the  two  fluids  a  dark-garnet  or  cherry- 
Ted  ring  will  form  if  the  reaction  takes  place,  and  if  the  tube  is  well  shaken, 
a  uniform  red  color  is  imparted  to  the  entire  fluid,  which,  when  allowed  to 
stand  for  some  hours,  shows  a  characteristic  olive-green  precipitate,  the 
tipper  layer  of  which,  as  a  rule,  has  a  still  darker-green  color.  The  reaction 
occurs  about  the  time  of  the  appearance  of  the  ras'h  and  usually  continues 
until  the  tzventy-second  day,  but  it  may  disappear  before  the  end  of  the 
second  week.  It  is,  as  stated,  symptomatic  and  not  diagnostic,  certainly  not 
pathognomonic,  as  it  occurs  in  many  diseases  with  high  fever,  among  which 
measles  and  miliary  tuberculosis   are  conspicuous.     It  may,  however,  be 


30 


INFECTIOUS  DISEASES. 


regarded  as  negatively  pathognomonic — that  is,  its  absence  is  strongly  pre- 
sumptive against  the  presence  of  typhoid  fever. 

Changes  in  the  Blood. — The  state  of  the  blood  in  typhoid  fever  early 
claimed  attention,  and  even  the  earliest  observers,  beginning  v^ith  Le  Canu  in 
1837,  noted  a  diminution  of  red  hlood-corpiiscles.    This  observation  has  been 


DEC.   1890  . 
19  22  26  28  311 

3 

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Fig.  3. — Chart  Showing  Anemia  of  Typhoid  Fever, — {From  Thayer's  ^'  Monograph.") 


essentially  confirmed  by  the  "most  recent  studies  with  modern  accurate 
methods,  among  vi^hich  those  by  Ouskow,*  by  Khetagurow,  f  and  by  W.  S. 
Thayer  %  are  conspicuous. 

At  the  beginning  of  the  fever  the  number  of  red  blood-corpuscles  is  nor- 
mal and  even  at  the  upper  limit  of  normal,  because  the  patients  are  apt  to  be 
young  and  strong,  while  in  some  instances  the  initial  diarrhea  or  pronounced 
sweating  may  cause  slight  concentration  of  the  blood.  During  the  first  two 
weeks  the  number  of  red  corpuscles  gradually  falls,  though  but  slightly. 
With  defervescence  they  fall  off  more  rapidly,  reaching  a  minimum  usually 
about  the  first  week  of  convalescence,  after  which  there  is  a  gradual  rise  to 
the  normal,  followed  again  by  a  possible  slight  fall  when  the  patient  gets  up. 

*"The  Blood  as  a  Tissue,"  St.  Petersburg:,  i8qo. 

t" Pathological  Changes  in  the  Blood  in  Typhoid  Fever,"    Inaug.  diss.,  St.  Petersburg,  1891. 
X  "  Two  Cases   of    Post-typhoid  Anemia,   with  Remarks  on  the  Value  of   Examination  of  the 
Blood,"  vol.  iv.,  "Johns  Hopkins  Hospital  Reports,"  1895. 


TYPHOID  FEVER.  31 

The  fall  in  the  number  of  red  corpuscles,  while  relatively  slight,  bears  usually 
a  direct  relation  to  the  severity  of  the  case. 

The  hemoglobin  is  always  reduced  and  the  reduction  is  relatively 
greater  than  the  corpuscular  loss,  with  an  even  slower  return  to  the  normal. 
Extreme  anemia,  with  a  blood  count  as  low  as  1,300,000  corpuscles  in  a  cubic 
millimeter  and  hemoglobin  as  low  as  twenty  per  cent.,  has  been  met. 

The  number  of  leukocytes  in  a  cubic  millimeter,  normal  at  the  begin- 
ning, tends  also  to  diminish  slightly  throughout  the  disease,  reaching  a  mini- 
mum toward  the  end  of  defervescence,  increasing  again  with  the  beginning 
of  convalescence,  and  reaching  the  normal  after  several  weeks.  More  defi- 
nitely the  change  consists  in  a  diminution  in  the  percentage  of  multinuclear 
or  overripe  elements,  with  a  relative  increase  in  the  large  mononuclear  or  ripe 
elements.  Thayer  regards  the  absence  of  leukocytosis  of  real  diagnostic 
value,  being  in  marked  contrast  with  the  distinct  increase  in  the  number  of 
colorless  corpuscles  and  overripe  elements  (multinuclear  cells)  characteristic 
of  most  other  infectious  processes.  Typhus  fever  is  unattended  by  blood 
changes,  and  while  in  a  few  cases  of  malignant  pneumococcus  infection  there 
may  be  no  leukocytosis,  there  is  no  diminution  in  the  leukocytes,  as  in 
typhoid.  The  condition  of  the  blood  in  malarial  fever  is  practically  the 
same  as  in  typhoid  fever,  but  the  presence  of  the  malarial  parasite  in  the 
former  is  distinctive.  In  pure  miliary  tuberculosis  unassociated  with  local 
inflammatory  processes  there  is  also  an  absence  of  leukocytosis.  It  is  impor- 
tant to  remember  that  cold  baths  have  the  effect  of  producing  a  decided  tem- 
porary increase  in  the  proportion  of  leukocytes,  probably  rather,  as  Thayer 
thinks,  in  consequence  of  an  accumulation  of  white  cells  in  the  vessels  of  the 
surface  than  as  the  result  of  a  true  leukocytosis.  More  rarely,  the  leuko- 
cytes are  increased.  Cabot  refers  to  four  cases  in  which  they  reached  11,000, 
and  in  one  17,000,  with  no  lesions  other  than  those  common  to  typhoid. 
Very  interesting  is  the  effect  of  suppuration  on  this  reduction  in  the  number 
of  leukocytes.  It  is  replaced  by  an  increase  as  shown  by  counts  after  per- 
foration, phlebitis,  and  otitis.  Especial  value  is  claimed  for  leukocytosis  as 
a  warning  of  impending  perforation  and  peritonitis. 

Unusual  Modes  of  Onset.  Unusual  Symptoms.  Atypical  Forms. — 
It  has  been  mentioned  that  while  slight  chilliness  is  often  an  initial  symptom, 
severe  rigor  at  the  same  stage  rarely  occurs.  It  does,  however,  happen,  as 
in  13  out  of  79  of  Osier's  cases.  More  frequently,  chills  have  been  observed 
in  the  course  of  the  disease  from  some  one  of  the  following  causes : 

1.  At  the  onset  of  a  relapse. 

2.  As  a  result  of  treatment,  especially  by  antipyretics  internally,  guaiacol 
externally,  or  of  a  hypodermic  injection  of  a  sterilized  culture  of  typhoid 
bacilli. 

3.  At  the  onset  of  complications,  such  as  pneumonia  or  pleurisy  or 
thrombosis. 

4.  From  sepsis  during  convalescence  in  severe  and  protracted  cases. 
Under  these  circumstances  chills  may  be  frequent,  severe,  and  of  grave 
import. 

5.  From  concurrent  malaria. 

In  epileptics  who  acquire  typhoid  fever  the  latter  disease  is  very  apt  to 
be  ushered  in  by  an  unusual  number  of  epileptic  convulsions,  which  continue 
frequent  until  the  fever  becomes  established,  then  diminish,  and  finally  cease, 
often  not  recurring  until  some  time  after  recovery,  causing  the  victim  and 
his  friends  to  believe  that  the  chronic  malady  has  disappeared.     It  returns, 


32  INFECTIOUS  DISEASES. 

however,  sooner  or  later.  The  same  is  true  of  choreic  attacks.  Rarely,  the 
■disease  is  ushered  in  with  convulsions  in  children.  In  diabetes  the  sugar 
may  disappear  during  the  fever. 

Among  the  more  unusual  modes  of  onset  should  be  mentioned  cases  be- 
ginning with  severe  bronchitis ;  those  with  the  initial  symptoms  of  pneu- 
monia, including  chill ;  those  with  initial  symptoms  of  nephritis  or  with 
intense  nervous  symptoms,  suggesting  cerebrospinal  meningitis.  Among 
the  latter  are  intense  headache  and  photophobia,  combinations  rapidly  pass- 
ing over  into  active  deUrium,  with  muscular  twitching  and  retraction  of  the 
head,  constituting  the  nervous  or  meningeal  form.  In  accordance  with 
recent  views  these  varieties  may  be  considered  as  representing  forms  in 
which  the  organs  especially  involved  are  the  primary  and  chief  seats  of  attack 
by  the  bacillus  as  contrasted  with  the  more  usual  intestinal  form.  In  certain 
long  and  severe  cases  septic  infection  occurs,  manifested  by  fever,  sweats, 
and  local  abscesses  in  various  parts  of  the  body,  including  the  perirectal  and 
perinephric  regions. 

Among  irregular  forms  is  the  so-called  abortive  form.  This  doubtful 
form  is  said  to  be  more  sudden  in  its  onset,  beginning  with  shivering  and 
fever  of  103°  F.  (39.4°  C.)  or  higher.  The  rose-colored  spots  appear  at  from 
the  second  to  the  fifth  day.  The  fever  falls  at  the  end  of  the  first  week  or 
beginning  of  the  second,  commonly  by  crisis  with  a  sweat,  after  which  fol- 
lows convalescence.  The  hemorrhagic  is  a  grave  variety  characterized  espe- 
cially by  cutaneous  and  mucous  hemorrhages,  and  is  fortunately  rare.  The 
mild  form  is  sometimes  so  mild  as  scarcely  to  be  recognized  as  typhoid  fever 
and  is  often  called  gastric  fever  or  simple  febricula.  There  is,  however,  no 
more  important  lesson  for  the  inexperienced  practitioner  to  learn  than  that 
some  cases  beginning  as  a  mere  febricula  may  pass  over  into  forms  of  great 
■severity,  and  may  even  terminate  fatally.  A  very  rare  form  is  the  tonsillar 
typhoid,  in  which  whitish  elevations  appear  on  the  tonsils,  subsequently 
becoming  ulcers. 

Complications  and  Sequelae. — The  recent  Spanish-American  war  has 
<:onfirmed  the  possibility  of  the  coexistence  of  typhoid  ever  and  of  malarial 
iever,  since  a  number  of  cases  from  among  the  soldiers  have  been  reported 
in  which  not  only  all  the  necessary  clinical  features  of  typhoid  fever  were 
present,  but  also  the  Widal  reaction,  in  which,  too,  the  malarial  organism 
was  found  in  the  blood.  Such  coexistence  occurred  in  two  of  the  cases 
•under  my  own  care  in  the  Hospital  of  the  University  of  Pennsylvania.  It  is, 
however,  an  infrequent  event.  On  the  other  hand,  a  mongrel  disease  that 
is  the  product  of  the  two  causes,  as  was  once  supposed  to  be  the  case,  and 
known  as  typhomalarial  fever,  does  not  exist.  The  term  should  be  dropped, 
as  it  is  confusing  and  gives  rise  to  erroneous  impressions. 

Persons  with  tuberculosis,  diabetes,  epilepsy,  and  other  forms  of  chronic 
nervous  disease  are  as  liable  to  typhoid  fever  as  others,  while  scarlet  fever, 
diphtheria,  measles,  chicken-pox,  rheumatism,  and  especially  erysipelas,  may 
iDefall  a  typhoid  case.  Typhoid  fever  in  diabetic  cases  is  especially  apt  to  be 
attended  with  low  temperature.  Typhoid  fever  itself  predisposes  to  tuber- 
culosis, and  not  a  few  patients  recover  from  the  former  disease  only  to  be 
attacked  by  the  latter. 

Thrombosis  of  the  femoral  vein,  more  frequently  the  left,  resulting  in 
phlegmasia  alba  dolens,  or  milk  leg,  is  a  complication  that  often  greatly 
delays  convalescence.  It  occurs,  according  to  Murchison,  in  one  per  cent, 
of  all  cases.     It  sometimes  invades  both  legs  in  succession,  and  may  extend 


TYPHOID  FEVER.  33 

into  the  iliac  veins  and  vena  cava,  thence  even  into  the  right  auricle,  caus- 
ing death  from  syncope.  Unless  the  latter  event  occurs,  however  tedious  the 
recovery,  it  takes  place  ultimately  almost  without  exception.  Very  rarely 
there  may  be  suppuration.  Bacilli  have  been  found  in  the  thrombus.  IMore 
or  less  phlebitis  is  always  present.  The  question  as  to  the  primary  event, 
whether  thrombosis  of  phlebitis,  is  seemingly  settled  by  this  finding  of  bacilli, 
in  favor  of  the  former.  Arterial  as  well  as  venous  thromhosis  may  occur, 
and  the  former  may  start  with  embolism ;  femoral  arterial  obstruction  is 
most  common,  resulting  in  gangrene  of  the  leg  and  foot.  Embolic  abscess 
may  occur  in  the  kidney  and  lung. 

Parotitis,  commonly  going  on  to  suppuration,  is  an  occasional  symp- 
tom.    It  is  the  result  of  infection  by  Steno's  duct. 

Xoiiia.  or  gangrenous  stomatitis,  has  appeared  as  a  complication  or 
sequel  in  children.  A\'.  W.  Keen  records  nine  cases  of  w^hich  five  proved 
fatal.  Gangrene  in  other  situations  occurs  more  rarely,  as  in  the  vulva  in 
females  and  in  the  perineum  and  about  the  anus  in  both  sexes.  This  may 
be  due  to  arterial  thrombosis.     Perineal  fistulae  may  follow  in  these  cases. 

It  has  been  mentioned  that  pneumonia  may  usher  in  the  disease,  and 
:a  few  words  may  be  said  here  of  the  relation  of  the  two  conditions,  pneu- 
monia and  typhoid  fever.  The  term  typhoid  pneumonia  is  one  in  common 
use  by  many  who  have  no  definite  notion  of  its  meaning,  and,  like  the  term 
typhomalax-ial,  has  occasioned  confusion.  In  the  first  place,  the  case  may 
begin  as  a  lobar  pneumonia,  the  intestinal  symptoms  appearing  at  the  end  of 
the  first  week  or  later,  at  which  time  also  the  spots  may  appear,  establishing 
the  diagnosis,  while  the  usual  crisis  of  pneumonia  fails  to  make  its  appear- 
ance. Again,  a  pneumonia  may  supervene  in  the  second  or  third  week  of  a 
typhoid  fever  as  a  complication  in  which  the  true  relation  is  less  difficult  to 
determine.  Finally,  there  may  be  a  true  pneumonia,  to  which  stupor,  a  dry 
tongue,  and  general  adynamia  may  be  added,  without  the  distinctive  lesions 
of  typhoid  fever.  This  is  true  typhoid  pneumonia,  which  it  may  not  always 
be  easy  to  separate  from  the  typhoid  fever  beginning  with  pneumonia. 
Both  of  the  forms  of  pneumonia  may  be  caused  by  the  typhoid  bacillus  or  the 
pneumococcus.  Hypostatic  congestion  has  been  referred  to.  Many  cases 
formerly  thus  named  are  really  instances  of  catarrhal  or  lobular  pneumonia 
iDelonging  to  the  class  of  inhalation  pneumonias.  Such  may  terminate  in 
abscess  and  gangrene.  When  pleurisy  occurs,  it  has  the  same  relations  to 
the  disease  as  pneumonia.  It  is.  however,  more  rare,  but  may  also  be  puru- 
lent.    An  initial  nephritis  has  been  mentioned  on  page  ^2. 

Certain  suppurative  processes  sometimes  included  as  symptoms  should 
be  regarded  rather  as  complications  than  symptoms.  Of  these  those  about  the 
ear  are  the  most  serious.  They  are,  however,  less  frequent  in  typhoid  than 
in  typhus  fever.  They  are  most  common  in  the  parotid  gland,  where,  how- 
ever, the  inflammatory  process  does  not  always  terminate  in  suppuration, 
occasionally  resolving  itself  with  or  without  local  treatment.  The  duct  of 
Steno  is  probably  the  route  of  infection  in  these  cases  by  the  pus  organisms 
that  find  conditions  favorable  to  their  work.  The  middle  ear  may  be  invaded, 
producing  otitis  media.  Here  the  Eustachian  tube  becomes  the  route  of 
infection.  Sometimes  abscesses  are  m.ultiple.  Not  infrequently  convales- 
ence  is  delayed  by  numerous  bods,  the  effect  of  which  in  keeping  up  the 
temperature  must  be  remembered. 

The  bladder  may  be  a  seat  of  suppuration,  and  pyuria  is  not  infrequently 
present.     George  Blumer  found  it  in  10  out  of  60  cases,  or  nearly  17  per 


34  INFECTIOUS  DISEASES. 

cent.,  of  a  series  admitted  to  the  Johns  Hopkins  Hospital.  I  have  met  it 
only  once  in  a  pronounced  form  in  a  series  of  41  cases,  but  also  in  isolated 
cases  more  frequentl}-  since  my  attention  has  been  called  to  its  possibility. 
It  is  probably  caused  by  the  typhoid  bacillus.  The  inflammation  may  extend 
to  the  pelvis  of  the  kidney  or  start  therefrom.  Orchitis  and  epididymitis 
are  also  occasional  symptoms  during  convalescence.  Thompson  S.  West- 
cott  collected  32  cases  for  Keen's  book,  "  Surgical  Complications  and  Sequels 
of  Typhoid  Fever,"  1898. 

Cardiac  complications,  including  pericarditis,  endocarditis,  and  myocar- 
ditis, are  sometimes  present.    The  latter  may  be  a  cause  of  sudden  death. 

Neuritis  is  an  occasional  complication  or  sequel  in  both  the  local  and 
multiple  forms.  Osier  found  it,  however,  m  but  4  of  389  cases.  The  pain 
may  be  severe  and  associated  with  the  usual  tenderness  of  the  nerve  trunks. 
I  recall  one  patient  who  made  a  splendid  recovery  under  the  tub-bath  treat- 
ment, but  had  the  exquisitely  tender  toes  first  described  by  Handford.  The 
tenderness  is  often  so  great  that  the  bedclothing  must  be  kept  raised  by 
a  cradle.  I  find  neuritis,  too,  more  frec|uent  since  I  have  been  watching  for 
it.  Even  cases  of  optic  neuritis  with  atrophy  of  the  optic  nerve  have  been 
reported,  but  it  is  probable  that  these  are  sequelae  of  meningitis  mistaken 
for  typhoid  fever.     Tetany  sometimes  succeeds  typhoid  fever. 

Two  sequelae  of  typhoid  fever,  neither  of  frequent  occurrence,  are  con- 
spicuous by  their  symptoms.  They  are  insanity  and  tubercular  phthisis. 
The  former  is  often  typical  acute  mania,  requiring  the  utmost  vigilance  to- 
prevent  the  patient  from  injuring  himself  and  others,  or  from  escaping  from 
the  house  or  jumping  from  a  window.  Although  this  form  of  insanity  is 
often  prolonged  for  many  weeks,  the  prognosis  is  singularly  favorable,  and 
recovery,  sooner  or  later,  takes  place.  Tubercular  phthisis,  when  it  occurs, 
has  its  predisposing  cause  in  the  lower  tone  of  cell  life,  favoring  the  suc- 
cessful implantation  of  the  specific  bacillus,  and  is  followed  by  its  usual 
consequences. 

Post-typhoid  hone  lesions  are  surprisingly  common.  Sir  James 
Paget,  Alurchison,  W.  W.  Keen,  Haywood,  Harold  C.  Parsons,  and  others 
have  collected  many  cases.  They  include  osteitis,  necrosis,  and  periostitis. 
The  tibia  is  the  favorite  seat, — 91  times  out  of  216  of  Keen's  collec- 
tion,— next  the  ribs  40  times,  the  femur  22  times,  the  ulna  15,  and 
the  humerus  11.  Ebermaier,  in  1887,  obtained  from  two  cases  of  suppura- 
tive post-typhoid  periostitis  the  bacillus  of  Eberth  in  pure  culture,  and  since 
then  quite  a  number  of  cases  have  been  reported  :  whence  pyogenic  properties 
of  this  bacillus  may  be  inferred.  Other  bacilli — viz.,  the  staphylococcus, 
streptococcus,  and  pneumonococcus — are,  how'ever,  at  times  associated. 
Golgi  also  produced  suppuration  by  injecting  pure  typhoid  bacilli  subcu- 
taneously  at  a  distance  from  the  fractured  ends  of  a  long  bone  in  a  lower 
animal.     The  pus  showed  in  culture  only  typhoid  bacilli. 

Perichondritis  appears  to  be  a  frequent  complication  in  Germany,  as- 
shown  by  the  collections  of  Keen,  Liining,  and  Westcott — 169,  13,  and  14 
respectively.  Keen's  and  Liining's  lists  include  the  same  cases.  The  disease 
is  certainly  less  common  in  England  and  America.  Necrosis  of  the  carti- 
lages, as  \vell  as  ulcers,  are  frequent  results.  .  All  of  these  surgical  compli- 
cations are  easily  explained  since  the  recognition  of  the  bacillus. 

The  typhoid  spine,  to  which  attention  was  called  by  Gibney  of  New  York 
in  1889,  is  a  sequel  of  undetermined  nature.  There  is  sever  pain  in  the 
back,  commonly  aggravated  by  motion.     The  pain  may  be  throughout  the 


TYPHOID  FEVER.  35 

whole  spinal  region  or  limited  to  the  cervical,  dorsal,  or  lumbar  por- 
tions. From  the  latter  it  may  extend  toward  the  hips.  It  may  be  a 
spondylitis,  but  is  probably  a  pure  neurosis.  Allied  to  this  condition  is 
perhaps  an  obstinate  periostitis  of  the  sternum  or  the  crest  of  the  ilium  or 
front  of  the  spinal  column  after  typhoid  fever,  alluded  to  by  William  Pepper 
in  the  "  Text-book  by  American  Teachers."  These  conditions  are  rare  and 
sometimes,  at  least,  may  be  coincidences. 

Cholelithiasis  is  now  a  well-recognized  sequel,  Dufourt  having  reported 
it  in  19  patients  who  had  their  first  attack  after  typhoid  fever.  Further 
interest  attaches  because  there  is  every  reason  to  believe  that  the  bacilli  in  the 
gall-bladder  are  the  initial  cause  of  the  process  which  results  in  stone, 
Bernheim  first  called  attention  to  this  possibility  in  1889,  and  is  sustained  by 
Dufourt,  Milian,  Hanot,  Maurice,  H.  Richardson,  Mason,  W.  H.  Welch, 
and  W.  W.  Keen. 

Polyuria  is  a  rare  complication.  A  remarkable  case  Avas  reported  by  Dr. 
James  C.  Wilson,  at  a  late  meeting  of  the  Section  on  Medicine  of  the  Col- 
lege of  Physicians  of  Philadelphia.  Such  excessive  polyuria  must  be  due  to 
an  irritation  by  bacilli  of  the  urinary  center  in  the  medulla. 

Relapses. — These  occur  readily,  succeeding,  it  used  to  be  taught,  upon 
premature  relaxation  of  diet.  The  demand  of  the  convalescent  for  change 
in  food,  and  especially  for  solid  food,  is  often  well-nigh  irresistible,  but 
should  be  denied  until  the  temperature  has  been  normal  for  a  week.  With 
our  present  views  as  to  the  etiology  of  typhoid  fever  relapses  cannot  be 
thus  explained ;  for,  while  such  indiscretion  in  diet  might  reasonably  be 
expected  to  renew  intestinal  lesions,  it  would  not  be  expected  to  revive  the 
life  of  the  original  cause,  the  bacillus.  Accordingly,  we  must  look  elsewhere. 
As  long  ago  as  1871  Hamernjk,  quoted  by  Murchison  and  Maclagan,* 
suggested  that  the  relapse  is  really  a  reinfection  of  the  large  intestine  from 
the  small  by  the  passage  of  sloughs  over  healthy  lymphoid  follicles.  Hugh 
Stewart  t  reiterated  this  suggestion  in  1894,  but  Murchison  early  noted 
that  the  fresh  lesions  are  sometimes  higher  up  in  the  ileum  than  those  of 
the  first  attack.  Liebermeister  believed  that  a  part  of  the  typhoid  poison 
remained  latent  somewhere  in  the  body,  awaiting  some  exciting  cause  to 
bring  it  into  activity.  G.  Fiitterer  |  claims  to  have  been  the  first  to  discover 
the  typhoid  bacillus  in  the  gall-bladder  in  1888;  §  also  that  he  was  the  first 
to  express  the  opinion  that  relapses  are  caused  by  typhoid  bacilli  entering 
the  intestines  with  the  bile.  Dupre  ||  and  Chiari  ^  were  among  the  first  to 
find  typhoid  bacilli  almost  constantly  present  in  the  gall-bladder  of  those 
ill  with  typhoid  fever,  and  suggested  the  possible  responsibility  of  these 
bacilli  for  relapses.  They  may  be  discharged  into  the  small  intestine  without 
harmful  result  after  immunity  is  secured.  Prior  to  this  period,  however, 
the  patient  may  suffer  a  relapse.  Thus  may  be  explained  the  occurrence 
of  relapses  after  indiscretions  in  diet,  which  stimulate  the  action  of  the 
liver  and  cause  more  bacilli  to  be  poured  into  the  bowel,  thus  increasing 
the  chances  of  infection.  Chiari's  experience  leads  to  further  confirmation, 
since  in  three  cases  of  relapse  the  number  of  bacilli  in  the  gall-bladder 
was  very  large.     B.  Curshmann,  in  his  paper  on  tphoid  fever  in  Nothnagel's 


♦"Edinburgh  Med.  Jour.,"  vol.  xiv.,  part  ii.  p.  865,  1871. 
t  "Practitioner,"  vol.  liii.  p.  185,  1894. 
i  "  Medicine."'  Noveinber.  1898. 
§  "Miinchener  mad.  Wochenschrift,"  No.  ig,  1888. 

|l  "Les  infections  biliaires,"  "These  de  Paris,"  1891.  ,        „  ..™         ^-  ^■.   ,.     ^ 

if"Prager  medicinische  Wochenschrift,"  1893,  No.  23.    See  also  Brannan,    ' Twentieth  Century 
Practice  of  Med.,"  vol.  xvi.  pp.  678  and  679. 


36  INFECTIOUS  DISEASES. 

"  Encyclopedia  of  Practical  Medicine,"  says  of  relapses :  "  Undoubtedly  their 
development  is  to  be  attributed  to  the  re-entrance  into  the  circulation  of 
living  typhoid  bacilli  which,  after  the  primary  attack,  were  left  behind  in 
various  organs ;  and  associated  with  this,  more  or  less  complete  development 
of  the  local  and  general  typhoid  lesions  occurs.'"^ 

It  has  been  usual  to  regard  as  necessary  to  the  diagnosis  of  relapse 
the  presence  of  those  symptoms  essential  to  the  primary  diagnosis — ^ 
viz.,  the  characteristic  spots,  a  return  of  the  tidal  or  step-like  tem- 
perature, and,  scarcely  less  so,  the  enlarged  spleen,  and  all  of  these  after 
complete  defervescence.  In  my  experience  this  dare  not  be  insisted 
upon.  The  attack  is,  however,  usually  less  severe,  the  duration  shorter, 
and  recovery  the  rule.  Relapses  are  to  be  distinguished  from  recru- 
descence, which  is  a  simple  return  of  fever,  often  induced  by  numerous 
ca.uses,  including  lapses  in  diet,  too  much  excitement,  and  the  like. 
Relapses  may  be  multiple.  Transverse  markings  on  the  finger-nails  incident 
to  multiple  relapses  are  sometimes  noted.  The  number  of  relapses  varies 
greatly  in  the  experience  of  different  observers — from  one  to  eighteen  per 
cent.  Of  112  cases  admitted  to  the  Hospital  of  the  University  of  Pennsyl- 
vania from  the  various  military  camps  of  the  country,  in  the  fall  of  1898, 
there  was  a  percentage  of  10.7.  Certainly  it  is  smaller  with  the  bath  treat- 
ment. 

Relapses  are  more  frequent  in  young  persons  than  in  older  ones. 

Diagnosis. — Typhoid  fever  is  usually  easily  recognized  by  the  fairly 
well-trained  medical  man,  while  the  experienced  hospital  physician  may 
even  know  the  disease  by  the  dull,  dusky  facies.  At  other  times  diagnosis 
mav  have  to  be  delayed  until  the  distinctive  signs  appear.  The  peculiar 
range  of  temperature  is  the  most  distinctive  symptom,  and  from  it  alone  the 
diagnosis  may  be  made.  The  rose-colored  spots,  occurring  about  the  eighth 
day,  are  conclusive  if  present,  but  they  are  occasionally  absent.  Diarrhea 
is  less  constant,  and  in  my  experience  nosebleed  still  less  so,  but  more  char- 
acteristic. Both,  however,  require  to  be  weighed  in  association  with  other 
symptoms.     No  one  symptom  is  pathognomonic. 

The  resemblance  of  typhoid  fever  to  certain  cases  of  rapid  consump- 
tion has  long  been  recognized,  but  the  modern  temperature  chart  has  greatly 
diminished  the  difficulty  of  distinguishing  them.  Certain  cases  of  malarial 
fever,  especially  the  autumnal  type,  also  very  closely  resemble  typhoid,  but 
here,  too,  the  temperature  diagram  is  not  identical,  while  the  usually  easy 
recognition  of  the  malarial  jorganism  completes  the  solution.  Where  the 
two  diseases  are  concurrent,  as  is  sometimes  the  case,  the  difficulties  are 
increased. 

Mention  has  been  made  of  the  close  resemblance  of  the  so-called  nervous 
variety  of  typhoid  fever  to  cerebrospinal  fever,  and  it  is  sometimes  so  mis- 
interpreted. As  the  disease  progresses,  however,  the  distinctive  signs 
develop  and  the  correct  diagnosis  is  gradually  made.  Further,  unless  an 
epidemic  of  cerebrospinal  meningitis  prevails,  the  probability  that  this  com- 
bination represents  the  early  stage  of  typhoid  fever  is  far  greater  than  that 
it  is  cerebrospinal  meningitis.  The  popular  term,  "  brain  fever."  now  pass- 
ing into  disuse,  doubtless  included  many  of  the  cases  of  nervous  typhoid. 

More  misleading,  e^-en  though  less  frequent,  are  the  cases  beginning 

*The  term  recrudescence  is  not  alwa^'s  similarly  used.  Thus  Curschmann.  in  the  article  alluded- 
to,  regards  relapse  and  recrudescence  as  due  to  the  same  cause  and  calls  it  relapse  if  it  succeeds 
upon  a  perfectly  afebrile  period,  and  recrudescence  if  the  reascent  occurs  during  the  period  of 
involution  before  the  declining  temperature  has  coiriDletely  returned  to  the  normal.  I  prefer  to 
retain  the  distinction  given  in  the  text,  which  is  also  that  adopted  by  Osier. 


TYPHOID  FEVER.  37 

with  decided  pulmonary  symptoms  suggesting  pneumonia  rather  than 
typhoid  fever,  and  unless  the  physician  is  awake  to  the  possibilities  of  such 
a  beginning  and  watches  further  developments  the  case  may  be  regarded  as 
one  of  typhoid  pneumonia.  Doubtless  some  cases  that  are  still  regarded 
as  lobar  pneumonia  are  typhoid  fever.  Such  a  mistake  might  have  been 
made  in  the  case  reported  by  Osier  in  the  third  edition  of  his  "  Text-book/' 
when  only  the  symptoms  and  morbid  anatomy  of  pneumonia  w€re  found, 
but  in  which  pure  cultures  of  the  typhoid  bacillus  were  isolated  from  the 
lungs,  liver,  kidneys,  and  spleen.  Xo  lesion  of  the  intestine  and  no  other 
organisms  were  present. 

Certain  cases  of  concealed  suppuration  resemble  typhoid  fever  in  the 
symptoms  produced,  and  may  for  a  time  mislead.  But  again  the  tempera- 
ture chart,  after  a  few  days'  observation,  will  solve  the  question.  It  is  in 
such  cases  that  a  study  of  the  blood  is  of  value — the  presence  of  leukocytosis 
pointing  to  suppuration,  and  its  absence,  to  typhoid. 

Of  specific  aids  to  diagnosis  the  isolation  of  the  bacillus  is  attended  with 
many  difficulties,  since  the  tapping  of  the  spleen  is  not  considered  justifiable, 
and  cultures  from  the  blood  and  feces  are  difficult  to  obtain  and  uncertain. 
The  serum  diagnosis,  or  the  JJldal  or  JVidal-Griibler  reaction,  which  depends 
upon  the  fact  that  the  diluted  serum  of  a  patient  suffering  from  typhoid 
fever  will  cause  actively  motile  typhoid  bacilli  to  lose  their  motility  and 
to  become  aggregated  into  clumps,  is  the  best  aid  at  hand.  The  active 
principle  underlying  this  reaction  is  the  presence  in  the  blood  of  a  substance 
termed  agglutinin.  In  many  diseases  this  substance  is  present,  and  it  is 
found  to  be  specific  in  its  reaction  to  the  causal  bacterium.  However,  in 
some  normal  sera  a  non-specific  agglutinin  is  found,  which  will  produce 
the  agglutination  of  several  varieties  of  bacteria.  The  test  may  be  said 
to  be  pathognomonic,  but,  because  of  conditions  to  be  spoken  of  later,  not 
always  applicable  as  an  aid  to  the  immediate  diagnosis  of  a  doubtful  case. 
Kneass  and  Stengel  *  report  that  in  2383  cases  of  typhoid  fever  the  reaction 
was  present  in  95.5  per  cent,  of  the  cases,  and  that  in  1365  non-typhoid 
cases  it  was  absent  in  98.4  per  cent,  of  the  cases.  Taking  these  statistics. 
the  absence  of  the  reaction  in  4.5  per  cent,  of  the  typhoid  cases  may  be  due 
first,  to  faulty  clinical  diagnosis,  for  at  the  present  time  there  is  reason  to 
believe  that  there  are  infections  caused  by  bacilli  of  the  typhoid-coli  group, 
the  sera  of  which  will  only  agglutinate  these  modified  types,  Avhich  have 
been  termed  paracolon  and  paratyphoid  infections.  Second,  it  may  be  due 
to  the  fact  that  in  these  cases  the  test  was  not  applied  continuously  during 
the  supposed  attack  of  typhoid  fever,  since  from  statistics  collected  by 
Hermann  Biggs,  of  the  Health  Department  of  New  York  City,  the  serum 
of  typhoid  patients  gave  the  reaction  during  the  first  week  in  about  70  per 
cent. ;  during  the  second  week  in  about  80  per  cent. ;  and  during  the  third 
and  fourth  weeks  in  about  90  per  cent,  of  the  cases.  Thus  in  cases  clinically 
typhoid  the  test  should  be  made  every  tw^o  or  three  days  during  the  disease 
before  it  can  be  said  that  the  reaction  is  absent.  This  late  reaction,  of 
course,  is  of  little  practical  value,  since  the  diagnosis  will  have  been  made 
much  earlier  by  the  more  usual  methods.  The  reaction  has  appeared  for  the 
first  time  as  late  as  the  forty-second  day.  and  in  a  few  isolated  cases  has 
rem.ained  absent  throughout  the  course  of  the  disease.  Indeed  the  reaction 
has  been  found  as  long  as  eight  years  after  recovery,  f 

•Gould's  "Year-book,"  i8q8. 

+  "Clinical  and  Scientiric  Contributions  upon  the  Value  of  the  Widal  Reaction,  based  upon  the 
Study  of  Two  Hundred  and  Thirty  Cases,"  Philadelphia  Med   Jour.,  vol.  iii.  p.  778. 


38  INFECTIOUS  DISEASES. 

The  presence  of  the  reaction  in  i.G  per  cent,  of  non-typhoid  cases  is  due 
either  to  faulty  technique,  /.  c,  the  dilutions  were  not  high  enough  since  the 
agglutinin  found  in  some  normal  sera  will  agglutinate  the  typhoid  bacilli  in 
insufficient  dilution ;  or  to  the  fact  that  the  patient  may  have  passed  through 
a  tvphoid  infection  some  months  previous,  because  the  reaction  has  been 
found  in  some  cases  to  be  present  many  months  after  the  recovery  from  the 
disease.  It  may  occur  as  early  as  the  third  day,  but  is  usually  observed 
about  the  seventh  day.  It  gradually  becomes  more  marked  as  the  disease 
progresses,  and  is  commonly  present  in  the  blood  of  convalescents,  and  for 
months  after  recovery,  though  in  some  cases  it  disappears  before  the  end  of 
the  disease.  It  is  also  true  that  the  severer  the  infection,  the  more  marked 
the  reaction,  and  vice  versa.  Pleural  and  pericardial  efifusions,  the  bile, 
the  milk,  and  to  some  extent,  the  urine  of  typhoid  fever  cases,  as  well  as 
the  blood  serum,   possess   this   agglutinative   property   for  typhoid   bacilli. 

Widal,  in  his  original  communication,  described  the  reaction  as  it 
occurred  in  vitro,  as  follows :  "  The  blood  or  serum  to  be  tested  was  added 
to  either  a  young  bouillon  culture,  or  to  sterile  bouillon  which  is  at  once 
inoculated  with  the  bacillus.  In  the  former  case  the  reaction  with  the  typhoid 
serum  appears  usually  within  two  or  three  hours,  and  consists  in  the  clarifi- 
cation of  the  previously  turbid  fluid  and  the  formation  of  a  clumpy 
sediment  composed  of  accumulated  bacilli.  In  the  latter  case  the  tube 
is  placed  in  the  incubator,  and  within  fifteen  hours  the  reaction  is  manifest 
in  the  growth  of  the  bacilli  in  the  form  of  a  sediment  at  the  bottom  of 
the  tube,  the  fluid  remaining  nearly  or  quite  the  same."  This  method,  of 
course,  is  impracticable  from  a  clinical  point  of  view,  nor  is  there  any 
attention  paid  to  the  degree  of  dilution  or  to  the  time  necessary  for  the 
agglutination  to  take  place. 

There  are  several  details  in  the  technique  of  this  test  which  require 
attention,  in  order  to  make  it  of  value  as  an  aid  to  diagnosis.  I  append 
the  method  employed  at  the  A\'illiam  Pepper  Laboratory  of  Clinical 
Medicine,  because  experience  has  proved  its  accuracy.  A  strain  of 
typhoid  bacilli  is  selected  which  by  experiment  is  known  to  be  easil}- 
agglutinated  by  sera  from  undoubted  cases  of  typhoid,  and  which 
gives  little  or  no  reaction  to  normal  sera.  The  stock  culture  of  this  strain 
of  bacilli  is  preserved  on  slanted  agar  at  room  temperature,  and  sub- 
cultures made  once  a  month.  For  the  test,  a  sub-culture  eighteen  to 
twenty-four  hours  old  is  used.  From  this  culture  an  emulsion  is  made  in 
physiological  salt  solution.  This  emulsion  is  examined  in  the  hanging  drop 
with  a  power  of  800  to  1 000  diameters,  and  should  be  entirely  free  from 
clumping,  the  bacteria  should  be  actively  motile,  and  the  number  of  bacteria 
to  the  field  should  not  be  too  great.  If  any  clumping  is  present,  the  emulsion 
should  be  filtered  through  a  sterile  filter  paper.  The  blood  is  collected  in 
a  sterile  capillary  tube  having  an  enlargement  in  the  middle.  After  it  is 
collected  the  ends  of  the  tube  are  sealed  in  the  flame.  One  drop  of  the  clear 
serum  is  diluted  in  five  drops  of  a  physiological  salt  solution  (dilution  i  to 
5).  One  drop  of  the  prepared  emulsion  of  typhoid  bacilli  and  one  drop 
of  the  diluted  serum  are  then  placed  on  a  cover  glass  and  examined  as  a 
hanging  drop.  If  no  agglutination  takes  place  within  ten  minutes  the  reac- 
tion is  said  to  be  negative;  but,  if  agglutination  does  take  place  within  that 
time,  it  may  or  may  not  be  positive,  since  normal  sera  may  agglutinate 
the  typhoid  bacilli  in  the  dilution  i  to  10.  A  dilution  i  to  50  is  then  made : 
one  drop  of  the  diluted  serum   (dilution  i  to  5)   is  added  to  10  drops  of 


TYPHOID  FEVER.  39 

the  bacterial  emulsion  in  a  watch  glass.  A  drop  of  this  mixture  is  then 
examined  in  a  hanging  drop;  and  if  agglutination  takes  place  within  an 
hour  and  there  is  no  clumping  in  the  control,  it  is  said  to  be  positive ; 
otherwise  it  is  said  to  be  negative.  This  method  furnishes  a  means  for  accu- 
rate dilution,  but  is,  of  course,  less  practical  than  the  dried  blood  method 
suggested  by  Wyatt  Johnson,  of  Montreal,  because  of  the  necessity  of 
having  at  hand  a  glass  capillary  tube. 

In  the  dried  blood  method  the  same  technique  may  be  followed  as  that 
described  above.  A  drop  of  the  dried  blood,  which  has  been  collected  on 
absorbent  or  smooth  paper,  or  on  a  piece  of  glass,  is  diluted  with  five  drops  of 
a  physiological  salt  solution,  making  an  approximate  dilution  of  i  to  5.  The 
test  should  then  be  carried  out  in  the  same  manner  as  in  the  serum  method.* 

Diagnosis  of  Perforation, — In  view  of  recent  increased  success  of 
operation  for  perforation,  an  early  recognition  of  this  accident  becomes 
important,  to  which  end  a  close  watch  should  be  kept  for  warning  symp- 
toms. Among  the  latter  is  hemorrhage  from  the  bowels,  for,  while  by 
no  means  always  followed  by  perforation,  it  precedes  this  accident  in  a 
certain  number  of  cases.  Its  occurrence  should,  at  least,  excite  increased 
vigilance  in  looking  for  the  signs  of  perforation,  and  particularly  suggests 
a  count  of  the  blood  with  a  view  to  discovering  leukocytosis.  To  this  end 
frequent  counts  should  be  made.  If  leukocytosis  be  found,  there  is  additional 
evidence  of  impending  perforation,  though  it  is  to  be  remembered,  too,  that 
abscess  in  the  parotid  and  otitis  media  also  produce  leukocytosis.  Perfora- 
tion itself  is  usually  ushered  in  by  sharp  pain,  tenderness,  rigid  abdomen, 
lowered  tempera«Lure,  frequent  pulse,  followed  later  by  meteorism, 
vomiting,  the  pinched  features,  and  cold,  clammy  skin  of  collapse.  If 
the  perforation  is  in  the  appendix,  the  symptoms  are  those  of  perforation 
succeeding  appendicitis.  It  may  occur  in  the  mildest  cases,  and  in  such 
especially,  the  appearance  of  localized  pain  and  tenderness  may  also  be 
regarded  as  a  warning.  Tympany  is  not  always  present,  while  it  is  often 
evident  when  there  is  no  perforation. 

In  a  second  class  of  severe  cases  where  there  is  delirium  or  stupor,  abdo- 
minal distention  may  be  the  only  symptom.  In  a  few  instances  there  are  no 
evident  signs  and  the  perforation  may  be  first  found  at  autopsy.  This  occurs 
commonly  in  cases  of  unusual  gravity,  where  the  event  is  masked  by  the 
severity  of  the  symptoms. 

Prognosis. — The  mortality  of  typhoid  fever  varies  so  much  in  dififerent 
epidemics  and  under  different  circumstances  that  statistics  are  of  doubtful 
value  in  measuring  fatality.  Extremes  of  mortality  claimed  are  as  low  as 
one  per  cent.,  and  even  less  by  the  Brand  bath  method  as  carried  out  on  the 
continent  of  Europe,  and  as  high  as  fifty-five  in  army  practice  during  cam- 
paigns and  among  negroes.  The  average  of  all  may  be  put  down  approxi- 
mately at  from  ten  to  thirty  per  cent,  before  the  Brand  cold  tub  treatment 
was  instituted.  Prior  to  this,  hospital  treatment  appeared  less  successful 
than  that  of  private  practice.  Since  its  introduction,  because  of  the  greater 
ease  with  which  that  treatment  can  be  applied  in  hospitals,  this  can  hardly  be 
said  to  be  the  case. 

In  private  practice  a  decided  majority  get  well,  fully  80  per  cent.,  with 
rest,  liquid  diet,  and  family  nursing.  With  skilled  nursing,  judicious  feed- 
ing, and  symptomatic  treatment,  a  larger  proportion  of  recoveries  takes  place. 


*  See  also  a  paper  on  the  "  Principles  Underlving  the  Serum  Diasfnosis  of  Typhoid  Fever  and  the 
Method  of  Its  Application,"  by  Prof.  W.  H.  Welch,  "Jour.  Am.  Med.  Assoc..'  August  14.  iSOT-  «-a 
interesting  resume  of  the  development  of  our  knowledge  of  the  subject  will  also  be  touna  tnere. 


40  IXFECTIOUS  DISEASES. 

sav  90  per  cent.  In  hospitals  where  the  Brand  method  is  correctly  carried 
out  there  is  an  easy  reduction  of  mortality  to  7  per  cent,  and  less.  In  this- 
country  the  results  have  not  been  quite  so  satisfactory  as  on  the  continent  of 
Europe.  The  mortality  of  \Mlliam  Osier's  cases  at  the  Johns  Hopkins 
Hospital,  Baltimore,  has  been  j.t,  per  cent.  My  own.  at  the  Hospital  of  the 
University  of  Pennsylvania  and  at  the  Philadelphia  Hospital,  has  been  7.3 ; 
that  of  James  C.  Wilson  and  others  at  the  German  Hospital,  up  to  January 
I.  1896,  7.25  per  cent. — astonishingly  uniform  results.*  Brand's  own  mor- 
tality has  been  but  i  per  cent.  Of  my  own  cases  treated  by  the  Brand  method 
all  who  died  perished  through  perforation  or  hemorrhage  of  the  bowels. 
Among  the  soldiers  under  my  care  at  the  Uniyer5!ty  Hospital  in  1898-99 
treated  by  the  Brand  method  the  mortality  was  4.5  per  cent.  Among  causes 
which  have  contributed  to  reduce  percentage  of  deaths  is  the  including  of 
mild  cases  as  determined  by  more  accurate  diagnosis. 

U)i favorable  synipfoins  are  persistent  high  temperature,  above  105^  F. 
(40.5^0.),  low  muttering  delirium,  extreme  tympany,  hemorrhage  from  the 
bowels,  and  the  signs  of  perforation.  Walking  typhoid  has  been  almost 
always  fatal  in  my  experience,  exhaustion  being  apparently  caused  by  the 
continued  muscular  effort  during  fever. 

Sudden  death  by  syncope  occasionally  occurs,  sometimes  when  least 
expected,  during  convalescence,  or  it  may  happen  during  the  acme  of  the 
fever.  In  either  event  the  immediate  cause  is  not  always  discoverable,  evident 
lesions  being  wanting  in  most  cases.  Pulmonary  thrombosis  and  myocarditis 
have  been  found  at  autopsy  in  these  obscure  cases.  Sudden  death  is  much 
more  frequent  in  men  than  women, — 114  to  26,  according  to  Dewevre's 
statistics, — a  surprising  and  almost  incredible  difference. 

The  prognosis  in  children  under  fifteen  is  especially  favorable. 
Recovery  takes  place  in  them  with  few  exceptions,  while  I  have  been  struck 
with  the  number  of  fatal  cases  in  young  people  from  eighteen  to  twenty-two. 
Then  follows  a  period  favorable  to  recovery,  but  after  forty  the  mortality 
again  increases.  The  dangers  at  this  older  age  appear  to  be  from  com- 
plications, especially  pneumonia,  as  the  symptoms  peculiar  to  the  disease  are 
not  increased  in  severity. 

The  prognosis  in  pregnant  women  is  grave.  In  the  first  place,, 
the  pregnant  woman  usually  aborts  in  the  second  week.  This  is.  how- 
ever, not  invariably  the  case.  Dr.  G.  H.  B.  Terry  reporting  i  a  case  of 
undoubted  typhoid  fever  occurring  in  a  woman  during  the  fourth 
month  of  her  third  pregnancy.  She  recovered,  and  on  April  5  following 
gave  birth  to  twin  girls,  healthy  and  weighing  respectively  six  and  seven 
pounds.  According  to  L.  Brieger,  the  mortality  was  20  per  cent,  of  cases 
treated  by  other  than  the  bath  method.  The  results  of  the  bath  treatment 
seem  to  be  better.  I  recently  had  under  my  care  two  pregnant  women  at  the 
end  of  the  fifth  and  sixth  months  respectively,  now  recovered,  who  were 
treated  throughout  by  cold  tub-baths  without  accident.  Under  any  circum- 
stances more  women  die  of  typhoid  than  men — this,  too,  though  the  disease 
is  more  frequent  in  men  than  in  women.     Fat  persons  bear  the  disease  badly. 

Hemorrhage  and  perforation  seem  to  be  in  no  degree  diminished  by  the 
Brand  bath  treatment.  On  the  other  hand,  careful  investigation  shows  that 
these  accidents  are  not  more  frequent,  as  has  been  alleged. 

*  These  are  the  figures  published  in  my  first  edition.  In  his  third  edition  Osier  reports  the  mor- 
tality up  to  date  fi8g8)  at  the  Johns  Hopkins  Hospital  7.1  per  cent.— a  trifle  less  than  that  to  date  of 
his  second  edition. 

+  "  Medical  News,"  February  16,  1901,  p.  263. 


TYPHOID  FEVER.  41 

Death  in  typhoid  fever  may  be  the  result  of  any  of  the  following  causes : 
exhaustion  incident  to  prolonged  illness,  hemorrhage,  peritonitis,  shock  due 
to  perforation,  intoxication  by  the  toxin  of  the  disease,  or  complications  such 
as  pneumonia  or  nephritis.  As  already  intimated,  sudden  death  sometimes 
occurs  inexplicably. 

Treatment. — Rest  and  Diet. — The  primary  conditions  of  a  successful 
treatment  of  typhoid  fever  are  rest  in  bed  and  a  liquid  diet,  of  which  milk  is 
the  type.  No  one  questions  the  necessity  of  putting  the  typhoid  fever  patient 
absolutely  at  rest  in  bed  and  not  permitting  him  to  rise  for  any  purpose  until 
convalescence  is  thoroughly  established.  That  the  diet  should  be  liquid  is  as 
little  disputed,  while  milk  is  generally  conceded  to  be  the  safest  form.  It 
should  be  given  at  stated  intervals,  say  once  in  two  hours,  in  doses  of  from 
four  to  six  ounces  ( 118.28  to  177.42  c.  c.)  or  even  eight  ounces  (236.56  c.  c), 
as  circumstances  determine.  Very  rich  milk  is  not  desirable,  hence  such 
milk  should  be  diluted  with  water  or  carbonic  acid  water,  Vichy,  or  lime- 
water.  The  stools  should  be  closely  watched  for  undigested  fragments  of 
casein,  and  when  these  are  present  the  milk  should  be  reduced  in  quantity  or 
further  diluted.  If  there  is  diarrhea,  the  milk  should  be  boiled  while  this 
lasts,  and  in  obstinate  cases  peptonized.  Animal  broths  of  mutton  or  of 
chicken,  also  beef-peptonoids,  may  be  associated  with  milk  when  change  is 
demanded,  but  they  are  not  as  convenient,  while  beef -tea  and  essences  are 
harmful.  When  the  stomach  is  very  irritable,  albumen  water  may  be  sub- 
stituted, in  the  proportion  of  the  whites  of  two  eggs  to  a  pint  of  water,  to 
which  may  be  added  a  little  lemon,  or  whisky  or  brandy  if  stimulants  are 
indicated.  Wine  whey  may  be  associated  or  substituted  where,  for  any  rea- 
son, milk  cannot  be  used.  In  extreme  feebleness  of  digestion  peptonized  milk 
may  be  administered  by  the  rectum,  but  this  is  rarely  necessary.  Not  more 
than  four  ounces  of  any  nutriment  should  be  administered  at  one  time  by  the 
rectum,  for  this  organ  soon  becomes  intolerant  of  large  doses. 

While  the  nourishment  above  described  fulfills  also  the  indications  for 
free  ingestion  of  liquids,  with  a  view  to  favoring  elimination  by  the  kidneys 
and  bowels,  plain  water  may  also  be  freely  given  in  the  intervals  between 
nourishment. 

There  can  be  no  reasonable  objection  to  enlarging  the  dietary  of  ordi- 
nary cases  of  typhoid  fever  by  any  easily  assimilable  albuminous  saccharine 
or  amylaceous  food.  It  is  a  mere  matter  of  convenience.  Typhoid  fever  does 
not  dififer  from  other  cases  of  fever  in  demanding  simple  and  easily  assimil- 
able food.  It  matters  not  much  what  it  is,  of  the  kinds  referred  to.  It  may 
be  that  we  have  been  needlessly  restricted  in  the  past.  Many  cases  are  so  ill 
that  they  can  with  difficulty  be  made  to  take  any  food,  and  whatever  they 
will  take  most  easily  is  best.  On  the  other  hand,  it  is  evident  that  in  the 
emergencies  of  hemorrhage  and  perforation  a  minimum  amount  of  nourish- 
ment should  be  given,  and  I  sometimes  allow  such  patients  to  go  many  hours 
without  food.  In  this  disease,  as  in  others,  we  must  treat  the  patient  and  not 
the  disease.  The  list  of  articles  named  by  Shattuck  *  and  embodied  in  the 
footnote  includes  foods  that  may  be  added  to  or  substituted  for  milk. 

The  Brand  Bath  Treatment. — In  addition  to  rest  and  liquid  nourishment 
the  treatment  that  my  own  experience  and  a  careful  study  of  the  experience 

*  The  following  list,  by  Frederick  C.  Shattuck  ("  Diet  in  Typhoid  Fever,"  "Jour.  Am.  Med.  Assc," 
1897,  xxix.  p.  51),  includes  many  allowable  articles  :  ,,.        . 

"  I.  Milk,  hot  or  cold,  with  or  without  salt,  diluted  with  lime-water,  soda-water,  ApoUinaris,  or 
Vichy  ;  peptonized  milk  :  cream  and  water  {i.  e..  less  albumin)  ;  milk  with  white  of  &%%,  buttermilk, 
kumiss,  matzoon,  milk  whey,  milk  with  tea,  coffee,  cocoa.  ,     , 

"2.  Soups:  Beef,  veal,  chicken,  tomato,  potato,  oyster,  mutton,  pea,  bean,  squash;  carefully 
strained  and  thickened  with  rice  (powdered),  arrowroot,  flour,  milk  or  cream,  egg,  barley.- ' 


42 


INFECTIOUS  DISEASES. 


of  others  place  easily  at  the  head,  in  every  case  when  it  can  be  carried  out,  is 
the  cold  tub-bath  treatment,  commonly  known  as  the  Brand  treatment.  Our 
method  in  the  Hospital  of  the  University  of  Pennsylvania  is  as  follows : 

Before  the  bath  the  patient  is  first  encouraged  to  empty  the  bladder,  and 
if  sweating,  he  is  wiped  dry.  He  is  then  covered  loosely  with  a  sheet  and 
gently  lifted  into  the  bath  sufficiently  filled  with  water  at  70°  F.  (21"  C), 
provision  being  made  to  rest  the  head  upon  an  air-cushion  or  platform.  Un- 
less very  weak,  he  may  at  first  step  from  the  edge  of  the  bed  into  the  tub, 
which  should  be  lower  than  the  bed.  During  the  bath  he  is  vigorously 
rubbed  by  the  nurse,  and  encouraged  also  to  rub  himself.  A  compress  wrung 
out  of  ice-water  or  an  ice-cap  is  kept  upon  his  head,  or  water  at  the  same 
temperature  is  poured  at  intervals  upon  it,  say,  three  times  in  the  course  of 
the  bath,  or  the  head  is  sponged  with  cold  water  from  time  to  time.  This  is 
important  in  severe  cases  with  decided  nervous  symptoms.  At  the  end  of 
fifteen  minutes  he  is  lifted  on  the  bed,  which  has  been  previously  protected 
with  a  mackintosh  and  blanket.  The  wet  sheet  is  replaced  by  a  dry  blanket, 
and  the  patient  is  rubbed  dry.  When  this  is  accomplished,  the  under 
blanket  and  mackintosh  are  withdrawn  and  he  is  comfortably  covered. 

As  soon  as  the  patient  ceases  to  shiver  after  his  removal  from  the  bath, 
which  is  usually  in  twenty  minutes,  the  temperature  is  taken  with  a  view  to 
determine  the  effect  of  the  bath.  If  delayed  longer  he  may  be  in  a  restful 
sleep,  and  to  wake  him  for  the  purpose  of  taking  his  temperature  is  needlessly 
disturbing.  After  this  the  temperature  is  not  again  taken  until  three  hours 
after  the  bath.  If  then  it  exceeds  102°  F.  (39°  C),  the  bath  is  repeated.  If 
the  temperature  is  between  101°  F.  (38.2°  C.)  and  102°  F.  (39°  C),  it  is 
taken  again  in  an  hour;  if  between  100°  F.  (37.8°  C.)  and  loi'  F.  (38.3°  C), 
in  two  hours;  if  below  100°  F.  (37.8°  C),  not  until  three  hours,  but  when- 
ever the  temperature  exceeds  102°  F.  (39°  C.)  the  bath  is  given,  provided 
three  hours  at  least  have  elapsed  since  the  previous  bath.  This  makes  more 
than  eight  baths  in  the  twenty-four  hours  impossible. 

The  effect  of  the  bath  upon  the  temperature  varies  with  the  stage  of  the 
•disease ;  the  reduction  during  the  first  week  being  often  less  than  one  degree, 
while  toward  the  end  of  the  second  week  and  in  the  third  week  a  fall  of  two  or 
more  degrees  is  quite  usual.  Fig.  4  shows  these  effects  very  nicely.  In 
addition  to  the  lowered  temperature  the  immediate  effect  of  the  bath  is  to  add 
strength  to  the  heart  and  volume  to  the  pulse.  The  shivering,  which  begins 
from  five  to  ten  minutes  after  the  immersion,  is  not  allowed  to  interfere  with 
the  continuance  of  the  bath,  and  it  very  rarely  happens — indeed,  scarcely  ever 
— that  anything  occurs  to  interrupt  the  bath.  It  would  be  wrong,  however, 
to  say  that  there  are  no  conditions  under  which  it  should  be  discontinued  and 
the  patient  at  once  returned  to  bed.  Such  conditions  would  be  an  almost 
absolute  pulselessness  with  a  blue,  cyanosed  appearance  of  the  skin.  Should 
this  occur,  hot-water  bags  should  be  applied  to  the  feet  and  legs  after  the 
patient  is  put  to  bed. 

The  more  remote  effect  of  the  bath  may  be  said,  in  a  word,  to  be  milden- 

"3.    Horlick's  food,  Mellin's  food,  malted  milk,  somatose. 

"  4.     Beef-juice. 

"  5.  Gruels  ;  Strained  corn-meal,  crackers,  flour,  barley-water,  toast- water,  albumin-water  with 
lemon-juice. 

"  6.     Ice-cream. 

"  7.     Eggs,  soft  boiled  or  raw,  egg-nogg. 

"  8.  Finely  minced  lean  meat ;  scraped  beef  ;  the  soft  part  of  raw  oysters  ;  soft  crackers,  with 
milk  or  broth  ;  soft  puddings,  without  raisins  ;  soft  toast,  without  crust ;  blanc  mange,  wine  jelly, 
apple  sauce,  and  macaroni  " 

I  should  be  disinclined  to  allow  ice-cream,  apple-sauce,  minced  meat,  scraped  beef,  or  even  soft 
toast,  while  there  is  fever. 


TYPHOID  FEJ^ER. 


43 


ing  of  the  symptoms  in  every  particular.  Delirium  and  stupor  are  scarcely 
known.  The  dry  tongue  is  very  much  more  infrequent,  and  diarrhea  rarelv 
demands  other  treatment.  In  the  majority  of  cases  I  give  no  medicine,  but 
do  not  hold  myself  bound  to  such  course,  meeting  whatever  symptoms  seem 
to  demand  it  by  appropriate  treatment.  For  a  time  I  used  to  give  the  patient 
a  little  whisky  and  water  during  the  bath.  Recently  I  have  discontinued  this, 
unless  there  seems  some  special  reason  for  it.  There  is,  however,  no  harm 
in  it,  and  it  serves  to  entertain  and  comfort  him.     I  do  not  give  a  preliminary 


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Fig.  4. — Chart  Contrasting  the  Drop  in  Temperature  after  the  Bath  Early  and  Later 

in  the  Disease. 

dose  of  calomel,  as  recommended  bv  some,  as  there  seems  nothing  gained 
by  it. 

None  of  the  complications  except  hemorrhage  from  the  bowels  is 
allowed  to  interfere  with  the  carrying  out  of  this  treatment,  nor  is  menstrua- 
tion or  even  pregnancy.  The  baths  are  discontinued  during  hemorrhage, 
lest  the  necessary  movements  of  the  body  should  re-excite  it ;  but  with  the 
portable  bath-tub  to  be  described  thete  need  be  no  interruption  even  during 
hemorrhage,  should  the  baths  be  indicated  by  the  temperature.  It  is  not 
claimed  that  the  baths  shorten  the  illness,  they  simply  milden  it.     ^^'hile  it  is 


44 


INFECTIOUS  DISEASES. 


probably  trvie  of  typhoid  fever,  as  of  pneumonia,  that  it  may  abort  sponta- 
neously, we  cannot  cause  it  to  abort  by  any  means  we  possess. 

In  private  practice  the  difficulties  of  the  Brand  treatment  are  greatly 
increased — unfortunately,  sometimes  are  insuperable.  They  consist  chiefly 
in  the  difficulty  in  arranging  the  bath  and  the  strain  on  the  attendants.  By 
means  of  a  portable  tub  devised  by  Dr.  A.  H.  Burr,  of  Chicago,  a  very  large 
part,  if  not  the  whole,  of  these  difficulties  is  removed.  Dr.  Burr's  tub  con- 
sists, first,  of  a  large  rubber  sheet,  with  rings  attached  near  its  margins  by 
elastic  tapes ;  second,  of  a  light  wooden  crib,  with  fastenings  along  the  lower 
rail  by  which  to  attach  the  sheet.  This  frame  folds  by  two  movements  into 
a  compact  bundle.     The  accessories  are  a  siphon-shaped  piece  of  hose  and  a 


Bath-tub  Completed,  Showing  Siphon  for  Drawing  off  the  Water. 
Fig.  5. — Burr's  Portable  Bath-tub. 

bath  thermometer.  In  using,  the  sheet  is  first  slipped  under  the  patient^, 
brought  up  over  the  pillow,  and  tucked  up  alongside  of  the  body.  The  frame 
is  unfolded  and  placed  down  over  the  patient,  resting  on  the  mattress,  and 
surrounding  patient  and  pillow.  The  edges  of  the  sheet  are  then  drawn  up 
and  over  the  top  rail  of  the  crib  down  to  the  lower  rail,  and  fastened  by  its 
rings.  This  completes  a  light  and  perfect  tub,  capable  of  holding  twenty 
gallons  of  water.  It  can  be  emptied  by  the  siphon  in  four  minutes  ( See  Fig. 
5).*  If  the  ordinary  tub  be  used. — and  in  hospital  service  this  is  usually 
more  convenient, — the  same  water,  if  it  remains  unsoiled  by  discharges,  as  it 
should,  may  serve  for  several  baths. 

Other  Methods  of  Reducing  Teuiperature. — As  contrasted  with  the 
Brand  bath,  other  methods  of  securing  the  good  efifects  of  hydrotherapy  seem 
trifling ;  yet,  as  it  may  be  impossible  to  carry  out  this  treatment,  such  methods 
must  be  considered.  Sponging  is  one  of  the  most  usual,  and  if  rightly 
carried  out  may  be  quite  efficient.  It  should  be  resorted  to,  as  is  the  bath, 
when  the  temperature  exceeds  102°  F.  (39°  C),  and  continued  for  fifteen 
minutes,  or  until  the  temperature  falls.     An  important  condition  of  success- 


*The  Burr  bath-tub  is  sold  by  E.  H.  Sargent  &  Co.,  io6  Wabash  Avenue.  Chicago,  Ul.  Another 
tub,  as  convenient  and  as  easily  managed,  has  been  devised  by  Dr.  S.  Clifford  Boston,  who  dispenses 
witli  the  framework,  substituting  strong  iron  supports,  made  by  Jones,  Leopold  &  Co.,  southwest 
corner  Ridge  Avenue  and  Fairmount  Avenue,  Philadelphia. 


TYPHOID  FEVER. 


45 


ful  sponging  is  often  overlooked.  A  thin  film  of  water  should  be  left  on  the 
surface  sponged,  as  it  is  the  evaporation  of  this,  rather  than  the  temperature 
of  the  water,  which  is  effectual  in  cooling  the  body.  Temperatures  that  can- 
not be  thus  controlled  can  often  be  kept  down  by  a  partial  wet-pack, 
which  I  have  found  very  efficient :  The  patient's  trunk  is  enveloped  from  the 
axilla  to  the  thighs  in  a  folded  sheet,  which  is  kept  constantly  wet,  or  as  much 
so  as  is  required  to  control  the  temperature,  by  the  continual  addition  of  cold 
water. 

Antipyretics,  including  antipyrin,  antifebrin  (acetanilid),  phenacetin, 
and  others  of  the  same  class,  which  act  by  producing  copious  perspiration, 
are  no  substitutes  for  the  baths,  for,  while  they  reduce  temperature,  their 
effect  is  but  temporary,  and  their  continuous  employment  too  depressing  to 
the  patient.  Moreover,  th-ry  are  purely  antipyretic,  and  lack  the  tonic  influ- 
ence to  the  nervous  and  muscular  systems  which  characterizes  the  cold  tub- 
baths.  Quinin.  formerly  used  in  massive  doses  for  its  antipyretic  effect,  has 
"been  replaced  by  the  more  modern  agents. 

Guaiacol,  locally  applied,  is  undoubtedly  an  efficient  antipyretic, 
and  has  a  warm  advocate  in  Horace  G.  McCormick  in  the  treatment  of 
typhoid  fever.  After  washing  the  skin,  from  one  to  ten  minims  are  rubbed 
into  it,  and  the  part  covered  with  oiled  silk.  The  fall  iia.  temperature  is 
prompt.  Some  rather  alarming  symptoms  of  collapse  are,  however,  reported 
from  its  use,  and  it  has  failed  to  secure  a  permanent  footing. 

The  Expectant-Symptomatic  Treatment. — Where  the  difficulties  in  the 
way  of  the  Brand  method  are  insuperable.  I  prefer  to  place  the  patient  in  bed 
on  the  diet  described,  combat  the  temperature  by  sponging  or  wet-packs, 
and  for  the  rest  adopt  what  may  be  termed  the  expectant-symptomatic 
method,  meeting  the  symptoms  as  they  arise  in  accordance  with  the  fol- 
lowing : 

(a)  Indications  for  Alcohol  and  Other  Stimulants. — I  prefer  to  reserve 
alcohol  until  called  for  by  signs  of  waning  strength.  That  it  is  a  remedy  of 
the  greatest  value  I  fully  admit,  but  it  is  also  true  that  mild  cases  may  be 
carried  to  a  favorable  termination  without  it.  On  the  other  hand,  I  favor 
its  liberal  use  when  needed,  giving  sometimes  as  much  as  an  ounce  (30  c.  c.) 
of  whisky  or  brandy  every  hour,  though  such  doses  are  rarely  needed. 
More  frequently,  a  half  ounce  ( 15  c.  c.)  every  four  or  two  hours  is  quite  suffi- 
cient, even  where  there  is  considerable  adynamia.  A  low,  muttering 
delirium,  feeble,  dicrotic  pulse,  and  dry  tongue  are  among  the  indications 
which  imperatively  demand  alcohol ;  a  high  temperature  does  not  contra-indi- 
cate  it,  as  an  antipyretic  effect  also  follows  the  use  of  large  doses,  and  delirium 
is  sometimes  calmed  by  it.  Other  diffusible  stimulants  which  may  be  used  in 
conjunction  or  alternation  with  alcohol  are  the  aromatic  spirit  of  ammonia  and 
the  carbonate  of  ammonium,  while  digitalis  and  strychnin  may  tide  a  feeble 
heart  over  a  period  of  weakness.  From  five  to  ten  minims  (0.333  to  0.666 
gm.)  of  the  tincture  of  the  former,  and  1-30  to  1-20  of  a  grain  (0.00216  to 
0.00324  gm.)  of  the  latter  may  be  given  as  demanded,  while  their  hypodermic 
use  may  be  availed  of.  At  the  Hospital  of  the  University  of  Pennsylvania 
we  have  found  hypodermic  injections  of  camphorated  oil  i  grain  (0.066 
gm.)  to  15  minims  (i  gm.)  very  useful  in  tiding  over  extreme  adynamia. 
The  injections  may  be  repeated  once  in  four  hours  or  oftener. 

Transfusion  or,  what  is  more  practicable  and  as  efficient,  hypodermoclysis 
of  normal  salt  solution  (0.8  per  cent,  sodium  chlorid)  may  be  availed  of  in  the 
extreme  adynamia  which  sometimes  attends  protracted  typhoid  fever. 


46  INFECTIOUS  DISEASES. 

{b)Treafmciif  of  Special  Syiiiptoiiis. — Methods  more  directly  adapted 
to  control  dcliriiini  are  an  ice-cap  to  the  head,  the  bromids,  spirit  of  chloro- 
form, chloral,  and  Hoffmann's  anodyne.  With  the  cold-bath  treatment  they 
are  rarely  necessary.  Occasionally,  meningeal  symptoms  are  so  violent  that 
leeches  may  be  used  to  the  temples  or  behind  the  ears.  I  have  seen  an  almost 
magically  quieting  effect  thus  produced.     Blisters  are  useless. 

Little  difficulty  is  commonly  experienced  in  controlling  the  diarrhea 
of  typhoid  fever.  As  stated,  with  the  cold  bath  treatment  very  little  special 
treatment  is  necessary.  Simple  preparations  of  opium,  either  alone  or  in 
combination  with  bismuth  or  nitrate  of  silver  or  acetate  of  lead,  or  salol,  are 
usually  sufficient.  Specific  action  has  been  claimed  for  nitrate  of  silver.  I 
have  not  been  convinced  of  this,  yet  it  is,  in  combination  with  the  extract  of 
opium,  1-4  of  a  grain  (0.0162  gm.)  of  each,  my  favorite  remedy  for  the  diar- 
rhea. Similar  specific  effect,  more  particularly  in  healing  the  ulcers,  has 
been  claimed  for  the  oil  of  turpentine.  The  impression  made  by  the  teach- 
ings of  the  late  George  B.  Wood  on  the  profession  of  the  United  States  as 
to  this  effect  has  not  yet  been  effaced.  He  held  that  the  dry,  leathery 
tongue  so  often  presented  in  this  disease  is  the  indication  for  its  use. 
Whether  such  view  was  correct  or  not,  few  who  have  used  the  oil  of  tur- 
pentine have  failed  to  see  the  coated  tongue  clear  up  under  its  use.  Tur- 
pentine is  also  useful  as  a  stimulant.  It  should  be  administered  in 
doses  of  ten  minims  (0.66  gm.)  in  mucilage  of  acacia  every  six  or  eight 
hours. 

Constipation,  especially  during  convalescence,  is  not  infrequent,  and 
should  not  be  too  hastily  interfered  with.  If  it  is  necessary  to  interfere,  it 
should  be  by  simple  enema  only.  Aperients  by  the  mouth  in  this  stage  are 
dangerous,  and  I  am  confident  I  have  seen  at  least  one  life  sacrificed  by 
purgatives  thus  administered,  having  been  succeeded  by  perforation,  peri- 
tonitis, and  death.  On  the  other  hand,  indifference  to  the  condition  of  the 
bowels  sometimes  leads  to  fecal  impaction,  which  can  only  be  relieved  by 
the  finger.     Such  a  state  of  affairs  should  be  averted  by  watchful  care. 

Hemorrhage  from  the  bowels  should  be  treated  by  absolute  quiet  wdth 
cold  to  the  abdomen.  Food  should  be  reduced  to  a  minimum  and  should 
be  of  the  blandest  character,  as  represented  by  peptonized  milk  and  liquid 
beef-peptonoids.  The  administration  of  food  may  be  suspended  for  some 
hours  without  risk.  In  severe  cases  the  foot  of  the  bed  should  be  raised, 
and  a  hypodermic  injection  of  1-8  to  1-4  of  a  grain  (0.008  to  0.016  gm.)  of 
morphin  given  at  once.  In  such  cases,  where  prompt  and  decisive  action 
is  necessary,  a  syringeful  of  a  filtered  fluid  extract  of  ergot  may  be  injected 
hypodermically,  and  repeated  later,  if  necessary,  in  half  the  dose.  In  mild 
cases  astringents,  such  as  tannic  acid  or  gallic  acid  and  the  acetate  of  lead, 
may  be  given  by  the  mouth,  the  former  in  doses  of  10  to  15  grains  (0.666 
to  I  gm.)  hourly  until  some  hours  have  elapsed  without  a  hemorrhage. 
The  acetate  of  lead  should  be  given  in  one  to  three  grain  (0.066  to  0.194  gm.) 
doses  every  three  hours,  combined  with  extract  of  opium,  1-4  of  a  grain 
(0.016  gm.).  Turpentine  is  highly  valued  by  some  in  the  treatment  of 
hemorrhage  from  the  bowels.  In  cases  of  extreme  weakness  ether  and 
digitalis  may  be  given  hypodermically. 

Tympanitic  distention  of  the  abdomen  is  often  a  distressing  symptom. 
It  is  usual  to  treat  it  with  turpentine  in  ten-minim  (0.666  gm.)  doses  every 
four  to  six  hours.  The  rectal  tube  should  be  cautiously  used  if  the  meteorism 
is  great,  and  large  quantities  of  gas  are  sometimes  thus  disengaged  from 


TYPHOID  FEVER.  47 

the  large  intestine.  The  quantity  of  food  should  also  be  reduced  to  a  min- 
imum, as  its  fermentation  and  decomposition  contribute  to  the  gas. 

Pain  induced  by  meteorism  or  otherwise  may  be  allayed  by  turpentine 
stupes  over  the  abdomen,  though  sometimes  it  may  be  necessary  to  rein- 
force the  stupes  by  small  doses  of  opium,  or  a  light,  warm  poultice  may  be 
substituted.  Sudden,  sharp  pain,  similar  to  that  produced  by  tympanitic  dis- 
tention of  the  bowel,  is  also  caused  by  peritonitis,  of  which  tympany  is  like- 
wise a  symptom,  and  the  two  often  occasion  many  anxious  moments  to  the 
physician  necessarily  in  doubt  as  to  whether  this  serious  complication  may 
occasion  them.  If  a  peritonitis  is  the  result  of  extension  of  inflammation  bv 
continuity  and  not  of  perforation, — a  possible  condition, — recovery  mav 
take  place.  Such  recovery  is  favored  by  absolute  rest  of  the  bowel,  best 
secured  by  hypodermic  injection  of  morphin,  1-4  grain  (0.016  gm.),  re- 
peated if  necessary.  Even  such  movement  as  is  necessitated  by  the  use 
of  the  bed-pan  is  of  questionable  propriety.  It  is  much  better  to  permit  the 
discharges  to  pass  into  a  soiled  sheet. 

Perforation  is  the  most  serious  accident  which  can  happen  to  the 
typhoid  fever  patient,  though  it  is  claimed  that  recovery  has  taken  place 
where  peritonitis  has  been  thus  caused.  Indeed,  according  to  ^lurchison, 
10  per  cent,  of  all  cases  recover,  5  per  cent,  if  general  peritonitis  supervenes. 
Even  this  seems  a  large  proportion,  for  in  my  experience  no  case  of 
undoubted  perforation  has  recovered.  On  the  other  hand,  recent  results 
after  operation  have  been  so  favorable  as  to  make  it  imperative  that  the 
propriety  of  this  treatment  should  be  considered  in  each  case.  It  is  impor- 
tant to  remember  that  early  operations  are  those  attended  with  largest 
success.  In  a  recent  and  exhaustive  paper  ("Jour.  Am.  Med.  Assoc," 
January  20,  1900)  on  the  "  Surgical  Treatment  of  Perforation  of  the  Bowel 
in  Typhoid  Fever,"  A\\  W.  Keen  collected  158  cases  and  summarizes  as 
follows : 

Oct  of  158  Cases  of  Operation  for  Perforation. 


When  Done.  Total.  Died.     Recovered.     Percentage  of  Recoveries 

Within  4  hours, 
In    4  to    8  hours, 
In    8  to  12    " 
In  12  to  18    " 
In  18  to  24 

■  '  '  44  38  6  13.63 

39  27  12  30.74 


After  24  hours, 
Not  given,    .   . 


I  S.33  \  '9-^^    )    '5         Uc  „ 

16             12               4  25                          /                (    ^5-35 

25             17               «  32  -  30.76    \  29.09 

14             10               4  28. 57  )                ) 


Total 15S  121  37  23.41 

Keen  also  formulates  the  rule  that  //  the  operation  is  not  done  within 
about  tzi'eiitx-four  hours  after  the  perforation,  there  is  probably  no  hope  of 
a  recoverx.  A  surgeon  should  therefore  be  immediately  called,  and  if  col- 
lapse is  not  too  profound  laparotomy  should  be  done. 

For  sleeplessness  the  milder  soporifics  usually  answer;  10  to  15  grains 
(0.666  to  one  gm.)  of  sulphonal  generally  furnish  the  required  rest.  Chlo- 
ralamid  30  grains  (two  gm.),  trional  15  to  30  grains  (one  to  two  gm.),  or 
chloral  10  to  15  grains  (0.666  to  one  gm.)  may  be  used.  If  these  rem- 
edies are  insufficient,  morphin  must  be  used,  1-4  grain  (0.016  gm.) 
being  given  by  the  mouth  or  half  as  much  hypodermically,  or  more  if 
necessary. 

Bed^  sores  can  generally  be  averted  by  scrupulous  attention  to  cleanli- 


48  INFECTIOUS  DISEASES. 

ness,  the  thorough  drying  of  the  patient  after  washing,  removing  thus  "  ' 
traces  of  urine  or  other  discharges,  and  by  sponging  the  patient  daily  with 
alcohol  or  whisky.  Above  all,  his  position  in  bed  should  be  frequently 
changed  and  all  inequalities  in  the  bed  clothing  should  be  smoothed  out, 
while  the  bed  should  be  kept  clear  of  crumbs  and  other  irritating  particles. 
Should  a  sore  appear  it  must  be  antiseptically  dressed,  while  the  part  should 
be  protected  from  pressure  by  pads  and  air-cushions. 

For  liiccough  the  more  ordinary  measures  commonly  effectual  are 
counter-irritation  by  mustard,  dry  cupping,  or  blistering ;  the  various  anodyne 
measures,  including  Hoffmann's  anodyne,  chloroform,  and  the  hypodermic 
injection  of  morphin.  The  anti-spasmodics,  including  sumbul,  the  oil  of 
amber,  and  especially  musk,  have  been  useful.  Cannabis  indica  is  also  recom- 
mended. In  an  obstinate  case  under  my  care  after  all  measures  had  failed, 
including  musk,  the  hypodermic  injection  of  one  grain  (0.06  gm.)  of 
camphor  dissolved  in  oil,  15  minims  (0.5  gm.)  repeated  hourly,  relieved 
the  case  in  six  doses.  A  second  case  has  been  relieved  in  the  same  hospital 
by  like  treatment.  In  other  cases  I  have  found  musk  useful  when  all  else 
failed,  but  it  is  a  most  costly  remedy  and  its  use  is  thus  necessarily  limited. 
The  dose  is  5  to  10  grains  (0.3  to  0.6  gms.). 

The  cystitis  sometimes  present  in  typhoid  fever  is  commonly  easily 
relieved  by  washing  out  the  bladder  with  boric  acid  solution,  say  a  dram 
(4  gm.)  to  a  pint  (0.5  liter)  of  sterilized  water;  or  instead  of  this  salol  may 
be  given  in  five-grain  (0.3  gm.)  doses  four  or  five  times  a  day,  as  a  urinary 
antiseptic.  The  best  remedy  is  urotropin,  which  is  a  derivative  of  formalde- 
hyd  and  is  said  to  be  non-toxic  and  non-irritating.  According  to  Mark  W. 
Richardson  daily  doses  of  30  grains  (2  gm.)  will  remove  typhoid  bacilli 
permanently  from  the  urine  in  a  week. 

The  Management  of  Convalescence. — In  no  disease  is  watchfulness  dur- 
ing convalescence  more  important.  The  effect  of  indiscretion  in  diet  in  pro- 
ducing relapse  and  recrudescence  has  been  referred  to.  But  there  are  other 
clangers  during  convalescence.  It  is  to  be  remembered  that  the  complete 
healing  of  intestinal  ulcers  is  often  delayed  after  all  other  symptoms  have 
disappeared  except  a  slight  elevation  of  temperature ;  that  a  deep-seated 
ulcer  may  thus  remain  with  the  thin  peritoneum  for  its  floor,  rendered 
weaker  by  reason  of  imperfect  nutrition.  Such  a  membranous  floor  is  known 
to  have  been  torn  by  simply  reaching  over  for  a  book  and  to  be  followed 
by  a  fatal  peritonitis.  These  are  reasons,  too,  for  putting  off  the  use  of 
solid  food  until  the  temperature  has  maintained  the  normal  for  a  considerable 
time,  certainly  a  week.  Then  the  diet  should  be  changed  most  gradually, 
first  permitting  a  soft-boiled  egg  or  poached  egg  in  the  morning,  and 
awaiting  developments.  If  no  fever  follows,  it  may  be  continued  daily. 
The  next  step  is  to  allow  some  thoroughly  softetied  milk  toast,  then  a  small 
quantity  of  well-boiled  rice,  with  a  suitable  interval  after  each  first  trial 
until  sure  that  no  harmful  results  follow.  Finally,  tender  meat  may  be 
•allowed,  and  then  soft  vegetables  one  after  another. 

Emotional  disturbance  is  a  well-recognized  cause  of  recrudescence,  and 
should  be  carefully  guarded  against. 

I  have  already  referred  to  constipation  and  the  importance  of  correcting 
it  by  enemata  only. 

During  convalescence  the  hair  is  very  apt  to  fall  out,  but  usually  returns 
in  a  natural  way.  It  may  be  desirable  to  cut  it  close,  though  scarcely  neces- 
sary to  shave  the  head,  as  some  recommend. 


TYPHOID  FEVER.  49 

Special  Forms  of  Treatment. 

The  Antiseptic  Treatment. — The  antiseptic  treatment  of  typhoid  fever 
is  based  upon  the  idea  of  destroying  the  germs  of  the  disease  in  the  intes- 
tinal canal,  and  thus  cutting  off  their  harmful  influence.  If  I  mistake  not, 
it  is  not  claimed  that  it  is  possible  to  destroy  the  bacilli  elsewhere  in  the 
economy — that  is,  in  the  blood,  the  spleen  or  other  lymphatic  tissues,  or 
wheresoever  they  may  be  present.  In  addition  to  the  localized  effect  on  the 
■specific  bacilli  in  the  intestine,  this  treatment  claims  also  to  arrest  fermenta- 
tion arid  check  the  activity  of  the  commoner  intestinal  bacteria,  which,  it  is 
alleged,  are  fanned  into  virulence  by  the  presence  among  them  of  typhoid 
bacilli.  The  claims  of  the  adherents  of  the  method  do  not  altogether  agree, 
but  its  more  moderate  supporters  hold  only  that  it  renders  the  disease  milder 
and  diminishes  its  mortality,  urging  it  more  particularly  in  those  cases  where 
for  any  reason  the  Brand  treatment  cannot  be  carried  out. 

Among  the  remedies  employed  for  their  antiseptic  eft'ect  are  calomel, 
betanaphthol,  carbolic  acid,  chlorin  water,  naphthalin,  salol,  and  tincture 
of  iodin.  Calomel  has  long  been  used  by  various  physicians  in  the  treat- 
ment of  this  disease.  Its  popularity  is  partly  due  to  the  fact  that  it  is  also 
an  excellent  and  safe  laxative.  It  had  the  early  support,  in  the  treatment 
of  typhoid  fever,  of  Liebermeister,  who  claimed  that  under  its  use  the  dura- 
tion of  the  disease  was  shortened  and  its  intensity  lessened.  His  plan  was 
to  give  three  or  four  doses  of  7  1-2  grains  (0.5  gm.)  each,  in  the  first 
tw^enty-four  hours  of  treatment.  I  have  said  that  some  of  the  supporters 
of  the  Brand  treatment  prefer  to  precede  that  treatment  by  such  a  dose  of 
calomel.  It  can  certainly  do  no  harm.  Betanaphthol  is  another  efficient 
and  non-toxic  germicide.  It  is  held  that  doses  sufficient  to  produce  an 
antiseptic  effect  are  not  irritating.  These  doses  are  5  to  10  grains  (0.33 
gm.  to  0.66  gm.)  three  times  a  day  in  a  wafer,  capsule,  or  tablet.  It  is 
sometimes  combined  wath  salicylate  of  bismuth  if  there  be  diarrhea,  or 
salicylate  of  magnesium  if  there  be  constipation,  as  suggested  by  Bouchard. 
All  the  advantages  of  this  treatment  are  claimed  for  it,  including  dimin- 
ished abdominal  pain,  diminished  meteorism,  a  clean  and  moist  tongue, 
inodorous  stools,  rapid  convalescence,  and  less  tendency  to  secondary  com- 
plications. 

Another  one  of  these  remedies  is  a  compound  of  carbolic  acid  and 
iodin, — I  part  of  the  former  and  2  of  the  latter, — given  in  doses  of  i  to  3 
drops,  well  diluted,  three  to  six  times  a  day.  Chlorin  water  is  also  an  old 
remedy  recommended  by  Sir  Thomas  Watson  and  by  Murchison,  and 
recently  revived  in  the  treatment  of  typhoid  by  Burney  Yeo,  who  claims 
that  it  cleans  the  tongue  quickly  and  removes  the  fetor  of  the  evacuations 
within  twenty-four  hours ;  that  it  reduces  the  temperature  and  shortens  the, 
attack ;  while  the  physical  strength  and  mental  clearness  of  the  patient  are 
maintained,  together  with  a  greater  power  of  assimilating  food  and,  conse- 
quently, rapid  and  complete  convalescence.  Yeo  even  claims  a  general 
antiseptic  influence  for  this  treatment.  He  adds  to  12  ounces  (360  c.  c.)  of 
chlorin  water,  24  to  36  grains  (1.584  to  2.376  c.  c.)  of  quinin  and  an 
ounce  (30  c.  c.)  of  syrup  of  orange-peel,  and  gives  an  ounce  (30  c.  c.)  every 
two,  three,  or  four  hours,  according  to  the  severity  of  the  case. 

Salol  is  recommended  for  the  s^me  antiseptic  purpose ;  40  to  50  grains 
(2.5  to  3.25  gm.)  in  the  twenty-four  hours,  in  capsules,  w^afers,  or  tablets, 
in  doses  of  5  to  10  grains  (0.3  to  0.66  gm.).     Thymol  is  recommended  in 


50  INFECTIOUS  DISEASES. 

the  same  doses.     All  these  doses  in  my  judgment  are  so  large  that  I  fear 
their  harmful  effect  would  more  than  equal  any  possible  advantage. 

The  Eliminative  and  Antiseptic  Treatment. — This  treatment  is  in- 
tended to  add  to  the  antiseptic  eft'ect  a  prompt  removal  from  the  bowels  of 
the  bacillus  and  its  toxic  products.  The  first  it  is  sought  to  accomplish  on 
the  principles  previously  described ;  the  second  by  thorough  datfly  evacuations 
of  the  bowels  by  means  of  purgatives,  large  quantities  of  fluids  being  given 
at  intervals  to  replace  the  liquid  carried  off  in  the  discharges.  This  treat- 
ment is  especially  associated  with  the  names  of  Woodbridge,  of  Cleveland, 
and  Thistle,  of  Toronto.  The  former  published  a  book  on  "  Typhoid 
Fever  and  its  Abortive  Treatment."  in  which  he  claims  that  if  this 
treatment  is  instituted  sufficiently  early,  not  only  is  the  disease  aborted, 
but  the  patient  need  not  go  to  bed  or  be  restricted  in  diet,  debarred  from 
social  enjoyment,  or  even  be  required  to  neglect  or  omit  his  business.  With- 
out commenting  further  upon  these  claims,  I  will  state  that  a  trial  of  the 
Woodbridge  treatment  was  made  during  1898  and  1899  in  the  wards  of 
the  New  York  hospitals  and  the  United  States  Army  Hospital  at  Fort 
Meyer,  Va.  Of  14  cases  treated  in  New  York  4  were  under  the  personal 
care  of  Dr.  Woodbridge.  Thirteen  cases  recovered  and  i  died,  the  fatal 
case  being  one  under  Dr.  Woodbridge's  personal  care.  The  cases  were 
treated  with  antiseptic  and  purgative  tablets  prepared  by  Parke,  Davis 
&  Co.,  according  to  Dr.  Woodbridge's  formulse.*  The  remaining  cases  were 
treated  at  Fort  Meyer  by  Dr.  Woodbridge.  Of  these,  4  patients  died,  3  of 
intestinal  hemorrhage  and  i  of  exhaustion,  giving  a  mortality  of  10.5  per  cent, 
for  the  38  cases,  as  compared  with  the  rate  of  9  per  cent,  among  the  cases 
treated  in  the  other  wards  of  the  hospital. 

Thistle's  method  is  much  simpler  and  more  easily  carried  out.  Calomel 
is  given  daily  in  fractional  doses,  1-2  grain  (0.033  S^^-)  every  half  hour, 
until  three  grains  have  been  taken,  followed  three  hours  later  by  Epsom  or 
Rochelle  salts  in  half-ounce  (15  gm.)  doses,  sufficient  being  given  to  secure 
from  3  to  5  movements  daily.  To  compensate  for  the  withdrawal  of  so  much 
fluid  from  the  body  as  well  as  to  eliminate  the  poison  through  the  kidneys, 
the  ingestion  of  large  qviantities  of  water  is  enjoined.  For  intestinal  anti- 
sepsis salol  is  given  in  five-grain  doses,  every  three  hours,  with  8  ounces 
(236.56  c.  c.)  of  water.  Thistle  is  not  so  extravagant  in  his  claims  as 
Woodbridge,  alleging,  however,  that  hemorrhage  and  perforation  are  both 
more  infrequent.  He  reports  in  a  recent  paper  172  cases  treated  by  himself 
and  other  physicians  in  Toronto,  with  5  deaths — a  mortality  of  3  per  cent. 
Of  the  fatal  cases  2  died  of  pneumonia  in  early  convalescence,  2  of  intestinal 
hemorrhage,  and  i  of  hemorrhage  from  the  stomach  and  nose  with  general 
purpura  in  all  parts  of  the  body. 
,         In  view  of  the  fact  that  typhoid  fever  is  a  general  and  not  a  local  infec- 

*  The  formulas  are  three  in  number,  designated  No.  i.  No.  2,  and  No.  3.  No.  i,  a  tablet,  contains  podo- 
phyllin  resin,  i-g6o  grain  ;  calomel.  1-16  grain  ;  guaiacol  carbonate,  1-16  grain  ;  mentliol,  1-16  grain  ; 
eucalyptol,  q.  s.  Immediately  on  the  appearance  of  fever,  and  before  the  diagnosis  is  made,  one  of 
these  tablets  is  given  every  fifteen  minutes  during  the  first  twenty-four  hours,  and  in  larger  doses, 
if  necessary,  in  the  second  twenty-four  hours,  until  not  less  than  five  or  six  evacuations  are  secured 
each  day.  On  the  third  or  fourth  day  tablet  No.  2,  consisting  of  the  same  ingredients  in  precise  pro- 
portion, with  1-16  grain  thymol  added,  is  given  every  one  or  two  hours  at  first,  the  size  and  frequency 
of  the  dose  of  both  tablets  being  regulated  to  allow 'the  movements  to  become  gradually  less  fre- 
quent until  the  temperature  drops  to  normal  and  the  passages  are  reduced  to  one  or  two  a  day.  On 
the  fourth  or  fifth  day,  formula  No.  3,  composed  of  guaiacol  carbonate,  gr.  iij.,  thymol,  gr.  j..  men- 
thol, gr.  ss.,  eucalyptol,  m.  v.,  in  capsule,  is  given  every  three  or  four  hours,  alternating  with  the 
tablet.  The  medicine  is  to  be  washed  down  with  copious  draughts  of  distilled  or,  if  necessary,  some 
laxative  or  diuretic  mineral  water. 

I  am  indebted  to  the  admirable  paper,  by  John  Winters  Brannan,  on  "Typhoid  Fever."  in  vol. 
xvi.  of  the  "  Twentieth  Century  Practice  of  Medicine,"  for  the  facts  here  presented  on  the  antiseptic 
and  eliminative  treatment  of  this  disease. 


TYPHOID  FEVER. 


51 


tion  and  that  the  local  lesions  in  the  bowel  are  only  a  part  of  the  local  mani- 
festation, the  antiseptic  and  eliminative  treatment  does  not  seem  to  rest  on 
a  thoroughly  rational  basis,  while  the  extravagant  claims,  especially  of 
Woodbridge,  discredit  his  results.  These  claims  have  finally  been  over- 
thrown by  his  own  experience  in  New  York  City  and  at  Fort  Meyer.  On 
the  other  hand,  it  does  seem  reasonable  that  sloughing  and  extensive  ulcera- 
tion in  the  bowel  may  cause  secondary  sepsis.  Toward  an  effort  to  prevent 
such  infection  the  antiseptic  treatment  may,  therefore,  be  permitted  if  the 
dosage  be  not  excessive  and  otherwise  harmless  to  the  patient ;  but  not 
with  a  view  to  eliminating  the  poison.  Theoretically,  one  might  object  to 
purgation  by  calomel,  because  the  unloading  of  the  gall-bladder  may  be 
attended  by  a  copious  discharge  of  bacilli  capable  of  reinfecting  the  bowel. 

Serum  Treatment  of  Typhoid  Fever. — The  practical  studies  and  appli- 
cation of  the  serum  treatment  by  Dr.  A.  E.  Wright,  of  Netley,  and  his 
pupils,  and  of  Chantemesse  in  Paris,  have  given  a  decided  impulse  to  this 
method  of  treatment  because  of  the  seemingly  satisfactory  results  obtained. 
These  results  include  immunity  as  well  as  cure.  Of  the  several  methods  of 
procedure,  Wright  adopted  that  of  inoculating  the  subject  with  measured 
quantities  of  dead,  but  still  poisonous,  micro-organisms.  He  prepared  an 
antityphoid  vaccine  from  agar  cultures  of  typhoid  bacilli,  grown  for  24 
hours  at  blood  heat.  The  cultures  thus  obtained  are  emulsified  by  the  addi- 
tion of  measured  quantities  of  sterile  broth.  The  resulting  emulsion  is 
sterilized  by  raising  it  to  a  temperature  of  140°  F.  (60°  C.)  and  keeping 
it  at  that  temperature  for  five  minutes. 

The  local  and  constitutional  symptoms  succeeding  the  injection  of  the 
vaccine  vary  in  degree  with  the  dose  used.  Local  symptoms  include  tender- 
ness two  or  three  hours  after  injection  at  its  site,  gradually  increasing  in 
severity  and  extending  upwards  into  the  armpits  and  downwards  into  the 
groin.  There  is  also  commonly  seen  a  patch  of  congestion  about  the  site 
of  inoculation  with  red  lines  of  inflamed  lymphatics,  extending  upwards 
into  the  armpits.  These  symptoms  disappear  about  48  hours  after  injection. 
Constitutional  symptoms  include  some  degree  of  tenderness,  beginning  gen- 
erally two  or  three  hours  afterwards.  There  is  loss  of  appetite,  while  nausea 
and  even  vomiting  may  supervene.  Rest  is  disturbed  and  there  is  some 
fever  in  all  cases.  These  symptoms  also  pass  away  in  a  couple  of  days. 
In  three  only  out  of  eleven  cases  tested  did  the  health  seem  to  be  shaken  for 
three  weeks. 

As  was  to  be  expected,  the  blood  of  persons  thus  inoculated  was  found 
to  immobilize  and  agglutinate  the  typhoid  bacilli.  Moreover,  Wright's 
observations  go  to  show,  in  harmony  with  those  of  Pfeififer,  that  the  immu- 
nity acquired  by  undergoing  an  attack  of  actual  typhoid  is  not  greater  than 
that  which  is  acquired  by  an  inoculation  of  typhoid  bacilli.  There  are. 
however,  limitations  the  consideration  of  which  is  scarcely  in  place  in  a 
text-book,  and  the  student  who  is  further  interested  is  referred  to  the  admi- 
rable papers  by  Wright  upon  this  subject.* 

A  summary  of  the  statistics  prepared  by  Prof.  Wright  as  to  results 
of  antityphoid  inoculation  f  in  India,  South  Africa,  and  England,  go  to  show, 
1st,  a  decided  reduction  of  incident  cases  in  the  inoculated;  2d,  a  reduced 
death-rate  in  the  inoculated  who  acquired  the  disease  as  contrasted  with  the 
uninoculated  who  acquired  the  disease ;  3d,  that  the  duration  of  immunity 

*  "Remarks  on   Vaccine  against   Typhoid   Fever,"   byA.E.   Wright,  M.  D.,  and   Surg.-Maj.  D. 
Semple,  M.  D..  "  British  Medical  Journal,"  January  30,  1897. 
t  The  "  Lancet,"  September  6,  1502,  page  256. 


52  INFECTIOUS  DISEASES. 

thus  obtained  varies  from  five  months  to  two  years,  as  determined  by  the 
duration  of  the  agglutinative  reaction;  4th,  that  double  (successive)  inocula- 
tion is  more  efficiently  protective  than  single  inoculation.  In  a  letter  received 
from  Professor  Wright  while  printing  this  edition  he  says  he  usually  com- 
mences with  5oo,ooo,ocxD  typhoid  bacilli  and  gives  ten  days  later  1,000,000,- 
000  dead  typhoid  bacilli.  He  also  writes  that  he  never  attributed  any  cura- 
tive value  to  antityphoid  inoculations. 

In  France  Chantemesse  has  prepared  an  antityphoid  serum,  as  con- 
trasted with  the  antityphoid  vaccine,  which  he  claims  to  be  curative  and 
prophylactic.  In  his  latest  publication  *  he  shows  from  a  review  of  the 
statistics  of  the  various  hospitals  of  Paris,  excepting  that  under  his  own 
direction,  a  combined  mortality  of  19.3  per  cent.,  and  that,  while  there  were 
natural  variations,  the  lowest  recorded  mortality  in  any  hospital  exceeded 
12  per  cent.  Under  the  serum  treatment,  which  had  been  received  by  356 
patients  up  to  the  time  of  his  report,  only  17  died,  a  mortality  of  4.7 
per  cent.  At  Toulon,  out  of  151  patients  13  died,  the  addition  of  this  mor- 
tality making  6  per  cent.,  as  contrasted  with  the  German  Army  statistics, 
which  gave  a  mortality  of  9.5  per  cent.  It  may  be  mentioned  in  passing 
that  the  reduced  mortality  thus  claimed  is  but  1.4  per  cent,  less  than  that 
obtained  by  the  tub-bath  treatment  by  physicians  in  the  United  States. 

In  this  country  Drs.  William  Royal  Stokes  and  John  S.  Fulton,t  fol- 
lowing Abel  and  Loeffler,  produced  an  antityphoid  serum  by  injecting  gradu- 
ally increasing  doses  of  a  48-hour-old  virulent  culture  obtained  from  the  Johns 
Hopkins  Hospital  Laboratory  into  the  subcutaneous  tissues  of  the  abdomen 
of  the  hog,  which  was  subsequently  bled,  the  serum  drawn  and  trikresolized. 
It  was  found  that  guinea  pigs  given  subcutaneous  injections  of  this  pro- 
tective serum  were  rendered  immune  against  a  peritoneal  injection  cf  a  viru- 
lent typhoid  bacillus.  More  precisely,  that  a  subcutaneous  injection  of  the 
serum  in  doses  of  from  1-600  to  1-800  of  the  body  weight  will  protect  guinea 
pigs  against  four  times  the  minimum  fatal  dose  of  intraperitoneal  injection 
with  the  typhoid  bacillus.  The  injection  of  1-3000  to  1-4000  of  the  serum 
by  weight  iiito  the  abdominal  cavity  will  protect  against  five  times  the  mmi- 
mum  fatal  dose,  and  a  dose  of  1-600  to  1-800  of  the  body  weight  will  protect 
against  seven  times  the  minimum  fatal  dose  of  the  typhoid  bacillus.  Thus 
far  only  18  cases  have  been  treated  by  Drs.  Stokes  and  Fulton's  serum,  and 
although  they  admit  that  so  few  cases  lead  to  no  conclusion  and  perhaps  no 
very  reasonable  inference,  they  are  encouraged  to  continue  their  experiments 
and  think  they  have  shortened  the  duration  and  intensity  of  the  fever  in  most 
of  the  cases,  while  none  were  lost.+ 

Prophylaxis. — Most  important  in  the  management  of  typhoid  fever  is 
the  disinfection  of  the  excreta,  which  are  the  contagium  bearers,  through  the 
careless  handling  of  which  the  disease  is  communicated  to  others.  The  same 
is  perhaps  true  of  the  vomited  matters. 

Among  the  most  suitable  disinfectants,  on  account  of  its  cheapness, 
harmlessness,  and  effectiveness,  is  chlorinated  lime  or  bleaching  powder, 
also  called   chlorid   of  lime,   which   contains   from   25   to   40   per   cent,   of 

*  "  Pi'esse  Medicale,"  December  24,  iqo2. 

t  "Maryland  Medical  Journal,"  August,  tqo2. 

t  In  explanation  of  the  imperfect  results  thus  far  obtained  bv  antityphoid  sera,  allusion  should  be 
made  to  the  observations  of  Ehrlich,  Bordel  and  Wasserman  to  the  effect  that  bacteria  are  de- 
stroyed in  artificial  immunity  by  the  joint  action  of  two  distinct  substances,  one  the  intermediate  or 
immune  body  produced  in  the  blood  when  animals  are  immunized  bv  the  injection  of  non-fatal  doses 
of  various  bacteria.  The  second  is  called  the  complement  or  end  body,  and'is  a  sort  of  digestive  fer- 
ment always  present  in  the  blood.  It  is  destroyed  by  a  temperature  of  60°  C.  (160°  F.)  while  the  im- 
mune body  is  not. 


TYPHOID  FEVER.  53 

available  chlorin.  A  solution  made  in  the  proportion  of  4  to  100  of 
water,  containing,  therefore,  at  least  i  to  1.5  per  cent,  of  chlorin,  is  suffi- 
ciently strong.  Some  of  the  solution  is  placed  in  the  chamber  vessel  before 
it  is  used,  and  the  remainder,  in  all  say  a  pint,  is  added  afterward. 
Thorough  admixture  should  be  made,  and  an  hour  allowed  to  elapse 
before  the  stool  is  thrown  into  the  privy  well  or  water-closet,  if  disposed  of 
thus.  In  the  country  the  disinfected  stool  may  be  buried.  Solution  of 
chlorinated  soda,  or  Labarraque's  solution,  is  a  more  elegant  but  not  more 
efifective  disinfectant.  As  it  contains  about  2  per  cent,  of  chlorin,  it  is  nearly 
equivaflent,  when  undiluted,  to  the  above  solution  of  chlorinated  lime. 
Chlorinated  lime  rapidly  loses  its  chlorin,  and  should  be  kept  in  tight  vessels. 

Carbolic  acid,  in  the  proportion  of  one  part  of  the  commercial  acid  to 
ten  of  water,  is  an  efficient  disinfectant  for  this  purpose.  The  same  method 
as  that  described  for  chlorinated  lime  must  be  employed,  and  an  exposure 
of  twenty  minutes  to  half  an  hour  maintained.  Quite  as  good  a  disinfectant 
for  intestinal  evacuations  is  milk  of  lime  or  ordinary  "  whitewash,"  composed 
of  lime  in  solution  and  in  suspension.  This  should  be  thoroughly  mixed 
with  the  evacuations  until  the  mass  is  distinctly  alkaline,  and  should  remain 
in  contact  for  one  or  two  hours,  since  it  is  slower  in  its  action  than  chlor- 
inated lime  or  carbolic  acid,  and  much  longer  exposures  are  required  to 
destroy  the  bacillus.  It  is  particularly  adapted  to  the  disinfection  of  privy 
wells  and  latrines,  into  which  it  m^ay  be  thrown,  freshly  prepared  in  the  pro- 
portion of  I  part  by  weight  of  recently  burned  calcium  hydrate  to  8  of  water, 
or  about  12  per  cent.  It  is  not  harmful  to  water-closet  pipes  in  such  quan- 
tities as  required  to  disinfect  the  stools  of  a  single  case  of  typhoid  fever. 

Acidulated  solution  of  corrosive  sublimate  i  to  500  is  an  admirable 
disinfectant  for  stools,  but  is  not  altogether  harmless  to  plumbing,  whence  it 
is  less  satisfactory  when  excreta  are  thrown  into  city  water-closets. 

Sulphate  of  iron  or  copperas  is  a  good  antiseptic  and  deodorant,  but 
not  a  true  disinfectant.  An  antiseptic  prevents  the  growth  of  bacteria  without 
necessarily  killing  them,  while  disinfectants  do  both.  Above  all,  it  must  not 
be  forgotten  that  simple  hot  w^ater  thoroughly  mixed  with  the  fecal  discharges 
is  an  efficient  disinfectant. 

Most  important  in  the  prophylaxis  of  typhoid  fever  is  drainage.  It 
seems  to  be  now  definitely  settled  that  the  fever  originates  in  every  instance 
from  the  ingestion  in  some  way  of  the  typhoid  bacillus  commonly  in 
drinking-water  or  milk,  or  in  food  contaminated  with  it,  more  rarely  by 
inhalation.  Hence,  it  is  of  the  greatest  importance  that  the  sources  of 
water  used  in  domestic  economy  should  be  protected  against  contamination 
by  discharges  containing  the  specific  bacilli,  which  sometimes  find  their  way 
into  wells  and  other  sources  of  water-supply. 

Nurses  should  be  enjoined  to  guard  against  their  own  infection  by  due 
attention  to  cleanliness  after  caring  for  the  discharges  of  a  patient  and  even 
after  tubbing,  while  watchful  care  should  be  taken  not  to  carry  the  hands  to 
the  mouth  during  the  bath.  On  the  other  hand,  the  infection  is  one  of  the 
easiest  controlled,  and  the  spread  of  typhoid  fever  can  be  efifectually  prevented 
if  the  precautions  advised  are  followed.  Moreover,  it  cannot  be  too  strongly 
insisted  upon  that  any  infected  water  or  milk  may  be  rendered  thoroughly 
harmless  by  boiling  and  filtration.  Physicians  should  lose  no  opportunity 
to  inculcate  this  truth  as  well  as  that' limpidity  of  a  water  does  not  guarantee 
its  innocuousness,  while  it  may  even  be  slightly  turbid  and  yet  harmless. 
Boiling  is  the  most  important  treatment,  far  more  important  than  filtration. 


54  INFECTIOUS  DISEASES. 

Paratyphoid  Fever. 

Definition. — A  form  of  infectious  fever  presenting  a  clinical  picture 
identical  with  that  usual  to  typhoid  fever,  but  due  to  a  bacillus  whose  char- 
acteristics are  intermediate  between  the  typhoid  and  colon  groups,  and  called 
therefore,  the  paratyphoid  or  paracolon  bacillus. 

Symptoms. — The  symptoms  are  those  of  typhoid.  Differences  observed 
are,  in  general,  greater  mildness  and  more  favorable  prognosis ;  greater  fre- 
quency of  diarrhea  and  more  frequent  termination  of  fever  by  crisis. 
Myositis  and  purulent  arthritis,  very  rare  in  typhoid  fever,  are  among  the 
complications.  Absence  of  intestinal  ulceration  is  characteristic.  The  dis- 
ease does  not  respond  to  the  Widal  test,  but  the  serum  reacts  upon  fresh 
cultures  of  the  paracolon  or  paratyphoid  bacillus. 

Treatment  is  in  no  way  different  from  that  of  typhoid. 

Mountain   Fever. 
Synonym. — Rocky  Mountain  Fever. 

Definition. — A  form  of  fever  met  in  the  mountain  regions  of  Western 
United  States,  characterized  by  its  moderate  temperature,  ioi°  to  103°  F. 
(38.2°  to  39.3°  C),  a  duration  of  from  two  to  four  weeks,  and  generally 
mild  course. 

Mountain  fever  has  come  to  be  pretty  generally  acknowledged  as  a 
variety  of  typhoid  fever,  modified  by  the  combined  factors  which  go  to  make 
up  the  influence  of  high  altitudes.  Certain  it  is  that  if  a  careful  study  of  the 
cases  reported  by  various  observers  is  made,  the  clinical  picture  differs  no 
more  from  the  typical  picture  of  typhoid  fever  than  the  abortive  forms  of 
typhoid  occurring  at  low  altitudes.  It  must  be  admitted,  however,  that  this 
view  is  not  unanimous,  and  it  should  be  mentioned  that  Surgeon  Charles 
Smart,*  of  the  United  States  Army,  in  a  careful  review  of  the  subject,  in 
1878,  in  a  paper  entitled  "  On  Mountain  Fever  and  Malarious  Waters," 
concluded  the  disease  was  typho-malarial  fever.  Such  a  view  implies  a 
separate  specific  disease,  typho-malarial  fever,  which  is  not  admitted  at  the 
present  day  by  the  best  authorities.  The  lesions  of  typhoid  fever  in  the 
ileum  have  been  found  in  at  least  two  of  the  very  few  fatal  cases  reported,  f 
An  enlarged  spleen  is  also  found.  Finally,  Woodruff's  J  studies  of  the 
serum  reactions  in  this  form  of  fever  have  furnished  all  necessary  proof  of 
the  identity  of  the  disease  wkh  typhoid  fever. 

Epistaxis  occurs.  So  far  as  I  am  aware,  however,  no  spots  have  been 
reported  except  a  "  doubtful  tCicIie  rouge "  by  Roland  G.  Curtin  §  in  one 
of  four  cases  seen  by  him  in  1868  in  Wyoming  Territory.  Diarrhea  has 
been  noted,  but  there  is  a  tendency  rather  to  constipation — not  infrequently 
the  case  in  typhoid  fever.  Tympanites  also  occurs.  The  other  symptoms 
are  those  incident  to  all  fevers,  such  as  debility,  headache,  and  frequent 
pulse. 

Doubtless  many  imperfectly  studied  instances  of  other  forms  of  disease 
are  classed  by  indifferent  observers  as  mountain  fever,  as  in  a  case  mentioned 
by  Curtin. 

*  "  Am.  Jour.  Med.  Sci.,"  January,  1878. 

+  One  is  reported  by  Siirgreon  Ho'ff,  U.  S.  Army,  "  Am.  Jour.  Med.  Sci.,"  January,  1880;  the  speci- 
men from  another  is  in  the  United  States  Armv  Medical  Museum.  Washington  D.  C. 

X  Woodruff,  C.  E.,  "  The  Form  of  Typhoid  "Fever  Called  Mountain  Fever;  Widal's  Test;  Afebrile 
Oases,"  "Jour.  Am.   Med.  Assoc,"  1808,  vol.  xxx,  p.  75:5. 

§  "Rocky  Mountain  Fever."     Reprint  from  the  "New  York  Med.  Jour.,"  January  8,  1887. 


TYPHUS  FEVER.  55 

Mountain  fever  is  not  to  be  confounded  with  mountain  sickness,  another 
condition  incident  to  unusual  exertion  at  high  altitudes.  In  it  there  are 
dyspnea,  frequent  pulse,  dizziness,  and  bleeding  at  the  nose ;  also  great 
prostration  on  exertion,  and  sometimes  slight  elevation  of  temperature. 

Treatment. — The  treatment  of  mountain  fever,  mainly  symptomatic 
and  roborant,  would  be,  so  far  as  any  special  measures  are  needed,  that  of 
typhoid  fever. 

TYPHUS    FEVER. 

Synon'Yms. — Typhus  Exanthematicns ;  Pctchial  Fever;  Pestilential  or  Putrid 
Fever;  Ship  Fever;  Jail  Fever;  Camp  Fever. 

Definition. — An  acute,  highly  contagious  fever,  favored  by  closely 
crowding  human  beings ;  especially  characterized  by  sudden  onset  of  high 
fever,  by  a  petechial  eruption,  typhoid  symptoms,  and  short  duration  as  com- 
pared with  typhoid  fever ;  terminating  suddenly  at  the  end  of  the  second 
week. 

Historical. — It  is  commonly  conceded  that  the  plague  of  Athens,  so  graphicall}'- 
described  by  Thucydides  (B.  C.  470  to  400),  was  the  same  as  the  typhus  fever  of  to-day, 
though  it  has  also  been  held  identical  with  the  Oriental  or  bubonic  plague,  which,  like 
typhus,  until  recently  has  been  regarded  as  growing  very  rare.  It  is  also  possible 
that  what  is  so  often  mentioned  in  the  Scriptures  as  pestilence  may  have  been  typhus, 
although  this  too  may  have  been  Oriental  plague.  The  same  is  true  of  numer- 
ous epidemics  which  prevailed  during  the  first  fifteen  hundred  3-ears  of  the  Christian 
era,  many  of  which  were  undoubtedly  typhus,  especially  in  Spain  and  Italy.  Among 
the  names  were  La  Pourpre  in  French,  Tabafdiglio  in  Spanish,  Petecchie  in  Italian, 
Fleckfieber  \Vi  German,  all  of  which  meant  "spotted."  It  was  called  pestilential, 
putrid,  malignant,  petechial,  and  "  jajd  "  fever  in  England,  and  also  "  the  plague' 
until  1760,  when  the  name  typhus  was  given  it  by  Sauvages.  The  history  of  its  sepa 
ration  from  typhoid  was  given  under  that  disease. 

Etiology. — Though  of  acknowledged  infectious  nature,  no  organism 
has  as  yet  been  isolated  that  can  be  held  responsible  for  typhus  fever,* 
"but  several  non-distinctive  bacilli  have  been  isolated  from  the  blood  and 
tissues  of  patients.  Fostered  by  close  crowding,  filth,  and  famine,  it  each 
year  becomes  more  infrequent  as  the  conditions  favoring  it  are  eliminated, 
and  there  is  reason  to  believe  it  will  ultimately  be  stamped  out.  Thus,  in  1897 
there  were  only  three  cases  in  all  the  London  fever  hospitals.  Ireland  has 
been  its  home  for  centuries,  but  filthy  and  crowded  sections  and  the  alms- 
Tiouses  of  large  cities  have  at  different  times  furnished  seats  for  its  lodgment. 
My  own  experience  with  the  disease  is  limited  to  two  mild  epidemics  in  the 
Philadelphia  Hospital  in  1866  and  1883.  and  another  quite  serious  in  the 
Camden  County  (Xew  Jersey)  Almshouse  in  the  winter  of  1880-81.  Quite 
a  serious  epidemic  prevailed  in  New  York  City  in  1881-82,  and  a  milder  one  in 
1892-93.  Sporadic  cases  rarely  occur,  but  its  spontaneous  origin  is  scarcely 
possible,  though  such  possibility  was  admitted  by  Murchison,  whose  judg- 
ment on  fevers  was  at  one  time  regarded  as  almost  infallible. 

Typhus  fever  is  eminently  contagious,  and  cases  should  be  promptly 

isolated.    Nurses  and  others  in  constant  attendance  upon  typhus  patients  are 

more  liable  to  be  attacked  than  those  who,  like  the  physician,  merely  visit 

them  daily,  although  perhaps  no  disease  in  the  past  has  included  among  its 

victims  so  many  medical  men.     It  is  not  known  precisely  what  the  contagium 

bearer  is.     It  may  be  all  the  exhalations  and  discharges  from  the  body,  but 

it  is  not  especially  the  bowel  discharges. 

f 

*  For  a  summary  of  the  observations  thus  far  made  on  the  "  Micro-organisms  in  T.vphus  Fever." 
see  a  paper  with  this  title  by  J.  B.  Byron  and  Egbert  Le  Fevre,  in  vol.  ii.,  "Researches  of  the 
Loomis  Laboratory,"  New  York,  i8g2,  p.  130. 


56 


INFECTIOUS  DISEASES. 


Morbid  Anatomy. — As  to  the  morbid  anatomy  of  this  disease,  there  is 
reallv  nothing  distinctive.  Rigor  mortis  is  apt  to  be  delayed.  The  petechial 
eruption  remains  after  death,  and  gangrenous  bed-sores  may  be  found  on 
the  body.  The  most  constant  lesion  is  moderate  enlargement  of  the  spleen, 
and  in  this  enlargement  the  liver  and  kidneys  may  share,  and  their  cells  be 
the  seat  of  cloudy  swelling  due  to  fever  heat.  Indeed,  all  the  tissues,  includ- 
ing the  heart  muscle,  may  be  granular  from  this  cause.  The  splenic  enlarge- 
ment is  mainly  due  to  vascular  engorgement,  but  there  may  also  be  some 
hyperplasia  of  lymph-cells.  The  lymph-follicles  of  the  intestine  may  be 
enlarged  from  the  same  cause,  but  there  is  no  ulceration  of  these  or  of  Peyer's 
patches.  The  blood  is  dark  and  liquid.  Hypostatic  congestion  of  the  lungs 
is  very  frequently  found ;  likewise  bronchial  catarrh.     The  permanence  of 


F 

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Fig.  6. — Temperature  in  Typhus  fever  ("  Pepper's  American  Text-book  of 

Medicine.") 

the  eruption  after  death  is  in  strong  contrast  with  that  of  typhoid  fever,, 
which  disappears  after  death. 

Symptoms. —  The  period  of  incubation  is  usually  about  twelve  days.  It 
may  be  less.  There  is  seldom  any  prodrome,  the  invasion  being  sudden,. 
announced  by  a  chill  or  chills  followed  by  headache  and  great  mitscular 
pain,  especially  in  the  back,  and  by  high  fever,  the  temperature  rapidly  rising 
to  103°,  104°,  105°,  and  106°  F.  (39.4°,  40°,  40.5°,  41.1°  C.)  without  any  of 
the  tidal-wave  rise  characteristic  of  typhoid  fever.  The  pulse  is  at  first  full 
and  strong,  but  soon  weakens  and  becomes  frequent — 120  and  more.  There 
is  extreme  debility.  Almost  characteristic  are  the  red,  congested  con- 
juncti'c'ce,  the  dusky  face,  dull  expression,  and  lozv,  muttering  delirium,  which 
contrasts  strongly  with  the  sometimes  active  delirium  of  typhoid.  The' 
tongue  is  early  coated  and  becomes  rapidly  dry.     The  bowels  are  constipated. 

On  the  third  to  the  fifth  day  the  eruption  presents  itself ;  it  is  of  tzvo- 


TYPHUS  FEJ^ER.  57- 

kinds.  The  petechial,  or  more  characteristic,  is  at  first  not  unhke  that  of 
typhoid  fever,  but  is  darker  in  hue  and  disappears  less  readily  on  pressure ; 
a  little  later  it  is  barely  influenced,  and  still  later  does  not  respond  at  all  to 
pressure.  It  has  become  hemorrhagic,  petechial — the  blood  is  without  the 
vessels.  There  may  be  spots  exhibiting  each  one  of  these  stages.  This 
eruption  is  also  more  scattered  than  that  of  typhoid  fever,  appearing  all  over 
the  body,  while  that  of  typhoid  is  limited  to  the  chest  and  belly.  In  addition 
to  the  petechial  eruption  there  is  also  a  peculiar  dark  mottling  of  the  skin, 
an  alternation  of  purple  blotches  with  others  of  a  light  hue,  generally  capable 
of  being  influenced  by  pressure,  but  these  blotches,  too,  may  become  blood 
extravasations. 

With  the  beginning  of  the  second  zceek  all  of  the  symptoms  deepen: 
The  tongue  becomes  dry,  fissured,  and  leathery ;  sordes  collect  on  the  teeth ; 
stupor  deepens,  there  are  subsultus  and  nystagmus,  coma  vigil, — the  patient 
is  unconscious,  but  the  eyes  are  wide  open, — and  picking  at  the  bed-clothes. 
At  this  time,  too.  the  peculiar  disagreeable  odor  said  to  be  characteristic  of 
typhus  fever  makes  its  appearance.  It  is  variously  described :  by  Gerhard, 
as  pungent,  ammoniacal.  and  offensive ;  by  the  late  George  B.  Wood,  as  like 
the  odor  of  badly  ventilated  rooms,  in  which  a  number  of  persons  are  col- 
lected ;  and  by  others,  as  like  the  odor  given  off  by  rotten  straw  or  the  urine 
of  mice.  Gerhard  and  ^^lurchison  both  held  that  its  degree  was  propor- 
tionate to  the  degree  of  contagiousness  of  the  case.  The  breathing  becomes 
more  rapid,  the  pulse  weaker,  scarcely  appreciable,  and  the  patient  may  die 
of  adynamia ;  or  at  the  end  of  the  second  week  a  crisis  occurs,  he  falls  asleep, 
the  temperature  declines  as  rapidly  as  it  rose,  and  often  after  a  long  sleep 
the  patient  wakes  up  refreshed  and  with  a  clear  head.  Convalescence  now 
progresses,  and  although  it  may  be  slow,  relapses  rarely  occur. 

A  few  symptoms  require  special  allusion :  First,  the  fever.  The  skin  is 
burning  hot  and  the  tem.perature  rises  to  106^  F.  (41.1°  C.),  and  even  108°  F. 
(42.2''  C. )  and  109'  F.  ( 42.7°  C. )  toward  a  fatal  termination.  It  is  the 
calor  mordax.  There  is  always  hypostatic  congestion  of  the  lungs  and, 
along  with  this,  a  great  deal  of  bronchial  catarrh  and  cough.  Such  catarrh 
may  pass  into  a  broncho-pneumonia,  which  may  terminate  in  gangrene  of  the 
lungs. 

The  urine  is  concentrated,  as  in  all  high  fevers,  and  urea  and  tiric  acid 
are  relatively  increased.  Albuminuria  is  also  common,  but  there  is  not  usually 
any  organic  change  in  the  kidney  beyond  the  cloudy  swelling  referred  to. 
Retention  of  urine  on  account  of  the  mental  hebetude  may  occur,  and  should 
be  guarded  against  by  frequent  examination  and  catheterization.  Bed-sores 
are  common,  and  there  may  e^-en  be  gangrene  of  the  extremities. 

Instances  of  the  ambulatory  form  of  typhus  fever  are  much  more  rare 
than  of  typhoid,  but  they  are  occasionally  met. 

Diagnosis. — How  does  typhus  fever  differ  from  typhoid  fever?  I  have 
referred  to  the  dift'erences  in  the  eruption  in  the  two  diseases.  But  the  tem- 
perature of  typhus  fever  is  quite  as  characteristic  as  that  of  typhoid  fever. 
In  the  latter  disease  we  have  the  peculiar  tidal-wave  course  described.  In 
typhus  fever,  in  the  first  place,  the  average  maximum  temperature  is  higher : 
for,  while  a  temperature  of  106'  F.  (42.1"  C.  )  is  not  uncommon  in  typhus 
fever,  105°  F.  (  40.5^  C.)  in  typhoid  is  quite  high.  The  temperature  in  typhus 
quickly  reaches  the  maximum,  usually  from  the  third  to  the  fifth  day,  con- 
tinues with  light  remissions  until  the  twelfth  or  fourteenth,  then  there  is  a 
sudden  decline.     The  ascent  is  steady  and  continuous,  and  only  marked  by 


58  INFECTIOUS  DISEASES. 

slight  morning  remissions,  while  in  typhoid  fever  the  morning  remissions  are 
decided.  The  pulse,  during  the  first  three  days,  is  usually  about  loo ;  after 
that  it  becomes  more  frequent  and  feeble,  running  up  to  120  or  higher,  until 
the  drop  in  temperature,  when  there  is  a  corresponding  fall  in  the  rate  of  the 
pulse.  It  is  seldom  dicrotic,  as  in  typhoid  fever.  Typhus  fever  more  fre- 
quently begins  with  a  chill  than  does  typhoid:  the  important  symptoms, 
including  the  eruption,  appear  earlier.  In  isolated  cases,  however,  there 
may  be  difficulty  in  diagnosis. 

Malignant  measles,  hemorrhagic  smallpox,  cerebrospinal  fever,  and 
"bubonic  plague  are  diseases  for  which  typhus  fever  may  be  mistaken.  The 
eruption  of  malignant  measles  is  not  unlike  that  of  typhus  fever,  and  it 
appears  first  in  the  face.  The  extreme  adynamia  and  the  typhoid  symptoms 
are  very  similar.  There  is  bronchitis  in  both,  but  the  coryza  and  acute  nasal 
catarrh  are  not  found  in  typhus,  while  concurrent  with  the  case  of  malignant 
measles  are  others  of  a  milder  and  more  typical  nature.  The  latter  fact  also 
aids  the  diagnosis  in  variola,  where,  too,  in  the  malignant  form  the  hemor- 
rhagic tendency  is  more  marked  and  occurs  early  in  the  disease. 

Cerebrospinal  fever  has  often  been  mistaken  for  typhus,  and  in  the  early 
stage  the  suddenness  of  onset,  the  eruption,  and  the  nervous  symptoms  are 
all  calculated  to  mislead.  One  has  to  wait  but  a  few  days,  however,  before 
the  courses  of  the  two  diseases  diverge.  Bubonic  plague  has  been  confounded 
with  typhus,  but  it  seems  to  have  been  a  very  difterent  disease,  resembling 
typhus  only  in  its  fatality.  Bubonic  plague,  as  described  to  us, — for  our 
knowledge  is  from  descriptions, — is  characterized  by  the  same  suddenness  of 
■onset,  the  chill,  high  fever,  and  prostration,  as  is  typhus  fever ;  but  the  erup- 
tion appears  earlier,  and  quickly  becomes  carbuncular.  while  the  course  of 
the  disease  is  much  shorter. 

Prognosis. — The  mortality  of  typhus  is  high,  but  different  epidemics 
vary  in  this  respect.  During  the  epidemic  at  the  Camden  County  Almshouse 
(1880-81)  referred  to,  103  of  the  officers  and  inmates  were  attacked.  Of 
this  number  2;^  died,  giving  a  mortality  of  a  little  over  22  per  cent.  I  might 
add  that  of  the  officers  of  the  institution,  7,  including  an  attending  physician, 
the  steward,  the  matron,  the  assistant  matron,  and  2  nurses,  together  with 
the  builder  of  a  new  hospital  building,  were  attacked,  and  all  died.  In  some 
epidemics  the  mortality  is  even  greater,  reaching  50  per  cent.,  but  it  is  com- 
monly put  down  at  from  12  to  20  per  cent.  The  disease  attacks  either  sex  at 
any  age.  One  of  the  modes  of  death  is  by  acute  fatty  degeneration  of  the 
heart,  and  the  peculiar  dusky  complexion  sometimes  seen  may  be  due  to  the 
inability  of  a  weak  fatty  heart  to  propel  the  blood  through  the  capillaries. 
Sudden  death  is  not  unusual.  It  is  more  than  likely  that  with  the  improved 
nursing  and  hygiene  of  the  present  dav  the  mortality  of  typhus  would  be  less. 

Treatment. —  Whenever  possible. typhus  fever  should  be  treated  in  the 
open  air  ( in  tents ) .  as  the  safety  of  attendants  as  well  as  recovery  of  patients 
is  favored  thereby.  There  is  no  reason  why  hydrotherapy  should  not  be  as 
serviceable  in  typhus  as  in  typhoid,  but  it  is  absolutely  necessary  that  free 
stimulation  should  be  associated  with  any  treatment.  We  know  that  the 
greatest  danger  lies  in  the  asthenia,  which  can  be  met  only  by  stimulants.  If 
there  is  one  disease  in  which  the  free  use  of  alcohol  is  indicated  more  than 
in  another,  it  is  typhus  fever.  The  quantity  required,  of  course,  must  be  gov- 
erned by  the  condition  of  the  patient.  In  some  case.s  it  may  be  necessary  to 
give  an  ounce  (30  c.  c. )  every  hour.  Quinin  is  also  strongly  indicated,  as  are 
digitalis    and    strychnin    as    heart    strengtheners.      When    the    temperature 


RELAPSING   FEVER.  59 

becomes  high,  if  the  cold  bath  be  not  used,  sponging  of  the  body  in  the  way 
described  under  typhoid  fever  may  be  substituted.  The  same  objection  exists 
to  phenacetin  and  antifebrin  as  in  typhoid ;  that  is,  they  dare  not  be  rehed 
upon  as  an  exclusive  means  of  reducing  temperature,  but  they  may  be  used 
as  adjuvants.  Other  symptoms  should  be  treated  as  they  arise.  .  Specific  anti- 
septic treatment  has  proved  to  be  Vi-'ithout  peculiar  advantage. 

After  the  crisis,  which,  as  has  been  said,  is  strikingly  well  marked  in 
this  disease,  it  is  simply  necessary  to  treat  symptoms  as  they  arise.  The 
accompanying  bronchitis  is  treated,  if  it  requires  treatment,  like  any  other 
bronchitis,  but  the  ammonium  salts  are  especially  indicated  on  account  of 
their  stimulating  qualities,  while  the  aromatic  spirit  of  ammonia  is  an  espe- 
cially convenient  preparation  for  these  purposes.  Alcohol,  ammonia,  and 
camphorated  oil  may  be  given  hypodermically  to  tide  over  emergencies. 

The  patient  should  be  nourished  as  in  typhoid  fever — by  nutritious 
liquids,  including  milk,  milk  punches,  egg-nogg,  and  nutritious  broths. 

RELAPSING   FEVER. 

Synonyms. — Febris  rccurrens;  Famine  Fever;  Seven-day  Fever;  Typhus 

ict  erodes. 

Definition. — Relapsing  fever  is  an  acute  infectious  disease,  character- 
ized by  two  or  more  febrile  relapses  separated  by  periods  of  total  remission, 
and  caused  by  the  inoculation  and  multiplication  of  the  spirochaeta  of 
Obermeier. 

Historical. — Like  typhus  and  typhoid  fevers,  relapsing  fever  is  not  a  new  malady, 
for  a  disease  corresponding  very  closely  to  it  was  described  b}^  Hippocrates  as  pre- 
vailing two  thousand  years  ago  on  the  island  of  Thasus,  off  the  coast  of  Thrace. 
Typhus  and  relapsing  fevers  often  prevailed  together,  and  many  of  the  older  reports 
of  typhus  with  relapses  doubtless  referred  to  relapsing  fever.  Strother,  in  1729, 
speaks  of  frequent  relapses;  also  Lind,  in  1763.  John  Rutty,  however,  in  1770,  gave 
the  first  clear  description  of  relapsing  fever  as  it  prevailed  in  Dublin  in  1739,  1741, 
1745,  1748.  After  this  many  epidemics  of  what  is  evidently  relapsing  fever  were  re- 
corded until  1817.  It  was  still  regarded  as  a  modification  of  typhus,  even  in  1817-19, 
and,  according  to  Christison,  "  there  was  a  very  general  impression  that  the  relapsing 
fever  could  produce  the  common  typhus."  After  iSiythe  disease  almost  disappeared 
until  1826,  when  another  epidemic  of  both  typhus  and  relapsing  fevers  broke  out. 
Then  for  the  first  time  a  distinction  was  drawn  between  the  two  fevers,  especially  by 
Dr.  O'Brien,  who  published  an  account  of  the  epidemic  as  it  appeared  in  Dublin. 
Numerous  epidemics  appeared  from  time  to  time  since  that  date  in  Great  Britain  and 
Ireland  and  on  the  continent  of  Europe,  but  it  has  been  growing  less  as  cleanliness 
and  hygiene  improved.  It  prevails,  also,  as  might  be  expected  on  account  of  the 
defective  sanitary  conditions,  in  India  and  Eastern  Europe.  It  made  its  first  appear- 
ance in  America  in  1844  in  an  emigrant  ship  from  Liverpool  to  Philadelphia,  and  was 
described  by  Dr.  Meredith  Clymer.  It  was  especially  studied  in  India  by  Vandyke 
Carter,  of  Bombay.  In  September,  1869,  it  again  visited  Philadelphia,  and  New  York 
in  November,  and  a  somewhat  extensive  epidemic  prevailed  in  the  former  city,  in 
which  I  had  some  experience  with  it. 

Etiology. — That  the  specific  cause  of  relapsing  fever  is  a  bacterium  of 
the  group  spirobacteria,  genus  spirochaeta,  is  now  generally  acknowledged. 
Plrst  discovered  by  Obermeier  in  the  blood  of  victims,  it  is  known  by  his  name 
as  the  spirochceta  Obermeier.  It  is  a  narrow  spiral  about  0.025  to  0.05  mm. 
(i-iooo  to  1-500  inch)  in  length — that  is,  its  length  is  three  to  six  times  the 
width  of  a  red  blood-disc.  It  is  found  floating  among  the  blood-discs  during 
the  fever.  Before  the  crisis  and  in  the  intervals  the  organism  is  not  found, 
but  small,  glistening  spherules,  said* to  be  its  spores,  take  its  place.  Confir- 
mation of  the  contagious  nature  of  the  disease  is  found  in  the  fact  that  it 
bas  been  communicated  from  one  human  beinsf  to  another  by  inoculation  of 


6o  INFECTIOUS  DISEASES. 

blood,  and  to  monkeys  in  the  same  way.  It  may  be  supposed  that  the  organ- 
ism is  given  off  in  the  breath  or  from  the  skin.  The  operation  of  the  cause 
is  undoubtedly  favored  by  overcrowding,  by  filth,  and  by  destitution.  Yet 
the  disease  is  not  confined  to  the  poorly  fed.  This  was  especially  proved  in 
the  Philadelphia  epidemic  of  1869,  when  a  considerable  number  of  fairly 
well-to-do  persons  were  affected,  although  they  always  resided  in  crowded 
districts.  Neither  age,  sex,  nationality,  nor  season  is  a  factor  in  its 
causation. 

Morbid  Anatomy. — There  is  no  essential  morbid  anatomy,  and  such  as 
is  found  corresponds  with  that  of  typhus.  Most  conspicuous  is  enlargement 
of  the  spleen. 

Symptoms. — The  period  of  mcubation  varies  greatly,  so  that  it  is  put 
down  at  from  two  to  fourteen  days.  According  to  Murchison,  there  may 
actually  be  no  interval  between  exposure  and  the  invasion.  The  latter  is 
sudden  by  a  chill,  fever,  intense  pain  in  the  back  and  limbs,  with  dic::iness. 
This  abrupt  invasion  is  a  distinctive  feature,  and  in  perhaps  none  of  the  con- 
tagious diseases  is  it,  as  a  rule,  so  marked.  Exceptionally  only  is  there  a 
short  period  of  malaise  with  loss  of  appetite.  On  invasion  the  temperature 
rises  rapidly  and  quickly  reaches  104°  F.  (40°  C.)  The  patient  cannot  retain 
his  feet,  and  promptly  takes  to  his  bed,  feeling  very  sick,  rather  than  pro- 
foundly weak.  There  may  be  nausea  and  vomiting  and  even  convulsions  in 
the  young;  the  pulse  rises  rapidly,  more  rapidly  than  in  typhus,  reaching  140 
on  the  second  day,  and  later  150  and  160.  The  patient  may  be  delirious^,  but 
the  typhoid  symptoms  are  not  usually  so  profound  as  in  typhus  and  the  tongue 
remains  moist.  laundice  appears  in  a  certain  number  of  cases  on  the  third 
or  fourth  day,  usually  in  one  out  of  every  12  cases,  occasionally  as  often  as 
one  in  every  four  or  five.  The  temperature  during  the  paroxysm  fluctuates 
slightly,  being  higher  in  the  evening.  Szvelling  and  sudaniina  are  often 
present,  and  occasionally  petechice,  but  there  is  no  characteristic  eruption. 
Rarely,  Murchison  says  in  8  out  of  600  cases,  a  roseolar  rash  appears,  or 
there  may  be  a  mottling  like  that  of  typhus,  which,  however,  always 
disappears  on  pressure,  and  disappears  entirely  in  three  or  four  days — dift'er- 
ing  in  these  respects  from  the  similar  eruption  of  typhus.  Herpes  may  be 
present.  There  is  occasionally  abdominal  tnderness  in  the  epigastric  or  iliac 
region,  and  the  enlarged  spleen  may  be  easily  detected,  but  there  are  no  active 
intestinal  symptoms.  The  liver  may  be  also  slightly  enlarged,  extending 
lower  than  in  health. 

The  spirillum  is  to  be  found  in  the  blood  and  should  always  be  looked 
for.  It  may  readily  be  detected  with  a  power  of  500  diameters  without  any 
special  preparation  of  the  blood,  care  being  simply  taken  to  secure  a  thin  film. 

Crisis. — If  the  invasion  of  relapsing  fever  be  sudden,  its  termination  is 
no  less  so.  It  is  by  crisis,  beginning  usually  with  sweating.  After  five  or  six 
days  of  unabated  fever  sweating  sets  in,  which  soon  becomes  profuse,  the 
temperature  falls  rapidly  to  normal  or  even  subnormal,  the  various  discom- 
forts fade  away,  and  in  the  course  of  a  few  hours  the  patient  is  apparently 
well.  Rarely,  the  crisis  may  be  ushered  in  by  a  diarrhea,  an  epistaxis,  or  the 
appearance  of  menstruation. 

The  crisis  does  not  always  take  place  at  the  same  stage  of  the  disease. 
It  may  occur  as  early  as  the  third  day  or  not  until  the  tenth,  or  even  the  fif- 
teenth, but  most  commonly  on  the  seventh.  While  the  crisis  is  ordinarily 
followed  by  some  relaxation  and  faintness,  there  soon  ensues  a  rapid  recovery 
of  natural  and  healthful  feeling.     Occasionally,  however,  the  depression  is 


RELAPSING  FEVER. 


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62  INFECTIOUS  DISEASES. 

greater  and  a  sensation  as  of  collapse  occurs,  especially  in  delicate  or  elderly 
persons. 

Relapses. — Again,  in  a  week  from  the  crisis,  generally  on  the  fourteenth 
day  from  the  primar}'  chill,  another  occurs,  or  a  series  of  them,  with  fever, 
and  the  paroxysm  repeats  itself,  to  be  again  succeeded  by  a  crisis  at  a  some- 
what shorter  interval.  There  may  be  a  third  or  even  fourth  and  fifth 
paroxysm ;  more  commonly  they  are  limited  to  two  or  at  most  three.  Each 
succeeding  attack  is  shorter  than  the  previous  one.  Occasionally  there  is  no 
relapse,  the  disease  terminating  with  the  first  crisis.  Convalescence,  usually 
rapid,  is  sometimes  prolonged,  and  the  duration  of  the  entire  illness  may  be 
put  down  at  from  eighteen  to  ninety  days,  and  the  patient  rarely  returns  to 
work  within  six  weeks.     One  attack  does  not  secure  immunity  from  another. 

Complications. — Among  the  complications  may  be  mentioned  bronchitis, 
pneumonia,  nephritis,  and  hematuria.  The  spleen  may  enlarge  until  it  rup- 
tures. It  may  attain  a  weight  of  4  1-2  pounds  (10  kilos.),  and  may  be  the 
seat  of  infarcts.  Albuminuria  occurs  as  in  other  fevers  characterized  by 
high  temperatures.  Pregnant  women  usually  abort  in  the  relapse,  and  the 
child,  if  not  still-born,  survives  but  a  few  hours.  Postfebrile  paralysis  may 
occur,  and  troublesome  ophthalmia  succeeds  in  some  epidemics. 

Diagnosis. —  In  its  early  stages  relapsing  fever  is  not  unlike  typhus. 
In  suddenness  of  onset,  rapid  rise  of  temperature,  habitat,  and  subjects,  the 
resemblance  is  close.  The  readiness  with  which  a  patient  takes  his  bed  is 
characteristic  of  each,  but  in  relapsing  fever  the  adynamia  is  not  so  great  as 
in  typhus,  and  it  is  rather  because  of  a  dizziness  that  he  cannot  keep  about. 
The  crisis  cuts  short  all  doubt  on  this  point  of  confusion  with  typhus.  In 
the  intense  muscular  pains,  especially  in  the  back,  relapsing  fever  resembles 
smallpo.r,  but  the  eruption  in  the  latter  disease  sets  doubt  at  rest. 

Malarial  fever  may  be  suggested  by  the  relapse,  but  the  presence  of  an 
organism  in  the  blood  of  each  of  these  affections,  widely  different  in  appear- 
ance, permits  the  settlement  of  such  confusion  by  the  microscope.  The  preva- 
lence of  an  epidemic  is,  of  course,  of  great  assistance  in  the  diagnosis  between 
relapsing  fever  and  any  of  the  diseases  with  which  it  may  be  confounded. 

Prognosis. — The  prognosis  of  relapsing  fever  is  not  unfavorable.  The 
higher  mortality  reported  in  some  of  the  earlier  epidemics  in  Great  Britain 
and  Ireland  was  doubtless  due  to  an  admixture  of  typhus.  An  average  for 
several  years  in  a  number  of  cities  in  Great  Britain  and  Ireland,  according  to 
Murchison,  has  been  4.3  per  cent. ;  in  the  epidemic  at  Bombay  in  1877-78, 
Vand3'ke  Carter  estimated  tha^mortality  at  18.02  per  cent. ;  while  in  the  Phila- 
delphia epidemic  the  studies  of  William  Pepper  and  Edward  Rhoads  found  it 
14  per  cent.  I  am  sure  that  in  private  practice  during  this  epidemic  the 
mortality  was  not  so  great.  There  are  some  accidents,  which  have  been 
already  alluded  to,  that  are  responsible  for  a  few  deaths.  Thus,  the  spleen 
has  ruptured  from  extreme  congestion.  Pneumonia  sometimes  causes  a 
fatal  termination.  It  has  been  said  that  the  crisis  sometimes  terminates  in 
collapse  with  its  characteristic  clammy  coldness,  pulselessness,  unconscious- 
ness, and  fatal  end.  A  fatal  nephritis  occasionally  complicates  the  disease, 
death  being  preceded  by  ursemic  convulsions.  Certain  cases  associated  with 
jaundice,  called  by  Griesinger  "  bilious  typhoid,"  are  often  fatal.  Some 
striking  cases  of  this  kind  were  noted  by  Pepper  at  the  Philadelphia  Hospital 
in  the  epidemic  of  1869-70. 

Treatment. — The  febrile  paroxysm  demands  much  the  same  treatment 
as  in  typhus — careful  nursing,  sponging  or  cool  bathing,  nutritious,  easily 


MALTA  FEVER.  65 

assimilable  food,  and  stimulation,  although  the  latter  is  less  important  than 
in  typhus.  No  drug  has  the  power  to  prevent  the  recurrence  of  the  relapse, 
although  quinin  is  indicated,  and,  as  in  other  adynamic  fevers,  is  useful  as  a 
roborant.  It  is  reasonable  to  expect  that  phenacetin,  antifebrin,  or  antipyrin 
will  relieve  the  muscular  pains.  Should  they  not  suffice,  morphin,  hypoder- 
mically,  can  be  relied  upon. 

MALTA   FEVER. 

Synonyms. — Mediterranean    Fever;    Neapolitan    Fever;    Rock    Fever; 

Undulant  Fever. 

Definition. — An  anomalous  fever,  characterized  by  irregular  remis- 
sions and  relapses,  copious  sweats,  and  rheumatoid  pains,  caused  by  the 
micrococcus  melitensis. 

Distribution. — The  various  names  of  Malta  fever  indicate  its  distribu- 
tion on  the  Mediterranean  littoral,  outside  of  which  it  has  been  thought  infre- 
quent; but  in  1898  J.  J.  Kinyoun  *  suggested  its  presence  on  the  Southern 
Atlantic  coast  of  America  and  the  islands  of  the  Gulf  of  Mexico,  a  suggestion 
confirmed  by  the  report  by  J.  H.  Musser  and  Joseph  Sailer  of  a  case  originat- 
ing in  Cuba.f 

Etiology. — The  cause  of  this  peculiar  fever,  the  micrococcus  melitensis^ 
has  been  studied  by  Bruce,  whose  researches  have  been  confirmed  by  Hughes. 
Its  morphological  and  biological  features  have  been  accurately  studied  by 
H.  E.  Durham.  It  is  found  in  large  numbers  in  the  spleen,  but  has  not  been 
isolated  from  the  blood.  Pure  cultures  have  been  obtained,  the  disease  has 
been  reproduced  in  monkeys,  and  the  micrococcus  isolated  from  the  infected 
animal.  It  has  been  regarded  as  a  form  of  typhoid,  malarial  typhoid,  and  in 
consequence  of  enlargement  of  the  mesenteric  glands,  noted  by  Italian 
observers,  called  adenotyphoid.  It  has  also  been  thought  to  be  an  anomalous 
form  of  malarial  fever,  and  ascribed  to  "  chronic  poisoning  with  fecal  accu- 
mulation." On  the  other  hand,  it  does  not  give  the  Widal  typhoid  fever 
reaction,  while  A.  E.  Wright  and  F.  Smith  have  shown  that  the  blood  of 
Malta  fever  patient  reacts  with  pure  cultures  of  the  micrococcus  melitensis. 
This  would  seem  to  settle  its  independent  nature.  The  disease  attacks  mostly 
the  young. 

Morbid  Anatomy. — Our  knowledge  of  the  morbid  anatomy  of  Malta 
fever  is  not  definite.  Thus,  Bruce  says  no  characteristic  lesion  of  typhoid 
fever  is  found,  while  Perry  says  of  "  rock  fever  "  that  in  100  autopsies 
made  during  four  years'  residence  in  Gibraltar,  the  typical  lesions  of  t3'phoid 
were  present  without  exception.     Hughes  also  says  the  spleen  is  enlarged. 

Symptoms. — There  is  usually  a  period  of  incubation  of  from  six  to 
ten  days.  The  onset  is  gradual,  with  headache,  sleeplessness,  and  thirst,  loss 
of  appetite,  zvithout  chilliness  or  high  fever  at  first.  There  is  no  diarrhea; 
spots  are  not  found.  These  symptoms,  more  or  less  pronounced,  last  from 
three  to  four  weeks,  when  the  first  remission  sets  in,  simulating  convales- 
cence. It  lasts  a  few  days  only,  when  the  first  relapse  appears,  this  time 
with  rigors,  high  fever,  and  often  diarrhea,  and  the  symptoms  of  the  first 
attack  intensified.  This  relapse  lasts  for  from  five  to  six  weeks,  to  be  fol- 
lowed by  another  remission  of  from  ten  days  to  two  weeks.  Then  follows 
the  second  relapse,  when  recur  the^symptoms  of  the  first  relapse,  to  which 

*  "  Gaceta  de  Caracas,"  July  15,  i8g8,  and  "  Philadelphia  Med.  Jour.,"  January  14,  iSag,  p.  63. 
+  "  Philadelphia  Med.  Jour.,"  December  31,  i8g8. 


•64 


IXFECTIOUS  DISEASES. 


THE  MALARIAL  FEVERS.  65 

are  superadded  great  debility,  night-szvcats,  pain  in  the  larger  joints,  includ- 
ing hips,  knees,  and  ankles,  and  in  the  testicles — one  or  both — lasting  three 
or  four  weeks.  Then  follows  a  third  remission,  which  may  last  for  a  month 
or  six  weeks.  Then  a  third  relapse  of  shorter  duration,  adding  to  the  other 
symptoms  a  heavily  coated  tongue,  a  high  temperature,  105°  F.  (40.5°'  C.) 
and  above  in  the  evening,  but  normal  in  the  morning,  the  night-sweats,  and 
especially  the  rheumatice  pains,  being  markedly  severe.  All  the  joints  now 
seem  to  be  involved,  and  motion  is  an  agony.  The  fibrous  tissues  are  also 
often  involved  in  this  relapse,  especially  the  tendo  Achillis  and  fibrous  struc- 
tures about  the  ankle ;  also  the  lumbar  aponeuroses  and  sheaths  of  the  nerves 
from  the  sacral  plexus. 

Diagnosis. — The  rarity  of  the  disease  and  the  peculiarity  of  its  symp- 
toms may  cause  it  to  be  overlooked  for  some  time.  The  serum  reaction  is, 
however,  characteristic,  cultures  of  the  specific  bacillus  responding  to  the 
serum  of  the  blood  of  the  disease  as  in  typhoid  fever. 

Prognosis, — This  is  generally  favorable,  not  more  than  two  per  cent, 
perishing. 

Treatment. — This  is  symptomatic,  being  directed  to  the  relief  of  the 
symptoms  and  the  support  of  the  patient  against  the  exhaustive  effects  of 
the  disease.  A  case  seems  to  have  been  successfully  treated  with  Malta 
iever  antitoxin  by  Fitzgerald  and  Ewart.'^ 

THE  MALARIAL   FEVERS. 

Synonyms. — Ague;  Fever  and  Ague;  Chills  and  Fever;  Mars'h  Fever; 
Swamp  Fever;  Paludal  Fever;  Miasmatic  Fever;  Intermittent,  Remit- 
tent, and  Pernicious  Remittent  Fever;  Bilious  Fever;  Estivo -autumnal 
Fever. 

Definition. —  An  infectious  fever,  of  intermittent  or  remittent  type, 
due  to  an  organism  known  as  the  Plasmodium  or  hematozoon  of  malaria. 

A  chronic  cachectic  condition  due  to  the  same  cause  is  known  as 
"  chronic  malaria  "  or  "  malarial  cachexia."  Chronic  malaria  has  really  a 
more  definite  morbid  anatomy  than  the  acute  malarial  fevers.  The  term 
"  malaria  " — meaning,  in  the  Italian,  bad  air — was  originally  applied  to  the 
supposed  specific  cause  of  the  fever,  but  it  is  also  used  to  express  the  con- 
sequences of  such   cause. 

Varieties  of  Malarial  Fever. — The  malarial  fevers  are  intermittent 
or  remittent.  The  former  is  characterized  by  paroxysms  of  fever,  between 
which  there  are  total  intermissions.  In  the  remittent  form  there  are  remis- 
sions or  abatements  in  the  fever,  but  not  intermissions.  The  remittent 
fevers  exhibit  much  less  regularity  than  the  intermittent  fevers,  even  in  their 
remissions,  and  in  consequence  of  their  prevalence  in  the  later  summer  and 
fall  have  recently  among  other  irregular  types  been  included  under  the 
head  estivo-autumnal.  This  term  embraces  also  all  the  malignant  types, 
which  are  rarely  seen  in  the  spring  months.  The  term  "  irregular  "  malarial 
fevers  is  quite  as  distinctive  and  perhaps  more  accurate. 

The  paroxysms  of  fever  may  come  on  daily  at  the  same  hour,  when 
they  are  called  quotidian;  they  may  occur  every  other  day,  when  they  are 
known  as  tertian;  or  they  may  OQCur  every  third  day, — that  is,  skip  two 
days, — when  they  are  called  quartan.     More  rarely  occur  quintan,  sextan, 

*  "  The  Lancet,"  April  15,  iSgg. 


66  INFECTIOUS  DISEASES. 

septan,  and  octan  fevers,  with  intervals  of  four,  five,  six,  and  seven  days,, 
respectively.  It  will  be  noted  that  in  naming  these  periods  the  day  of  the 
paroxysm  and  that  of  the  following  paroxysm  are  both  counted.  The 
"  double  tertian  "  is  a  fever  in  which  paroxysms  occur  each  day  but  at  dif- 
ferent hours,  the  hours  on  alternate  days  corresponding  with  each  other.  In 
these  cases  the  alternate  paroxysms  may  also  be  of  dift'erent  intensities.  In 
like  manner  there  may  be  double  quartans  and  even  double  quotidians. 

Although  the  parox}sms  in  true  intermittent  fever  commonly  occur  at 
the  same  hour,  they  may  happen  a  little  earlier  each  day,  when  they  are 
called  "  retarding."  The  former  is  apt  to  occur  when  the  disease  is  becoming 
more  severe,  the  latter  when  it  is  abating.  The  paroxysm  varies  in  length 
in  the  different  varieties.  In  the  quotidian  form  it  lasts  from  ten  to  twelve 
hours,  in  the  tertian  six  to  eight  hours,  and  in  the  quartan  four  to  six  hours. 

Malarial  cachexia  referred  to  in  the  definition,  also  known  as  chronic 
malaria,  will  be  fully  considered  later. 

Etiology. — The  malarial  fevers  are  to-day  believed  to  be  caused  by  a 
protozoon  known  as  the  Plasmodium  malarice  hematasobn,  or  hematomonas 
malaria:.  These  fevers  have  ever  been  a  field  which  seemed  to  promise 
reward  to  the  seekers  after  such  a  cause.  In  the  days  of  Hippocrates 
(B.  C.  460-357)  it  was  recognized  that  marshes  breed  malaria.  John  K.. 
Mitchell,*  an  eminent  American  physician,  was,  however,  the  first  to  sug- 
gest, in  a  scientific  manner,  the  parasitic  origin  of  malarial  fever.  This  was 
in  1849;  in  1859  John  K.  Barnes,f  of  the  United  States  Army,  also  called 
attention  to  such  a  mode  of  origin.  In  1869  Binz,  the  pharmacologist,, 
declared  that  the  cause  of  malaria  M^as  an  ameboid  protozoon,  because  of 
the  specific  action  of  quinin  on  ameboid  organisms.  Alassy,  Basa,  Wiener, 
Polk,  Holden,  Salisbury,  and  others,  all  suggested  a  fungous  origin  of 
malaria  on  more  or  less  unstable  foundations.  It  was  not  until  1879  ^^^'^ 
Ed.  Klebs  and  C.  Tommasi-Crudeli  succeeded  in  isolating  a  germ  which 
they  called  bacillus  malarice,  from  the  low-lying  atmosphere  over  marshes 
and  from  the  soil  itself,  the  inoculation  of  which  into  rabbits,  they  alleged, 
produced  malarial  paroxysms  with  enlargement  of  the  spleen  and  pigmenta- 
tion. No  permanent  impression  was,  however,  made  by  this  announcement. 
The  very  next  year,  1880,  A.  Laveran,  a  French  army  surgeon,  discovered 
the  Plasmodium  referred  to,  and  announced  the  discovery  to  the  Paris  Acad- 
emy of  Medicine  in  1881  and  1882.  His  researches  were  made  in  Algiers, 
and  in  the  course  of  the  next  three  years  he  published  numerous  papers. 
His  results  were  confirmed  by  Richard  in  1882.  E.  Marchiafava  and  A. 
Celli  published,  in  1885,  their  observations  on  the  same  organism  in  the 
blood  of  malarial  patients  in  Rome.  These  observers  were  the  first  to  insist 
upon  the  ameboid  property  of  the  intracellular  form.  From  this  time  our 
knowledge  has  been  enormously  extended  by  many  observers,  among  whom 
may  be  especially  mentioned  Golgi  (1885-92)  and  Canalis  (1893)  in  Italy; 
Vandyke  Carter  (1887)  and  Patrick  Alanson  (1893-96)  in  England; 
in  this  country  A.  C.  Abbott,  W.  T.  Councilman  (1885),  Surgeon  General 
Sternberg  and  William  Osier  (1886),  Walter  James  (1888),  George  Dock 
(1889-92),  William  Sydney  Thayer  and  John  Hewetson  as  authors  of  a 
mastrely  monograph  in  1895,  and  James  Ewing  in  1900;  Patrick  Manson 
(1894-96),  Surgeon  Major  Ronald  Ross  (1895-96),  and  Daniels  (1899)  in 
England  from  their  India  studies;  Grassi,  Bignami,  and  Bastianelli  (i^ 


*  "  On  the  Crvptog-amic  Oriarin  of  Malarias  and  Epidemic  Fevers,"  "American  Journal  of  the  Medi- 
cal Sciences,"  Philadelphia,  1849. 
t  "  U.  S.  Army  Reports,"  1859,  p.  163. 


THE  MALARIAL  FEVERS.  67 

99)  in  Italy,  and  W.  G.  AlacCallum  and  Eugene  L.  Opie  in  this  country,  have 
developed  the  mosquito  theory  to  a  positive  demonstration  that  malaria  may 
be  conveyed  from  the  mosquito  to  man,  and  from  man  to  the  mosquito. 

To  Study  the  Malarial  Organism. — The  malarial  organism  ^  is  best 
studied  as  follows : 

A  drop  of  blood  is  taken  from  the  finger  or  lobe  of  the  ear  of  a  case 
of  ordinary  tertian  intermittent  fever  during  the  chill,  or  an  hour  or  two 
previous,  while  the  temperature  is  gradually  rising.  It  should  be  suitably 
spread  on  a  slide  and  carefully  examined  by  the  microscope.  There  will  prob- 
ably be  found  a  number  of  pale,  mulberry-like  bodies  analogous  to  those  in 
figure  9,  A„,  A\,  made  up  of  from  twelve  to  twenty  segments,  massed  about 
a  clump  of  black  pigment  granules.  Careful  focusing  will  show  that  this 
body  lies  within  a  red  blood-corpuscle,  whose  delicate  walls  and  pale  sub- 
stance surround  it.  If,  now,  a  little  solution  of  gentian-violet  or  fuchsin 
be  successfully  added  to  the  preparation,  the  stain  will  impart  itself  to  each 
of  the  little  segments,  differentiating  a  deep-tinted  central  nucleolus  and 
more  lightly  stained  surrounding  protoplasm.  In  the  same  slide  may  be 
seen  other  similar  bodies  (-B,,  B„_,),  uninclosed  in  the  ring  of  hemoglobin, 
loosely  arranged,  apparently  falling  apart ;  also  small,  pale  spherules  ( C  j, 
C  2)  floating  alone  in  the  liquor  sanguinis,  apparently  derived  from  the  same 
source. 

If  the  blood  be  taken  during  the  chill,  careful  searching  may  also 
discover  certain  red  corpuscles  (D^,  D „,)  on  which  are  imposed  minute  pale 
spots  (epicorpuscular)  which  exhibit  ameboid  movement.  These  also  take 
a  stain  which  may  develop  a  central  nucleolus  and  lighter  surrounding  area, 
deepening  in  color  at  its  periphery.  The  colorless  intermediate  area  is 
usually  interpreted  as  a  bladder-like  nucleus,  the  deeper-stained  dot  at  one 
side  representing  the  nucleolus  which  is  not  apparent  in  the  unstained  speci- 
men. Sometimes  there  is  more  than  one  disc-like  body.  A  few  hours 
later,  after  the  chill,  none  of  the  free  bodies  described  is  visible,  but  within 

*  These  organisms  are  readily  seen  with  a  power  of  500  to  600  diameters,  but  are  best  studied  when 
magnified  1000  times,  say  by  an  oil  immersion  Tjth.  For  more  precise  study  take  from  the  finger- 
end,  or  better,  the  lobe  of  the  ear,  thoroughly  cleansed,  a  drop  of  blood  and  place  on  a  sterilized 
cover-glass,  which  should  then  be  allowed" to  fall  gently  on  a  glass  slide,  without  pressure.  If  the. 
study  is  prolonged,  the  edge  may  be  sealed  with  paraffin,  or  a  ring  cf  oil.  Staining  maj'  be  practiced 
as  follows : 

A  thin  layer  of  blood  is  spread  on  several  clean  cover  slips,  which  are  first  left  to  dry  in  the  air 
for  a  few  minutes,  and  then  placed  in  absolute  alcohol  to  fix  the  blood  corpuscles  and  parasites. 
After  13  to  20  minutes  the  cover-slips  are  dried  and  are  ready  for  staining,  although  the  last  stage 
may  be  deferred  indefinitely. 

They  may  be  stained  with  saturated  solution  of  methylene  blue,  which,  as  shown  by  Celli  and 
Guarnieri,  is  best  dissolved  in  blood  serum  or  ascitic  fluid. 

Double  staining,  which,  if  successfully  performed,  gives  brilliant  results,  should  be  done  by 
Ehrlich's  method,  as  modified  and  improved  by  Romanowsky,  i8go;  Ziemann  in  1898,  and  Nocht  in 
i8qq.  The  staining  fluid  is  a  mixture  of  a  one  per  cent,  solution  of  eosin  •with  a  saturated  solution  of 
methylene  blue,  which  develops  a  third  stain  that  colors  the  chromatin.  The  eosin  stains  the  red 
discs  pink,  the  methylene  blue  stains  the  hemosporidea  blue,  while  the  third  stain  colors  the  chrom- 
atin a  violet  tint. 

To  prepare  the  Xocht-Romanowsky  staining  fluid,  Ewing  directs  as  follows.  Make  first  the 
following  three  solutions: 

(i)  Polychro7}ie  Methylene  Blue  Solution.— To  i  oz.  of  polychrome  methylene  blue  (Grubler) 
add  5  drops  of  3  per  cent,  solution  of  acetic  acid  (U.  S.  P.  33  per  cent.)  to  neutralize  the  undue 
alkalinity. 

(2)  O'rdinarv  .Methvletie  Blue  Solution.— yisike  a  i  per  cent,  (saturated)  watery  solution  of  methy- 
lene blue,  prefe'rably  Ehrlich's  rectified,  or  Koch's,  by  aid  of  gentle  heat.  This  solution  improves 
with  age  and  should'  be  at  least  a  week  old. 

(3)  Eosin  Solution. — A  i    per  cent,  solution  in  water  of  Griibler's  aqueous  eosin. 
Then  to  10  c.  c  of  water  add  4  drops  of  (^).  6  drops  of  (i),  and  2  drops  of  (2I,  mixing  well. 

To  Use.— Ttie  specimens  fixed  bv  alcohol  or  heat  are  immersed  for  two  hours  specimen-side 
down,  and  will  not  overstain  bv  twentv-four  hours'  immersion.  They  should  be  then  washed  in 
distilled  water,  dried  slowl  v  over  the  flame  and  mounted,  if  desired,  in  Canada  balsam.  The  density 
af  the  blue  may  be  varied  to  suit  individual  fancv,  nor  need  the  proportions  be  rigidly  followed,  but 
most  important  is  the  accurate  neutralization  of  the  polvchrome  solution. 

Preliminarv  studies  mav  be  made  of  the  drepanidiutn  ranarutn,  a  similar  parasite  in  the  red 
corpuscle  of  the  frog  (Osier."  "  Canadian  Lanaet."  Xo.  7.  1882);  or  on  the  hematozoa  of  birds._  (See 
papers  by  W.  G.  MacCallum  and  Eugene  L.  Opie  in  "  Tour,  of  Experimental  Medicine,"  vol.  111.  No. 
I,  1808;  see  also  Angelo  Celli's  admirable  book  on  "  Malaria,"  2d  ed..  translated  by  John  Joseph  Eyre, 
London,  iqoo,  where  the  whole  subject  is  treated  most  interestingly  and  fully.) 


6S 


INFECTIOUS  DISEASES. 


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Ai 


BZ 


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aj^fo, 


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Fig.  g.— Illustrating   Different  Forms   of  the   Malarial  Organism  with    their  Stages 

of  Development. 

Au  --^3,  As,  Ai.  Sporulation  stage.  Bi,  B^.  Sporules  separating.  C  C^.  Free 
sporules.  Dx,  D^.  Epicorpuscular  forms.  E^,  E^,  E%,  E^.  Intracorpuscular 
forms.  Fx,  F^.  The  large  extracorpuscular  body.  Gx,  d,  Hs.  The  flagellate 
forms.  Hi,  H^,  Hz,  Hi,  H^,  H^.  The  crescent-shaped  parasite  and  forms  result- 
ing from  its  evolution.  Drawings  in  the  upper  part  of  the  plate  from  the  blood  of 
a  case  in  the  wards  of  the  Hospital  of  the  University  of  Pennsylvania,  those  in 
the  lower  portion  selected. 


THE  MALARIAL  FEVERS.  69 

the  corpuscles  are  seen  actively  moving  ameboid  bodies  (£3,  E^,  )  of  con- 
siderable size,  constantly  changing  shape,  and  sending  out  pseudopodia  into 
the  substance  of  the  blood-corpuscle.  These  intracorpuscular  bodies  stain 
with  the  same  differentiation  as  the  smaller  disc-like  bodies,  but  the  nucleus 
is  larger  and  less  distinct.  Many  of  them  contain  one  or  more  dark  granules 
in  active  motion. 

Still  later,  toward  the  next  paroxysm,  the  pale  body  fills  the  entire 
corpuscle,  its  ameboid  movement  ceases,  while  the  pigment  granules  are 
more  numerous  and  stationary.  It  has,  moreover,  lost  its  nucleus  and  nucle- 
olus. The  pigment  now  tends  to  mass  itself  into  clumps  or  radiating  lines, 
and  just  before,  or  at  the  time  of  the  chill,  the  picture  first  described,  of 
rosettes  or  loosely  attached  and  free  spherules,  is  seen.  The  same  cycle  of 
successive  steps  is  kept  up  from  paroxysm  to  paroxysm.  The  conclusion 
reached  by  all  observers  is  that  the  large  intracorpuscular  body  (Fig.  9,  A^) 
is  the  mature  parasite  ready  for  sporulation,  and  the  mulberry  mass  presents 
the  sporules  perfectly  formed,  which  a  few  seconds  later  become  free  spher- 
ical spores.  These  attach  themselves  to  the  red  discs,  penetrate  them,  and 
grow  at  the  expense  of  the  hemoglobin,  leaving  the  black  granular  residue 
as  excrementitious  substance,  which  is  let  loose  in  the  blood  at  the  time  of 
sporulation.  As  a  consequence  of  this,  the  presence  of  pigment  in  the  blood 
and  tissues  is  one  of  the  most  characteristic  features  of  malaria. 

The  time  required  to  attain  the  perfect  growth,  from  the  free  sporule  to 
the  last  stage  of  sporulation,  varies  in  the  different  varieties  of  malarial  fever. 
During  this  period  certain  groups,  perhaps  numbering  myriads  of  cor- 
puscles, pass  through  the  same  stages,  and  the  final  sporulation  of  such  a 
group  of  parasites  is  always  followed  by  the  malarial  paroxysm.  This  is 
probably  due  to  some  toxic  substance  developed  at  the  time  of  sporulation. 
Thus,  with  the  typical  quotidian  type,  sporulation  takes  place  every  day  at 
the  same  hour,  with  the  tertian  type  every  other  day,  the  quartan  type  every 
seventy-two  hours,  and  so  on.  If,  however,  two  groups  ripen  at  different 
hours,  we  have  the  double  forms,  be  it  double  tertian  or  double  quartan. 
Or  two  groups  of  tertian  parasites  may  mature  on  alternate  days,  causing 
a  quotidian  paroxysm,  though  at  different  hours.  A  paroxysm  may  be 
expected  at  once  in  the  tertian  form,  if  radiating  lines  appear  in  the  organism 
with  concentration  of  pigment.  The  cycle  of  existence  of  the  estivo- 
autumnal  type  has  an  undetermined  duration,  and  probably  varies  from 
twenty-four  to  forty-eight  hours.  The  irregular  ripening  of  different  groups 
would  explain  the  irregularity  of  the  estivo-autumnal  forms  of  fever,  which 
may  begin  as  regular  types. 

Attempts  are  further  made  to  differentiate  the  parasite  of  the  different 
types  of  fever  by  its  dimensions,  rapidity  of  ameboid  movement,  size  and 
number  of  pigment  granules,  number  of  segments  in  sporulation,  etc.  Thus 
the  full-grown  parasite  of  tertian  fever  is  about  as  large  as  a  normal  red 
blood-corpuscle,  beginning  its  cycle  of  development  as  a  much  smaller 
hyaline  ameboid  body.  It  acquires  rapidly  fine,  brown  pigment  granviles 
formed  at  the  expense  of  the  surrounding  blood-disc,  which,  becoming 
gradually  decolorized,  becomes  larger  and  more  indistinct  until  it  disappears. 
The  granules  exhibit  active  movement.  In  the  sporule  stage  the  segments 
number  from  fifteen  to  twenty,  or  even  more.  The  parasite  has  a  cycle  of 
48  hours. 

The  parasite  of  quartan  fever  is  very  similar,  but  it  is  smaller;  its 
ameboid  movements  are  slower,  and  the  pigment  granules  coarser,  darker, 


70  INFECTIOUS  DISEASES. 

and  less  active  in  motion.  The  red  corpuscle  embracing  it,  instead  of 
becoming  larger  and  paler,  shrinks  about  the  parasite  and  assumes  a  deeper, 
greenish  hue.  The  sporulation  segments  are  fewer,  only  from  five  to  ten  in 
number,  and  arranged  with  great  regularity  about  the  central  pigment  (Fig. 
C),  A  „).     Its  cycle  is  y2  hours. 

The  parasite  of  the  estivo-aiitiimnal  fever  is  still  smaller,  being,  when 
fullv  developed,  often  less  than  half  the  size  of  a  red  blood-corpuscle,  and 
tlie  quantity  of  pigment  is  much  smaller.  Only  the  early  stages  of  its 
development,  represented  by  small  hyaline  bodies,  often  with  one  or  two 
pigment  granules,  are  found  in  the  peripheral  circulation,  the  later  stage 
being  seen  in  the  blood  of  internal  organs,  such  as  the  spleen  and  bone- 
marrow.  The  fewness  of  the  pigment  granules  is  characteristic.  The 
corpuscles  containing  the  parasite  are  also  apt  to  become  shrunken,  crenated, 
and  brassy  in  color.  After  a  week  or  more,  the  larger  crescentic  ovoid  and 
round  bodies  to  be  described  make  their  appearance,  and  are  characteristic 
of  this  form  of  fever.     The  cycle  of  this  parasite  is  about  48  hours. 

The  large  extracorpuscular  body  {F ^,  F^,),  which  presents  the  same 
pigmentation  and  other  features  of  the  intracorpuscular  body,  is  the  latter 
escaped  from  the  corpuscle.  The  event  of  its  escape  may  sometimes 
be  observed  while  studying  blood  taken  about  the  time  when  most  of  the 
intracorpuscular  bodies  have  disappeared  by  sporulation.  Such  escape, 
it  is  thought,  does  not  take  place  in  the  living  blood,  since  the  corpuscle  is 
not  found  in  preparations,  dried  or  ""  fixed."  immediately  after  the  removal 
of  the  blood  from  the  body.  It  is  found,  however,  in  preparations  watched 
with  the  microscope  for  some  minutes  after  being  taken. 

The  crescejit-shaped  parasite  (Fig.  9,  i7,,  H.,,  H^,  H^,  H^,  H^,)  is  also 
a  striking  object,  far  less  frequently  met,  at  least  in  the  vicinity  of  Philadel- 
phia, than  the  ordinary  pigmented  form.  Unlike  the  large  extracorpuscular 
form  already  described  and  the  flagellate  form  to  be  next  described,  it  is 
apparently  a  constituent  of  living  blood,  and,  according  to  the  studies 
of  Thayer  and  Hewetson.  as  well  as  the  earlier  ones  of  Marchiafava  and 
Celli,  appears  in  most  of  the  cases  of  estivo-autumnal  fever  after  a  certain 
time,  generally  during  the  second  or  third  week,  and  not  in  the  cycle  of 
development  of  tertian  or  quartan  fevers.  The  crescent  develops  in  the 
interior  of  the  red  corpuscle  from  the  small  hyaline  forms,  which  gradually 
increase  in  size,  lose  their  ameboid  movement,  and  assume  a  crescentic 
shape,  while  pigment  granules  collect  in  a  group  at  the  center.  The  cor- 
puscle itself  gradually  becomes  decolorized  and  ultimately  destroyed, 
though  for  some  time  a  delicate  line  can  be  seen  running  between  the  horns 
of  the  crescent,  a  shell,  as  it  were,  of  the  corpuscle  in  which  the  parasite 
is  developed.  The  crescents  in  turn  change  into  elliptical,  ovoid,  and  finally 
round  forms.  When  the  round  form  is  assumed  the  pigment  starts  into 
active  motion,  and  sporulation  may  take  place.  Such  sporulation  may  also. 
according  to  Canalis,  Manson.  and  Ross,  be  by  flagellation. 

The  flagellate  organism  (  G^,  G„)  may  also  com.e  into  view  on  the  slide 
some  fifteen  or  twenty  minutes  after  the  blood  is  mounted,  but  is  never  seen 
on  slides  "  fixed  '"  immediately  after  the  blood  is  drawn.  It  develops  from 
the  full-grown  tertian  and  quartan  parasites  and  from  the  round  bodies  with 
central  pigment  in  estivo-autumnal  infections.  It  is  a  very  interesting 
object,  the  tentacle-like  prolongations  lashing  about  the  central  mass  and 
agitating  the  surrounding  corpuscles  in  a  seemingly  violent  manner,  throw- 
ing the  latter  and  its  own  melanin  particles  into  a  state  of  extreme  commo- 


THE  MALARIAL  FEVERS.  71 

tion.     Sometimes  portions  of  these  tentacles  break  loose  and  float  away  in 
the  blood  plasma. 

It  will  be  noted  that  no  quotidian  parasite  is  described.  It  is  not 
thought  that  a  special  form  causing  this  variety  of  intermittent  fever  exists, 
but  that  the  quotidian  paroxysm  is  due  to  the  maturation  on  successive  days 
of  two  swarms  of  the  tertian  parasite. 

Though  the  mosquito  theory  of  malaria  is  by  no  means  new,  it  was  not 
imtil  1894  that  Patrick  Manson  gave  it  definiteness  by  suggesting  the  mos- 
quito might  be  the  intermediate  host  for  the  extracorporeal  forms  of  the 
parasite,  that  the  flagellate  form  is  the  first  extracorporeal  stage,  and  that 
the  flagella,  breaking  off  from  the  residual  body,  may  penetrate  the  cells 
of  some  organ  of  the  insect.  He  first  claimed  that  the  crescentic  form  of 
estivo-autumnal  malaria  and  the  tertian  and  quartan  spherical  forms  from 
which  develop  flagella  are  the  "  extracorporeal  sporulating  homologues  of 
the  intracorporeal  organism ;  that  the  flagellum  is  the  extracorporeal  homo- 
logue  of  the  intracorporeal  spore."  Both  types  of  sporulating  plasmodium 
possess  the  same  function, — the  propagation  of  the  parasite, — one  in  the 
human  body ;  the  other,  outside  of  it.  Surgeon  Major  Ronald  Ross,  whose 
studies  were  stimulated  by  Manson,  found  the  flagellate  form  in  the  stomach 
of  mosquitos  that  had  fed  on  subjects  suffering  with  estivo-autumnal  fever 
whose  blood  contained  large  numbers  of  crescents,  confirming  Manson's 
observations.  Again,  Daniels,  working  in  Calcutta  under  Ross'  direction, 
was  able  to  confirm  all  the  latter 's  observations.  Angelo  Celli,  while  admit- 
ting that  Ross  partly  saw  the  first  stages  of  development  of  the  estivo- 
autumnal  parasites  in  the  body  of  a  dapple-winged  mosquito,  holds  that 
Grassi,  Bastianelli,  and  Bignami  have  given  us  all  the  details  of  its  develop- 
ment.* W.  G.  MacCallum  demonstrated  in  his  observations  on  halteridium 
of  Labhe,  a  malarial  parasite  of  birds,  that  the  flagella  represent  male  sexual 
elements. 

Favoring  Causes  and  Geographical  Distribution  of  the  Malarial  Fevers. 
— Such  is  the  belief  as  to  the  immediate  cause  of  malarial  fever  at  the 
present  day,  evidence  being  strongly  in  favor  of  the  view  that  inoculation 
is  the  only  mode  by  which  the  infection  is  carried  from  the  mosquito  to  man 
and  from  man  back  to  the  mosquito.  Indeed,  most  recent  studies  by  the 
Italians,  Bastianelli  and  Bignami,  have  determined  the  species  of  mosquitos 
that  are  capable  of  producing  two  forms  of  infection.  They  are  the 
anopheles  claviger  and  anopheles  pictns  (dapple-winged  mosquito  of  Ross), 
both  conveying  the  estivo-autumnal  form,  while  the  former  is  the  conveyer 
of  tertian  infection.  These  views  are  further  confirmed  by  the  conditions 
which  favor  malarial  fever,  and  these  conditions,  notwithstanding  exceptions, 
are  hot  climates  and  hot  seasons  plus  decomposing  vegetable  matter,  low 
river  banks  frequently  covered  and  uncovered  with  water  and  exposed  to  the 
sun — in  a  word,  conditions  that  favor  the  breeding  of  mosquitos. 

Wherever  these  conditions  occur,  malaria  is  rife.  Especially  are  they 
found  in  the  southern  borders  of  the  north  temperate  zone,  as  in 
Southern  United  States,  Southern  Italy,  and  along  the  lower  Danube ;  the 
northern  border  of  the  south  temperate  zone,  in  the  tropics,  as  Central 
America,  the  West  Indies,  Central  Africa,  and  Southern  Asia.  A  freshly 
upturned  soil  may  furnish,  under  a  sufficiently  high  temperature,  a  min- 
imum of  60°  F.  (15.6°  C),  as  favorable  a  focus  almost  as  a  marshy  river 
bank.     All  ages  are  susceptible,  but  children  are  especially  liable  to  take  the 


*  Celli,  "Malaria,"  2d  ed.    Translated  by  John  Joseph  Eyre,  London,  igoo. 


72  INFECTIOUS  DISEASES. 

disease  on  exposure.  More  men  have  it  than  women,  for  evident  reason. 
Currents  of  air  carry  the  disease  to  localities  in  which  it  is  not  primarily 
engendered,  only  by  carrying  the  mosquitos  laden  with  the  extracorporeal 
forms.  Water  ingested  cannot  be  a  cause  of  malarial  infection,  according 
to  modern  views. 

Morbid  Anatomy, — The  morbid  anatomy  of  malaria  includes  mainly 
changes  in  the  blood,  the  liver,  and  the  spleen, — changes  that  vary  with 
the  duration  and  intensity  of  the  disease,  to  which,  however,  they  do  not 
always  correspond. 

As  to  acute  malaria:  In  the  true  intermittent  fevers  there  is  a  loss,, 
sometimes  considerable,  of  red  corpuscles  after  each  paroxysm,  which  is 
made  up  during  the  intermission.  In  the  estivo-autumnal  form  the  blood 
losses  are  greater  and  more  permanent.  The  absence  of  leukocytosis  is 
characteristic.  In  remittent  and  pernicious  malaria — the  latter  a  form  char- 
acterized by  the  intensity  of  the  poison  and  severity  of  the  symptoms — 
the  morbid  changes  may  not  be  very  striking  if  the  patient  die  in  the  first 
attack,  but  more  marked  after  a  second.  The  blood  is  described  as  hydremic,, 
the  serum  is  sometimes  tinged  with  hemoglobin,  and  the  corpuscles,  while 
containing  the  parasite,  present  all  stages  of  destruction.  The  spleen  is 
enlarged,  but  not  nearly  so  much  as  in  chronic  recurring  forms  of  malaria. 
It  is,  m.oreover,  soft  and  its  pulp  is  dark  from  accumulated  pigment  in  the 
intervascular  cords.  The  liver  is  enlarged  and  dark-hued,  sometimes 
described  as  bronze  and  sometimes  slate-color.  Even  when  not  visibly 
altered  to  the  naked  eye,  there  may  be  no  difficulty  in  recognizing  the  excess 
of  pigment  within  and  without  the  small  vessels,  some  of  which  may  be 
occluded.  In  fact,  by  the  aid  of  a  microscope,  almost  all  the  tissues  may 
be  found  abnormally  pigmented,  even  the  brain,  some  small  vessels  of  which 
may  also  be  occluded.  The  kidneys  are  the  seat  of  pigment  deposits,  and 
their  cells  of  cloudy  swelling. 

In  chronic  malaria  the  blood  changes  are  even  more  marked.  There 
is  a  positive  secondary  anemia  in  which,  as  usual,  the  hemoglobin  is  de- 
creased rather  more  than  the  corpuscles.  The  leukocytes  are  almost  invari- 
ably diminished,  the  polynuclear  leukocytes  most,  while  the  larger  mono- 
nuclear forms  are  relatively  increased.  Pigment  deposits  are  abundant, 
especially  in  the  spleen,  which  is  enlarged  and  hard. 

In  chronic  malaria,  of  whatever  form,  the  enlarged  spleen  is  the  most 
characteristic  morbid  product.  It  may  weigh  as  much  as  ten  pounds  (4.5 
kilos.)  and  measure  ten  inches ^(25  cm.)  long  and  four  (10  cm.)  to  six  (15 
cm.)  in  width;  its  capsule  is  thickened,  its  substance  firm,  and  the  tra- 
beculse  prominent.  Pigmented  areas  abound,  due  to  the  plugging  with 
pigment  of  the  intercommunicating  lymphoid  spaces  of  the  pulp,  and  in- 
some  cases  the  melanosis  is  general.  The  pigment  particles  resulting  from 
the  disintegration  of  the  hemoglobin  in  the  vessels  are  retained  in  the  spleen,, 
as  by  a  filter. 

The  liver  is  also  enlarged,  to  a  less  degree,  however,  than  the  spleen. 
It  is  indurated  and  presents  various  degrees  of  pigmentation,  which  may 
reach  a  slate-gray  tint.  The  pigment  is  contained  in  the  portal  canals  and 
beneath  the  capsule. 

The  kidneys  may  be  similarly  pigmented,  the  pigment  lying  about  the 
smaller  blood-vessels  and  the  Malpighian  bodies,  and  in  the  cells  lining  the 
tubules.  In  protracted  cases  of  malarial  cachexia  other  tissues  may  be 
pigmented.     Thus,  the  small  vessels  of  the  brain  may  be  surrounded  by 


INTERMITTENT  FEVER.  75, 

pigment  and  even  occluded,  so  that  hemorrhagic  infarcts  may  occur.  Even 
the  mucous  membrane  of  the  stomach  and  the  peritoneum  may  be  pig- 
mented in  extremely  chronic  cases.  Malarial  poisoning  is  included  among 
the  causes  of  chronic  nephritis,  but,  in  considerable  experience  with  renal 
diseases,  I  can  recall  but  one  or  two  cases  of  nephritis  doubtfully  traceable 
to  this  cause. 

CLINICAL  VARIETIES. 

The  chief  varieties  of  malarial  fever  admit  of  easy  separation  by  their 
symptoms. 

Intermittent  Fever. 

Definition. — This  form  of  malarial  fever  is  characterized  by  a  total 
remission  of  fever  between  paroxysms. 

Symptoms. — This,  the  well-known  fever  and  ague,  characterized  by 
distinct  paroxysms  of  chill,  fever,  and  sweat,  has  a  distinct  period  of  incuba- 
tion, which  mav  be  as  short  as  twenty-four  hours  or  even  less,  though  usually 
it  is  from  a  week  to  fourteen  days.  Sometimes  it  is  very  nmch  longer,  and 
even  months  are  said  to  elapse  after  exposure  before  the  first  paroxysm  sets 
in.  The  paroxysm  is  usually  preceded  by  a  prodrome  of  uneasiness  and  dis- 
comfort, sometimes  languor  and  yawning,  sometimes  headache,  sometimes 
nausea,  which  forewarns  the  patient  of  its  coming.  As  often  as  not  there  is 
no  such  prodrome.  The  paroxysm  consists  of  the  chill  or  cold  stage,  the 
fever,  and  the  sweat. 

The  chill  commonly  begins  gradually.  First  there  is  a  creep,  then 
another  a  little  more  severe,  then  another,  each  growing  in  severity  until  the 
teeth  chatter  and  the  body  shakes  violently.  There  is,  however,  great  dif- 
ference in  the  severity  of  the  chill.  It  may  be  a  barely  noticeable  creep  or 
such  a  chill  as  will  cause  the  bed  and  even  the  windows  of  the  room  to  shake. 
At  the  same  time  the  patient's  lips  are  blue,  his  face  is  pale  and  pinched,  and 
he  looks  very  cold.  Yet  he  has  fever.  Even  before  the  chill  there  is  a  slight 
rise  in  temperature,  and  during  it  the  latter  may  reach  105°  F.  (40.5  C.)  and 
106°  F.  (41.1°  C.)  in  the  axilla  or  mouth.  A  surface  thermometer  may 
show  a  lower  temperature  of  the  skin,  but  the  internal  heat  is  in  strong  con- 
trast with  the  apparent  coldness.  There  may  be  nausea  or  vomiting  and 
severe  headache.  The  pulse  is  small,  hard,  and  frequent.  The  hands  are 
pale,  cold,  and  the  nails  blue.  The  urine  is  increased,  light-hued,  of  low 
specific  gravity,  though  before  the  chill  it  may  be  concentrated  and  the  specific 
gravity  high.  The  duration  of  the  chill  varies  from  a  few  minutes  to  an  hour 
or  more. 

To  the  chill  succeeds  the  fever.  The  skin  is  intensely  hot  and  dry  and 
the  face  flushed.  There  is  intense  thirst.  The  mouth  is  dry,  the  tongue 
coated,  the  breath  foul.  There  is  no  mistaking  this  stage  any  more  than  the 
first.  Yet  the  actual  temperature  is  but  little  higher  than  during  the  chill. 
This  is  well  shown  in  the  appended  chart,  in  which  it  will  be  seen  that  the 
temperature  during  the  chill  at  two  successive  observations  was  104.2°  F. 
(40°C.)  and  104.4°  F-  (40.18°  C.)  ;  during  the  succeeding  fever  it  reached 
at  the  first  observation  104.8°  F.  j,40.4°  C),  and  at  the  second,  105°  F. 
('40.45°  C).  The  duration  of  this  stage  is  from  half  an  hour  to  four  or  six 
hours. 

The  siveating  stage  follows,  with  the  appearance  of  drops  of  sweat  on 


74 


INFECTIOUS  DISEASES. 


the  face,  whence  it  extends  all  over  the  body  and  is  various  in  quantity.  With 
it  comes  relief  to  all  the  symptoms.  Indeed,  a  sense  of  great  comfort  super- 
venes. It  may  be  a  mere  suggestion  of  moisture,  or  it  may  be  very  profuse, 
drenching  the  patient's  clothing  and  even  wetting  the  bed.  It  is  commonly 
proportionate  to  the  severity  of  the  chill.  During  the  sweat  the  temperature 
falls  rapidly,  but  if  the  paroxysm  is  severe  several  hours  elapse  before  it 
attains  the  normal.  It  lasts  for  half  an  hour  to  tzvo  hours,  after  which  the 
patient  feels  comfortable  and  well. 

It  is  not  easy  to  give  a  satisfactory  rationale  of  the  three  stages.     The 


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Pig.  10. — Temperature  Chart  in  Intermittent  Fever,  Showing  Paroxysms  and  Inter- 
missions. 

It  will  be  noted  that  the  temperature  has  been  taken  during  the  chill,  and  during  the 
fever  just  after  the  chill,  and  that  although,  as  is  well  known  the  fever  is 
very  high  during  the  chill  while  the  patient  feels  cold,  it  is  still  a  little  higher 
during  the  fever  just  after  the  chill. 

first  and  second  are  undoubtedly  the  direct  result  of  the  same  cause — a  toxin 
generated  by  the  plasmodium,  since  the  actual  fever  which  characterizes  both 
is  irritative.  The  superficial  coldness  and  sense  of  cold  of  the  first  stage  may 
be  the  result  of  vasomotor  spasm  contracting  the  blood-vessels  of  the  surface 
and  due  to  an  irritation  of  vasomotor  centers  by  the  toxin ;  the  second  stage 
to  a  derangement  of  the  heat-regulating  centers.  The  third  stage  is  probably 
a  reactive  vasomotor  paralysis,  with  the  usual  leakage  from  the  skin  inci- 
dent to  it. 

The  total  duration  of  the  paroxysm  is  from  eight  to  tivelve  hours,  and 
usually  between  the  paroxysms  the  patient  feels  perfectly  well.  During  the 
paroxysm  the  spleen  becomes  enlarged  and  the  malarial  patient  has  often 
herpes  labialis,  a  symptom  which  is  almost  pathognomonic  of  malarial  fever. 
The  size  of  the  spleen  subsides  after  the  paroxysm,  although  with  its  repe- 
tition there  is  a  disposition  to  permanent  enlargement,  resulting  finally  in  the 
ague  cake. 


INTERMITTENT  FEVER. 


75 


The  types  of  the  paroxysm  so  characteristic  of  intermittent  fever  have 
already  been  referred  to.  The  order  of  frequency  is  quotidian,  tertian,  and 
quartan ;  the  first  being  by  far  the  most  frequent. 

Diagnosis. — The  diagnosis  of  intermittent  fever  is  most  easy,  and  a 
typical  case  should  be  easily  recognized  after  the  second  paroxysm,  if  not 
after  the  first.  If  the  case  be  less  typical  and  the  chill  omitted  or  so  slight 
as  to  escape  recognition,  a  certain  resemblance  between  such  a  paroxysm 
and  the  hectic  fever  of  tubercular  consumption,  with  its  subsequent  sweat, 
must  be  admitted,  and   it  not   infrequently  happens  that  such   fevers  are 


Fis;  II.— Temperature    Chart   in    Intermittent   Fever,  Showing  the    Paroxysms   and   Intermissions. 

declared  to  be  malarial  by  the  attending  physician — more  frequently,  it  is  to 
be  hoped,  for  the  sake  of  comforting  the  patient  than  as  a  matter  of  accurate 
diagnosis. 

Still  more  close  is  the  resemblance  of  the  paroxysm  to  the  chills,  fever, 
and  sweats  of  septicemia  and  pyemia,  while  suppuration  is  frequently  ushered 
in,  and  its  progress  associated  with  like  symptoms.  Other  conditions  cal- 
culated to  produce  these  symptoms  may  generally  be  discovered  on  careful 
inquiry,  though  they  may  escape  notice  for  a  time.  In  addition  to  suppura- 
tion, surgical  operations,  catherization,  puerperal  fever,  the  incidence  of 
empyema,  and  the  like,  all  produce  chill,  fever,  and  sweat.     The  so-called 


16  INFECTIOUS  DISEASES. 

nervous  chill  is  easily  distinguished,  because  with  it  there  is  no  rise  of  tem- 
perature— at  least  nothing  at  all  comparable  to  that  of  the  malarial  chill. 
The  possible  combination  of  malaria  with  other  causes  of  chill  and  sweats 
is  to  be  remembered.  A  search  for  the  hematozoon,  scarcely  necessary  for 
diagnosis  in  typical  cases,  may  under  such  circumstances  prove  extremely 
useful. 

Prognosis.— The  prognosis  of  simple  intermittent  fever  is  always  fav- 
orable. Very  frequently,  if  the  disease  is  not  treated  by  medicine,  it  will 
exhaust  itself  in  a  couple  of  weeks  and  disappear,  v.'hile  the  administration  of 
suitable  doses  of  quinin  always  puts  an  end  to  it.  The  worst  that  can  happen 
is  the  conversion  of  the  disease  into  chronic  malaria  or  the  malarial  cachexia. 
This  may  occur  when  treatment  is  neglected,  or  when  constant  exposure  to 
the  cause  operates  to  produce  such  a  state  notwithstanding  suitable  treatment. 

Remittent  Fever — Estivo-autumnal  Fever. 

Definition. —  Remittent  fever  is  the  form  of  malarial  fever  characterized 
by  a  continued  fever  with  paroxysmal  exacerbations.  It  is  also  known  as 
bilious  fever.  It  has  become  rare  at  the  present  day  in  the  North  Atlantic 
States  of  America,  and  is  confined  mainly  to  the  South,  to  Italy,  the  lower 
Danube  sections  in  Europe,  and  to  tropical  countries.  It  occurs  in  the  late 
summer  and  fall,  and  hence  is  included  among  the  estwo-autiimnal  fevers. 

Symptoms. — It  generally  begins  with  a  chill  after  a  period  of  incuba- 
tion analogous  to  that  of  intermittent  fever.  It  is  more  likely  to  be  preceded 
by  prodromal  symptoms  than  is  intermittent.  There  are  malaise,  intense 
headache,  a  coated  tongue,  and  often  obstinate  nausea  and  vomiting.  Vomit- 
ing of  bilious  matter  is  a  conspicuous  symptom.  These  gastric  symptoms, 
formerly  ascribed  to  gastritis,  are  probably  caused  by  central  nervous  irrita- 
tion due  to  the  toxin.  There  may  be  jaundice  resulting  from  obstructing 
cholangitis ;  the  liver  may  be  tender  on  pressure.  The  chill  may  be  less 
severe,  and  the  other  stages  of  the  paroxysm  less  characteristic.  The  fever 
does  not  pass  off,  but  continues  with  a  full,  bounding  pulse  and  a  tempera- 
ture of  102°  to  103°  F.  (38.9°  to  39.5°  C).  There  are  daily  remissions,  as 
in  typhoid  fever,  but  they  do  not  follow  the  same  rule  of  tidal  rise.  Yet  the 
two  diseases  are  very  similar,  and  often  thoroughly  try  the  diagnostic  skill, 
even  of  those  who  are  accustomed  to  meet  bilious  remittent  fever.  The  tem- 
perature rises  quite  as  high  as  in  typhoid  fever,  and  the  patient  is  usually  very 
ill.  The  two  diseases  occur  a-t  the  same  time  of  the  year — the  autumn.  It  is 
not  impossible  for  them  to  be  concurrent. 

There  is  little  else  that  is  peculiar  in  the  symptomatology  of  the  common 
forms  of  remittent  fever  besides  the  prodrome,  the  malarial  organism,  and 
the  peculiar  paroxysmal  character.  In  prolonged  remittent  fever  the  typhoid 
state  is  sometimes  assumed,  manifested  by  dry  tongue,  hebetude,  stupor,  and 
feeble,  frequent  pulse. 

The  urine  is  high-colored,  with  high  specific  gravity,  depositing  a 
copious  sediment  of  urates,  and  sometimes  contains  biliary  coloring-matter. 
Not  infrequently    it  contains  blood-corpuscles  or  hemoglobin. 

Diagnosis. — As  intimated,  it  is  with  typhoid  fever  that  remittent  fever 
is  most  likely  to  be  confounded.  Occasionally  in  the  South  there  has  been 
confusion  with  yellow  fever.  To  us  who  study  typhoid  fever  in  the  North 
it  seems  surprising  that  there  should  be  any  confusion  with  this  disease.  It 
is  ordinarily  so  easy,  after  watching  the  temperature  chart  for  a  few  days,  to 


PERNICIOUS  MALARIAL  FEVER.  yy 

recognize  typhoid  fever.  In  the  South  it  is,  however,  different,  and,  before 
the  discovery  of  Laveran's  plasmodium,,  the  therapeutic  test — administration 
of  quinin — was  frequently  needed  to  settle  the  question ;  for  remittent  fever, 
like  intermittent  fever,  yields  to  quinin.  In  such  cases  a  successful  search 
for  the  hematozoon  will  settle  the  question  promptly.  This  is  the  variety  in 
which  we  have  the  small,  actively  motile  hyaline  forms  of  organism,  while 
the  larger  crescentic,  ovoid  bodies  are  to  be  looked  for  as  soon  as  the  disease 
has  existed  over  a  week.  An  unsuccessful  search  may  still  leave  the  matter 
in  doubt,  but  if  the  nasal  hemorrhage,  the  typhoid  spots,  the  diarrhea  of 
typhoid,  and  the  temperature  are  not  sufficiently  characteristic,  the  quinin 
test  ought  to  put  an  end  to  all  doubt.  The  Widal  test  has  come  to  our  aid, 
also,  of  late,  and  if  responded  to  affords  conclusive  evidence  of  the  presence 
of  typhoid  fever.  Although  it  may  seem  presumptuous  for  one  who  has  not 
practiced  in  the  South  to  say  it,  such  study  as  I  have  been  able  to  give  to  the 
subject  impels  me  to  say,  with  Osier,  that  all  of  the  continued  endemic  fevers 
of  the  South  may  be  resolved  into  typhoid  or  malarial  fever. 

The  diagnostic  distinction  between  remittent  fever  and  yellozv  fever  will 
be  given  when  considering  the  latter  disease. 

Prognosis. — This  is  usually  favorable  when  treatment  can  be  promptly 
applied. 

Pernicious  Malarial  Fever — The  Congestive  Chill. 

Definition. — This  variety  of  malarial  fever  is  characterized  by  the 
extreme  severity  of  its  paroxysms. 

Occurrence. — It  still  presents  itself  occasionally  in  the  North,  but  is 
much  rarer  than  it  was  fifty  years  ago.  Up  to  a  few  years  ago  it  was 
not  uncommon  to  hear  of  the  death  from  this  cause  of  a  prominent  citizen  at 
his  country  seat  on  the  banks  of  the  Delaware  above  Philadelphia.  Later, 
the  cases  became  confined  to  the  servants  and  others  out  late  at  night  or  early 
in  the  morning,  and,  more  recently  still,  even  such  cases  as  these  are  seldom 
reported,  although  the  milder  forms  of  malaria  prevail.  It  is  still  prevalent 
in  the  Southern  United  States,  in  Italy,  the  lower  Danube,  the  Niger  delta, 
and  other  parts  of  tropical  Africa.  According  to  the  Italian  observers,  per- 
nicious malarial  fever  is  associated  with  the  small  plasmodium. 

Two  principal  types  present  themselves — the  comatose  and  the  algid. 
Other  forms,  named  from  special  features  more  or  less  characteristic,  are  the 
hematuric,  the  bilious  and  the  asthmatic  types.  As  malarial  hematuria  is 
not  confined  to  the  pernicious  variety,  it  will  receive  separate  consideration. 
The  bilious  type  is  that  of  the  ordinary  severe  form  of  remittent  fever,  while 
asthma  characterizes  the  comatose  and  algid  types. 

I.  The  comatose  type  may  or  may  not  begin  with  a  chill,  but  in  its  more 
serious  forms  the  chill  is  a  conspicuous  feature,  being  severe.  To  it  suc- 
ceeds the  comatose  state,  whence  the  term  congestive  chill  often  used  in  the 
South,  where  the  popular  notion  prevails  that  if  the  first  paroxysm  does  not 
kill,  the  second  will.  This  is  an  exaggerated  idea  of  its  seriousness, 
although  it  is  certainly  a  very  grave  affection  and  often  terminates  fatally. 
A  low,  muttering  delirium  may  supervene,  the  eyes  are  bloodshot,  the  skin  is 
hot  and  dry,  the  temperature  rising  to  105°  or  106°  F.  (40.6°  or  41.1°  C). 
The  comatose  condition  is  probably  a  toxic  one,  and  lasts  until  a  partial  elimi- 
nation of  the  poison  has  taken  place,  usually  from  twelve  to  twenty-four 
hours  later.     The  patient  may,  however,  perish  without  return  to  conscious- 


78  INFECTIOUS  DISEASES. 

ness,  or  consciousness  may  return  to  be  followed  in  a  short  time  by  fatal 
relapse. 

2.  The  algid  type  is  characterized  by  gastric  symptoms,  extreme  nausea 
and  vomiting,  which  are  mostly  followed  by  collapse,  for  there  is  intense 
prostration,  with  coldness  of  the  surface  and  extremities.  The  symptoms  are, 
indeed,  comparable  to  those  of  the  collapse  of  cholera.  There  are  the  same 
small,  feeble  pulse,  frequent,  shallow  breathing,  cramps,  vomiting,  purging,, 
husky  voice,  and  thirst  wath  suppressed  urine,  and  with  these  the  same  clear- 
ness of  intellect  until  death  steps  in — the  last  scene  in  the  drama,  in  which 
asthenia  also  plays  a  leading  role. 

In  these  cases  there  may  or  may  not  be  a  chill,  yet  the  patient  feels  cold 
and  the  surface  temperature  is  never  high,  rarely  exceeding  ioi°F.  (38.3° 
C),  and  falHng  as  low  as  96°  F.  (35.6°  C).  The  internal  temperature  is, 
however,  high. 

Diagnosis. — Pernicious  malarial  fever  is  to  be  distinguished  in  its 
comatose  form  from  typhoid  fever,  and  in  its  algid  type  from  yellozv  fever.. 
The  presence  of  the  plasmodium  and  pigment  in  the  blood  are  the  distinctive 
features  to  be  carefully  sought. 

Irregular  Forms  of  Malarial  Fever. 

It  sometimes  happens  that  the  paroxysm  in  intermittent  fever  omits  one 
or  more  of  its  stages.  Especially  is  this  the  case  with  the  chill  in  which 
event  the  disease  has  received  the  characteristic  name  of  "  dumb  ague." 
Frequently,  however,  what  receives  the  name  of  "  dumb  ague  "  is  something 
altogether  different.  The  "  malarial  cachexia,"  for  instance,  is  sometimes 
spoken  of  as  "  dumb  ague."  Like  malarial  cachexia  "  dumb  ague  "  is  found 
among  the  older  residents  of  a  malarial  district. 

Quite  often  it  happens  that  the  malarial  paroxysm  consists  of  nothing 
but  a  state  of  drowsiness,  which  recurs  at  regular  intervals  and  is  very  char- 
acteristic. The  temperature  in  these  cases  is  elevated,  but  not  very  high, 
100°  F.  (37.8°  C.)  or  perhaps  101°  F.  (38.3°  C.)  ;  there  may  be  slight 
delirium.  Another  irregular  form  is  intermittent  neuralgia,  which  is  clearly 
malarial,  the  proof  of  it  being  the  facility  with  which  it  is  broken  up  by 
quinin.  Usually  there  is  no  fever  ki  this  variety.  The  nerve  commonly 
involved  is  one  of  the  branches  of  the  trigeminal.  The  intercostal  nerves 
are  also  the  seats  of  such  an  attack,  giving  rise  to  one  of  the  forms  of  pain 
in  the  chest,  but  any  nerve-trunk  or  its  branches  may  be  affected,  as  the 
sciatic  or  brachial. 

The  term  latent  intermittent  fever  is  applied  to  a  combination  of  symp- 
toms affecting  persons  living  in  malarial  districts — consisting  in  a  weary, 
languid  feeling,  associated  with  want  of  appetite,  headache,  nausea,  vomit- 
ing, constipation,  and  coated  tongue.  Sometimes  the  so-called  "  bilious 
attacks,"  which  exhibit  the  above  symptoms  in  an  aggravated  form,  espe- 
cially the  headache  and  vomiting,  are  malarial  in  their  origin,  and  may  be 
broken  up  with  quinin.     Such  attacks  may  be  called  malarial  migraine. 

Irregularity  of  fever  or  chills,  or  both,  may  be  caused  by  infection  with 
more  than  one  group  of  the  same  kind  of  parasite  occurring  at  different 
times,  or  there  may  be  infections  of  different  kinds  of  parasite  maturing  at 
their  own  specified  time. 


MALARIAL  HEMATURL4.  79 

Malarial  Hematuria^  or  Hemoglobinuria,  or  Intermittent   Hema- 
turia— Blackwater  Fever. 

This  form  of  hematuria  is  the  direct  result  of  malarial  poison.  The 
first  account  of  it  in  this  country  was  published  by  George  Troup  Maxwell 
in  the  "  Oglethorpe  Medical  and  Surgical  Journal,"  Savannah,  Ga., 
volume  iii.  pages  12-18,  July,  i860.  While  it  is  a  very  frequent  symptom  ot 
the  pernicious  or  malignant  type  of  malarial  fever,  it  also  occurs  as  a  symp- 
tom, and,  indeed,  sometimes  the  sole  symptom,  of  the  milder  varieties  of 
malaria,  such  as  occur  in  the  Middle  States  of  the  United  States.  I  have 
met  a  number  of  these  cases.  Rarely  are  they  accompanied  by  a  chill,  and 
there  may  be  no  symptoms  whatever  except  the  bleeding.  More  frequently 
there  is  a  cold  feeling,  the  tips  of  the  nose  and  of  the  fingers  become  cold,  and 
the  lips  become  blue,  immediately  after  which  the  urine  is  found  to  be  bloody. 
Microscopic  examination  of  the  urine  will  recognize  in  some  instances  blood- 
discs,  in  others  no  corpuscles  can  be  found.  It  is  a  hemoglobinuria:^  The 
hemorrhage  occurs  daily  or  on  alternate  days,  more  rarely  at  longer  intervals. 
Sometimes  it  is  continuous,  with  exacerbations  at  regular  intervals.  In  all 
cases  of  unexplained  hematuria  the  blood  should  be  examined  for  the  mala- 
rial organism. 

When  a  symptom  of  pernicious  malarial  fever,  the  condition  is  more  apt 
to  be  hemoglobinuria  than  hematuria ;  it  is  more  aggravated  and  more  con- 
tinuous, although  still  intermittent.  It  may  also  be  associated  with  hemor- 
rhages from  the  nasal  and  oral  mucous  membranes,  and  even  from  the 
stomach,  which  add  much  to  the  gravity  of  the  case. 

To  such  a  grave  form  of  malarial  fever  occurring  in  the  Niger  delta  m. 
Africa  the  name  blackwater  fever  has  been  given. 

Chronic  Malaria  and  Malarial  Cachexia. 

Definition. —  This  is  a  condition  which  often  supervenes  in  cases  imper- 
fectly or  ineffectually  treated,  or  in  persons  living  in  malarial  districts  where 
there  is  constant  exposure  to  the  cause  and  consequent  repeated  attacks. 

Symptoms. — The  most  striking  symptom  of  this  condition  is  anemia 
of  a  peculiar  kind.  The  incident  changes  in  the  blood  have  been  referred  to 
on  page  y2.  The  skin  exhibits  a  dirty-yellow  or  sallow  appearance,  often 
erroneously  characterized  as  "  bilious,"  as  though  it  were  a  form  of  jaundice,, 
which  it  is  not,  although  there  may  be  sometimes  slight  jaundice  also.  Such 
persons  have,  in  addition,  deranged  digestion.  The  tongue  is  pale,  flabby, 
and  coated,  and  the  breath  sometimes  foul.  The  bowels  are  constipated. 
The  hands  and  feet  are  cold,  the  circulation  is  generally  bad,  and  the  tempera- 
ture is  subnormal,  though  it  may  alternate  with  the  feverish  state.  In  con- 
sequence of  the  hydremic  blood  there  is  sometimes  edema  of  the  feet,  and 
even  general  anasarca.  The  spleen  is  enlarged,  often  extending  as  low  as  the 
ilium. 

Some  very  unusual  symptoms  are  included  in  the  symptomatology  of 
this  form  of  malaria — as,  for  example,  paraplegia  and  orchitis.     The  former 

*The  presence  of  hemoglobin  can  be  easily  shown  by  making  Teichmann's  hemin  crystals  in  the 
following  manner:  The  earthy  phosphates  are  precipitated,  filtered  out,  and  a  small  portion  placed 
on  a  glass  slide,  and  carefully  warmed  until  completely  dry.  A  minute  granule  of  common  salt  is 
carried  on  the  point  of  a  knife  to  the  dried  mass  and  thoroughly  mixed  with  it.  Any  excess  of  salt 
is  then  removed,  the  mixture  is  covered  with  a  thin  glass  cover,  a  hair  being  interposed,  and  a  drop  or 
two  of  glacial  acetic  acid  allowed  to  pass  under  the  cover.  The  slide  is  then  carefully  warmed  until 
bubbles  begin  to  make  their  appearance.  After  cooling,  hemin  crystals  can  be  seen  by  aid  of  the 
microscope.  These,  though  often  verv  small  and  incompletely  crystallized,  are  easily  recognizable 
by  an  amplification  of  300  diai_i&ter3.     They  are,  chemically,  hydrochlorate  of  heniatin. 


So  INFECTIOUS  DISEASES. 

condition  may  be  the  result  of  deranged  circulation  in  the  spinal  cord,  but 
it  is  difficult  to  regard  the  latter  as  anything  except  a  coincidence.  A  remark- 
able case  of  malaria  with  symptoms  of  disseminated  sclerosis  was  reported 
by  Dr.  William  G.  Spiller  in  the  "  American  Journal  of  the  Medical 
Sciences  "  for  December,  1900.  The  autopsy  disclosed  sclerosis  of  the  right 
crossed  pyramidal  tract  throughout  the  spinal  cord,  not  intense,  but 
unmistakable. 

The  plasniodinin  is  found  in  this  form  of  malaria  also,  and  the  crescent 
is  said  to  be  the  form  more  or  less  characteristic  of  it.  The  recognition  of 
the  organism  is  of  value  in  the  diagnosis  of  this  from  other  forms  of  anemia, 
although  the  history  of  the  case  and  the  presence  of  enlarged  spleen  are  also 
important  factors  in  diagnosis,  especially  as  the  plasmodium  may  elude  detec- 
tion altogether,  and  malaria  still  be  present.  It  is  to  be  remembered,  how- 
ever, that  in  leukemia  there  is  also  enlarged  spleen,  but  the  microscopic 
examination  of  the  blood  reveals  at  once  in  the  latter  disease  the  excess  of 
colorless  corpuscles. 

Prophylaxis  of  Malarial  Fever. — Much  may  be  done  to  avert  malarial 
infection.  It  is  not  considered  possible  for  the  organism  to  enter  the  system 
by  the  stomach  or  respiratory  passages.  This  being  established,  prophylaxis 
must  consist  in  measures  to  destroy  the  mosquito  or  escape  its  bite.  To  exter- 
minate the  adult  mosquito  is  manifestly  impossible.  Yet  it  is  not  chimerical 
to  look  forward  to  the  possibility  of  destroying  the  insect  in  the  larval  state 
as  it  exists  in  pools  and  ponds.  While  all  the  more  common  species  of  mos- 
quito belong  to  the  genus  culex  or  genus  anopheles,  Ross  has  shown  that  up 
to  the  present  only  mosquitos  belonging  to  the  genus  anopheles  have  been 
found  to  contain  malarial  parasites.  The  larvae  of  this  genus  live,  not  in 
artificial  collections  of  water,  but  in  natural  ponds  in  rural  regions.  Ross 
believes  that,  if  future  experiments  show  that  malaria  is  confined  to  the  genus 
anopheles,  the  task  will  be  much  more  simplified,  and  there  would  be  a  chance 
of  exterminating  the  whole  genus  in  a  given  locality.  In  the  meantime  our 
prophylactic  measures  must  consist  in  protecting  against  mosquito  bites  by 
netting,  and  in  making  the  blood  as  uncomfortable  a  habitat  for  the  Plas- 
modium as  possible  by  charging  it  with  quinin.  To  this  end  a  few  grains  of 
quinin,  say  five  to  ten  (0.333  to  0.666  gm.),  should  be  taken  daily,  especially 
by  newcomers  and  by  all  residents  at  times.  It  seems  pretty  well  founded, 
too,  that  the  cause  of  malaria  is  more  active  after  nightfall.  This  is  not 
inconsistent  with  the  mosquito  theory.  Hence,  exposure  at  these  times 
should  be  avoided.  It  is  also  a  notion  with  residents  in  malarial  districts 
that  exposure  while  the  stomach  is  empty  is  apt  to  invite  the  poison.  This  is 
probably  erroneous.  Should  it  be  true,  exposure  while  fasting  should 
i)e  avoided.  In  this  matter,  as  in  others,  it  may  be  necessary  to  give 
lip  a  good  many  of  our  old  notions,  but  until  the  new  theories  are  thoroughl}- 
established  it  may  be  just  as  well  to  adhere  to  practices  justified  by  ex- 
perience. 

Treatment  of  the  Different  Forms  of  Malaria. — The  treatment  of 
■intermittent  fever  is  preeminently  by  quinin.  Not  only  does  it  promptly 
break  up  the  paroxysms,  but  it  causes  also  the  rapid  disappearance 
of  the  Plasmodium,  which  is  responsible  for  them.  The  dose  required 
varies,  but  fifteen  to  thirty  grains  (i  to  2  gm.)  are  usually  sufficient 
for  an  adult.  Sometimes  larger  doses  may  be  needed  in  inveterate 
cases.  It  does  not  matter  very  much  how  the  drug  is  administered,  but 
there  is  a  best  way  for  each  case.     I  prefer,  as  a  rule,  to  give  an  hourly 


TREATMEXT  OF  MALARIA.  8i 

dose  of  three  to  five  grains,  beginning  long  enough  before  the  expected 
paroxysm  to  get  the  quantity  previously  decided  upon  into  the  blood  at  least 
two  hours  before  the  chill  is  expected.  If  the  dose  first  selected  fails,  the 
second  should  be  made  larger.  It  is  to  be  remembered,  however,  that  quinin, 
like  other  drugs,  acts  more  efficiently  after  a  free  aperient,  while  constipation 
decidedly  interferes  with  its  prompt  and  efficient  action.  Some  prefer  a 
mercurial,  as  eight  to  ten  grains  (0.05  to  0.666  gm.)  of  blue  mass,  or  six  to 
ten  grains  of  calomel,  but  provided  a  free  movement  is  secured,  it  does  not 
matter  much  how  it  is  accomplished.  Having  broken  the  paroxysm,  it  is 
well  to  continue  the  quinin  for  a  few  days  in  smaller  doses,  and  to  anticipate 
the  seventh  day  subsequent  to  the  last  chill  by  another  full  dose  of  the  drug, 
and  to  do  so  at  intervals  of  seven  days  for  some  weeks.  Under  ordinary 
circumstances  the  freshly  prepared  pill  of  quinin  made  with  aromatic  sul- 
phuric acid  is  to  be  preferred.  This  is  easily  soluble  and  is  not  so  unpleasant 
to  take  as  the  solution,  which  is,  however,  more  readily  absorbed.  The 
sugar-coated  and  gelatin-coated  pills  are  not  so  certainly  efficient,  as  they 
sometimes,  especially  with  deranged  digestion,  pass  through  the  bowel 
undissolved. 

Some  physicians  prefer  to  administer  quinin  during  the  decline  of  the 
fever.  This  was  the  practice  of  Sydenham  in  giving  the  bark.  Among 
modern  physicians  disposed  to  follow  this  method  are  Bacelli,  A.  Plehn, 
Maclean,  Alanson  and  other  East  Indian  physicians :  and  in  this  country 
George  Dock. 

The  treatment  of  the  paroxysm  itself  is  by  measures  calculated  to 
combat  each  stage.  During  the  chill,  to  satisfy  the  patient,  artificial  warmth 
should  be  supplied,  though  it  does  no  good  and  the  temperature  is  already  a 
fever  temperature ;  during  the  fever,  if  the  temperature  is  above  102°  F. 
(38.9°  C),  the  body  may  be  sponged  to  reduce  the  heat,  and  during  the 
^'  sweat ''  the  patient  should  be  carefully  dried.  If  there  be  any  reason  why 
quinin  should  not  be  exhibited,  the  other  alkaloids  of  cinchona,  as  cinchoni- 
din,  are  equally  effectual  in  doses  about  one-fourth  larger.  Xo  substitute 
for  cinchona  or  its  alkaloids  has  ever  been  suggested  which  has  stood  the  test 
of  trial. 

The  treatment  of  remittent  fever  is  essentially  that  of  intermittent 
fever.  It  is  in  this  form  that  the  mercurial  aperient  is  deemed  especially 
valuable  as  a  preliminary  by  those  having  wide  experience  in  its  treatment. 
The  continued  nature  of  the  fever,  and  the  tendency  to  a  typhoid  state  which 
often  develops,  demands  a  liquid  diet,  with  the  careful  addition  of  stimulants. 

The  pernicious  forms  of  malarial  fever  are  treated  by  quinin,  as  are 
the  other  varieties  of  the  disease.  In  the  congestive  variety  advantage 
must  be  taken  of  the  first  lucid  interval  to  push  the  drug  in  very  large 
doses.  Sixty  grains  or  more  may  be  necessary,  and  advantage  may  be 
taken  of  rectal  or  even  hypodermic  injections,  but  abscesses  are  almost  sure 
to  occur  if  the  latter  be  used.  Extreme  cases,  however,  demand  extreme 
remedies.  Soluble  salts  should  be  used,  such  as  the  bisulphate,  hydrochlorate, 
and  hydrobromate.  of  which  15  grains  (i  gm.),  dissolved  in  distilled  water, 
are  a  dose.  Double  this  dose  may  be  given.  The  bisulphate  of  quinin 
may  also  be  administered  hypodermically  with  tartaric  acid,  30  grains  (2 
gm.)  of  the  former  to  5  grains  (0.333  §.^'^-^  of  the  latter.  The  muriate  of 
quinin  and  urea  may  also  be  given  hypodermically  in  ten-,  fifteen-,  or  tAventy- 
6 


82  INFECTIOUS  DISEASES. 

grain  (0.666,  i,  and  1.33  gm.)  doses.  It  is  especially  commended  by  Solo- 
mon Solis-Cohen,  who  advises,  as  soon  as  the  diagnosis  is  established,  and 
without  reference  to  the  time  of  paroxysm,  a  single  injection  of  from  10  to  15 
grains  (0.66  to  i  gm.)  of  the  salt,  dissolved  in  a  syringeful  (20  to  30  minims) 
of  boiling  water.  Should  a  paroxysm  recur  at  the  following  period,  a  second 
injection  is  given,  and  should  further  paroxysms  occur,  injections  are 
given  in  corresponding  number;  otherwise  but  three  injections  are  given 
during  the  first  seven  days,  and  two  injections  during  the  second  seven  days. 
My  experience  in  the  hypodermic  use  of  this  drug  has  been  satisfactory  from 
the  therapeutic  standpoint,  but  I  have  not  escaped  abscesses.  It  may  also  be 
given  by  the  mouth  in  capsules  in  the  same  doses. 

Even  the  intravenous  injection  of  quinin  has  been  recommended  in 
intractable  cases,  and  for  this  purpose  the  soluble  bimuriate  is  most  suitable. 
Fifteen  grains  (i  gm.)  with  one  grain  (0.066  gm.)  of  sodium  chlorid  are  dis- 
solved in  two  drams  (8  c.  c.)  of  distilled  water  and  injected. 

In  addition  to  the  use  of  quinin,  prompt  measures  must  be  taken  to  com- 
bat all  symptoms  which  add  to  the  dangers  of  the  situation — stimulants  for 
the  asthenia ;  artificial  heat  for  low  temperature ;  morphin  hypodermicallyv 
to  relieve  the  pain  and  allay  nausea ;  cool  sponging  or  bathing  to'  reduce  the 
temperature,  and  saline  cathartics  to  relieve  congestion  in  the  comatose  form. 

The  treatment  of  the  milder  varieties  of  hematuria  is  most  satisfactory.. 
The  administration  of  quinin  in  almost  any  way,  say  three  grains  (0.19  gm.) 
every  three  hours  for  several  days,  will  effectually  break  up  the  paroxysms,, 
and  its  use  in  smaller  doses  for  some  time  longer  will  prevent  a  return- 
All  practitioners,  even  those  residing  where  it  is  most  prevalent,  are 
not  agreed  upon  the  treatment  of  the  graver  forms  of  malarial  hematuria 
met  in  southern  latitudes.  While  some  still  urge  quinin,  others  strongly 
object  to  it  and  hold  even  that  it  precipitates  hemoglobinuria.  Only  so 
long  as  sporulating  parasites  are  present  in  the  blood  would  they  use  it, 
and  the  actual  presence  of  hematuria  contra-indicates  it.  At  most  it 
must  be  used  tentatively  in  doses  as  small  as  a  grain,  and  if  the  urine 
redden  or  a  chill  supervene,  they  omit  it.  If  well  borne,  the  dose  may  be 
increased. 

Treatment  is  otherwise  symptomatic — usually  eliminative  and  restora- 
tive. Elimination  is  obtained  by  water-drinking  and  salt  solution  ingestion, 
the  latter  by  enteroclysis,  hypodermoclysis,  or  even  intravenous  injection.. 
The  skin  must  be  kept  active  b}L, cautious  doses  of  pilocarpin,  by  woolen  cloth- 
ing and  avoiding  draughts.  In  urgent  cases  pilocarpin  may  be  cautiously 
used,  but  the  hot  pack  is  a  safer  measure.  Morphin  in  small  doses  may  be 
used  to  control  vomiting,  and  for  its  general  tranquilizing  effect.  Strychnin 
and  diffusible  stimulants,  ammonia,  brandy,  and  champagne,  are  often  neces- 
sary. Strychnin  may  be  given  hypodermically.  Stimulating  diuretics  are 
strongly  disadvised. 

It  is  in  chronic  malaria  especially  that  arsenic  becomes  a  useful  remedy, 
Fowler's  solution  being  the  best  preparation.  It  should  be  given  in 
ascending  doses.  Iron  is  often  advantageously  associated  with  it,  and 
for  such  a  combination  the  solution  of  the  chlorid  of  arsenic  and  the 
tincture  of  the  chlorid  of  iron  are  especially  suitable.  Here,  as  elsewhere,  I 
am  disposed  to  believe  that  needlessly  large  doses  of  iron  have  been  given 
and  that  the  constipating  effect  of  iron,  so  justly  complained  of,  would  be 


YELLOW  FEVER.  83 

obviated  by  giving  doses  little  in  excess  of  what  can  be  absorbed.  For  it  is 
this  excess  remaining  in  the  alimentary  canal  that  works  the  mischief.  Five 
minims  (0.333  S^^^-)  of  the  tincture  of  the  chlorid,  combined  with  as  many  of 
the  solution  of  the  chlorid  of  arsenic,  are  a  proper  dose,  but  the  arsenic  should 
be  increased  until  a  slight  puffiness  of  the  face  results.  The  carbonate  of  iron 
or  the  reduced  iron  sulphate  may  be  given  in  doses  not  exceeding  one  grain 
(0.066  gm.).  A  modified  Blaud's  pill  containing  in  addition  to  the  carbonate 
of  iron  arsenic  in  1-25  grain  (0.0026  gm.)  doses  is  a  very  efficient  and  con- 
venient remedy.     The  administration  of  iron  should  be  kept  up  a  long  time. 

Q  it  in  ill  should  not  be  omitted  in  this  form  of  malaria,  but  there  is  no 
advantage  in  giving  it  in  large  doses.  Strychnine  and  mineral  acids  are  also 
useful  remedies  for  the  gastric  derangement,  while  constipation  may  be 
treated  by  an  occasional  mercurial  purge,  say  a  couple  of  grains  (0.132  gm.) 
of  blue  mass,  to  which  may  be  added  as  much  compound  extract  of  colocynth, 
and  as  much  extract  of  hyoscyamus,  or  1-8  grain  (0.008  gm.)  of  extract  of 
belladonna. 

Very  popular  in  the  hands  of  some  physicians  is  Warburg's  Tincture, 
and  it  does  seem  that  it  succeeds  where  quinin  alone  fails.  Besides  quinin,  it 
contains  aloes,  rhubarb,  and  a  number  of  aromatics.  One  formula  omits  the 
aloes,  so  that  in  prescribing  one  should  say  with  or  without  aloes.  It  usually 
proves  a  powerful  sudorific.  It  is  given  in  half-ounce  doses,  repeated  after 
two  or  three  hours.  The  action  is  similar  to  that  of  antipyrin,  phenace- 
tin,  etc. 

YELLOW    FEVER. 

Synonyms. — Febris  flava;  Bilious  Remittent  Fever  (Rush)  ;  Kendall's 
Fever;  Barbadoes  Distemper;  Indies  occidentalis ;  Elodes  icterodes; 
Typhus  icterodes;  Typhus  tropicus. 

Definition. —  Yellow  fever  is  an  acute  infectious  disease,  characterized 
by  a  febrile  paroxysm  succeeded  by  a  brief  remission  and  a  relapse.  It  is 
associated  more  or  less  constantly  with  jaundice,  and  tendency  to  hemorrhage 
especially  into  the  stomach,  whence  the  blood  is  vomited  constituting  "  black 
vomit."     Neither  jaundice  nor  black  vomit  is  essential  to  the  disease. 

History. — The  birthplace  of  yellow  fever  is  unknown.  It  appeared  in  Barba- 
does in  1647;  prevailed  in  Jamaica  in  1671;  at  St.  Domingo  in  1691;  Pernambuco, 
in  Brazil,  from  1687  to  1694;  in  Martinique  in  1690;  in  Boston  Harbor  probably  in  1692; 
Philadelphia  and  Charleston  in  1692:  Rocheford,  France,  in  1694;  and  Philadelphia  again 
in  1699,  when  a  severe  epidemic  prevailed.  Philadelphia  was  again  visited  in  1741 
and  1762;  New  York  in  1791,  and  Philadelphia  in  1793,  during  which  time  there  reigned 
one  of  the  most  frightful  epidemics  history  records,  4040  dying  out  of  a  population  of 
40,000.  After  1793  the  disease  prevailed  more  or  less  every  j^ear  in  the  United  States 
until  1S05.  From  1805  to  1820  the  epidemics  were  limited  or  only  isolated  cases  oc- 
curred, until  1820,  when  Philadelphia  was  again  severely  attacked.  After  1820  there 
was  a  period  of  comparative  immunity,  but  not  without  cases  and  small  epidemics  in 
various  cities  of  the  United  States,  until  1853,  when  there  raged  a  violent  outbreak 
through  the  southern  cities  of  the  Union.  In  New  Orleans  alone  in  that  year  nearly 
8000  died.  In  1867  and  1873  there  were  other  epidemics  of  moderate  severity,  and  in 
1878  another  severe  epidemic  appeared,  chiefly  in  Louisiana,  Alabama,  and  Mississippi, 
during  which  nearly  1600  died.  This  was  the  last  severe  epidemic.  In  1897  there 
were  several  local  outbreaks  in  the  Gulf  States.  In  New  Orleans  alone,  between 
September  8  and  December  11,  there  were  1902  cases,  with  288  deaths,  according 
to  the  Marine  Hospital  Reports. 

Thus,  it  is  in  a  sense  an  American  disease,  and  except  in  Spanish  ports 
it  has  been  limited  in  Europe  to  ports  to  which  it  has  been  carried,  its  spread 
from  these  having  been  also  prevented.  It  is,  however,  endemic  at  the 
present  day  on  the  west  coast  of  Africa  as  well  as  in  the  West  Indies. 


84  IXFECriOUS  DISEASES. 

Distribution. — John  Guiteras  makes  three  areas  of  infection :  (  i )  The 
focal  zone,  in  which,  up  to  1901,  the  disease  was  never  absent,  including 
Havana,  Vera  Cruz,  Rio  de  Janeiro,  and  other  Spanish-American  ports. 
(2)  Perifocal  zone,  or  region  of  periodic  epidemics,  including  the  ports  in 
the  tropical  Atlantic,  in  America,  and  Africa.  (3)  The  zone  of  accidental 
epidemics,  between  the  parallels  of  45  degrees  north  and  35  degrees  south 
latitude. 

A  very  interesting  fact  in  connection  with  yellow  fever  is  its  limitation 
to  the  sea  and  the  seacoast,  as  it  rarely  invades  interior  cities  or  altitudes 
higher  than  1000  feet  (300  meters). 

Etiology. — The  analogy  between  yellow  fever  and  the  other  forms  of 
contagio-infectious  disease,  in  its  origin,  spread,  and  conditions,  renders  it 
more  than  likely  that  it,  in  common  with  them,  is  the  result  of  a  specific 
organism.  Domingos  Freire,  of  Brazil ;  Carmona,  of  Mexico ;  Gibier  at 
Havana,  and  others  have  described  organisms  as  possibly  responsible,  all  of 
which  have  been  rejected.  In  1889  Surgeon  General  Sternberg,  U.  S.  A., 
discovered  a  bacillus  in  the  tissues  of  yellow  fever  patients,  which  he  called 
bacillus  X.  In  1896  Sanarelli,*  Director  of  the  Institute  of  Experimental 
Medicine  at  Montevideo,  isolated  a  bacillus,  which  he  called  bacillus 
icterodes.  These,  Sternberg  says,  are  identical,  but  the  late  Dr.  Walter 
Reed  and  Dr.  James  Carroll,  after  a  careful  study,  concluded  that  the  bacillus 
X  belongs  to  the  colon  group,  and  the  bacillus  icterodes  to  the  hog  cholera 
group.f 

N"otwithstanding  the  fact  that  Sanarelli's  bacillus  has  been  found  by  a 
number  of  observers  in  from  thirty-three  per  cent,  to  fifty  per  cent,  of  cases 
examined,  conclusive  evidence  that  it  is  the  specific  germ  of  yellow  fever  is 
w^anting.  On  the  other  hand,  the  most  recent  studies  of  Reed  and  Carroll  go 
to  show  that  it  is  probably  an  ultra-microscopic  organism  in  the  blood  of  the 
infecting  person.  I  As  to  the  propagation  of  the  disease,  the  same  observers 
with  Aristides  Agramonte,  all  of  the  United  States  Army  Aledical  Depart- 
ment, §  have  placed  the  moscjuito  theory  of  the  origin  of  yellow  fever  on  so 
substantial  a  basis  that  it  would  seem  that  further  discussion  of  other  theories 
may  as  well  be  laid  aside.  This  theory,  which,  it  will  be  remembered,  makes 
the  mosquito  the  host  of  the  unknown  parasite  of  yellow  fever,  was  first 
advanced  by  Carlos  J.  Finlay,  of  Havana,  as  far  back  as  1881,  ||  but  made 
little  impression.  The  studies  of  Reed  and  his  colleagues,  made  in  the  island 
of  Cuba  in  1900,  are  most  convincing.  They  included  two  divisions:  First, 
the  exposure  of  immunes  to  the  bites  of  mosquitos  which  had  bitten  yellow 
fever  subjects  :  and  second,  exposure  of  the  same  to  fomites  by  handling 
ind  sleeping  in  clothing  saturated  with  the  discharges  of  yellow  fever 
patients.  Their  conclusions  are  as  follows:  i.  The  mosquito — Stegomyia 
fasciatus — serves  as  the  intermediate  host  for  the  parasite  of  yellow  fever. 
2.  Yellow  fever  is  transmitted  to  the  non-immune  individual  by  the  bite  of 
a  mosquito  that  has  previously  fed  on  the  blood  of  those  sick  with  this  dis- 
ease. 3.  An  interval  of  about  twelve  days  or  more  after  contamination 
appears  to  be  necessary  before  the  mosquito  is  capable  of  conveying  the 
infection.  4.  The  bite  of  the  mosquito  at  an  earlier  period  after  contamina- 
tion does  not  appear  to  confer  any  immunity  against  a  subsequent  attack. 

*  "  Annalesde  I'lnstitut  Pasteur,"  xi.  438,  18Q7. 

+  "  Tournal  of  Experimental  Medicine,"  vol.  v.  No.  3.  December,  iqoo. 
i  "EtioloRv  of  Yellow  Fever:  A  Supplemental  Note."     "Am.  ^Med.,"  February  22,  igo2. 
§  "Etiology  of  Yellow  Fever,"  "  Philadelphia  Jledical  Journal,"  October  27,  igoo.     "Etiology  of 
Yellow  Fever:  An  Additional  Note,"  Journal  of  American  Medical  Association,"  February  16,  igoi. 
f  "  Annales  de  la  Real  Academia,"  vol.  xviii.,  1881,  pp.  147-169. 


YELLOW  FEVER.  85 

5.  Yellow  fever  can  also  be  experimentally  produced  by  the  subcutaneous 
injection  of  blood  taken  from  the  general  circulation  during  the  first  and 
second  days  of  this  disease.  6.  An  attack  of  yellow  fever  produced  by  the 
bite  of  a  mosquito  confers  immunity  against  the  subsequent  injection  of 
the  blood  of  an  individual  suffering  from  the  non-experimental  form  of  this 
disease.  7.  The  period  of  incubation  in  thirteen  cases  of  experimental 
yellow  fever  has  varied  from  forty-one  hours  to  five  days  and  seventeen 
hours.  8.  Yellow  fever  is  not  conveyed  by  fomites,  and  hence  disinfection 
of  articles  of  clothing,  bedding,  or  merchandise  supposedly  contaminated  by 
contact  with  those  sick  with  the  disease  is  unnecessary.  9.  A  house  may 
be  said  to  be  infected  with  yellow  fever  only  when  there  are  present  within 
its  walls  contaminated  mosquitos  capable  of  conveying  the  parasite  of  this 
disease.  10.  The  spread  of  yellow  fever  can  be  most  effectually  controlled 
by  measures  directed  to  the  destruction  of  mosquitos  and  the  protection 
of  the  sick  and  well  against  the  bites  of  the  insects.  11.  While  the  mode 
of  propagation  of  yellow  fever  has  now  been  definitely  determined,  the 
specific  cause  of  this  disease  remains  to  be  discovered. 

It  is  evident  that  many  of  the  older  views,  so  long  accepted,  must  be 
given  up  if  this  theory  is  adopted.  On  the  other  hand,  many  well-known 
facts  are  more  satisfactorily  explained.  Among  these  is  this,  that  freezing 
weather  terminates  the  activity  of  the  disease,  but  does  not  destroy  it. 

Yellow  fever  attacks  all  races,  both  sexes,  and  all  ages  except  the  very 
young.  Yet  it  is  through  the  young  that  the  disease  is  maintained  in  a 
native  population,  because  protection  is  secured  by  a  previous  attack  or  long 
residence  in  a  locality  in  which  it  is  endemic,  and  it  is  the  young  who.  as 
they  grow  up,  furnish  the  pabulum  for  fresh  cases.  The  negro  and  the 
Creole,  although  not  immune,  are  comparatively  so.  More  males  are  attacked 
than  females,  because  of  their  frequent  exposure.  Strangers  are  especially 
liable. 

Morbid  Anatomy. — Intense  yellozu  coloration  and  hemorrhagic  extra- 
vasations under  the  skin  are  present.  The  yellow  coloration  is  due  to  a 
mixed  hepatogenous  and  hematogenous  jaundice.  The  serum  of  the  blood 
is  red-tinted,  because  of  its  containing  dissolved  hemoglobin.  The  liver 
is  the  organ  which  has  always  been  regarded  as  exhibiting  the  most  char- 
acteristic change.  Yet  this  is  not  always  so.  It  becomes  ultimately  fatty, 
when  its  color  resembles  the  yellow  of  admixed  coffee  and  milk — a  cafe  ait 
lait  appearance — as  contrasted  with  the  more  bronzed  appearance  of  the 
liver  of  remittent  fever.  Earlier  in  the  disease  the  organ  may  be  slightly 
enlarged  from  hyperemia.  It  may  be  a  nutmeg  liver.  The  liver-cells  pre- 
sent various  stages  of  fatty  degeneration,  with  necrotic  masses  in  and  be- 
tween the  liver-cells,  described  by  George  M.  Sternberg.  The  gall-bladder 
is  generally  empty.  The  kidney  may  exhibit  cloudy  swelling  or  even  acute 
nephritis,  and  pale,  fatty  areas  may  be  seen  at  the  bases  of  the  pyramids. 
Various  bacteria  are  found  in  the  liver  and  kidney. 

The  stomach  after  death  contains  more  or  less  of  the  "  black  vomit." 
which  is  a  mixture  of  transuded  serum  and  altered  blood  pigment.  The 
mucous  membrane  of  the  stomach  is  hyperemic  and  more  or  less  swollen, 
and  there  are  blood  extravasations. 

Surgeon  Eugene  Wasdin,*  in  a  paper  on  the  postmortem  findings  of 
yellow  fever,  says  the  morbid  appearances  postmortem  cannot  be  regarded 
as  sufficiently  distinctive  to  admit  a  diagnosis  from  them  alone. 

*  "  United  States  Marine  Hospital  Reports  for  the  Fiscal  Year  i8g8." 


86  INFECTIOUS  DISEASES. 

Symptoms. — Yellow  fever  has  a  period  of  incubation  of  from  twenty- 
four  hours  to  five  days,  very  rarely  exceeding  the  latter.  It  is  usually  three 
or  four  days.  (See  Reed  and  Carroll's  conclusions.)  After  this  follows 
the  stage  of  invasion  or  febrile  stage,  with  sudden  onset  and  generally  a 
chill,  promptly  followed  by  headache  and  severe  pain  in  the  back  and  limbs. 
The  patient  may  be  seized  at  any  time,  day  or  night.  Surgeon  R.  D. 
Murray,*  of  the  United  States  Marine  Hospital  Service,  emphasizes  the  fact 
that  yellow  fever  usually  begins  at  night  when  the  patient  is  relaxed,  while 
malarial  fever  attacks  him  more  frequently  when  at  work.  The  fever  rises 
rapidly  to  102°  F.  (38.9°  C.)  and  as  high  as  105°  F.  (40.5°  C).  The  pulse 
corresponds.  The  skin  feels  hot  and  dry,  but  less  pungently  so  than  in 
typhus.  Even  on  the  first  day  the  face  is  flushed,  the  eyes  are  injected, 
the  lids  perhaps  slightly  tumid,  the  tongue  furred  but  moist,  the  throat 
sore,  the  bowels  constipated,  the  urine  is  scanty  and  often  albuminous, 
though  albuminuria  does  not  generally  appear  until  the  evening  of  the  third 
day.  So,  too,  at  this  early  stage  there  may  be  slight  jaundice,  and  Guiteras 
says  this  "  early  manifestation  of  jaundice  is  undoubtedly  the  most  char- 
acteristic feature  of  the  facies  of  yellow  fever."  There  may  be  nausea  from 
the  beginning,  but  it  is  not  until  the  second  or  third  day  that  it  is  aggravated 
and  the  characteristic  "  black  vomit  "  makes  its  appearance.  This  resembles 
an  infusion  of  coffee,  and  deposits  a  sediment  comparable  to  coffee  grounds, 
and  which  consists  of  broken-down  red  corpuscles  and  hematin.  In  the 
worst  cases  the  vomited  matter  may  be  tar-like  in  appearance  and  consistence. 
On  the  other  hand,  "  black  vomit  "  is  not  always  present,  being  generally 
confined  to  the  severe  cases.  In  some,  the  vomited  matter  is  watery  or 
bilious.     This  stage  lasts  from  a  fezv  hours  to  tzvo  or  three  days. 

Then  follows  the  second  stage,  or  stage  of  calm,  in  which  there  is  a 
decline  in  the  fever  and  of  the  other  symptoms  generally.  This  may  be  the 
beginning  of  convalescence  in  the  mild  cases.  But  in  severe  cases  this  stage 
is  of  short  duration, — from  a  few  hours  to  one  or  two  days. 

Then  the  third  stage,  or  stage  of  febrile  reaction,  sets  in,  lasting  one, 
two,  or  three  days.  The  temperature  now  rises  again,  although  the  pulse 
may  continue  to  fall;  the  nausea  and  vomiting  return — the  latter  becomes 
hemorrhagic  and  may  be  accompanied  by  abdominal  pain.  Black  and 
offensive  stools  occur.  Jaundice,  if  not  previously  present,  now  makes  its 
appearance ;  the  tongue  becomes  dry  and  brown,  and  there  may  be  bleeding 
of  the  gums — indeed,  from  all  the  mucous  membrances.  To  albuminuria 
may  be  added  hematuria.  ^The  strength  rapidly  fails,  the  pulse  grows 
weaker,  there  is  nervous  trembling,  suppression  of  urine,  mental  wandering, 
convulsions  or  stupor,  and  death. 

Such,  however,  is  not  always  the  termination,  even  when  there  has  been 
"  black  vomit."  The  symptoms  may  all  gradually  subside  and  the  patient 
recover,  although  the  jaundice  may  persist  for  a  long  time.  In  mild  cases 
the  calm  stage,  as  stated,  may  be  succeeded  by  convalescence. 

Guiteras  f  regards  as  the  three  characteristic  symptoms  of  yellow 
fever:  First,  the  facies,  including  especially  early  jaundice.  Second, 
albuminuria,  which,  he  says,  is  rarely  so  early  in  other  fevers,  unless  of  an 
unusually  severe  type.  "  Even  in  the  mild  cases,  that  do  not  go  to 
bed — cases  of  '  walking  yellow  fever  ' — on  the  second,  third,  or  fourth  day 
of  the  disease  albuminuria  will  show  itself,"  though  it  may  be  quite  transr- 

*  "  Marine  Hospital  Reports,"  iSgQ,  p.  303. 

t  "  Diagnosis  of  Yellow  Fever,"  "  U.  S.  Marine  Hospital  Reports  for  the  Fiscal  Year  1898." 


YELLOW  FEVER.  By 

€nt.  Third,  a  peculiar  slowing  of  the  pulse,  with  a  steady  or  even  rising  tem- 
perature. This  symptom  was  first  pointed  out  by  Faget,  of  New  Orleans.  It 
is  noted  more  particularly  on  the  second  or  third  day,  when  the  fever  is  still 
keeping  up,  that  the  pulse  begins  to  slow,  dropping  as  much  as  twenty 
beats,  while  the  temperature  has  risen  i  1-2°  to  2°.  On  the  evening  of  the 
third  day  there  may  be  a  temperature  of  103°  to  104°  F.  (39.4°  to  40°  C), 
with  a  pulse  running  from  70  to  80.  During  defervescence  the  pulse  may 
become  still  slower — down  to  50,  48,  45,  or  even  30. 

Diagnosis. — The  three  characteristic  s3'mptoms  of  Guiteras  above 
pointed  out  should  be  borne  in  mind,  viz.,  facies,  early  albuminuria,  and  slow 
pulse.  As  to  differential  diagnosis,  yellow  fever  is  most  likely  to  be  con- 
founded with  severe  fever  of  bilious  or  malarial  remittent  type.  Indeed, 
the  resemblance  is  sometimes  very  close,  especially  when  the  latter  is  accom- 
panied by  hematuria.  But  the  remission  occurs  earlier  in  remittent  fever 
and  the  chill  is  of  much  longer  duration,  while  the  presence  of  Laveran's 
Plasmodium  in  the  blood  settles  the  question  in  favor  of  the  latter.  Acute 
ycllozv  atrophy  of  the  liver  is  a  disease  more  insidious  in  its  approach  and 
less  febrile.    The  urine  in  acute  yellow  atrophy  is  loaded  with  bile. 

Relapsing  fever  resembles  yellow  fever  only  in  the  s3'mptoms  of  the 
relapse,  but  this  occurs  much  earlier  in  yellow  fever.  The  similarity  of 
the  mild  forms  of  yellow  fever  to  thermic  fever  has  been  emphasized  by 
Guiteras. 

As  to  dengue,  or  break-bone  fever,  increased  importance  has  recently 
attached  to  the  diagnosis  between  this  disease  and  yellow  fever  because  of 
the  dispute  as  to  whether  certain  cases  in  the  epidemic  of  1897  in  the 
Southern  United  States — as  at  Galveston,  for  example — were  cases  of 
dengue  or  of  yellow  fever.  The  question  is  one  which  presents  difficulties, 
for  both  jaundice  and  hemorrhage,  including  black  vomit,  have  been  in  the 
past  credited  to  dengue,  while  in  the  disputed  cases  black  vomit,  at  least, 
was  wanting.  In  favor  of  yellow  fever  were  the  authoritative  names  of 
Guiteras  and  H.  A.  West,  of  Galveston.  The  following  table  of  contrasted 
symptoms  was  kindly  prepared  for  me  by  Dr.  West : 

Yellow  Fever.  Dengue. 

1.  One  febrile  paroxysm,  character-  i.  Usually  one  febrile  paroxysm,  but 
ized  by  a  steady  rise  and  lasting  usually  sometimes  two,  a  steady  rise  of  temper- 
about  three  days.  The  temperature  rises  ature  until  the  acme  is  reached;  a  short 
rapidly,  the  acme  is  often  reached  within  stadium,  followed  by  a  remission,  then 
a  few  hours  from  the  onset.  not  infrequently  a  second  rise.     Duration 

four  to  eight  da^^s. 

2.  The  pulse  rate  is  characterized  by  2.  The  pulse  usually  increases  in 
abnormal  slowness  and  want  of  corre-  rapidity  with  rise  of  temperature,  though 
spondence  with  the  temperature;  while  an  abnormally  slow  pulse  ma}^  sometimes 
the   latter   is   rising   from   three    to  four      be  observed. 

degrees  the  pulse  continues  to  diminish 
in  frequency. 

3.  There  are  cutting  pains  through  the  3.  Headache  is  more  or  less  intense, 
forehead,  the  eyes  ache,  the  muscles  of  the  pains  in  the  limbs  and  back  are  severe  and 
back,  loins,  thighs,  and  calves  are  sore  and  apparently  involving  the  bones  and  joints 
often  ache  severely,  even  in  mild  cases.  The  latter  are  not  only  painful  and  stif- 
Thepain  is  muscular  rather  than  articular,  fened,  but  in  many  instances  swollen. 

4.  There  is  no  glandular  involvement.  4.  The  Ij'mphatic  glands  are  enlarged 

with  varying  degrees  of  frequency  in  dif- 

(  ferent  epidemics. 

5.  The  face  is  turgid,  not  infrequently  5.  The  face  is  generally  flushed,  the 
a  dusky  red.  The  upper  eyelid  is  often  eyelids  swollen,  the  eyes  injected  and 
swollen.  The  appearance  is  that  of  watery;  there  may  be  a  slight  jaundice, 
typhus  or  of  measles  before  the  eruption,  but  this  symptom  'is  extremely  suspicious 
with  the  addition  of  slight  or  well  marked  of  yellow  fever. 


INFECTIOUS  DISEASES. 


jaundice.  The  conjunctivae  are  congested 
and  shiny  with  a  slight  yellow  tinge,  the 
eyes  sometimes  intensely  red  and  sensi- 
tive to  light.  The  jaundice  becomes  more 
distinct  after  the  first  or  second  day,  the 
skin  showing  the  same  combination  of 
capillary  stasis  with  an  icteroid  hue  as  the 
eyes.  As  the  case  progresses,  jaundice 
may  become  intense. 

6.  The  tongue  is  whitish  in  the  center, 
with  red  tip  and  edges,  and  is  pointed; 
gums  swollen  and  disposed  to  bleed. 
Epigastric  tenderness  and  pain,  nausea 
and  vomiting  are  common;  in  the  stage  of 
depression  black  vomit  is  not  infrequent; 
it  is  alarming  and  often  of  fatal  import. 

7.  Eruption  absent,  or  extremely  rare 
and  insignificant. 


8.  Urine  scanty, albumin  usually  found 
within  seventy-two  hours  ;  there  may  be 
only  a  trace  in  the  evening  urine. 
In  the  second  stage  albumin  may  be 
abundant  and  accompanied  by  all  the 
evidences  of  a  severe  nephritis,  the  pres- 
ence of  casts,  hematuria,  disposition  to 
anuria  and  uremia,  /n  eve7'y  sez>ere  case 
nephritic  complicatiojis  doviinate  the 
clitiical  picture. 

9.  Tendenc}'  to  hemorrhages  common, 
from  nose,  gums,  bowels,  uterus,  kidneys, 
and  stomach,  the  last  often  fatal. 

10.  Disease  often  fatal. 

11.  One  attack  protects  from  another. 

12.  Not  protective  against  dengue. 


6.  The  tongue  at  first  is  covered  with 
a  white  fur;  it  is  swollen  and  the  edges 
are  red,  and  as  the  case  progresses  the 
coating  increases  in  thickness  and  be- 
comes a  dirty  yellow.  In  man^'  cases 
there  is  nausea,  but  vomiting  is  rare. 

7.  An  eruption  occurs  in  quite  a  large 
number  of  cases;  it  may  be  a  simple  ery- 
thema or  resemble  that  of  scarlatina, 
measles,  lichen,  or  urticaria. 

8.  The  urine,  except  in  rare  instances, 
is  free  from  albumin;  if  present  at  all,  it 
is  evanescent.  There  is  no  evidence 
whatever  that  serious  kidney  compli- 
cations belong  to  the  pathology  of  dengue. 


9.  Hemorrhages  from  mucous  mem- 
branes, nose,  gums,  intestines,  uterus  and 
kidneys  not  infrequent,  but  rarely  of 
serious  import. 

10.  Prognosis  proverbially  favorable. 

11.  One  attack  does  not  protect  from 
another. 

12.  Not     protective     against     yellow 
fever. 


Prognosis. — Yellow  fever  is  a  grave  disease,  and  in  its  severe  forms 
one  of  the  most  fatal  of  the  infectious  diseases.  The  mortality  ranges  from 
15  per  cent,  to  85  per  cent.  Among  the  dissipated,  the  worn-out,  the  poor, 
and  in  hospitals  the  mortality  is  higher ;  it  is  less  in  the  colored  race. 
"  Black  vomit  "  is  not  necessarily  a  fatal  symptom.  Many  malignant  cases 
terminate  in  a  couple  of  days.  Modern  studies  go  to  show  the  ravages  of 
yellow  fever  will  be  greatly  diminished  in  the  near  future,  emphasized  by  the 
statement  of  Dr.  Guiteras  at  the  Sanitary  Conference  of  American  Republics, 
held  in  Washington,  D.  C,  in  December,  1902,  to  the  effect  that  "  not  a  case 
of  yellow  fever  has  originated  in  Cuba  for  fourteen  months." 

Treatment. — There  is  no  specific  treatment  for  yellow  fever,  and  the 
symptoms  are  to  be  met  as  they  arise.  The  practice  quite  general  in  the 
Southern  United  States  to  give  an  initial  dose  of  castor  oil  is  justified. 
Some  prefer  calomel  five  to  ten  grains  (0.33  to  0.66  gm.)  ;  others  compound 
cathartic  pills,  one,  two,  or  three  at  a  dose  followed,  if  necessary,  by  a  saline 
such  as  cold  citrate  of  magnesia,  Epsom  salt,  or  Glauber  salt.  The  last  is 
preferred  by  some  who  have  had  the  longest  experience.  These  measures  are 
followed  by  efiforts  to  cause  perspiration,  in  which  the  hot  foot-bath  is 
included.  Quinin  is  not  recommended  by  those  of  wide  experience  for 
any  specific  effect,  though  it  may  be  given  for  its  antipyretic  effect.  The 
latter  is,  however,  better  accomplished  in  the  early  stages  by  the  coal-tar 
derivatives  antipyrin  and  acetanilid.  Seven  and  one-half  grains  (0.5  gm.) 
may  be  given  hourly  until  relief  is  afforded.    Recent  views  as  to  the  etiology 


YELLOW  FEVER.  89 

of  the  disease  would  seem  to  justify  a  return  to  quinin  for  its  original 
purpose.  We  may  seek  to  stop  vomiting  by  ice  internally  and  externally 
and  hypodermic  injections  of  morphin,  by  cold  dry  champagne  and  cold 
efifervescing  waters.  Food  should  be  withheld  for  from  three  to  five  days, 
and  then  be  of  the  simplest  kind,  of  which  a  mixture  of  equal  parts  of  milk 
and  Vichy  is  the  type.  The  hemorrhagic  tendency  may  be  combated  by 
astringents,  including  iron.  Washing  out  the  rectum  by  warm  soap  and 
water  and  enemas,  carried  high  up  in  the  bowel,  is  highly  recommended 
by  Marine  Hospital  Surgeon  H.  D.  Geddings.  *  Two  or  three  pints  must 
be  used.  Normal  salt  solution  may  be  thus  used  with  a  view  to  its  being 
retained  and  absorbed. 

The  failing  strength  is  to  be  supported  by  alcohol,  strychnin,  and 
digitalis  ;  the  high  temperature  reduced  by  sponging  and  cool  baths.  Nutrient 
enemas  are  to  be  relied  on  when  vomiting  is  uncontrollable. 

The  following  line  of  treatment  laid  down  by  Surgeon-General  Stern- 
berg appears  to  have  been  especially  satisfactory  in  cases  treated  in  United 
States,  Cuba,  and  Brazil,  with  a  mortality,  according  to  Carroll,  of  only  7.3 
per  cent.  In  addition  to  sodium  bicarbonate  7  1-2  grains  (0.5  gm.),  mer- 
cury bichlorid  1-60  grain  (0.001  gm.)  every  hour,  he  advises  a  hot  mustard 
foot-bath  during  the  first  24  hours,  cold  sponging,  cold  applications  to  the 
head,  protection  from  currents  of  air,  sinapisms  over  the  stomach  and  lumbar 
region,  the  promotion  of  perspiration,  withholding  of  food  during  the  first 
three  days,  and  stimulants,  in  the  form  of  iced  champagne  or  good  brandy, 
after  the  fourth  day.  If  the  stomach  be  irritable  he  advises  milk  and  lime 
water,  and  if  these  do  not  agree,  nutrient  enemas.  Later  on  he  allows  milk 
punch,  ale,  porter,  etc. 

Good  judgment  should  be  exercised  in  discriminating  against  the  over- 
use of  drugs. 

Prophylaxis  is  more  efficient  than  direct  treatment,  but  modern  etiology 
has  overthrown  rules  formerly  supposed  well  established  and  resolved  it 
chiefly  into  (i)  Guarding  non-immunes  against  infection  by  the  mosquito. 
(2)  Screening  the  house  of  the  infected  person  against  the  insect  in  order 
to  prevent  the  spread  of  the  disease.  (3)  The  destruction  of  as  many  mos- 
quitos  as  possible,  by  drainage,  by  covering  breeding  places  with  insecticides 
and  larvicides.  Among  these  may  be  mentioned  tobacco  leaves,  chrysanthe- 
mum powder,  the  anilin  dyes,  and  petroleum.  (4)  Depopulation  of  infected 
places — that  is,  the  removal  of  all  susceptible  persons  whose  presence  is  not 
necessary  for  the  care  of  the  sick. 

Sermn  Treatment. — Recent  attempts  at  protective  inoculation  have  not 
been  followed  by  satisfactory  results  in  yellow  fever,  though  success  for  this 
treatment  was  claimed  by  W.  L.  de  Humboldt  as  far  back  as  1854,  Caromon 
in  1 88 1,  and  Freire  in  1884.  Sanarelli  has  used  the  "  antiamarylic  "  serum 
of  a  horse  inoculated  with  gradually  increasing  doses  of  the  icteroid  bacillus 
for  eighteen  months.  He  treated  eight  cases  subcutaneously,  of  whom  two 
died.  He  also  treated  fourteen  cases  by  intravenous  injection,  of  whom 
four  died.f 

*  "  United  States  Marine  Hospital  Reports  for  Fiscal  Year  i8q8." 
+  Sanarelli,  "  Annales  de  I'lnstitul;  Pasteur,"  vol.  xii.  p.  348,  i8g8. 


90  INFECTIOUS  DISEASES. 

DENGUE. 

Synonyms. — Break-hone  Fever;  Dandy  Fever. 

Definition. — Dengue  is  an  epidemic,  infectious,  possibly  contagious 
■disease,  characterized  by  paroxysms  of  extreme  pain  in  the  joints  and 
muscles,  accompanied  by  fever  and  sometimes  eruptions  on  the  skin. 

Historical. — Dengue  was  recognized  as  a  distinct  disease  in  the  latter  part  of  the 
■eighteentli  centuiy,  lirst  in  Spain  in  1764-68.  It  prevailed  in  Cairo  and  Java  in  1779. 
In  1780  an  epidemic  prevailed  in  Philadelphia,  which  was  described  by  Benjamin 
Rush  under  the  name  of  bilious  intermitting  fever.  In  1824  it  prevailed  in  Calcutta, 
in  1827  and  1828  in  Charleston,  Savannah,  and  in  New  Orleans,  U.  S.,  and  in  the 
West  Indies,  and  was  described  by  the  late  Professor  S.  H.  Dickson,  then  of  Charles- 
ton. Since  then  there  have  been  numerous  epidemics,  for  the  most  part  south  of  the 
thirty-second  parallel  of  latitude.  It  is  said  that  in  Galveston,  Tex.,  in  1897,  20,000 
were  attacked  in  two  months. 

Etiology. — J.  W.  McLaughlin,  of  Texas,  has  found  in  the  blood  of  a 
dengue  patient  a  micrococcus,  which  he  holds  accountable  for  the  disease, 
but  the  eflfect  of  inoculations  requires  to  be  studied.  Analogy  would  lead 
us  to  suspect  such  an  organism,  while  experience  justifies  a  like  conclusion. 
Dengue  spreads,  as  do  diseases  thus  caused,  by  the  routes  and  means  of 
travel.  It  attacks  both  sexes  and  all  ages,  regardless  of  season,  although 
warm  climates  are  its  natural  habitat,  and  it  is  rather  more  common  in  sum- 
mer. It  is  not  usual  to  have  more  than  one  attack.  No  morbid  anatomical 
changes  have  been  found  associated  with  the  disease. 

Symptoms.— Dengue  is  usually  sudden  in  its  onset,  after  a  period  of 
mctihation  lasting  from  three  to  five  days,  at  the  end  of  which  there  may  be 
some  sense  of  discomfort  (more  frequently  there  is  not),  headache,  and  even 
chilliness.  Suddenly,  often  at  night,  the  patient  is  struck  with  pain  in  the 
muscles  and  joints,  and  especially  the  muscles  of  the  back  and  loins.  The 
pain  is  searching,  as  though  extending  into  the  bones  themselves.  The 
small  as  well  as  the  large  joints  are  affected,  and  the  pain  is  aggravated 
on  motion.  The  suffering  is  extreme,  and  it  may  be  said  that  the  patient  is 
literally  racked  with  torture. 

Simultaneously  there  are  headache  and  fever,  the  former  severe  and  the 
latter  quite  high,  rising  rapidly  to  102°,  103°,  105°  F.  (38.9°,  39.4°,  40.5° 
C),  and  even  106°  or  107°  F.  (41.1°  or  41.6°  C),  reaching  its  maximum 
from  the  second  to  the  fourth  day,  then  declining,  reaching  the  normal  about 
the  fifth  day.  The  face  is  flushed,  the  conjunctivae  are  congested,  commonly 
less  so  than  in  yellow  fever  ;^the  pulse  is  frequent,  100  to  120,  rising  and 
ialling  with  the  fever.  Delirium  is  not  a  marked  feature,  save  in  children. 
The  tongue  is  coated  and  red  at  the  tip  and  edges,  there  are  loss  of  appetite, 
slight  nausea,  and  extreme  thirst,  scanty  urine,  and  constipation ;  at  times, 
liowever,  the  urine  is  copious  and  clear.  Hemorrhage  from  the  nose  and 
•gums  has  been  noted,  and  both  Eugene  Foster  and  D.  C.  Holliday  have  seen 
black  vomit  similar  to  that  of  yellow  fever ;  and  in  one  case  copious  hemor- 
rhage from  the  bowels,  which  persisted  three  months  and  terminated  in 
■death,  was  observed. 

The  paroxysm  lasts  three  or  four  days,  at  the  end  of  which  the  tem- 
perature falls,  the  pain  subsides,  and  a  short  period  of  comparative  comfort, 
though  one  also  of  great  prostration,  succeeds  that  of  great  suffering.  It 
is  during  this  remission  that  an  erythematous  rash  makes  its  appearance  on 
the  face,  neck,  and  shoulders,  and  thence  over  the  whole  body  in  two  or 
three  days.    At  the  same  time  the  lymphatic  glands  at  the  back  of  the  head 


CHOLERA. 


91 


and  neck,  in  the  axillse  and  groins,  swell,  with  some  return  of  fever.  The 
eruption  is  not  constant  or  always  uniform.  It  lasts  from  a  few  hours  to 
a  couple  of  days,  when  it  subsides  with  the  beginning  of  the  second  febrile 
movement,  which  is  milder  and  shorter,  after  which  true  convalescence  sets 
in.     The  eruption  may  also  reappear,  though  rarely. 

Diagnosis. — On  account  of  the  joint  involvement,  associated,  as  it  often 
is,  with  redness,  dengue  has  not  inexcusably  been  mistaken  for  acute  rheu- 
matism; but  the  decided  remission  in  tAvo  days,  the  altogether  short  dura- 
tion of  the  disease,  and  its  epidemic  character,  should  soon  extricate  the 
physician  from  such  confusion.  The  absence  of  any  glandular  swelling  or 
eruption  in  rheumatism  and  the  more  close  limitation  of  the  pain  to  the 
joints  aid  in  the  discrimination. 

After  rheumatism,  influenza  is  perhaps  the  next  disease  with  which 
dengue  may  be  confounded.  It,  too,  is  epidemic,  and  is  attended  often  by 
extreme  and  sudden  muscular  pains,  but  the  sudden  intermission  charac- 
teristic of  dengue  does  not  occur  in  influenza,  nor  does  the  eruption  or 
glandular  swelling. 

The  resemblance  of  dengue  to  yelloiv  fever  has  been  referred  to  under 
the  latter  disease,  where,  too,  the  two  conditions  are  contrasted. 

Prognosis. — Notwithstanding  the  extreme  suffering,  recovery  is  the 
invariable  rule. 

Treatment. — Nothing  can  be  done  to  cut  short  the  disease.  The  most 
satisfactory  method  to  control  the  pain  is  by  the  hypodermic  injection  of 
morphin  and  atropin.  One-fourth  grain  (0.016  gm.)  of  the  former  and 
1-150  grain  (0.00044  gm.)  of  the  latter  may  be  given,  supplemented  by 
phenacetin  and  antipyrin,  in  doses  of  ten  grains  (0.66  gm.)  of  the  former 
and  five  grains  (0.33  gm.)  of  the  latter,  every  two  hours,  when  the  hypo- 
dermic injection  may  be  repeated  if  relief  has  not  been  obtained.  The 
coal-tar  derivatives  are  also  the  best  remedies  for  the  fever,  but  they  may 
be  supplemented  by  sponging  with  cool  water,  or  the  cold  bath  in  extreme 
cases.     Prostration  must  be  met  by  alcoholic  preparations. 


CHOLERA. 

Synonyms. — Cholera  asiatica;  Cholera  algid  a;  Cholera  maligna;  Cholera 
infectiosa;  Epidemic  Cholera. 

Definition. —  Cholera  is  an  acute  infectious  disease  caused  by  the 
invasion  and  toxic  action  of  the  comma  bacillus  or  spirillum  of  Koch.  It  is 
characterized  especially  by  vomiting,  purging,  painful  cramp,  and  collapse. 

Historical. — Cholera  is  a  disease  long  endemic  in  certain  localities  in  India, 
whence  it  has  made  periodical  visitations  to  Europe,  and  in  1S31-33  for  the  first  time- 
to  North  America.  It  invaded  the  United  States  in  1832  by  two  channels  of  immi- 
gration— first,  from  Great  Britain  b)^  way  of  Quebec  and  the  Great  Lakes,  reaching  the 
then  limits  of  settlement,  the  militarj^  posts'of  the  upper  Mississippi;  second,  by  way 
■of  New  York.  In  1835-36  another  visitation  occurred,  and  in  184S  another  by  way  of 
New  Orleans  and  the  Mississippi  Yalle5%  extending  even  to  California.  In  1854  a 
severe  epidemic  raged  through  the  United  States,  for  which  immigration  was  also 
responsible.  In  1865  Arabia  and  Egypt  were  severely  visited  in  the  spring,  Constanti- 
nople in  July,  and  thence  all  Europe.  In>  1866  it  a'gain  appeared  in  Egj-pt,  spread 
over  all  Europe,  reaching  the  United  States  the  same  summer,  during  which  there 
were  quite  a  number  of  cases,  some  of  which  came  under  the  observation  of  the 
author  in  the  Philadelphia  Hospital.  An  extensive  outbreak  prevailed  in  Europe  in 
1884,  extending  to  Italy,  Spain,  and  France,  but  it  did  not  reach  the  United  States._ 

Much  more  serious  than  any  of  the  more  recent  epidemics  was  that  of  i8g2,  which 


92  INFECTIOUS  DISEASES. 

started  in  March  or  April  in  the  northwestern  provinces  of  India,  attacking  with  great 
violence  the  pilgrims  at  the  great  Hurdwar  Fair,  near  the  source  of  the  Ganges,  and 
extending  thence  through  Cashmere  and  Afghanistan  to  Persia,  where  it  arrived  in 
May  or  June.  Thence  it  crossed  the  Caspian  Sea  and  spread  rapidly  thi-ough  Euro- 
pean Russia  into  Prussia,  seating  itself  most  stubbornly  and  savagely  in  Hamburg  in 
August.  Havre,  Antwerp,  Berlin,  Vienna,  and  especially  Budapesth  in  Hungary, 
were  also  visited.  A  few  cases  occurred  in  Southampton,  London,  and  Liverpool,  and 
it  reached  New  York  Harbor  in  September,  1892.  A  few  cases  were  also  reported  in 
New  York  City,  but  there  was  no  further  spread. 

Etiology, — It  is  now  generally  acknowledged  that  cholera  owes  its 
existence  to  the  comma  bacillus  or  spirochseta,  a  semispiral  rod-bacillus  dis- 
covered by  Koch  in  1884.  It  is  thicker,  but  not  more  than  half  so  long  as 
the  tubercle  bacillus.  Sometimes,  by  the  apposition  of  two  bacilli,  an  S-  or 
a  corkscrew-shape  is  produced.  Its  multiplication  is  favored  by  heat,  mois- 
ture, and  filth.  It  is  easy  of  destruction,  even  by  weak  acids  and  a  tempera- 
ture of  140°  F.  (60°  C).  It  can  produce  cholera  only  when  it  is  taken  in 
by  the  stomach,  where,  however,  a  normal  gastric  juice  is  always  able  to 
destroy  it,  while  weak  digestion  induces  a  vulnerability  that  is  promptly 
availed  of  by  the  bacillus,  which  quickly  passes  into  the  intestine,  where  the 
alkaline  reaction  of  the  secretions  favors  its  development  in  enormous  num- 
bers. Bacilli  are  rarely  found  in  vomited  matters,  but  are  numerous  in  the 
fecal  discharges,  and  are  found  in  the  intestines  after  death.  They  may 
invade  the  follicles  and  intestinal  wall,  but  some  time  is  required  for  this,, 
and  such  invasion  does  not  occur  in  cases  speedily  fatal. 

Medium  of  Infection. — Drinking-water  and  contaminated  food  are  the 
acknowledged  media  through  which  the  bacillus  is  commonly  introduced 
into  the  human  organism,  but  it  may  be  conveyed  in  clothing  or  food,  on 
the  hands,  and  may  even  enter  the  mouth  while  floating  in  the  air.  The 
postal  service  is  regarded  as  a  means  of  infection.  It  frequently  follows  in 
the  train  of  moving  masses  of  human  beings,  such  as  emigrants  and  pilgrims, 
but  it  prefers  the  sea-level  and  lower  altitudes,  especially  less  than  1000  feet 
(30.5  meters)  above  the  sea. 

While  at  the  present  day  the  views  of  Koch  as  to  the  origin  and  spread 
of  cholera  are  largely  dominant,  it  should  not  be  overlooked  that  an  authority 
so  high  as  that  of  Pettenkofer,  of  Munich,  still  holds  that  the  germ  of  cholera 
develops  in  the  soil-water  of  the  earth  during  the  heated  months,  and  rises 
in  the  atmosphere  as  a  miasm.  He  claims  that  the  conditions  peculiarly 
favorable  to  its  development  are  a  low-ground  water,  associated  with  por- 
osity, moisture,  and  a  contamination  with  organic  matter,  especially  sewage. 
A.  Rubino,  in  his  article  in  "^ajous'  Annual,"  volimie  ii.,  1899,  says  that 
both  theories  are  in  accordance  with  fact,  and  Asiatic  cholera  must  there- 
fore be  regarded  as  a  contagious  and  miasmatic  disease. 

As  stated,  anything  that  enfeebles  digestion  favors  its  permanent  lodg- 
ment and  multiplication.  Hence,  general  ill-health,  fatigue,  the  alcoholic 
habit,  depression  of  spirits,  fright,  or  anxiety,  any  one  or  all  may  be  predis- 
posing causes.  All  ages  and  sexes  are  liable  to  be  infected,  but  young  chil- 
dren seem  most  vulnerable. 

Morbid  Anatomy. — The  appearance  of  a  man  dead  of  cholera  may 
present  no  peculiarity.  More  commonly,  there  is  a  shrunken  aspect  of  the 
whole  frame,  the  skin  of  the  exposed  and  non-dependent  parts  is  gray  or 
ashen  hued,  while  the  dependent  portions  are  livid.  The  eyes  are  deeply 
sunken,  the  temples  hollow,  the  nose  is  pinched,  and  the  skin  clings  closely 
to  the  bones  beneath  it.  The  appearances  of  such  a  body,  in  brief,  are  those 
of  a  wasted  cadaver  long  immersed  in  the  pickling  vats  of  the  dissecting  room. 


CHOLERA.  93 

Very  striking  are  the  postmortem  elevations  of  temperature  and  the 
phenomena  of  postmortem  muscular  contraction.  The  former  has  reached 
109°  F.  (42.8°  C.)  and  higher.  The  latter  include  movements  of  the  lower 
jaw,  rotation  of  the  eyes,  contraction  of  the  arms  and  legs,  sometimes  start- 
lingly  life-like. 

On  section  of  the  body  the  subcutaneous  tissue  is  found  dry,  the  blood 
in  the  vessels  thick  and  dark.  The  condition  of  the  stomach  and  bowels 
differs  somewhat  with  death  at  different  stages  of  the  disease.  If  death  takes 
place  early  the  stomach  is  commonly,  but  not  always,  filled  with  a  turbid  liquid 
grayislvwhite  in  color,  resembling  rice  w^ater.  In  this  the  microscope  may 
recognize  columnar  epithelial  cells,  isolated  and  in  flakes ;  also  the  remnants 
of  partially  digested  food,  such  as  disintegrating  muscular  fasciculi  and  oil 
globules.  The  mucous  membrane  of  the  stomach  appears  congested,  and  the 
course  of  the  larger  vessels  can  be  readily  traced  in  consequence  of  their 
teing  full  of  thick  blood.  A  populated  appearance  ascribed  to  enlargement 
of  the  solitary  follicles  is  often  present.  The  epithelium  is  detached  in 
places ;  in  others,  intact. 

The  mucous  membrane  of  the  sjnall  intestine  may  also  be  much  con- 
gested; the  bowel  is  filled  with  rice-water  fluid.  On  its  surface  lie  numerous 
patches  or  flakes  of  detached  epithelium,  while  the  papillated  appearance  pro- 
duced by  the  enlarged  lymphadenoid  follicles  is  everywhere  present.  The 
villi  are  largely  denuded  of  epithelium,  but  in  places  they  are  intact. 

If  death  takes  place  during  imperfect  reaction,  the  gastro-intestinal 
mucous  membrane  is  still  more  congested  and  dark-red  in  color  from  hyper- 
emia and  blood  extravasation.  At  such  times,  too,  the  solitary  glands  are 
conspicuous  and  cause  also  a  papillated  appearance  even  more  striking  than 
that  in  the  stomach.  Peyer's  patches  may  also  be  raised,  and  the  same  denu- 
dation of  epithelium  from  the  villi  and  elsewhere  is  present.  The  signs  that 
suggest  an  inflammatory  process  are  a  slight  cellular  infiltration  of  the  intes- 
tinal walls  and  the  enlargement  of  the  solitary  follicles ;  also,  at  times,  a  diph- 
theritic exudate. 

The  liver  is  natural  in  size,  but  may  be  congested  and  darker  hued  than 
in  health,  while  the  cells  exhibit  cloudy  swelling,  and  in  places  small  areas  of 
fatty  change.     The  spleen  is  usually  small,  certainly  not  enlarged. 

The  condition  of  the  kidneys  is  interesting,  and  varies  with  the  stage 
at  which  the  patient  dies.  If  early  in  the  disease  the  organ,  superficially,  is 
not  much  altered ;  it  may  be  somew^hat  enlarged.  The  veins  are  slightly  over- 
filled, but  there  is  no  marked  capillary  injection.  There  may  be  a  few  white 
or  yellowish  patches,  where  the  epithelium  is  found  compressed,  cloudy,  and 
fatty.  The  lumina  of  the  tubes  may,  in  places,  be  blocked  with  granular 
matter  or  well-formed  casts,  and  there  may  be  a  few  hemorrhagic  foci,  the 
changes  starting  from  the  pyramids. 

If  death  takes  place  later,  after  reaction  has  set  in,  the  kidney  is  enlarged. 
The  changes  are  chiefly  in  the  cortical  substance,  in  w^hich  are  seen  grayish- 
white  and  yellow  patches,  alternating  with  normal-hued  portions.  In  these 
altered  places  the  tubes  are  opaque,  with  granular  and  fatty  debris.  Hemor- 
rhagic infarcts  may  also  be  found  in  the  cortical  substance.  The  ^lalpighian 
capsules,  with  their  included  glomerular  capillaries,  are  intact.  These 
changes  correspond  in  the  two  stages'  with  the  phenomena  described  by 
Cohnheim  several  years  ago  as  the  results  of  ligation  of  the  renal  artery, — 
the  first  to  those  following  ligation  of  short  duration,  the  second  to  those 
following  ligation  of  longer  duration. 


94  INFECTIOUS  DISEASES. 

The  heart  is  normal  in  size,  but  its  walls  flaccid.  The  right  cavities  are 
commonly  filled  with  dark,  liquid  blood ;  the  left  cavities,  empty. 

In  many  instances  the  Iiuigs  also  present  an  appearance  more  or  less 
characteristic,  being  shrunken  and  small,  lying  back  in  the  thorax,  as  though 
collapsed.  Like  the  other  tissues,  they  are  empty  of  blood  except  in  their 
dependent  portions,  which  are  the  seat  of  hypostasis.  They  have  been  com- 
pared by  Parkes  to  fetal  lungs.  Sutton  found  the  two  organs  to  weigh  but 
20  ounces  (600  gm.),  as  compared  with  45  ounces  (1350  gm.),  when  death 
occurred  after  reaction  had  been  established — that  is,  after  the  blood  had 
again  occupied  the  pulmonary  artery  and  its  branches.  Collapse  may  be 
interfered  with  by  adhesions,  in  which  event  it  is  only  partial. 

Such  appearances  could,  of  course,  occur  in  death  from  hemorrhage  and^ 
after  all,  the  only  distinctive  condition  is  the  presence  of  the  rice-water  fluid 
in  the  stomach  and  intestine,  or  in  both,  containing  the  "  comma  "  bacillus 
and  desquamated  epithelium.  The  latter,  to  which  the  earlier  descriptions 
attached  great  importance,  is  now  generally  regarded  as  postmortem  in 
origin.  The  flakes  thus  produced  are  also  what  the  older  authors  described 
as  patches  of  lymph. 

Symptoms. — After  a  period  of  incubation  ranging  from  thirty-six  to 
fifty-six  hours,  rarely  five  days,  the  symptoms  of  cholera  commonly  present 
themselves  sufificiently  gradually  to  admit  of  arrangement  into  three  distinct 
groups  or  stages : 

1.  The  stage  of  preliminary  diarrhea. 

2.  The  stage  of  collapse. 

3.  The  stage  of  reaction. 

The  stages  are  by  no  means  always  recognizable,  and  the  severity  of  the 
symptoms  varies  greatly,  such  variations  being  reasonably  ascribed  to  the 
varying  quantities  or  virulence  of  the  specific  poison.  Mildness  in  a  given 
case  is  no  guarantee  against  virulence  in  another  caused  by  it. 

1.  The  stage  of  preliminary  diarrhea  *  is  characterized  by  moderate 
diarrhea,  which  is  characteristically  painless,  but  may  be  associated  with 
colicky  pains.  The  stools  are  yellow  or  yellowish  throughout  this  stage,  and 
are  alkaline  in  reaction.  Xausea  and  vomiting  are  not  usual  in  it,  and  the 
patient  may  feel  but  slightly  indisposed.  There  is  generally  a  feeling  of  rest- 
less discomfort  and  depression,  to  which  headache  may  contribute.  The 
temperature  remains  normal.  The  first  stage  may  last  for  a  week  or  longer, 
or  for  a  few  hours  only,  or  it  may  be  entirely  absent. 

2.  In  the  stage  of  collapse  the  diarrhea  has  become  profuse.  The  dis- 
charges have  lost  their  yellowish  color  and  resemble  thin  gruel  or  rice-water. 
The  fluid  gushes  out  with  great  profuseness  and  apparent  force.  There  may 
be  griping  or  tenesmus,  but  more  characteristic  are  the  very  painful  muscular 
cramps,  which  usually  begin  in  the  fingers  and  toes  and  extend  thence  to  the 
calves  of  the  legs  and  abdominal  walls.  Vomiting,  bilious  at  first,  is  soon 
added  to  the  diarrhea.  The  fluid  vomited  soon  assumes  the  rice-water  char- 
acter, and  gushes  from  the  mouth  as  from  the  bowel,  in  enormous  quantities. 

Extreme  weakness  and  exhaustion  are  by  this  time  present.  The  skin 
is  blanched  and  shrunken,  the  lusterless  eyes  are  sunken  and  bounded  below 
By  great  circles  of  blue.  The  nose  is  pinched,  the  lips  are  thin,  the  cheeks 
hollow,  and  the  countenance  pallid  to  bluish  grayness.  The  extremities  and 
entire  body  become  clammy  and  cold,  the  superficial  temperature  falls  5°  or 

*  To  this  stage  the  term  cholerine  has  also  been  applied,  but  this  word  is  now  more  commonly 
used  to  indicate  a  mild  form  of  cholera. 


CHOLERA.  95, 

6°i  while  that  of  the  rectum  rises  to  103°  and  104°  F.  (39°  and  40°  C). 
Speech  is  husky,  whispering,  and  labored.  The  pulse  is  feeble  or  frequent, 
or  absent  at  the  wrist,  and  the  patient  appears  to  be  dying.  Even  the  heart- 
beat and  sounds  are  almost  gone,  but  the  breathing  continues.  Through  all 
this,  consciousness  may  be  maintained  to  the  end  or  coma  may  supervene. 
Death  commonly  occurs  in  this  stage. 

On  account  of  the  scantiness  of  blood  certain  secretions  cease  and  there 
is  neither  urine  nor  saliva,  while  power  to  perspire,  and  even  the  lacteal  secre- 
tion in  nursing  women,  remain. 

A  more  close  examination  of  the  rice-water  vomited  matters  and  bowel, 
discharges  reveals  flakes  of  epithelium,  mucus,  and  granular  debris,  and,  with 
sufficiently  ,high  powers  and  suitable  preparation,  the  cholera  bacillus 
together  with  numerous  other  bacteria.  Occasionally  a  little  blood  is  present. 
The  fluid  is  albuminous  and  contains  the  salts  of  the  blood,  among  which 
sodium  chlorid  is  conspicuous.  Sometimes,  however,  there  may  be  no  vomit- 
ing or  purging,  whence  the  term  cholera  sicca.  In  these  cases,  however,  the 
stomach  and  bowels  are  commonly  found  containing  the  characteristic  fluid 
after  death. 

This  second  stage  is  generally  of  shorter  duration,  commonly  a  few  hours 
only,  but  it  may  be  prolonged  to  twelve  or  twenty-four.  The  disease  is  some- 
times ushered  in  with  the  symptoms  of  this  stage.  It  has  been  ascribed  to  the 
action  of  a  toxin  produced  by  the  bacilli,  which,  when  absorbed,  produces  the 
systemic  effects  of  this  stage,  but  it  is  likely  that  the  flux  is  the  principal 
factor  in  its  production. 

3.  The  stage  of  reaction  is  characterized  by  the  return  of  warmth  and 
color,  the  latter  more  slowly,  and  the  re-establishment  of  secretions.  Espe- 
cially favorable  is  the  return  of  the  urinary  secretion.  Along  with  these 
changes  the  vomiting  and  purging  occur  at  longer  intervals.  Such  improve- 
ment is,  however,  often  delusive.  The  diarrhea  may  return,  the  collapse 
repeat  itself,  and  the  patient  die.  Or  there  may  supervene  cholera  typhoid,  a 
state  characterized  by  a  frequent,  feeble  pulse,  dry  tongue,  delirium,  and 
sometimes  an  erythematous  or  roseolar  eruption  on  the  extremities.  This 
may  end  in  recovery.  Or  there  may  be  superadded  symptoms  of  nephritis^ 
including  uremia,  coma,  and  death.  Or  there  may  be  inflammation,  diph- 
theritic or  catarrhal,  of  the  bowels. 

Diagnosis. — In  the  matter  of  the  diagnosis  it  is  well  known  that,  so  far 
as  symptoms  are  concerned,  cases  of  cholera  morbus,  cholera  nostras,  or 
sporadic  cholera,  as  we  may  prefer  to  name  it,  have  occurred  with  symptoms 
absolutely  identical  with  those  of  true  cholera,  including  the  fatal  termi- 
nation. 

There  is  one  very  important  etiological  difference  between  cholera  mor- 
bus and  true  cholera,  which  is  also  of  great  diagnostic  value,  and  that  is  that 
almost  invariably  cholera  morbus  is  traceable  to  a  severe  and  irritating  excit- 
ing cause,  such  as  a  meal  of  indigestible  fruits  or  vegetables,  or  imperfectly 
cooked  or  decomposing  fish  or  shell-fish,  while  cholera  comes  on  without  any 
such  cause,  or  succeeds  trifling  derangements  of  digestion,  which  in  other 
than  cholera  seasons  pass  away  without  harmful  results.  As  a  rule,  too,  the 
symptoms  of  cholera  morbus  are  much  more  severe  at  first  than  those  of  true 
cholera,  and  the  substances  first  vomited  are  undigested  articles  that  have 
acted  as  exciting  causes,  succeeded  by  green,  bilious  matter.  The  discharge 
from  the  bowels  is  first  also  of  a  more  bilious  character,  and  above  all,  the 
mortality  is  much  less  serious ;  indeed,  recovery  is  the  rule.     Yet  these  dif- 


96  INFECTIOUS  DISEASES. 

ferences   are  not  to  be  relied  upon.      (See,  also,  Appendix  to   Section  on 
Cholera,  p.  102.) 

By  bacteriological  investigation  only  can  a  given  case  be  identified  with 
absolute  certainty.  The  agglutinative  reaction  is  the  most  ready  method. 
It  is  similar  to  the  Wldal  test  for  typhoid  fever,  and  depends  on  agglutina- 
tion of  the  bacilli  in  a  culture  of  cholera  vibrios,  produced  by  the  blood-serum 
of  the  infected  case.  Some  hours  are,  however,  necessary  to  complete  such  a 
bacteriological  diagnosis.  Further,  such  investigation  can  be  made  only  b}' 
those  who  are  expert  and  provided  with  proper  facilities.  Such  expertness 
and  facilities,  moreover,  are  not  found  in  the  hands  of  the  general  prac- 
titioner, and  the  bacteriological  investigation  is,  therefore,  of  limited  appli- 
cation. Doubtless,  should  occasion  demand,  the  authorities  in  the  large  cities, 
at  least,  will  furnish  the  same  assistance  they  now  do  in  the  case  of  diph- 
theria and  typhoid  fever. 

As  to  the  microscopic  examination  of  the  dejecta,  which  is  more  feasible 
for  the  practitioner,  it  may  be  said  if  the  examination  reveals  a  preponder- 
ance of  curved  bacilli,  comma-shaped,  and  sometimes  joined  end  to  end,  so 
as  to  form  figures  somewhat  resembling  the  letter  S,  and  again  appearing  in 
long  threads,  we  may  feel  justified  in  considering  the  case  one  for  careful 
study  by  bacteriological  methods.  Although  there  are  found  in  the  alimen- 
tary tract  other  bacilli,  the  morphology  of  which  is  much  like  that  of  the 
cholera  bacillus,  they  are  not  numerous.  The  bacillus  of  Prior  and  Finkler, 
found  in  the  stools  of  cholera  morbus,  while  closely  resembling  the  true 
comma  bacillus  of  Koch,  is  larger  and  thicker.  i\Iore  easily  distinguished 
are  the  cultures.  The  Prior  and  Finkler  bacillus  grows  more  rapidly  and 
the  shape  of  its  culture  is  saccular,  while  that  of  the  cholera  bacillus  is 
conical.     It  also  liquefies  the  gelatin  much  more  rapidly. 

How,  then,  shall  we  know  a  case  of  vomiting,  serous  diarrhea,  severe 
colicky  pain,  followed  by  collapse,  to  be  a  case  of  cholera  ?  In  this  country, 
w^here  such  a  thing  as  endemic  cholera  is  unknown,  it  goes  without  saying 
that  any  isolated  case,  even  if  fatal,  cannot  be  one  of  true  cholera  unless 
there  be  traceable  some  connection  with  an  acknowledged  focus  of  cholera 
elsewhere.  Second,  such  communication  must  have  taken  place  within  the 
period  of  incubation  required  for  the  development  of  the  case,  say  within 
six  davs.  Of  course,  such  communication  need  not  be  a  personal  one.  It 
may  be  by  clothing,  merchandise,  and  probably  even  letters. 

These  conditions  being  fulfilled,  the  patient  suffering  with  the  symptoms 
of  cholera  must,  for  the  time  being,  be  regarded  as  a  case  of  the  true  dis- 
ease, and  isolated  until  the  bacteriological  investigation  can  be  made,  but 
the  rapid  occurrence  of  similar  cases  increases  the  probability  of  its  being 
true  cholera,  and  finally  establishes  its  certainty.  Yet  local  epidemics  of 
cholera  morbus  do  sometimes  take  place,  severe  and  grave  in  character,  due 
to  local  causes,  and  favored  by  extreme  and  long-continued  heat.  Thus  it 
is  still  the  question  whether  the  epidemic  of  cholerine  that  prevailed  in 
Paris  in  May,  June,  and  July,  1892,  was  true  cholera  or  cholera  morbus, 
and  there  seems  much  reason  to  believe  it  to  have  been  the  latter,  notwith- 
standing the  prevalence  of  true  cholera  elsewhere  in  Europe. 

Symptoms  similar  to  those  of  cholera  arise  from  poisoning  by  cor- 
rosive sublimate,  tartar  emetic,  arsenic,  mushrooms,  and  ptomains  from 
various  sources,  but  their  symptoms  are  rarely  confounded  with  those  of 
■cholera. 

Prognosis. —  The  prognosis,  always  grave,  varies  with  the  stage  of  the 


CHOLERA. 


97 


epidemic.  It  is  well  known  that  in  the  beginning  a  very  large  proportion  of 
cases  die,  fully  80  per  cent.,  but  as  the  epidemic  is  prolonged  the  ratio  of 
deaths  to  persons  attacked  grows  less,  the  mortality  falling  to  30  per  cent, 
or  less.  The  habits  and  morals  of  the  patient  have  an  important  influence. 
Intemperance  and  dissipation  diminish  greatly  the  powers  of  resistance,  as 
do  also  fatigue,  indigestion,  fright,  and  fear. 

Treatment. — The  treatment  of  cholera  is  very  appropriately  divided 
into  prophylactic  and  medicinal ;  the  former,  when  properly  carried  out, 
being  more  effectual  than  the  latter. 

Prophylaxis. — In  the  first  place,  it  has  been  sho^^^l  that  a  certain  degree 
of  immunity  from  cholera  is  secured  by  a  first  attack.  This  was  the  con- 
clusion of  a  collective  investigation  directed  by  the  Academy  of  Medicine 
of  Paris  in  1884,  and  by  Edward  O.  Shakespeare  from  information  collected 
by  him  during  his  residence  in  Spain  in  1885,  appointed  by  the  United 
States  Government  to  investigate  the  subject.  From  this  standpoint  Ferran 
and  others  sought  to  secure  immunity  by  inoculation  of  protective  virus. 
The  former,  using  a  pure  culture  in  bouillon  of  the  comma  bacillus,  prac- 
ticed the  method  in  Spain  during  the  epidemic  of  1885,  but  a  French  com- 
mission appointed  to  investigate  it  reported  unfavorably,  and  it  fell  into 
disuse,  although  Dr.  Shakespeare  in  his  "  Report  on  Cholera  in  Europe  and 
America  "  is  inclined  to  believe  there  are  possibilities  in  Ferran's  method 
which  make  it  scorthy  of  further  trial. 

Gamaleia,  Lowenthal,  Brieger,*  and  Wassermann  secured  immunity 
in  animals,  by  blood  seram  from  others  treated  with  injections  of  from  o.i 
to  I  c.  c.  of  cholera  bacilli  sterilized  by  heat,  and  G.  Klemperer  t  obtained 
results  which  went  to  show  that  immunity  could  be  conferred  on  man  by  the 
same  treatment;  also  by  the  subcutaneous  injection  of  the  milk  of  immu- 
nized goats,  though  the  immunity  is  considerably  less  by  the  latter  than 
by  the  former.  A.  Lazarus  showed  (1892)  that  the  blood  of  man,  after 
recovery  from  an  attack  of  cholera,  has  the  property  of  protecting  guinea- 
pigs  from  fatal  infection  when  injected  in  very  small  quantities  into  the 
peritoneal  cavity  along  with  intraperitoneal  injections  of  cholera  vibrios. 
Issaefif,  in  1894,  confirmed  the  latter  observation,  but  showed  that  the  prop- 
erty was  temporary.  Lazarus  regarded  this  effect  antitoxic,  R.  Pfeiffer  as 
the  direct  result  of  bacteriolytic  or  lysogenic  action  of  the  serum. 
Pfeiffer's  studies  on  immunity  from  Asiatic  cholera  were  published  in  con- 
junction with  Issaeff  in  1894.  He  showed  that  the  destruction  of  living 
cholera  bacilli  quickly  takes  place  in  the  peritoneal  cavity  of  the  immunized 
guinea-pig,  if  at  the  same  time  a  minute  quantity  of  the  serum  from  an 
immune  animal  is  injected.  This  constitutes  Pfeift'er's  "  serum  reaction." 
or  phenomenon,  and  was  demonstrated  by  him  and  Kolle  for  typhoid  fever 
infection,  and  was  one  of  the  steps  that  led  to  recognition  of  the  importance 
of  the  agglutinating  reaction  of  sera.  L'p  to  the  present  time,  apparently 
but  three  cases  of  cholera  have  been  treated  by  subcutaneous  injections  of 
blood-serum  from  persons  who  recently  sufifered  attacks  of  cholera.  Of 
these,  one  died  and  two  recovered. 

The   results  of  protective  inoculations  by  cultures   by   'SI.   Haff'kine's 


♦Brieger's  exp°riments  ■were  upon  guinea-pig's,  which  he  succeeded  in  making  _  immune  to 
virulent  cultures  of  cholera  bacilli.  The  method  consisted  in  making  intraperitoneal  injections  of 
comma  spirilla  cultures  prepared  in  watery  extract  of  calves'  thymus  or  in  beef-bouillon. — 
"Deutsche  med.  Wochenschrift,"  i8q2.  No.  31. 

(•"Berliner  klin.  Wochenschrift,"  1892,  No.  39,  S.  969;  "  Med.  News,"  Philadelphia,  October 
2g,  1892,  p.  496. 


98  INFECTIOUS  DISEASES. 

method  are  more  practical.  His  researches  at  the  Pasteur  Institute,  pub- 
Hshed  in  1892,  started  with  inoculation  of  the  animal  in  the  peritoneal  cavity 
and  exposure  of  the  resulting  exudate  to  the  open  air  for  several  hours.  A 
transfer  of  this  to  the  peritoneum  of  another  animal  secures  an  "  exalted  " 
or  "  fixed  "'  vaccine,  the  subcutaneous  injection  of  which  secures  anticholeraic 
immunity,  but  with  necrosis  of  the  cutaneous  tissues.  This  necrotic  effect 
is  removed  by  cultivating  it  at  a  temperature  of  39°  C.  (102.2°  F.)  in  an 
atmosphere  constantly  aerated.  Successive  inoculations  result  in  an  attenua- 
tion of  cultures,  which,  injected  under  the  skin  of  animals,  even  in  an  exag- 
gerated do'^e,  produces  only  a  passing  edema,  while  it  leaves  the  animal 
immune  to  the  "  exalted  "  or  "  fixed  "  virus.  The  same  harmlessness  attends 
its  inoculation  under  the  skin  of  men,  where  the  microbes  die  and  disappear, 
setting  free  a  substance  which  acts  upon  the  organism  and  confers  immunity 
on  it.  The  same  result  follows  the  injection  of  their  dead  bodies  only. 
Thus  he  was  enabled  to  prepare  vaccine,  preserved  in  weak  solutions  of 
carbolic  acid,  which  remains  efficacious  for  six  months,  and  may  be  used 
by  persons  without  bacteriological  training. 

From  the  summary  of  cases,  some  32,000  treated  by  his  method  in 
India  during  1 893- 1894,  published  by  AI.  Haffkine  in  January,  1895,  we 
note  a  reduction  of  mortality  from  6.51  per  cent,  in  cases  not  treated  to  3.8 
per  cent,  of  those  treated.  Xo  other  method  has  been  tested  by  anything 
like  as  many  cases,  and  though  the  correct  treatment  may  not  yet  have 
been  arrived  at,  it  seems  reasonable  to  believe  that  we  are  in  close  pursuit 
of  one  which  is  .  most  promising  of  results.  More  recent  inquiry  into 
results  of  Haffkine's  treatment  in  Calcutta  during  two  years  by  Simpson 
("  Indian  Med.-Chir.  Rev.,"  July,  1896)  shows  a  reduction  of  mortality  of 
72.47  per  cent. 

Until  these  processes  are  perfected  we  must  be  satisfied  with  a  proph- 
ylaxis which,  in  point  of  fact,  is  little,  if  at  all,  less  efficient  in  securing 
immunity  than  the  most  successful  inoculation  methods  as  yet  suggested.  By 
means  of  it  cholera  has  been  virtually  kept  out  of  England  and  the  United 
States  since  1873,  though  brought  to  certain  ports  where  it  has  been  held 
at  quarantine.  It  consists  mainly  in  the  isolation  of  the  patient  and  in 
certain  precautions  against  the  spread  of  infection  by  sterilizing  the  dis- 
charges.    To  this  end : 

1.  The  vomited  matter  and  the  discharges  from  the  bowels  are  to  be 
gathered  in  carbolic  solution,  i  to  20,  or  chlorinated  lime,  i  to  10,  some  of 
which  should  be  in  the  vessels  before  it  is  used.  After  use,  more  should  be 
added.  The  matter  thus  collected  should  be  gently  stirred  and  allowed  to 
remain  twenty  minutes  before  being  poured  into  the  water-closet  hopper. 
Where  the  excreta  can  be  thrown  into  a  pit,  or  even,  as  may  be  done  in  the 
country,  on  the  manure  pile,  milk  of  lime,  or  what  is  the  same  thing, 
ordinary  whitewash,  is  a  very  efficient  and  cheap  medium  with  which  to 
disinfect  them. 

2.  After  vomiting,  the  mouth  of  the  patient  should  be  rinsed  with  a 
solution  of  hydronaphthol,  i  to  5000,  care  being  taken  that  none  is  swal- 
lowed. After  each  evacuation  from  the  bowels,  the  buttocks,  thighs,  and 
anus  should  be  washed  with  soap  and  water. 

3.  All  body  and  bed  linen  soiled  with  the  discharges  should  be  imme- 
diately moistened  with  carbolic  solution,  i  to  60,  and  removed  in  a  covered 
vessel  from  the  apartment,  placed  in  a  wash-boiler,  and  boiled  for  half  an 
hour  in  a  one  per  cent,  solution  of  washing  soda. 


■CHOLERA.  99 

4.  Xapkins,  towels,  and  table  linen  should  be  placed  in  a  similar  vessel 
or  canvas  bag  for  removal  and  similarly  boiled. 

5.  All  dishes,  knives,  forks,  spoons,  etc.,  used  by  the  patient  should 
be  boiled  after  each  meal  in  a  one  per  cent,  solution  of  soda. 

6.  The  remains  of  meals  should  be  thrown  into  a  vessel  containing 
milk  of  lime  or  whitewash,  and  removed  at  the  end  of  the  day. 

7.  Door-knobs  are  liable  to  be  soiled  by  the  hands  of  one  carrving 
out  excreta,  and  should  be  carefully  washed  and  cleaned  and  sterilized, 
lest  they,  in  turn,  communicate  the  infectious  material  to  another  person 
handling  them. 

8.  In  case  of  death,  the  body,  without  being  vrashed,  should  be  wrapped 
in  sheets  wet  in  a  solution  of  bichlorid  of  mercury,  i  to  1000,  and  allowed 
to  remain  until  removed  for  prompt  burial. 

Special  Directions  to  Nurses: 

1.  In  like  manner  nurses  of  cholera  patients  should  not  hold  any  direct 
communication  with  others  during  attendance  on  such  cases. 

2.  They  should,  under  no  circumstances,  take  their  meals  in  the  sam.e 
apartment  with  the  patient,  and  before  leaving  the  room  the  hands  should 
be  cleansed  with  soap  and  bichlorid  solution,  and  such  portion  of  the  dress 
as  is  liable  to  be  soiled  should  be  changed.  The  hands  should  be  again 
rinsed  in  bichlorid  solution,  i  to  1000,  after  leaving  the  patient's  room. 
A  very  convenient  plan  is  to  wear  a  slip  or  '"  overall  "  with  a  hood  to  cover 
the  hair,  which  can  be  easily  thrown  aside  before  leaving  the  room.  A 
canvas  slipper  or  overshoe,  readily  removed,  should  also  be  worn  in  the 
sick-room. 

3.  The  food  of  the  nurse  should  be  wholesome  and  plain,  freshly 
cooked,  and  served  hot.  Xo  uncooked  vegetables  should  be  eaten.  ]\Iilk 
should  be  boiled  and,  if  desired,  cooled  before  using.  Cold  drinks  should 
be  taken  moderately,  if  at  all.     Coffee  and  tea  may  be  taken  hot. 

4.  Teeth  should  be  cleansed  after  each  meal,  as  the  mouth  affords  a 
peculiarly  favorable  nidus  for  decomposing  matters  and  a  favorable  nidus 
for  the  multiplication  of  pathogenic  fungi.  A  daily  bath  in  warm  water, 
with  the  use  of  soap,  should  be  taken  by  each  nurse. 

5.  Care  should  be  observed  to  keep  the  body  from  being  chilled  by  drafts 
or  other  cool  exposures,  and  to  this  end  woolen  underclothing  should  be 
worn. 

6.  Courage  and  cheerfulness  are  amply  justified,  because  it  is  really 
almost  impossible  to  take  cholera  if  the  above  precautions  are  carried  out. 

The  Treatment  of  the  Attack. — The  indications  in  the  management  of 
cholera,  apart  from  isolation  of  the  patient  and  the  sterilization  of  the  dis- 
charges, are.  in  the  ^rst  stage,  to  check  the  diarrhea,  combat  the  multi- 
plication of  bacilli,  and  neutralize  their  toxic  influence.  In  the  second  stage, 
to  relieve  the  cramp  and  pain  and  check  the  flux. 

I. — The  former  is  to  be  attained  by  the  judicious  use  of  opiates  and 
acids  on  the  one  hand  or  opiates  and  antiseptics  on  the  other ;  for  antiseptics 
and  acids  can  scarcely  be  used  together,  and  the  physicians  must  decide  on 
which  of  the  germicides  he  proposes  to  fely.  Any  of  the  mineral  acids,  such 
as  hydrochloric,  nitromuriatic,  and  sulphuric  acids  in  doses  of  10  to  15 
minims  (0.66  to  i  c.  c.)  of  the  dilute  acid  wdth  as  much  tincture  of  opium 
or  a   corresponding   dose   of  paregoric  or  deodorized   tincture   of  opium 


loo  INFECTIOUS  DISEASES. 

properly  diluted,  may  be  given  every  two  hours.     Or  a  lemonade  of  tartaric 

or  citric  or  lactic  acid,  2.5  drams  to  i  quart  of  water  (9.5  gm.  to  a  liter),, 

may  be  used  in  conjunction  with  the  opiate.     In  addition,  the  rectum  may  be 

washed  out  by  the  warm  solution  of  tannic  acid  in  water  or  camomile  tea, 

to  be  again  referred  to  on  page  10 1. 

It  has  long  been  the  practice  to  prescribe  in  cholera,  as  well  as  cholera 

morbus,  a  mixture  of  stimulating  aromatics  and  irritants  with  opiates,  and 

there  is  no  doubt  that  in  the  early  stages  of  cholera   such   combinations 

may  be  of  value.     The  following  is  one  of  them : 

IJ    Tr.  opii,  ^ 

Tr.  capsici,  { 

J^-^i'^gj^'    .  Ua        f3ss(2c.  c.) 

Sp.  menth.  piper.,  ^       \  / 

Sp.  chloroformi,  | 

Sp.  camphoras,  J 

Sp.  vin.  rect q.  s.  ad f  rij  (60  c.  c.) 

M.    Sig. — Teaspoonful  in  hot  water  or  black  tea  every  fifteen  minutes 

until  relieved. 

Paregoric,  in  one-dram  doses  (4  c.  c),  similarly  administered  early  in 
the  disease,  is  often  sufficient  to  control  the  symptoms. 

The  following  is  the  well-known  cholera  mixture  or  diarrhea  mixture 

of  Squibb,  which  is  given  under  the  same  circumstances : 

^     Tr.  opii,  ^ 

Sp.  camphorge,     |- aa       .     .      .      .  .      .     f^j    (30  c.  c.) 

Tr.  capsici,  ) 

Chloroformi   pur f  3  iij  (12  c.  c.) 

Alcohol.   . q.  s.  ad f  3  v  (150  c.  c.) 

M.    Sig. — Teaspoonful  every  hour  or  every  two  hours. 

Instead  of  the  acid  solutions,  antiseptics  may  be  given  for  the  same 
purpose.  Of  these,  salol  is  a  favorite,  and  may  be  given  in  doses  of  10  to 
-1 5  grains  (0.66  to  i  gm.)  every  two  or  three  hours,  and  it  may  be  combined 
with  subnitrate  of  bismuth  in  large  doses,  with  wine  of  opium  or  deodorized 
tincture. 

The  greater  or  less  usefulness  of  calomel  in  cholera,  as  attested  by 
experience  in  so  many  epidemics,  beginning  in  1885,  may  be  ascribed 
to  its  antiseptic  qualities,  although  it  is  probably  as  efficient  in  con- 
trolling vomiting  as  any  other  drug.  The  plan  pursued  at  the  New 
Hamburg  Hospital  and  at  the  ^loabit  Hospital  in  Berlin  was  to  give 
an  initial  dose  of  four  to  seven  grains  (0.3  to  0.5  gm.),  after  wdiich  1-3 
to  3-4  grain  (0.02  to  0.05  gm.)  was  given  every  two  hours  through  the  first 
and  second  stages.  A  portion  of  the  calomel  becomes  changed  in  the 
intestine  to  corrosive  sublimate ;  and  as  corrosive-sublimate  solutions  have 
a  fungus-destroying  action,  in  a  strength  of  i  to  30,000,  it  is  reasonable  to 
suppose  that  the  bacilli  in  the  intestine  are  directly  killed  by  the  calomel. 

II. — The  indications  in  the  second  stage  are  to  relieve  the  painful  cramp, 
to  continue  to  try  to  check  the  discharges,  and  to  compensate  for  the  loss 
of  liauid  by  the  vomiting  and  purging. 

For  the  relief  of  cramps  morphin  hypodermically  is  to  be  preferred, 
because  of  the  promptness  of  its  effect  and  because  absorption  from  the 
gastro-intestinal  mucous  membrane  is  much  hindered,  if  not  altogether  pre- 
vented, in  true  cholera,  while  the  vomiting  is  a  further  obstacle  to  the 
administration  of  medicine  by  the  mouth.  Full  doses  should  be  given,  1-6 
to  1-4  grain  (o.oi  to  0.016  gm.),  which  may  be  repeated,  if  necessary.  If 
circumstances  compel  the  administration  of  anodynes  by  the  mouth,  chloro- 
dvne  is  one  of  the  best,  and  is  well  administered   in  brandy  or  whisky. 


CHOLERA. 


lOl 


Such  administration,  too,  fulfills  any  indication  for  opium  to  control  the 
bowels.  Some  difference  of  opinion  exists  as  to  the  propriety  of  checking 
the- discharges  in  this  stage,  the  chief  reason  assigned  being  that  the  bacilli, 
whose  presence  is  directly  or  indirectly  the  cause  of  the  flux,  are  thus 
retained.  But  such  objection  is  offset  by  the  fact  that  the  flux  itself  is  the 
greater  source  of  danger  and  that,  if  it  can  be  controlled,  the  bacilli  in  the 
bowel  are  comparatively  harmless.  Unfortunately,  in  the  later  stages, 
when  the  flux  is  established,  nothing  avails  to  control  it,  and  the  opiate 
may  as  well  be  limited  to  that  hypodermically  administered  for  the  relief 
of  pairi.  I  quite  agree  with  those  who  hold  that,  notwithstanding  the  oppo- 
sition to  it,  opium  will  retain  its  place  among  the  chief  weapons  against  the 
disease. 

The  effect  of  the  copious  discharge  is  to  produce  the  intense  exhaus- 
tion referred  to  under  symptomatology,  and  it  is  imperative  to  counteract 
this,  if  possible,  by  stimulants  freely  administered.  Champagne,  brandy,  and 
ammonia,  combined  with  ice  and  carbonated  waters,  are  suitable.  If  not 
retained  by  the  stomach,  whisky,  ether,  and  the  aromatic  spirit  of  ammonia 
may  be  given  hypodermically  in  thirt^'-minim  (2  gm.)  doses  frequently 
repeated.  The  hope  of  benefit  from  these  remedies  is  justified,  if  reaction 
once  sets  in. 

More  serious  still  is  the  drainage  of  liquid  from  the  tissues,  and  the 
most  serious  consequences  ensue  from  the  resulting  stagnation  in  the  blood. 
To  restore  its  liquidity  is,  therefore,  of  the  greatest  importance.  Transfu- 
sion of  watery  solutions  suggests  itself,  but  the  difficulty  and  delay  involved 
in  practicing  are  opposed  to  its  use.     Hypodermic  injections  of  hot  saline 


Fig  12. — I.  Rubber  reservoir  and.  tube  o£  fountain  syringe  for  hypodermoch^sis.     2. 
Attachment  for  cannula.     3.  Soft  rubber  rectal  tube.     4.  Needle.     5.  Cannula. 

solutions  or  hypodermoclysis,  also  enemas  or  enteroclysis  of  similar  fluids, 
slightly  astringent,  were  practiced  successfully  by  Cantani  in  Italy  in  1892, 
and  have  been  continued  with  various  results  in  Europe,  and  in  a  more 
limited  manner,  with  satisfactory  results,  at  Swinburne  Island  in  New  York 
Harbor.  The  method  practiced  at  the  latter  place,  as  described  by  Judson 
Daland,  is  as  follows:  Water  at  40°  C.  (104°  F.)  previously  steriHzed,  and 
containing  0.8  per  cent,  of  sodium  chlorid  and  one  per  cent,  of  brandy,  was 


102  INFECTIOUS  DISEASES. 

Introduced  under  the  skin  in  the  midaxillary  hne  in  the  region  of  the  floating 
ribs,  through  a  long  hypodermic  needle  and  cannula  attached  to  the  tube  of  a 
fountain  syringe  or  Davidson  syringe.  The  former  is  preferred,  because 
the  pressure  may  be  neatly  regulated  by  raising  or  lowering  the  bag.  One 
or  two  quarts  may  be  introduced,  thirty  to  forty-five  minutes  being  required, 
in  favorable  cases  for  the  former  quantity.  When  absorption  is  slow,  it  may 
be  facilitated  by  manual  manipulation  at  the  seat  of  the  swelling  that  results 
at  the  point  of  injection.  In  unfavorable  cases  a  much  longer  time  is  required 
to  introduce  this  quantity,  as  much  as  four  hours,  whence  the  rate  of  absorp- 
tion becomes  of  prognostic  value.  The  operation  may  be  repeated  in  two 
hours,  or  in  severe  cases  one  quart  may  be  injected  in  each  flank,  repeated 
as  soon  as  absorption  is  complete.  The  quantities  to  be  used  may  be  laid 
down  at,  for  an  adult,  two  pints  ( i  liter)  ;  an  adolescent,  one  pint  (0.5  liter)  ; 
and  an  infant,  1-2  pint  (0.250  liter).  Other  sites  may  be  selected  for  injec- 
tion, as  the  buttocks,  inner  surface  of  the  thighs,  or  below  the  pectoral 
muscle.  The  neighborhood  of  the  neck  should  be  avoided  because  of  the 
possible  edema  of  the  larynx,  such  an  accident  having  occurred  at  Swin- 
burne Island.  The  benefit  derived  from  the  use  of  this  measure  under  other 
circumstances, — as,  for  example,  succeeding  large  hemorrhages  and 
uremia, — together  with  the  facility  with  which  it  can  be  carried  out,  com- 
mend it  strongly.  A  heaping  feaspoonftd  of  common  salt  to  a  quart 
of  sterilised  zvater  furnishes  zvith  suffieient  nearness  the  proportion  desired. 

Whenever  the  discharges  have  been  so  copious  as  to  make  it  reasonable 
that  the  vessels  are  becoming  drained,  hypodermoclysis  is  indicated,  and  may 
be  repeated  every  two,  four,  or  six  hours  as  required. 

Enteroclysis  is  made  with  a  one  or  two  per  cent,  solution  of  tannie 
acid  at  a  temperature  of  45°  C.  (113°  F.).  For  an  adult  2  quarts  (2  liters) 
may  be  administered;  for  an  adolescent,  i  quart  (i  liter).  It  is  introduced 
slowly,  by  a  fountain  syringe  or  Davidson  syringe,  through  a  rectal  tube 
with  lateral  outlets  but  closed  at  the  end.  The  tube  is  introduced  gently  by 
a  combined  rotary  and  pushing  motion  to  the  depth  of  10  inches,  when  the 
fluid  is  allowed  to  enter  slowly,  consuming  not  less  than  ten  minutes.  The 
patient  should,  of  course,  be  encouraged  to  retain  the  fluid,  and  may  be  aided 
by  pressure  on  the  anus  witli  a  napkin.  Enteroclysis  is  said  to  be  useful  in 
any  moderately  severe  case  of  cholera,  and  may  be  given  night  and  morning, 
more  frequently  in  severe  cases.  According  to  Daland,  experiments  made  at 
Swinburne  Island  in  the  autumn  of  1892  showed  conclusively  that  when 
thus  introduced  fluid  can  be  "made  to  pass  through  the  ileocecal  valve  into 
the  small  intestine.     In  fact,  several  patients  vomited  the  solution. 

It  is  in  the  algid  stage  that  this  treatment  is  more  particularly  used, 
but  other  means  must  be  taken  to  keep  up  the  warmth  of  the  body.  To  this 
end  the  patient  is  immersed  in  the  hot  bath  at  a  temperature  of  38°  to  42°  C. 
(100°  to  107°  F.).  In  favorable  response  the  warmth  of  the  body  returns, 
the  pulse  is  fuller  and  stronger,  the  respiration  deeper.  Hot-water  bottles, 
hot-w^ater  bags,  and  hot  bricks  may  be  applied  alongside  the  body. 

III. — In  the  third  stage,  that  of  reaction,  indicated  by  the  return 
of  warmth,  pulse,  and  heart-beat,  and  especially  the  establishment  of  the 
urinary  secretion,  restorative  measures  are  continued  with  the  addition  of 
judicious  nutriment,  preferably  in  the  shape  of  peptonized  foods,  especially 
peptonized  milk.  Great  care  must  be  exercised  lest  diarrhea  be  induced  by 
too  liberal  feeding.  Convalescence  is  necessarily  very  slow  in  serious  cases, 
and  relapses  are  prone  to  occur. 


CHOLERA.  103 

Appendix. — The  Examination  for  Cholera  Bacillus. 

I  add  the  method  practiced  for  this  purpose  in  the  Bacteriological  Insti- 
tute at  Berlin  furnished  by  Dr.  Louis  Fischer. 
The  articles  necessary  are : 

1.  A  microscope  with  Abbe's  condenser  and  an  oil-immersion  lens  of 
1-12  inch  focal  distance. 

2.  A  solution  of  fuchsin  i  gm.  in  90  c.  c.  distilled  water  and  10  c.  c. 
alcohol. 

3.  A  few  pipettes,  glass  rods,  cover-glasses,  and  slides. 

4.  A  few  platinum  wires  melted  or  soldered  to  the  ends  of  glass  rods. 

5.  A  few  "  hollow  "  slides. 

6.  Ten  to  12  glass  plates  or  glass  panes,  about  12  cm.  long  and  9  cm. 
wide. 

7.  About  a  dozen  ordinary  flat  plates. 

8.  An  alcohol  lamp  or  gas,  preferably  a  Bunsen  burner. 

9.  A  number  of  test-tubes  with  sterilized  gelatin. 

10.  A  number  of  test-tubes  with  sterilized  nutrient  bouillon. 

11.  A  few  Erleymer's  glasses,  about  one-third  filled  with  i  per  cent, 
peptone  solution — i  gm.  peptone,  0.5  gm.  chlorid  of  sodium,  100  gm.  dis- 
tilled water. 

12.  Concentrated  sulphuric  acid. 

The  dejecta  of  the  suspected  patient  are  scattered  in  as  thin  a  film  as 
possible  on  a  glass  plate,  and  this  is  carefully  examined  by  the  aid  of  a  plati- 
num wire  for  a  mucous  flake  ("  Schleimflocke  "),  which  is  laid  on  the  edge 
of  the  plate  and  isolated.  From  this  is  taken  a  piece  the  size  of  a  pinhead  by 
means  of  a  platinum  loop  sterilized  by  drawing  it  through  a  Bunsen  burner. 
The  fragment  is  rubbed  on  a  cover-glass  until  it  is  evenly  divided ;  super- 
fluous material  is  removed  by  pressing  another  cover-glass  over  it ;  the  two 
are  separated,  and  allowed  to  air-dry. 

The  glass  cover  is  then  drawn  three  times  through  the  flame  of  the  Bun- 
sen burner  in  the  same  manner  as  for  the  examination  of  sputum  for 
tubercle  bacilli,  and  by  means  of  a  pipette  a  few  drops  of  fuchsin  solution  are 
placed  on  it,  allowed  to  remain  one  or  two  minutes,  and  then  washed  off  in 
distilled  water.  A  drop  of  water  is  put  on  the  cover-glass,  which  is  laid  on 
a  slide  and  examined  with  the  oil-immersion  system.  If  it  be  desired  to 
preserve  the  specimen,  after  staining  with  fuchsin  solution  wash  off  the 
excess  of  stain  with  distilled  water,  allow  it  to  get  thoroughly  air-dry,  add 
Canada  balsam,  and  mount. 

In  some  of  the  fulminating  cases  where  the  intestinal  contents  are  color- 
less or  have  a  pale-red  color,  with  slimy  flakes  or  with  a  flour-soup  mass, 
especially  in  the  period  of  reaction,  the  cases  running  a  slow  course,  no 
mucous  flakes  will  be  found,  but  large  quantities  of  blood.  Here  may  be 
found,  besides  cholera  bacilli,  numerous  other  micro-organisms,  while  the 
cholera  bacilli  are  but  sparingly  present.  To  render  a  diagnosis  absolutely 
positive  in  such  cases,  "  cultures  "  are  necessary. 

Cultures  can  be  made  in  "  hollow  slides  "  by  smearing  the  border  with 
vaselin,  then  bringing  a  small  drop  of,  sterilized  bouillon  into  this  hollow 
groove  of  the  slide  by  means  of  a  platinum-wire  loop,  and  inoculating  the 
bouillon  with  the  smallest  possible  particle  of  the  suspected  mucous  flake. 
The  cover-glass  is  carefully  laid  on  the  vaselin,  which  serves  to  render  the 
groove  air-tight,   and   also  prevents  evaporation   of  the  drop   of  sterilized 


I04  IXFECTIOUS  DISEASES. 

bouillon.  The  slide  is  then  laid  aside  at  a  temperature  of  20"  to  22°  C. 
(68°  to  70°  F.)-  The  room  can  be  heated,  if  the  temperature  is  below  this. 
In  about  twenty-four  hours  the  bouillon  becomes  turbid,  and  the  slide  can 
be  examined  with  the  oil-immersion  lens  without  disturbing  the  culture. 
The  best  place  to  examine  is  the  border  line,  and  even  if  but  few  cholera 
bacilli  were  originally  present,  they  grow  so  rapidly  that  they  can  be  easily 
recognized  by  their  curved  shape. 

Culture  Method  by  Scliottelius. — Take  100  to  200  c.  c.  of  the  suspected 
dejecta  from  the  intestinal  contents  and  place  them  in  a  beaker  glass  contain- 
ing 250  to  500  c.  c.  of  mild  alkaline  meat-bouillon,  and  mix  thoroughh' ;  then 
let  this  mass  stand  twelve  to  twenty-four  hours  at  a  temperature  of  30°  to 
40°  C.  (86''  to  104°  F.).  After  this  time  the  cholera  bacilli  have  usually 
increased  in  numbers,  and  are  found  on  the  upper  layer  of  the  fluid.  Intro- 
duce at  the  upper  layer  a  platinum  loop,  take  out  a  small  drop  the  size  of  a 
lentil  seed,  rub  it  on  a  cover,  and  allow  it  to  dry  thoroughly  in  the  air ;  then 
stain,  as  previously  described,  with  the  fuchsin  solution. 

Postmortem  Tests. — To  examine  suspected  intestinal  contents,  open  the 
abdominal  cavity  carefully  and  ligate  at  two  places  with  stout  twine  a 
piece  of  the  ileum  well  filled  with  fecal  contents,  about  three  to  four  centi- 
meters in  length,  and  taken  from  near  the  cecum.  A  double  ligature  should 
be  applied  at  each  end  and  the  cut  made  between  the  two,  so  that  the 
intestinal  contents  will  not  be  spilled  in  the  abdominal  cavity.  It  is  well 
also  to  cut  out  a  piece  of  the  intestine  three  to  four  centimeters  in  length 
from  the  upper  portion  of  the  ileum,  and  to  lay  the  excised  portions  in  ordi- 
nary water  until  ready  for  examination.  The  method  is  the  same  as  has 
been  described — that  is.  take  a  small  piece  of  nocculent  mucus  the  size  of  a 
pinhead.  etc. 

Gelatin  stroke  and  stick  cultures,  and  also  potato  cultures,  can  be 
made  for  examination.     The  spirilla  also  grow  on  blood-serum  and  agar. 

Cholera  bacilli  require  for  their  growth  a  mild  alkaline  nutrient  medium, 
and  are  very  quickly  destroyed  by  mineral  acids.  They  do  not  develop 
readily  in  ordinary  water,  owing  to  the  presence  of  other  bacteria,  which 
destroy  them ;  they  do  develop,  however,  very  rapidly  in  sterilized  water. 


DYSENTERY. 

Syxoxym. — Bloody  flux. 

Definition. —  The  term  dysentery,  derived  from  the  Greek  w^ords  for 
difficult  and  bowel,  is  applied  to  inflammations  of  the  large  and  sometimes, 
although  to  a  less  extent,  of  the  small  bowel.  The  condition  can  be  best 
considered  under  three  heads  which  represent  varieties  or  different  forms 
of  the  disease.  These  are:  ist,  catarrhal,  2d,  bacillary,  and  3d,  amoebic 
dysentery. 

Catarrhal    Dysextery. 

Definition. —  Catarrhal  dysentery  is  the  simplest  and  most  common 
form  of  the  disease  met  with  in  temperate  climates.  It  is  characterized  by  an 
increased  mucous  secretion  associated  with  desquamation  of  the  epithelium 
covering  the  gut.  together  with  a  variable  involvement  of  the  solitary  lym- 
phatic nodules  of  the  large  intestine  and  of  both  the  solitary  and  agminated 
nodules  of  the  small  intestine. 


DYSENTERY. 


105 


Etiology. — This  form  occurs  more  frequently  as  an  accompaniment  of 
other  diseases  of  adults  than  as  a  simple  uncomplicated  process.  It  attends 
the  specific  intestinal  lesions  in  typhoid  fever  and  tuberculosis  and  is  com- 
monly associated  with  the  acute  infectious  exanthemata  and  not  infrequently 
with  diphtheria.  It  is  the  form  of  dysentery  caused  by  simple  irritants,  of 
which  unripe  and  indigestible  food  forms  a  liberal  source.  In  children, 
especially  during  the  hot  summer  months,  but  to  a  certain  extent  through- 
out the  entire  year,  this  form  is  met  with.  As  in  adults,  it  may  be  the  result 
of  the  ingestion  of  indigestible  food  or  other  irritants,  but  in  young  and 
nursing  children  it  forms  a  part  of  the  so-called  entero-colitis  of  the  summer 
months.  In  the  better  characterized  entero-colitis  of  children  Duval  and 
Bassett  have  obtained  the  bacillus  of  Shiga  from  the  dejections  and  from 
the  mucous  membrane  of  the  intestines  in  fatal  cases. 

Morbid  Anatomy. — Changes  in  the  affected  intestine  are  of  dift'erent 
grades.  In  the  lighter  forms  there  is  merely  an  excessive  secretion  of  mucus 
associated  with  desquamation  of  the  epithelial  cells,  exudation  of  more  or 
less  serum,  and  the  emigration  of  a  small  number  of  leukocytes.  The 
mucosa  is  swollen  and  congested.  In  severer  forms  the  surface  of  the  gut 
is  covered  with  mucus,  streaked  with  blood.  The  mucosa  is  much  injected, 
bleeding  points  or  ecchymoses  can  be  made  out,  and  the  lymphoid  nodules 
are  enlarged  and  prominent.  Not  infrequently  small  defects  in  the  mucosa 
exist  in  connection  with  the  nodules,  constituting  small  ulcers.  The  latter 
rarely  extend  beyond  the  limits  of  the  nodules,  and  pseudo-membrane  never 
occurs   in  connection  with  them. 

Symptoms. — Catarrhal  dysentery  is  usually  ushered  in  by  diarrhea,  the 
first  stools  being  copious  and  painless.  Soon,  however,  these  are  replaced 
by  small  mucous  discharges  streaked  with  blood  and  accompanied  by  crampy 
abdominal  pains,  technically  known  s^s  tormina  (twisting  pains)  and  strain- 
ing or  tenesmus.  The  latter  is  exceedingly  trying,  causing  a  constant  feel- 
ing of  unsatisfied  desire  for  stool,  so  that  the  patient  is  disposed  to  sit  con- 
stantly on  the  closet  or  to  go  back  repeatedly  many  times  in  a  single  hour, 
experiencing  at  the  same  time  intense  burning  pain  at  the  anus.  Yet  the 
total  quantity  discharged  in  the  twenty-four  hours  is  not  large.  From  28 
to  42  ounces  are  a  full  amount. 

Sometimes  a  chill  is  the  initial  symptom.  The  tongue  is  furred  and  at 
first  moist ;  later  it  may  become  dry.     There  may  be  nausea  and  vomiting. 

There  is  always  more  or  less  fever,  sometimes  very  slight,  at  others 
decided,  the  temperature  seldom  exceeding  103°  F.  (39.4°  C).  There  are 
the  thirst  and  acceleration  of  pulse  usually  attending  fever,  and  sometimes 
the  former  is  extreme.  The  abdomen  may  be  tender,  but  not  necessarily 
so.  It  may  be  tumid  or  flat  and  hard.  In  addition  to  the  characteristic 
features  of  the  stools  already  mentioned,  scybala  or  hard  fecal  masses 
may  be  present  at  first.  Later  the  stools  are  frequently  green  in  color, 
from  the  presence  of  bile — bilious  dysentery — and  increase  in  their  transit 
the  burning  feeling  already  mentioned.  In  addition  to  blood-corpuscles  and 
leukocytes  the  microscope  recognizes  large  round  and  oval  epithelioid  cells 
containing  fat-drops  and  vacuoles;  also  at  times  the  ccrcomonas  intcstinalis. 
Until  recently  no  specific  organisms  w^re  found  in  the  simple  catarrhal  form 
of  dysentery.  F.  C.  Curtis  has  found  the  bacillus  pyocyaneus  in  an  epi- 
demic of  dysentery  at  Harlwick,  N.  Y. 

The  milder  cases  of  catarrhal  dysentery  are  self-limiting,  terminating 
usually  in  a  week,  when  the  character  of  the  stool  changes.     Other  cases 


io6  INFECTIOUS  DISEASES. 

are  more  intractable  and  resist  even  judicious  treatment  for  a  long  time, 
becoming  even  chronic. 

Diagnosis. — The  diagnosis  of  acute  catarrhal  dysentery  is  very  easy. 
The  tormina  and  tenesmus  with  the  frequent  blood-stained  mucous  stools 
occur  in  no  other  affection.  ^Malignant  disease  of  the  rectum  is  sometimes 
mistaken  for  chronic  dysentery.  Examination  of  the  rectum  should  be 
made  in  all  prolonged  cases. 

Prognosis. — The  prognosis  is  generally  favorable.  As  intimated, 
many  mild  cases  get  well  without  treatment,  and  when  judiciously  handled 
unfavorable  termination  is  rare.  Favorable  termination  is  not,  however, 
invariable,  and  cases  sometimes  end  unfavorably  after  a  prolonged  course, 
or  thev  become  permanently  chronic  and  incurable.  Emaciation  and  exhaus- 
tion are  rapid,  and  even  a  mild  attack  rapidly  reduces  the  strength  of  its 
victim. 

Bacillary  Dysentery. 

Definition. — The  form  of  dysentery  most  commonly  present  in  tem- 
perate and  tropical  regions,  appearing  in  a  variety  of  forms.  Under  it  are 
to  be  included :  First,  pseudo-membranous,  croupous,  or  diphtheritic.  Sec- 
ond, ulcerative.     Third,  chronic  dysentery. 

Etiology. — The  lower  part  of  the  large  intestine  is  most  frequently 
the  site  of  the  lesion,  but  the  entire  large  and  more  rarely  the  small  gut 
may  be  affected.  The  difference  between  the  acute,  pseudo-membranous, 
and  chronic  forms  are  striking,  notwithstanding  which,  the  evidence  at 
hand  tends  to  connect  them  to  one  causative  factor.  Beginning  with  the 
researches  of  Shiga  in  Japan,  in  1898,  which  were  followed  by  the  investi- 
gations of  Flexner  and  Barker  carried  out  in  Manila,  in  1900,  and  after- 
wards by  Flexner  in  this  country,  and  Kruse  and  others  in  Germany,  the 
evidence  has  grown  in  favor  of  the  B.  dysenterise  (Shiga)  as  being  the 
specific  cause  of  this  variet}'  of  dysentery. 

The  Bacillus  dysenterice  is  a  well-characterized  micro-organism  belong- 
ing to  the  colon  typhoid  group  of  bacilli,  which  can  be  distinguished  by 
its  cutural  and  other  characteristics.  In  morphology  it  differs  only  slightly 
from  the  typhoid  bacillus,  with  which  it  has  certain  cultural  properties  in 
common.  It  grows  upon  ordinary  culture  media  readily,  and  brings  about 
little  change  in  milk  excepting  to  cause  a  slight  alkalinity.  It  is  slightly 
motile  when  first  isolated,  but  quickly  loses  its  motility  on  artificial  cultures, 
but  this  can  be  restored  by  pas^ge  through  experimental  animals.  Flagella 
surrounding  the  body  of  the  bacillus  have  been  demonstrated  by  Vedder 
and  Duval,  of  the  University  of  Pennsylvania.  The  organism  is  pathogenic 
for  a  wide  series  of  laboratory  animals,  and  when  injected  into  the  intestine 
of  cats,  or  fed  to  them  after  alkalinization  of  the  gastric  juice,  it  is  capable 
of  setting  up  an  inflammation  of  the  gut  from  which  the  bacillus  may  be 
recovered.  Taken  into  the  stomach  of  man  it  rapidly  sets  up  a  severe 
colitis.  There  are  two  instances  on  record  of  its  action  on  man :  The  first, 
reported  by  Flexner,  in  which  a  small  quantity  of  a  culture  was  accidentally 
aspirated  into  the  mouth  by  one  of  his  assistants,  the  intestinal  symptoms 
appearing  within  forty-eight  hours ;  the  second,  reported  by  Strong,  in 
which  a  Filipino  prisoner  voluntarily  swallowed  a  portion  of  a  culture  of 
the  bacillus,  in  which  case  the  symptoms  quickly  developed  and  were  of 
marked  severity,  the  bacillus  being  recovered  from  the  stools.  The  man 
finallv  recovered. 


DYSENTERY.  107 

Bacteriological  Diagnosis. — Diagnosis  of  this  form  of  dysentery  can 
be  established  in  two  ways :  First,  by  recovery  of  the  specific  organism  from" 
the  stools ;  second,  by  obtaining  the  agglutination  reaction  with  the  blood 
of  the  patient  and  the  specific  bacilli  in  a  manner  similar  to  that  of  the 
Widal  test  in  typhoid  fever. 

In  the  acute  disease  the  specific  bacilli  are  abundant,  and  can  be  sep- 
arated without  great  difficulty  from  the  dejecta.  For  this  purpose  solid 
contents  are  avoided  and  mucus  or  blood-stained  mucus  is  selected  for 
examination.  Plate  cultures  upon  agar-agar  are  made  and  incubated  for 
twenty-four  hours.  The  colonies  which  have  developed  at  the  end  of  this 
period  are  not  chosen  for  further  study,  but  are  carefully  marked  with 
a  blue  wax  pencil  and  the  plates  returned  to  the  incubator  for  another 
twenty-four  hours.  The  second  crop  of  colonies  usually  contains  a  large 
proportion  of  the  dysentery  organisms,  which  grow  more  slowly  than  the 
colon  bacillus  in  the  mixtures  of  the  two  organisms.  Transplantations 
from  the  second  crop  of  colonies  are  made  into  glucose  agar  tubes,  which 
are  incubated  for  a  day  and  all  gas-forming  colonies  excluded  as  being 
non-dysenteric.  The  tubes  which  show  no  gas  are  then  further  examined, 
and  among  them  the  specific  organism  will  be  found.     (Duval.) 

The  agglutination  test  with  the  blood  of  persons  ill  of  bacillary  dysen- 
tery is  easily  obtained.  For  this  purpose  cultures,  twenty-four  hours  old, 
upon  agar-agar,  are  employed,  from  which  suspensions  are  m.ade  in  bouillon. 
In  using  the  blood,  it  is  preferable  to  employ  the  wet  method  by  which  the 
blood  is  obtained  in  capillary  tubes,  from  which  the  serum  can  be  col- 
lected. After  proper  dilution  of  the  serum  the  tests  are  carried  out  in  the 
usual  manner.  Positive  reactions  may  be  obtained  in  dilutions  varying 
from  1-20  to  I- 1000  in  a  period  of  from  one-half  to  one  hour,  and  as  early 
as  from  the  third  to  the  fourth  day  of  illness.  This  method  is  applicable 
to  the  study  of  all  cases  of  dysentery,  as  well  as  the  entero-colitides  of 
children. 

Morbid  Anatomy. — The  anatomical  features  of  bacillary  dysentery 
vary  with  the  form  and  duration  of  the  disease.  The  most  acute  cases  are 
those  running  a  rapidly  fatal  course  and  involving  the  entire  large  gut  and 
a  variable  length  of  the  lower  small  intestine.  The  mucous  membrane  is 
greatly  swollen,  suffused  with  serum  and  blood,  presenting  a  pulpy  appear- 
ance, but  without  visible  false  membrane.  These  are  the  forms  which 
result  fatally  in  48-72  hours,  and  which  are  met  with  in  tropical  countries, 
and  sometimes  in  institutional  and  other  epidemics  in  temperate  climates. 
The  usual  form  of  bacillary  dysentery  is  the  pseudo-membranous.  In  this 
the  extent  of  the  lesion  varies,  sometimes  appearing  in  the  rectum  and 
sigmoid  flexure,  and  sometimes  extending  throughout  the  large  gut.  The 
membrane,  which  is  grayish-white  in  color,  presents  a  granular  surface,  and 
appears  first  upon  the  elevations  of  the  mucosa  corresponding  to  the  inser- 
tion of  the  bands  of  longitudinal  muscle  and  the  transverse  lines  of  the 
colic  pouches.  As  the  condition  progresses  in  severity  the  intervening 
mucosa  is  covered  with  pseudo-membrane.  The  entire  mucosa  is  injected, 
swollen,  and  covered  with  blood-stained  mucus,  beneath  which  bleeding 
points  may  be  discerned.  Upon  mi^croscopical  examination  the  pseudo- 
membrane  is  found  to  consist  of  a  filarinous  and  cellular  exudation  which 
lies  upon  the  surface  and  penetrates  into  the  substance,  for  a  variable 
distance,  of  the  mucosa.  The  glands  of  Liberkiihn  undergo  necrosis  and 
become  invaded  by  pseudo-membrane.     Large  numbers  of  micro-organisms 


io8  INFECTIOUS  DISEASES. 

are  present  in  the  dead  tissue,  and  the  blood-vessels  of  the  mucosa  are 
extensively  occluded  by  thrombi. 

A  demarcating  inflammation  "takes  place  at  the  limits  of  the  living  and 
necrotic  tissue,  causing  separation  of  the  latter,  which  upon  exfoliation 
leaves  behind  defects  which  constitute  the  acute  dysenteric  ulcers.  The  dis- 
ease may  come  to  an  end  at  this  stage  or  an  earlier  one,  and.  the  integrity 
of  the  mucosa  be  restored,  or  the  necrosis  may  extend  more  deeply  and 
involve  the  depth  of  the  mucosa  and  be  associated  with  marked  inflamma- 
tory changes  in  the  submucous  and  muscular  tunics.  In  these  instances 
iflceration  may  extend  through  the  mucosa  and  invade  the  submucosa,  and 
even  penetrate  more  deeply,  and  in  the  subsequent  process  of  repair  new 
tissue  develops  in  the  submucosa  which  leads  to  the  permanent  thickening 
of  the  intestinal  wall.  It  is  this  form  of  dysentery  which  tends  to  pass 
into  the  chronic  disease,  in  which  ulceration  is  deep  and  persistent,  and  much 
new  tissue  develops  in  the  submucosa,  in  the  mucosa,  and  even  in  the 
muscular  coat.  Owing  to  the  persistence  of  the  ulceration  and  possibly 
to  the  interaction  of  secondary  micro-organisms,  including  the  pyogenic 
cocci,  always  present  in  the  intestinal  canal  of  man,  the  ulceration  extends 
not  only  mOre  deeply,  but  tends  also  to  heal  slowly  and  imperfectly,  whence 
arise  the  symptoms  characterizing  chronic  ulcerative  dysentery.  That  the 
specific  organism  persists  throughout  long  periods,  where  these  pathological 
conditions  are  present,  is  shown  by  the  acute  exacerbations  of  the  disease 
and  by  the  association  of  the  chronic  ulcerative  with  fresh  pseudomem- 
T^ranous  inflammation  met  with  not  infrequently  at  autopsy.  It  is  during 
the  exacerbation  that  the  specific  bacillus  is  to  be  sought  in  the  dejecta 
and  the  blood  reaction  looked  for.  Among  the  consequences  of  the  tissue 
production  in  chronic  dysentery,  polypoid  outgrowths  are  met  with.  These 
consist  of  portions  of  the  mucosa  and  submucosa,  in  which  an  overplus 
of  new  tissue  is  developed,  and  which  come  to  project  into  the  lumen  of 
the  gut.  Partially  through  the  action  of  gravity  and  through  other  causes 
they  tend  to  lengthen,  whence  they  come  to  be  attached  by  narrow  pedicles 
to  the  wall  of  the  gut.  Depressed  scars,  over  which  the  mucosa  is  atrophied, 
also  mark  the  site  of  healed  ulcerations. 

The  new  formation  of  connective  tissue  throughout  the  coats  of  the 
gut  may  be  so  extensive  as  to  bring  about,  after  its  contracture,  serious 
deformation  and  narrowing  of  the  lumen.  Inflammation  sometimes  extends 
to  the  peritoneal  coat,  whence  adhesions  to  the  neighboring  parts  take 
place.  Only  rarely  does  ulceration  proceed  so  rapidly,  or  fail  to  be  attended 
by  connective  tissue  formation,  as  to  perforate  the  peritoneal  coat. 

Symptoms. — The  symptoms  of  bacillary  dysentery  are  those  of  the 
simple  catarrhal  form  greatly  intensified.  The  fever  is  higher,  the  pain  is 
greater,  the  tormina  and  tenesmus  are  more  severe,  the  stools  are  more 
l)loody,  and  the  adynamia  is  more  profound.  Delirium  is  often  present, 
and  the  tongue  may  be  dry.  The  abdomen  is  tender  and  swollen,  and 
typhoid  fever  may  be  simulated.  The  symptoms  in  the  secondary  form 
are  less  severe  than  in  the  primary. 

Complications  and  Sequelae. — The  complications  in  this  form  of 
■dysentery  are  more  numerous.  Abscess  of  the  li-vcr  is  one  of  them,  and  is 
ascribed  to  thrombotic  extension  from  the  seat  of  inflammation  along  the 
vessels  of  the  portal  system  into  the  liver,  or  to  emboli  carried  from  the 
primary  focus  to  the  liver.  Perforation  of  the  bowel  is  not  a  very  rare  com- 
plication, having  been  found  by  Woodward,  in  a  study  of  the  statistics  of 


DYSENTERY.  109 

the  late  Civil  War  in  America,  11  times  in  108  autopsies.  This  accident  is 
followed  by  a  peritonitis,  which  is  usually  fatal,  the  local  symptoms  of  which. 
vary  with  its  exact  seat.  If  in  the  neighborhood  of  the  cecum,  perityph- 
litis ensues ;  if  lower  down  in  the  rectum,  a  proctitis.  A  peritonitis  may  also 
arise  by  extension  of  the  inflammation  from  the  mucous  lining  of  the 
bowel. 

The  same  opportunities  enabled  Woodward  to  show  the  undoubted 
association  of  malaria  with  dysentery,  though  it  is  likely  that  the  "  chills  " 
referred  to  in  older  reports  were  sometimes  septic  and  due  to  the  dysentery. 
The  same  is  true  of  the  joint  szvelling  described  by  the  older  authors,  among 
whom  was  Sydenham.  They  may  be  a  part  of  pyemic  processes.  Paralysis, 
commonly  paraplegia,  as  a  sequel,  is  attested  by  Woodward  and  Weir 
Mitchell.  Pleurisy,  pericarditis,  endocarditis,  and  Bright's  disease  are 
among  sequelae  reported. 

Diagnosis. — The  same  diagnostic  symptoms  that  enable  us  to  recog- 
nize the  other  varieties  of  dysentery  attend  this  in  severe  degree,  but  it  is 
the  occurrence  of  successive  cases  that  gives  the  stamp  by  which  we  recog- 
nize the  diphtheritic  type.      (See  also  bacteriological  diagnosis,  page  107.) 

Prognosis. — The  prognosis  of  this  form  of  dysentery  is  the  most  un- 
favorable of  all  the  varieties.  Most  cases  perish,  death  being  preceded  by 
extreme  adynamia  and  other  symptoms  of  the  typhoi-d  state,  including  dry 
tongue,  stupor,  emaciation,  and  the  cadaveric  countenance.  Consciousness 
is  sometimes  painfully  persistent  to  the  end. 

Amcebic  Dysentery. 
Synonyms. — Aniochic  Enteritis;  Tropical  Dysentery. 

Definition. — An  ulcerative  inflammation  of  the  large  intestine  due  to 
anioeha  coli.  This  form  has  sometimes,  incorrectly,  been  termed  tropical 
dysentery.  It  occurs  in  the  tropics,  but  also  in  temperate  regions,  while 
the  commonest  form  of  the  disease  in  the  tropics  would  appear  to  be  bacil- 
lary  dysentery. 

Etiology. — The  studies  of  Kartulis  in  Egypt,  of  Councilman  and 
Lafleur  in  America,  and  Kruse  and  Pansini  in  Italy,  have  established  amoeba 
coli  as  the  cause  of  this  variety  of  dysentery.  The  organism  was,  however, 
first  described  by  Lambl  in  1859,  and  later  by  Losch,  but  its  relation  to 
tropical  dysentery  was  first  clearly  established  by  Kartulis.  The  amoebae 
are  found  in  the  dejecta,  in  the  intestinal  ulcers,  and  in  secondary  liver 
abscesses  of  the  disease.  The  organism  varies  from  15  to  20  microns  in  diam- 
eter and  is  actively  motile  when  examined  in  the  living  state.  It  consists  of 
two  portions,  an  outer  ectosarc  and  an  inner  endosarc.  Its  movements  are 
brought  about  through  the  propulsion  of  the  former,  after  which  the  granular 
inner  substance  flows  into  the  pseudopodia.  The  amoeba  is  phagocytic,  taking 
up  foreign  substances  from  the  intestine,  etc.,  and  especially  englobing  the  red 
corpuscles.  At  present  two  varieties  of  amoebje  are  distinguished  as  occur- 
ring in  the  stools :  the  first  non-pathogenic — amoeba  coli  mitis — and  the  sec- 
ond pathogenic — amoeba  coli.  The  former  has  been  found  repeatedly  in 
healthy  stools,  and  it  does  not  exhibit  phagocytic  properties  for  red  cor- 
puscles. In  this  country  amoebic  dysentery  has  been  found  to  occur  as  a 
sporadic  disease,  especially  in  the  Southern  States,  but  also  in  Pennsylvania, 
New  York,  and  the  New  England  States. 

Morbid  Anatomy. — The  intestinal  lesions   are  usually  limited  to  the 


no  INFECTIOUS  DISEASES. 

large  intestine ;  rarely  they  are  found  in  the  ileum.  The  characteristic  lesion 
is  ulceration,  involving  the  mucosa  and  submucosa.  In  early  ulcers  a  small 
defect  only  is  found  in  the  mucosa ;  more  rarely  the  muscular  coat  is  invaded, 
and  rarest  of  all,  the  peritoneal  coat.  In  the  course  of  the  ulceration  the 
submucosa  becomes  infiltrated  with  a  grayish,  gelatinous  material,  the  ex- 
foliation of  which  gives  rise  to  the  ulcer.  In  this  material  there  are  few 
preserved  cells,  but  it  consists  chiefly  of  necrotic  material,  in  which  only 
a  few  pus  cells  can  be  made  out.  Amoebse  may  be  discovered  in  the  necrotic 
tissue,  as  well  as  in  the  adjacent  portions  of  the  mucosa  and  submucosa. 
In  the  immediate  neighborhood  of  the  ulcer  proliferation  of  the  connective 
tissue  takes  place  which,  in  favorable  cases,  may  completely  restore  the 
defect,  and  in  chronic  cases  brings  about  permanent  changes  in  the  gut 
similar  to  those  described  in  chronic  bacillary  dysentery.  Pseudo-membrane 
is  never  present  in  uncomplicated  cases,  but  instances  of  combined  amoebic 
and  bacillary  dysentery,  in  which  pseudo-membrane  has  been  present,  have 
been  described. 

Microscopical  Diagnosis. — Detection  of  the  specific  amceb^  in  the 
stools,  or  of  secondary  liver  abscesses,  confirms  the  diagnosis  of  the  disease. 
Great  care  should  be  exercised  to  obtain  fresh  material  for  microscopical 
examination,  and  bits  of  mucus,  rather  than  fecal  material,  should  be  chosen 
for  study.  The  mucus  or  pus  is  slightly  pressed  out,  but  not  too  firmly,  under 
a  cover-glass,  and  the  slide  slightly,  but  carefully,  warmed  up  to  body  heat, 
before  examination.  Inasmuch  as  desquamated  epithelial  cells  sometimes 
take  on  a  round  form  and  simulate  amoebae,  it  is  desirable  that  a  definite 
movement  be  detected  before  passing  upon  the  nature  of  the  suspected  cells. 
Living  amcebge,  especially  those  enclosing  red  corpuscles,  are  taken  to 
indicate  the  nature  of  the  pathological  condition  of  the  intestine. 

Symptoms. — The  symptoms  of  amoebic  dysentery  are  similar  to  those 
of  catarrhal  dysentery,  but  much  more  irregular  and  prolonged.  The  onset 
is  usually  less  sudden,  but  may  be  equally  so.  The  stools  are  less  numer- 
ous, and  are  apt  to  be  more  liquid  and  more  copious.  They  abound  in  the 
amoebae  coli.  The  straining  at  stool  is  less  severe  and  persistent,  while  there 
may  be  several  days  of  relief,  to  be  followed  by  the  usual  train  of  symptoms. 
The  fever  may  be  severe  or  mild. 

Complications. — The  most  common  and  serious  complication  is 
abscess  of  the  liver,  which  is  now  believed  to  be  due  to  the  w-andering 
amoeba  dysenterica,  which  reaches  the  liver  through  the  blood-vessels.  The 
abscess  may  be  single  or  multiple.  In  the  former  case  it  may  be  of  large 
size,  in^'olving  fully  half  of  the  bulk  of  the  liver.  The  multiple  abscesses 
are  smaller  in  size  and  superficial.  The  abscess  walls  are  peculiar,  being 
ragged  from  the  presence  of  necrotic  projections.  Only  occasionally,  in  the 
older  abscesses,  are  there  firm,  smooth,  fibrous  walls.  Next  to  the  iniieniiosf 
necrotic  ::oiie  is  a  zone  of  cclhdar  infiltration  encroaching  upon  and  destroy- 
ing the  liver-cells,  and  external  to  this  again  a  zone  of  intense  hyperemia. 
The  contents  of  the  abscess  are  not  pure  pus.  In  fact,  the  paucity  of  the 
pus-cells  here  is  as  significant  as  in  the  inflammatory  infiltration  of  the 
mucosa,  indicating  a  similarity  in  the  etiology.  The  pyoid  material  consists 
rather  of  fatty  and  granular  debris  and  the  amoebae,  which  are  also  found  in 
the  walls  of  the  abscess.  These  abscesses  sometimes  break  into  the  lungs, 
carrying  the  amoebae  with  them,  which  are  sometimes,  under  these  circum- 
stances,  found  in  the   expectoration. 

In  addition  to  the  abscesses  described  there  are  found  also  in  the  liver 


DYSENTERY.  m 

in  amoebic  dysentery  patches  of  circiimscrihed  necrosis,  scattered  through 
the  Hver  as  the  result  of  the  action  of  the  amoebae. 

Diagnosis. — The  diagnosis  is  rendered  easy  by  the  recognition  of  the 
amoeba  coli  in  the  stools,  which  should  be  examined  by  the  microscope  in 
every  case  of  dysentery  as  directed  under  microscopical  diagnosis. 

Prognosis. — The  prognosis  is  much  more  serious  than  that  in  the 
catarrhal  variety.  The  course  of  the  disease  is  always  prolonged,  and  a 
fatal  issue  is  much  more  frequent.  It  would  seem  that  the  patient  must 
outlive  the  organism  before  he  can  recover,  and  even  then  recovery  is 
delayed  by  the  exhausted  condition  into  which  he  has  fallen  in  the  struggle 
with  his  microscopic  guest.  When  the  termination  is  most  favorable,  cases 
of  amoebic  dysentery  last  from  six  to  twelve  weeks. 

Treatment  of  Dysentery. — The  first  measure  of  treatment  of  catarrhal 
dysentery  duly  recognized  should  always  be  a  purgative.  No  aperient  is 
better  than  castor  oil.  An  ounce  of  oil  (30  c.  c),  guarded  by  10  to  20  drops 
(0.66  to  1.33  gm.)  of  laudanum,  is  the  proper  dose  for  an  adult.  The  saline 
treatment,  especially  when  there  is  high  fever  and  no  marked  adynamia,  is 
also  efficient,  working  a  rapid  cure  in  many  cases.  Two  drams  (8  gm.)  of 
sulphate  of  magnesium,  or  1-2  ounce  (16  gm.)  of  Rochelle  salts  dissolved  in 
water,  should  be  given  every  hour  until  copious  watery  purgation  results.* 

When  this  end  is  obtained  by  either  remedy,  an  opiate  may  be  given. 
Plain  opium  in  doses  of  one  grain  (0.066  gm.)  every  three  hours,  or  1-2 
grain  (0.033  gi"-)  of  the  extract,  is  the  favorite.  Or  the  drug  may  be 
combined  with  bismuth  subnitrate  in  ten-grain  (0.66  gm.)  doses,  or  with 
one  of  the  astringents,  tannic  acid  in  two-  to  five-grain  (0.132  to  0.33  gm.) 
doses,  or  the  acetate  of  lead,  one-  to  two-grain  (0.066  to  0.132  gm.)  ;  or 
with  salol.  Very  comforting  in  quieting  rectal  irritation  is  an  opium  sup- 
pository containing  one  grain  to  two  grains  (0.066  gm.  to  0.132  gm.) 
of  opium,  or  1-2  grain  to  a  grain  (0.033  g™-  to  0.066  gm.)  of  the 
extract. 

Hope's  camphor  mixture  is  an  old  remedy  which  sometimes  acts  well, 
especially  in  cases  disposed  to  become  chronic.  Dr.  Hope's  formula,  origi- 
nally suggested  in  1826,  is  as  follows: 

I^    Acidi  nitrosi, f  3  j  (4         c.  c.) 

Mist,  camphorje f  §  viij  (240     c.  c.) 

M.  et  adde  tr.  opii, gtt.  ,xl  (     1.2  c.  c.) 

Sig. — A  fourth  part  to  be  taken  every  three  or  four  hours. 

The  Hope's  camphor  mixture  of  the  shops;  made  with  nitric  acid  in- 
stead of  nitrous  acid,  should  not  be  substituted. 

It  goes  without  saying  that  the  food  should  be  liquid  and  of  the 
blandest  kind :  boiled  milk,  better  still  peptonized,  light  animal  broths,  and 
beef-juice,  not  beef-teas,  are  the  type.  Barley  or  rice  may  be  added  to  such 
broths,  and  should  be  thoroughly  cooked. 

The  first  consideration  in  the  treatment  of  hacillary  dysentery  is  a  hland 
and  non-irritating,  hnt  nourishing,  diet,  one  that  leaves  as  little  residue  as 
possible.     The  peptonized  foods,  such  as  peptonized  milk  and  beef-pepto- 

*  The  following-  striking-  results  -would  seem  to  jiustify  the  saline  treatment :  Day  treated  60  cases 
of  dysentery,  25  of  which  received  ipecacuanha  and  opium;  the  remaining  35  were  treated  with 
magnesium  sulphate.  Under  the  former  method  of  treatment  the  death-rate  was  32  per  cent,  and 
under  the  latter  2.q  per  cent.  The  recoveries  occurring-  under  the  former  treatment  were  slo-\v  and 
accompanied  by  frequent  relapses;  under  the  latter  they  were  complete  and  rapid,  but  it  was 
always  found  advisable  to  continue  one-dram  doses  of  magnesium  sulphate  three  times  daily  for  a 
couple  of  days  after  the  stools  had  ceased  to  be  dysenteric. 


112  IXFECTIOUS  DISEASES. 

noids,  in  addition  to  beef -juice  and  somatose,  are  the  types.  To  these,  stimu- 
lants should  be  freely  added.  Opiates  are  needed  to  relieve  the  pain,  and 
their  hypodermic  use  is  sometimes  especially  efficient  for  this  purpose.  When, 
the  necrotic  membrane  is  removed,  an  extensive  ulcerated  surface  remains  to 
be  healed.  Such  healing  is  favored  by  the  restrained  peristalsis  that  opium 
produces.  The  same  purpose  may  be  served  by  the  use  of  ipecacuanha,  if  the 
effect  claimed  for  it  by  the  East  Indian  physicians  is  produced.  Directions 
for  its  administration  are  given  below. 

On  the  other  hand,  it  is  doubtful  whether  soluble  remedies  intended 
for  the  direct  healing  of  the  ulcers  ever  reach  these  surfaces  in  an  active 
state,  when  administered  by  the  mouth.  Nitrate  of  silver,  when  administered,, 
does  sometimes,  however,  reach  the  lower  bowel.  Bismuth,  being  largely 
insoluble  when  administered  in  large  doses,  undoubtedly  reaches  the  bowel, 
and  mav  produce  some  healing  eitect.  ]\Iore  promising  is  the  use  of  iodo- 
form, which  may  be  also  expected  to  reach  the  part  affected,  and  which  is 
not  onlv  more  healing  in  its  action,  but  is  also  antiseptic.  It  may  be 
given  in  a  pill  or  capsule,  in  doses  of  1-2  grain  to  3  grains  (0.0324  to 
0.194  gm.}. 

The  same  indication  as  to  diet  exists  in  the  atnccbic  as  in  the  other  forms 
of  dysentery.  It  is  apparently  in  this  form,  of  which  only  isolated  cases 
are  met  in  temperate  chmates,  that  the  ipecacuanha  treatment  of  the  East 
Indian  phvsicians  has  been  so  successful.  It  is  claimed  to  act  as  a  muscular 
sedative  and  secretory  stimulant ;  by  its  effect  the  former  allays  the  exag- 
gerated peristaltic  activity  so  characteristic  of  the  disease,  by  the  latter  it 
augments  the  secretion  cf  mucus  as  well  as  stimulates  the  activity  of  the 
liver-cells  in  bile  formation — a  function  which  in  dysentery  is  in  abeyance. 
Great  stress  is  laid  on  the  mode  of  administration.  A  preliminary  dose  of 
laudanum  is  given,  and  in  half  an  hour  afterward  from  20  to  60  grams 
(T.332  to  4  gm.)  of  ipecacuanha.  For  three  hours  after  the  first  dose  only 
a  little  ice  should  be  sucked,  and  after  that  a  little  iced  soda-water  and  milk 
administered.  Beef-tea  or  bread  or  light  foods  are  fatal  to  the  favorable 
action  of  ipecacuanha,  and  to  the  use  of  such  foods  failures  are  ascribed  by 
the  advocates  of  the  treatment.  On  the  second  day  the  drug  is  administered 
in  reduced  quantity,  supplemented  by  salicylate  of  bismuth,  quinin,  naphthoic 
and  opium,  while  milk  should  form  the  staple  food.  Later,  farinaceous 
foods  and  soups  may  be  carefully  given,  but  no  solids  should  be  permitted 
for  a  long  time. 

Warm  injections  of  quinin,  i  to  5000,  i  to  2500,  and  i  to  1000,  have 
been  employed  at  the  Johns  Hopkins  Hospital  with  good  results,  the  amceb^e 
being  rapidlv  destroyed  by  them.  Perhaps  ipecacuanha  acts  similarly.  For 
the  relief  of  pain  opiates  must  also  be  administered,  preferably  by  the 
rectum  in  suppository  or  small  starch-water  enemas;  or  morphin  may  be 
given  hypodermically  if  the  stomach  be  sensitive. 

Seniin  Therapy. — The  immunizing  protective  effect  of  vaccines  against 
the  dysentery  bacillus  and  the  protective  and  curative  effect  of  antidysenteric 
sera  demand  allusion.  Their  availability  has  received  fresh  support  from 
recent  experimental  studies  by  Simon  Flexner  and  Frederick  P.  Gay.* 

D\senter\  vaccines  were  made  of  dead  cultures  as  described  in  Gay's 
paper.  Guinea  pigs  which  received  one  or  more  subcutaneous  injections 
of  subminimal  lethal  doses   showed  a  marked  protection   against  multiple 

*  "Vaccination  and  Serum  Therapv  against  the  Bacillus  of  Dysentery    An  Experimental  Study.'" 
By  Frederick  P.  Gay,  "  University  of  Pennsylvania  Medical  Bulletin,"  November,  1902. 


DYSENTERY. 


113 


intraperitoneal  lethal  doses  of  the  living  organism.  It  is  interesting  to  note 
that  while  protection  afforded  by  a  given  vaccine  against  its  own  strain  of 
bacillus  dysenterise  was  absolute  within  limits,  it  was  found  that  under  simi- 
lar condition  such  protection  may  not  be  secured  against  other  strains,  sug- 
gesting the  advisability  of  combining  several  strains  of  bacilli  after  their 
cultivation  in  the  preparation  of  vaccines. 

Antidysenteric  scrum,  was  obtained  from  the  horse  after  immunization. 
It  was  found  to  possess  agglutinative  properties  for  bacillus  dysenteriae. 
This  serum  also  had  protective  and  curative  properties  against  multiple 
fatal  intraperitoneal  doses  in  guinea  pigs.  Gay  concludes  that  this  protective 
power  may  be  regarded  as  proven  beyond  peradventure. 

The  effect  of  antidysenteric  sera  in  the  cure  of  dysentery  in  the  human 
being  is  as  yet  limited  to  the  serum  treatment  of  Japanese  dysentery, 
as  reported  by  Shiga.  Of  250  cases  thus  treated  the  mortality  aver- 
aged 10  per  cent,  as  against  36  per  cent,  in  cases  treated  by  ordinary 
methods. 

Chronic   Dysentery. 

Any  one  of  the  forms  of  dysentery  described  may  become  chronic,  but 
bacillary  dysentery  is  the  more  usual  form. 

Morbid  Anatomy. —  All  the  lesions  described  as  occurring  in  the  dif- 
ferent varieties  of  dysentery  may  be  present.  The  most  common  is  ulcera- 
tion, which  is  variously  extensive  and  exhibits  also  efforts  at  healing.  On 
the  other  hand,  cases  of  chronic  dysentery  are  met  with  in  which  there  are 
no  ulcers  whatever.  The  coats  of  the  bowel  are  thickened,  especially  the  sub- 
mucosa  and  the  muscularis,  while  patches  of  black  and  slate-gray  discolora- 
tion are  scattered  through  it,  the  result  of  blood  extravasation  and  dis- 
integration. Puckering,  pseudopolyposis,  and  cystic  degeneration  may  be 
present  as  described  under  Morbid  Anatomy  of  bacillary  dysentery. 

Treatment. — The  patient  should  be  put  to  bed  on  a  diet  easy  of  assimi- 
lation and  furnishing  a  minimum  of  waste.  Its  quantity  should  be  just  what 
is  needed  and  no  more.  From  what  has  been  said  it  may  be  inferred  that  I 
have  little  confidence  in  methods  of  treatment  the  object  of  which  is  to  get 
remedies  to  the  diseased  bowel  by  way  of  the  mouth.  Bismuth  in  large 
doses,  iodoform,  and  even  nitrate  of  silver  may,  however,  be  tried  for  the 
purpose.  One-half  to  i  dram  (2  to  4  gm.)  of  bismuth  should  be  given  at  a 
dose,  so  that  from  12  to  15  drams  are  administered  in  the  course  of  a  day. 
Iodoform  may  be  given  as  above  directed. 

The  topical  treatment  of  chronic  dysentery  by  way  of  the  rectum  is  that 
on  which  most  reliance  is  placed  at  the  present  day.  Its  object  is  to  get 
remedies  to  the  diseased  part.  To  this  end  they  are  dissolved  and  their 
solutions  are  introduced  into  the  lower  bowel.  Nitrate  of  silver  is  the  fav- 
orite remedy,  but  alum,  sulphate  of  zinc,  sulphate  of  copper,  and  acetate  of 
lead  are  also  used  in  the  same  doses.  Twenty  to  30  grains  (1.3  to  2  gm.) 
are  dissolved  in  a  pint  (1-2  liter)  of  water,  and  from  3  to  6  pints  (1.5  to  3 
liters)  are  injected  at  one  time  through  a  long  tube  gently  introduced  well 
up  into  the  bowel,  but  at  the  onset  weaker  solutions  and  smaller  quantities 
are  injected.  The  patient  should  be  p^aced  on  his  back  with  the  hips  ele- 
vated by  a  pillow,  so  that  there  may  be  the  cooperation  of  gravity.  I  have 
had  many  opportunities  to  use  this  treatment  in  the  wards  of  the  Hospital 
of  the  University  of  Pennsylvania,   and  confess  to   disappointment  in  the 


114  INFECTIOUS  DISEASES. 

results.     My  cases  improved  to  a  certain  point,  but  none  got  well.     The 
treatment  is  sometimes  painful. 

Very  decided  counterirritation  to  the  abdomen,  by  iodin  and  even  by 
blisters,  is  sometimes  of  decided  advantage.  At  least  these  measures  seem 
to  mark  the  turning  point  in  the  disease. 


THE    PLAGUE.* 

Synonyms. — The  Bubonic  Plague;  Oriental  Plague;  Black  Death;  Black 

Plague;  Pcstis  Hominis. 

Definition. —  The  plague  is  a  febrile  infectious  disease,  characterized 
by  a  tendency  to  buboes  or  carbuncles,  in  addition  to  the  usual  phenomena 
of  the  typhoid  state. 

Historical. — It  has  already  been  said  that  the  historical  plague  of  Athens, 
described  by  Thucj'dides,  corresponded  rather  with  the  typhus  of  to-day  than  with  the 
Oriental  plague,  which  still  occurs  in  Asia,  and  of  which  a  grave  epidemic  is  now 
(1903)  raging  in  the  East  Indies  and  China,  the  last  previous  epidemic  having  oc- 
curred in  Hong-Kong,  China,  in  May,  1894,  from  which  2500  died  in  three  months. 
The  plague  of  the  sixth  century,  Justinian  era,  the  Justinian  Plague,  is  believed  to  be 
the  bubonic  plague  of  to-daj^  as  was  also  "  the  black  death  "  of  the  fourteenth  cen- 
tury, in  which  perished  a  fourth  of  the  population,  and  the  plague  of  London  in  1665, 
which  destroyed  70,000.  With  the  improvement  of  hygienic  conditions  it  has  been 
growing  rarer,  until  the  last  outbreak  occurred,  which  has  practically  prevailed  since 
September,  1896,  with  certain  abatements  and  exacerbations.  From  that  date  to 
January  13,  iSgg,  in  the  Bombay  Presidency,  214,197  had  the  disease,  and  169.240  died. 
This  epidemic  has  spread  to  Japan,  Honolulu,  and  to  Portugal.  A  few  cases  also 
occurred  in  San  Francisco,  U.  S.  A.,  in  the  first  half  of  1900.  According  to  J.  F. 
Payne,  there  are  Jive  independent  endemic  centers  of  the  disease:  (i)  The  province 
of  Tripoli;  (2)  Southwestern  Arabia;  (3)  A  large  section  of  Asia,  including  Mesopo- 
tamia, Persia,  and  Kurdistan;  (4)  The  districts  of  Kumaon  and  Gurwhol  in  northwestern 
India;  and  (5)  Southwestern  China.  Robert  Koch  considers  there  are  three  endemic 
main  plague  foci  in  Asia — viz.,  Mesopotamia,  Thibet,  and  Assia,  while  he  places 
the  primary  source  of  the  disease  in  the  English  territor}^  at  Uganda  ("  Sajous' 
Annual,"  vol.  v.,  1900).  In  addition  to  the  recent  epidemic  in  China  the  region  of  the 
lower  Volga  and  neighboring  Turkey  was  visited  as  recentlj^as  1878  and  1879. 

Etiology. —  The  epidemic  of  1894  gave  the  opportunity  of  isolating  the 
specific  germ  of  plague  which  was  discovered  by  Kitasato  and  later  by  Yersin. 
It  is  a  short  rod  with  rounded  ends,  and  resembles  the  bacillus  of  chicken 
cholera.  It  is  found  in  the  blood,  glands,  and  other  viscera,  and  in  no  other 
disease  excepting  the  plague.  Obtained  in  pure  cultures,  it  can  produce  in 
inoculated  animals  the  same  effects  as  in  human  beings.  It  obtains  entrance 
through  the  respiratory  and  digestive  tracts,  but  especially  by  way  of 
excoriations.  It  occurs  generally  in  pure  culture,  but  may  be  associated 
with  pus-forming  bacteria,  which  enter  the  system  with  it  or  after  it  and  are 
responsible  for  the  suppuration.  Filth  is  a  potent  predisposing  cause,  as  the 
description  of  Dr.  Aoyoma,  who  was  a  member  of  Kitasato's  expedition  and 
himself  fell  a  victim,  vividly  portrayed.  The  rat  is  a  medium  of  transmis- 
sion from  house  to  house,  while  man  in  his  travels  is  the  agent  of  transmis- 
sion through  long  distances.  Flies,  fleas,  ants,  and  other  insects  may  trans- 
mit the  disease,  while  almost  any  of  the  lower  animals  are  subject  to  it. 

Plague  is  a  disease  of  hot  countries  and  of  hot  seasons,  but  it  may  break 
out  in  midwinter.     It  attacks  all  ages  and  classes,  but  the  poor,  who  live  in 

*  For  an  admirable  series  of  papers  on  the  Plag'ue  see  "British  Med.  Jour.,"  October  27,  1900; 
also.  "  Bubonic  Plague,"  by  Simon  Flexner,  M.  D.,  "University  of  Pennsylvania  Medical  Bulletin," 
November,  1902. 


THE  PLAGUE. 


115 


crowded  quarters  and  amid  unfavorable  hygenic  surroundings,  are  its 
favorite  victims.  The  fact  that  small  animals  such  as  monkeys,  squirrels, 
rats,  and  mice  die  in  great  numbers  during  epidemics  and  seem,  indeed,  to 
be  the  first  victims,  suggested  that  the  specific  organism  is  of  telluric  origin. 
At  any  rate,  the  bacilli  have  been  found  in  the  soil  and  dust  of  houses  inhab- 
ited by  its  victims.  In  this  respect  it  is  similar  to  anthrax  and  tetanus. 
Persons  who  live  in  upper  stories  are  less  frequently  attacked  than  those  who 
live  on  the  ground  floor.  The  boating  population  of  China,  which  lives 
mostlv  on  the  water,  is  comparatively  exempt.  Body  linen,  bed  clothing, 
carpets,  rags,  and  baggage  are  frequent  media  of  communication. 

On  the  other  hand,  virulent  as  is  the  plague,  its  contagium  appears  to 
be  more  controllable  than  that  of  such  diseases  as  smallpox  and  scarlet  fever, 
as  evidenced  by  the  fact  that  with  ordinary  cleanly  precautions  few  phvsi- 
cians,  nurses,  or  others  attendant  on  the  sick  acquire  the  disease,  and  even 
those  employed  to  guard  and  disinfect  infected  houses  commonly  escape. 
In  the  epidemic  in  Canton,  during  which  upward  of  30,000  Chinese  died, 
not  one  of  300  American  and  English  residents  was  affected. 

Morbid  Anatomy, — There  is  no  morbid  anatomy  to  the  plague  beyond 
the  buboes  and  internal  suppurating  processes,  which  seem  to  be  essential 
symptoms,  the  cutaneous  and  other  hemorrhages,  and  the  various  tissue 
alterations  that  attend  high  fevers  generally.  The  liver  and  kidneys 
are  congested  and  the  spleen  is  enlarged  to  two  or  three  times  its  normal 
size. 

Varieties  of  the  Disease. — Three  principal  forms  are  easily  separated : 
(i)  Pcstis  mijior,  abortive  or  larval  form,  which  commonly  appears  before 
the  outbreak  of  an  epidemic.  It  is  also  the  form  which  is  endemic.  It  is 
characterized  by  moderate  swelling  of  the  lymphatics,  little  fever  or  other 
constitutional  disturbance,  and  usually  terminates  favorably  at  the  end  of 
about  two  weeks.  (2)  The  bubonic  form  is  the  more  common  severe  epi- 
demic form — the  malignant  adenitis  of  James  Cantlie.  Until  recently  all 
plague  was  called  "  bubonic,"  but  it  is  now  known  that  only  about  70  per 
cent,  of  cases  are  accompanied  by  glandular  enlargement.  (3)  The  septic 
ccmic  form,  also  known  as  toxic,  fulminant,  or  siderans,  a  severe  form,  in 
which  death  may  occur  in  twenty-four  hours  with  associated  hemorrhages, 
but  in  which  glandular  enlargement  is  slight :  the  time  between  the  onset  and 
the  fatal  termination  being  too  short  to  allow  its  development.  Prostration 
is  extreme.  (4)  The  pneumonic  form,  in  which  no  buboes  appear  on  the 
surface,  but  the  force  of  the  disease  is  spent  on  the  lungs,  the  spu- 
ttim  swarming  with  bacilli.  The  processes  in  the  latter  organs  are  septi- 
cemic. 

Symptoms. — Of  the  bubonic  or  ordinary  form. — A  period  of  incubation 
of  from  two  to  seven  days  usually  precedes  the  appearance  of  the  intense 
weakness  which  is  one  of  the  earliest  characteristic  symptoms  of  the  plague. 
A  second  period  or  period  of  prodrome  may  follow  the  incubation,  though 
it  is  not  common.  It  is  short,  from  a  few  hours  to  a  couple  of  days,  and 
includes  headache,  prostration,  marked  nausea,  vomiting,  vertigo,  and  rarely 
lumbar  pain.  A  chill  is  not  usual,  but  there  may  be  chilliness,  after  which 
the  usual  fever  of  the  infectious  diseases  sets  in  with  great  severit}^  and  with 
its  accompaniments,  among  which  severe  headache,  backache,  delirium,  and 
the  typhoid  state  are  conspicuous.  The  temperature  rises  rapidly  to  102''  and 
104°  F.  (39°  and  40°  C.)  and  even  higher.  The  pulse  ranges  from  90  to 
120,  of  fair  volume,  often  dicrotic.     Before  the  fever  sets  in  great  weak- 


Ii6  INFECTIOUS  DISEASES. 

ness  is  manifest.  The  patient  reels  like  a  drunkard,  with  weakness  and 
vertigo.  He  breathes  hurriedly  and  is  anxious,  restless,  and  depressed. 
The  features  are  drawn  and  haggard.  Petechia:,  vibices,—i\-it  plague-spots 
of  the  Bible, — albuminuria,  hematuria,  and  even  hematemcsis  may  be 
included.     Slight  enlargement  of  the  spleen  is  present. 

Pre-eminently  characteristic  is  the  bubo  or  suppurating  gland.  It 
appears  on  the  second  or  third  day,  if  the  patient  live  to  it.  It  occurs  in  order 
of  frequency  in  the  glands  of  the  groin,  the  armpit,  the  neck,  or  in  the  pop- 
liteal region.  It  commonly  reaches  the  size  of  a  walnut  or  egg,  when  it  rup- 
tures, if  not  opened  with  the  lance.  It  may,  however,  subside  without  dis- 
charging. Suppuration  is  a  desirable  termination.  It  is  painful  and  tender, 
as  buboes  commonly  are.  Coincident  with  the  appearance  of  the  bubo  the 
fever  subsides,  a  profuse  szveat  breaks  out,  and  the  pulse  falls  to  90  or  100. 
In  addition  to  the  bubo,  carbuncles  may  also  be  present  in  the  lower  extremi- 
ties, the  buttocks,  or  in  the  neck.  In  some  epidemics  hemorrhages  are 
common,  and  even  the  buboes  may  contain  blood. 

In  the  pneumonic  form  there  are  the  usual  symptoms  of  pneumonia,, 
chill,  high  fever,  severe  pain  in  the  side,  dyspnea,  cough,  rusty  sputum,  and 
physical  signs  of  consolidation,*  and  marked  prostration. 

In  the  septicemic  form  the  patient  is  stricken  by  a  virulent  poison  and 
the  prostration  is  extreme.  The  glands  are  enlarged,  but  there  are  no  buboes. 
The  enlargement  is  slight  and  may  only  be  detected  at  necropsy,  but  it  is  gen- 
eral. Hemorrhages  from  the  nose,  bowel,  and  kidney  are  most  frequent  in 
this  form.  Apyrexia  is  not  uncommon,  fever  reaction  being  impossible 
because  of  the  extreme  depressing  influence  of  the  disease.  The  delirium 
is  of  the  typhoid  type. 

Diagnosis. — In  its  fever,  its  intense  prostration,  its  petechise  and  vibices 
of  the  early  stages  the  plague  resembles  typhus.  No  other  fever  is  charac- 
terized by  such  intense  prostration.  The  bubo  and  the  carbuncle  seem  to  be 
the  distinctive  signs,  although  they  are  said  to  be  sometimes  absent  in  the 
milder  cases  of  a  declining  epidemic,  as  well  as  in  the  intense  pestis  siderans. 
The  diazo  reaction  of  the  urine  is  usually  absent. 

Prognosis. — The  plague  is  said  to  be  the  most  fatal  of  all  diseases,  70 
to  90  per  cent,  perishing,  districts  and  towns  being  half  depopulated,  while 
whole  families  have  been  annihilated.  Death  occurs  from  the  second  to  the 
fourth  day,  and  if  recovery  take  place  it  is  delayed  by  the  slowly  healing 
buboes  and  carbuncles.     These  may,  however,  heal  rapidly. 

Treatment. — Free  stimulation,  nutritious  food,  as  in  the  most  adynamic 
forms  of  typhus  and  typhoid  fevers  together  with  cool  baths  to  combat  the 
fever,  are  the  measures  indicated.  Antiseptic  treatment  of  the  buboes  and 
abscesses  should  be  practiced,  and  may  shorten  the  duration  of  these  plagues 
of  the  skin  as  compared  with  the  older  treatment.  Morphin  should  be 
given  to  produce  sleep  and  relieve  pain.  Kitasato's  general  directions,  scv 
often  quoted,  can  hardly  be  improved.     They  are  as  follows : 

"  The  disease  prevails  under  faulty  hygienic  conditions ;  it  is,  therefore, 
urged  that  general  hygienic  conditions  be  carried  out.  Proper  receptacles 
for  sewerage  should  be  provided,  a  pure  water  supply  afforded,  and  streams 
cleansed ;  all  persons  sick  of  the  disease  isolated ;  the  furniture  of  the  sick- 
room washed  with  a  two  per  cent,  carbolic  solution  in  milk  of  lime ;  old 
clothes  ajid  bedding  are  to  be  steamed  at  100°  C.  (212°  F.)  for  at  least  one 

*  For  reports,  see  "  Sajous'  Annual,"  vol.  v.,  igoo,  article  "Plague." 


THE  PLAGUE. 


117 


hour,  or  exposed  for  a  few  hours  to  sunUght.  If  feasible,  all  infected  articles 
should  be  burned.  The  evacuations  of  the  sick  are  to  be  mixed  with  milk 
of  lime,  and  those  who  die  of  the  disease  are  to  be  buried  at  a  depth  of  three 
meters  (about  12  feet)  or,  preferably,  cremated.  After  recovery  the  patient 
is  to  be  kept  in  isolation  at  least  one  month.  All  contact  with  the  sick  is  to 
be  avoided,  and  great  care  exercised  with  reference  to  food  and  drink." 
Instead  of  carbolic  acid  and  milk  of  lime  for  the  disinfection  of  buildings, 
Haffkine  suggests  sulphuric  acid  in  the  proportion  of  i  to  200  of  water. 

Serum  Therapy. — Preventive  inoculation  was  introduced  by  Yersin, 
Calmet-te,  and  Borrell  conjointly  in  1895.  Dead  cultures  of  plague  bacilli 
were  injected  subcutaneously  into  rabbits  and  guinea  pigs  and  found  to 
convey  a  certain  degree  of  immunity  against  plague.  Haffkine  extended 
this  method  of  preventive  inoculation  to  man.  The  dead  bacilli,  suspended 
in  bouillon,  are  injected  subcutaneously.  These  injections  were  first  made 
upon  lower  animals,  notably  m.onkeys,  with  the  result  of  protecting  them 
against  subsequent  inoculation  with  virulent  plague  bacilli ;  then  upon  human 
beings  in  India  and  China. 

The  results  of  these  inoculations  are  more  definitely  stated  in  the  fol- 
lowing conclusions  reached  by  the  Indian  Commission:  "  (i)  Inoculation 
sensibly  diminishes  the  incidence  of  plague  attacks  on  the  inoculated  popu- 
lation, but  the  protection  which  it  affords  against  attacks  is  not  absolute;  (2) 
Inoculation  diminishes  the  death-rate  among  the  inoculated  population. 
This  is  due  not  only  to  the  fact  that  the  rate  of  attack  is  diminished,  but 
also  to  the  fact  that  the  fatality  of  the  attacks  is  diminished  ;  (  3)  Inoculation 
does  not  appear  to  confer  any  great  degree  of  protection  within  the  first  few 
days  after  it  has  been  performed;  (4)  Inoculation  confers  a  protection 
which  certainly  lasts  for  some  considerable  number  of  weeks.  It  is  pos- 
sible that  the  protection  lasts  for  a  number  of  months.  The  maximum 
duration  of  protection  can  only  be  determined  by  further  observation;  (5) 
The  varying  strengths  of  the  vaccine  employed  have  apparently  had  a  great 
effect  upon  the  results  which  have  been  obtained  from  inoculation.  There 
seems  to  be  a  definite  quantum  of  vaccinating  material  which  gives  the  maxi- 
mum amount  of  protection;  and  provided  that  this  quantum  can  be  injected 
in  one  dose,  and  provided  also  that  the  protection  turns  out  to  be  a  lasting 
one,  reinoculation  might  with  advantage  be  dispensed  with."  * 

As  contrasted  with  preventive  treatment  Yersin's  antipest  serum  t  and 
Lustig's  serum  are  intended  for  curative  purposes,  after  the  manner  of  diph- 
theritic antitoxin.  The  former  is  prepared  by  injecting  the  horse,  first,  with 
dead  and  then  with  living  plague  cultures.  The  serum,  to  insure  sterility, 
is  heated  to  60°  C.  (140°  F.)  before  being  sent  out.  Lustig's  serum  is  pre- 
pared from  the  horse  after  injection  with  a  substance  derived  from  bacilli  by 
treatment  with  alkali  and  precipitation  by  hydrochloric  acid. 

Small  animals  have  been  rescued  from  infection  by  plagtte  germs  by 
Yersin's  serum,  but  in  human  beings  the  results  have  been  less  conclusive, 
Arnold  %  claiming  that  it  reduced  the  mortality  of  cases  70  to  90  per  cent., 
w^hile  Cremow  §  denies  any  therapeutic  value.  Calmette  and  Salimbini  claim 
to  have  shown  from  their  observations  and  experiments  during  the  plague 
epidemic  in  Oporto,  Portugal,  that  much  larger  doses  of  the  antipest  serum 

*  See  Dr.  Simon  Flexner's  paper  on  "  Bubonic  Plague,  its  Nature,  Mode  of  Spread,  and  Clinical 
Manifestations,"   "'  University  of  Pennsylvania  Med.  Bulletin,"  November,  igo2. 
+  "  Sajous'  Annual,"  vol.  v.  p.  491. 
t"Med.  News,"  January  i,  i8q8. 
§  "  London  Lancet,"  May  6,  1899, 


Ii8  INFECTIOUS  DISEASES. 

may  be  used,  and  are  sometimes  demanded,  than  have  heretofore  been 
deemed  sufficient.  Their  report  also  shows  that,  while  the  use  of  the  Haft- 
kine  prophylactic  may  be  attended  with  danger  among  those  who  have  been 
exposed  to  the  infection  of  the  disease  prior  to  inoculation,  the  use  of  a  pre- 
liminary immunizing  dose  of  antipest  serum,  followed  by  an  injection  of  a 
dose  of  Haft'kine's  proph3dactic,  removed  the  element  of  danger  and  con- 
ferred an  immunit}-  of  probably  longer  duration  than  would  be  produced  by 
the  exhibition  of  the  serum  alone. 

Notwithstanding  the  seeming  inconclusiveness  of  these  observations, 
the  Indian  Commission  reports  that  "  though  the  method  of  serum  therapy 
as  applied  to  plague  has  not  been  crowned  with  a  therapeutic  success  in  any 
way  comparable  to  that  obtained  in  the  treatment  of  diphtheria,  nevertheless, 
the  method  of  serum  therapy  is  in  plague,  as  in  other  infectious  diseases,  the 
only  one  which  holds  forth  the  prospect  of  success." 

^^^alter  Wyman,  Supervising  Surgeon-General  United  States  ^Marine 
Hospital  service,  has  directed  that  between  i6o  and  200  c.  c.  of  antipest 
serum  should  be  given  during  the  first  forty-eight  hours  of  the  disease.  In 
severe  cases,  20  to  40  c.  c.  of  this  amount  should  be  injected  into  a  vein.  In 
immunizing  with  the  serum,  use  5  to  c.  c.  every  fifteen  days.  In  case  the 
Haffkine  prophylactic  cannot  be  administered  on  account  of  exposure  to  the 
disease,  the  mixed  plan  of  immunization  may  be  used.  This  consists  of 
giving  5  to  10  c.  c.  of  antipest  serum,  and,  three  days  later,  i  c.  c.  of  the 
Hafifkine  prophylactic."^ 


MEASLES. 

Syxoxvms. — Rubeola;  MorbilU. 

Definition, —  ^Measles  is  an  acute,  highly  contagious  disease,  character- 
ized especially  by  a  mottled  eruption  and  nasobronchial  catarrh. 

Historical. — Measles  and  smallpox  are  first  recognized  in  the  writings  of  Ahrun, 
a  Christian  priest  and  physician  of  Alexandria,  A.  D.  610-641.  It  was,  however,  first  ac- 
curately described  bj-  Rhazes,  A.  D.  900,  and  Avicenna,  A.  D.  9S0-1037.  Rhazes  is  ac- 
credited with  distinguishing  it  from  smallpox.  It  continued,  however,  to  be  confused 
with  the  latter  disease  as  late  as  the  middle  of  the  seventeenth  century.  The  two  were 
clearh'  separated  by  AVithering  as  late  as  1792.  The  distinction  of  having  separated  the 
disease  from  scarlet  fever  was  awarded  to  Thomas  Sydenham  about  1665,  but  this 
separation  is  also  said  to  have  been  made  one  hundred  years  earlier — that  is,  in  1563 — 
by  Forestus,  of  Holland.  Rhazes  and  Avicenna  described  it  under  the  name  hhasbah. 
The  term  rubeola  or  its  equivalent  in  Arabic  is  said  to  have  been  first  used  by  the 
Arabian,  Haly  Abbas,  in  the  latter  part  of  the  tenth  century,  but  was  replaced  bj-  the 
Italian  word  viorbilli,  meaning  little  disease,  up  to  the  middle  of  the  eighteenth 
centurj^  when  Sauvages  reapplied  the  name  rubeola,  which  was  adopted  by  Cul- 
len  and  Willan.  AYithin  the  last  few  years  some  English  writers  have  reapplied  the 
name  morbilli.  The  disease  has  prevailed  in  Asia  and  Europe  for  centuries,  and  was 
imported  into  the  United  States  with  the  first  settlers. 

Etiology. — ^Measles  is  in  all  probability  due  to  a  micro-organism,  which, 
however,  has  not  as  yet  been  isolated,  although  micrococci  have  been 
found  in  the  blood  and  tracheal  mucus  by  Babes  and  by  Klebs.  ]\Iore 
recentlv,  1892,  P.  Canon  and  W.  Pielicke  f  found  with  considerable  con- 
stancy a  bacillus  in  the  blood,  the  expectoration,  and  nasal  and  conjunctival 
mucus  of  cases  of  measles.     Whatever  it  is,  it  is  very  unerring,  since  the  dis- 

*  "Philadelphia  Medical  Journal,"  February  lo,  icoo. 
t  "  Berliner  klin.  Wochenschrift,"  vol.  xxix.  377. 


MEASLES, 


119 


ease  is  more  unfailingly  communicated  to  those  unprotected  by  previous 
attacks  than  is  scarlet  fever.  Nor  is  the  contagium-bearer  definitely  known, 
but  it  is  likely  to  be  the  nasal  and  bronchial  discharges,  and  probably  also 
the  tears.  The  contagium  has  been  transmitted  by  the  inoculation  of  mor- 
billous  blood  and  nasal  mucus,  and  it  is  most  active  when  the  breath  is  its 
medium.  It  is  communicable  by  a  third  party  and  by  fomites ;  though  more 
active  and  unfailing  than  the  contagium  of  scarlet  fever,  it  is  less  so  than 
that  of  smallpox.  It  is  not,  however,  so  tenacious  as  the  causes  of  these. 
Measles  is  a  disease  of  childhood,  but  adults  often  get  it,  and  that  very 
severety.  Repeated  attacks  are  possible,  but  as  other  eruptive  affections 
resemble  it  and  diagnosis  is  often  careless,  some  of  the  repeated  attacks  may 
be  thus  explained.  It  is  milder  and  rarer  in  sucklings  under  six  months, 
while  the  age  during  which  the  disease  is  more  commonly  contracted  is  from 
one  to  five  years. 

Morbid  Anatomy. — There  is  no  essential  morbid  anatomy  of  measles 
beyond  the  nasal  and  bronchial  catarrh,  and  the  signs  of  these  generally  dis- 
appear with  death.  When  death  occurs  it  is  usually  the  result  of  complica- 
tions, and  the  morbid  anatomy  of  such  is  present.     The  most  frequent  com- 


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Fig.  13. — Temperature  Chart  oi  Measles— (E/c/^/iors/). 

plication  is  bronchopneumonia.  There  may  be  lobar  pneumonia,  and  among 
the  morbid  phenomena  are  to  be  included  sometimes  those  of  collapse  of  the 
lung.  In  those  rare  instances  of  hemorrhagic  or  "  black  "  measles  there  is 
the  usual  discoloration  of  hemorrhagic  extravasation.  Rarely  also  the 
morbid  states  of  intestinal  catarrh  are  found. 

Symptonis. — The  period  of  incubation  of  measles  varies,  but  is  com- 
monly between  seven  and  fourteen  days.  Rarely  it  is  a  day  or  two  longer. 
A  prodrome,  if  present,  in  measles  is  of  short  duration.  It  may  be  manifested 
by  sneezing,  fretfulness,  chilliness,  and  feverishness ;  or,  if  the  child  is  old 
enough  to  express  itself,  by  headache.  Then  comes,  on  the  first  day,  the 
initial  or  prodromal  fever,  a  peculiarity  of  which  is  a  remission  on  the  second 
day.     This  is  shown  by  the  appended  cut  from  Eichhorst.     But  very  early. 


I20  INFECTIOUS  DISEASES. 

and  even  almost  suddenly,  coryza,  with  red  and  watery  eyes,  and  photophobia 
present  themselves,  closely  followed  by  troublesome  cough  and  correspond- 
ing feverishness  reaching  103°  and  104"  F.  (39.4°  and  40°  C).  Much  less 
frequently  than  in  scarlet  fever  is  there  vomiting,  but  the  tongue  is  apt  to  be 
furred :  the  cough  is  sometimes  croupy.  Convulsions  very  rarely  usher  m 
the  disease. 

On  the  fourth  day  from  the  onset  the  eruption  makes  its  appearance. 
It  appears  first  in  the  face  in  the  form  of  papules  and  blotches,  which  coalesce 
more  or  less  imperfectly,  leaving  sometimes  islands  of  white  skin  between 
them.  Under  any  circumstances  the  boundary  between  the  eruption  and 
the  sound  skin  is  uneven  and  crescentic.  The  eruption  is  somewhat  raised 
above  the  surface,  and  the  W'hole  effect  is  to  make  the  face  appear  swollen. 
This  elevation  of  surface  at  times  becomes  distinctly  papular  and  even  shot- 
like, resembling  closely  the  papular  stage  of  smallpox.  In  fact,  this  appear- 
ance has  quite  often  led  to  a  diagnosis  of  smallpox,  which  twelve  hours  later 
had  to  be  withdrawn.  From  the  face  the  eruption  spreads  to  the  neck, 
thorax,  abdomen,  and  extremities.  It  is  bright  red,  as  a  rule  disappearing 
on  pressure.  Sometimes,  however,  even  in  mild  cases,  there  are  petechise, 
and  in  malignant  cases  the  extravasations  are  extensive.  At  the  same  time, 
the  mouth  and  fauces  are  bright  red  in  color,  and  not  infrequently  there  is 
diarrhea,  as  though  the  eruption  extended  throughout  the  entire  mucous 
tract  as  well  as  over  the  skin.  At  the  maximum  of  the  eruption  there  may 
be  slight  swelling  of  the  cervical  lymphatic  glands.  At  the  end  of  two  or 
three  days  after  its  appearance  the  rash  fades  gradually,  first  from  the  situa- 
tions in  w^hich  it  appeared  earliest,  and  a  fine,  branny  desquamation  occurs, 
easily  overlooked.  The  fading  takes  place  in  the  order  of  invasion.  The 
typical  rash  may  be  accompanied  by  sudamina. 

In  1896  Henry  Koplik  *  called  attention  to  a  sign  that  seems  likely 
to  be  of  real  value  in  the  diagnosis  of  measles.  It  is  the  appearance,  on  the 
first  day  of  invasion,  on  the  buccal  and  labial  mucous  membrane,  of  a  scat- 
tered eruption  consisting  of  small  irregular  spots,  bright  red  in  color,  in  the 
center  of  which  is  a  minute  bluisJi-zi'liite  speck.  They  have  been  found  45 
times  in  52  cases  and  31  times  in  32  cases.  The  spots  somewhat  resemble 
those  of  thrush,  from  which  they  are  distinguished  by  their  roundish  shape 
and  their  color,  as  contrasted  with  the  more  yellozcisli  center  of  those  of 
thrush.  ^M'lile  thoroughly  discrete  in  the  beginning,  later  in  the  disease 
the  spots  may  coalesce,  and  the  characters  of  a  discrete  eruption  or 
spotting  disappear,  producing^  an  intense  general  redness,  "  which  is 
simply  dusted  over  with  myriads  of  these  bluish-white  specks."  They  can- 
not be  wiped  off,  but  the  whitish  portion  can  be  removed  by  forceps  without 
causing  pain  or  bleeding.  Tliey  consist  of  thick  layers  of  epithelium  in  a 
state  of  partial  fatty  degeneration.  They  require  a  good  light  for  their 
demonstration.      (See  plate  opposite.) 

The  other  symptoms  described  continue  until  the  eruption  begins  to 
fade — that  is,  on  the  fifth  or  sixth  day.  when  they  abate.  The  cougJi,  except 
at  times,  often  hangs  on  quite  stubbornly,  especially  in  scrofulous  children, 
and  sometimes  even  persists  as  the  catarrhal  symptom  of  a  tuberculosis,  the 
development  of  w^hich  seems  peculiarly  favored  by  the  disease.  Hence,  the 
cough  of  measles  should  never  be  slighted,  and  early  exposure  to  cold  and 
dampness  should  be  guarded  against. 

*  "  Archives  of  Paediatrics,''  December,  1896,  and  "  Medical  Record,"  April  g,  1898. 


Fig.  2. 


OffllK    Y" 


Fig.  3. 


Fig.  4. 


/e<jf 


Kopii^ 


The  Pathognomonic  Sign  of  Measles  (Koplik's  Spots). 

Fig.  I. The  discrete  measles  spots  on  the  buccal  or  labial  mucous  membrane,  show- 
ing the  isolated  rose-red  spot,  with  the  minute  bluish-white  centre,  on  the  nor- 
mally colored  mucous  membrane. 

Fig.  2. Shows  the  partially  diffuse  eruption  on  the  mucous  membrane  of  the  cheeks 

and  lips ;  patches  of  pale  pink  interspersed  among  rose-red  patches,  the  latter 
showing  numerous  pale  bluish-white  spots. 

Fig.  3. The  appearance  of  the  buccal  or  labial  mucous  membrane  when  the  measles 

spots  completely  coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish- 
white  specks.  The  exanthema  on  the  skin  is  at  this  time  generally  fully  de- 
veloped. 

Fig.  4. — Aphthous  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  mem- 
brane normal  in  hue.  W\i\v\%  yellow  points  are  surrounded  by  a  red  area.  Al- 
ways discrete.  ,  ,,       ,,^ 

'  — [From  " Medical  Aews.") 


MEASLES.  121 

It  has  already  been  intimated  that  a  mahgnant  f-orm  of  measles  some- 
times occurs,  called  also  "  black  "  measles,  which  is  very  serious — often, 
indeed,  fatal.  It  is  generally  epidemic,  occurs  in  institutions  and  camps,  and 
its  presence  is  characterized  by  subcutaneous  extravasations  of  blood  and 
hemorrhages  from  the  mucous  membranes. 

Complications  and  Sequelae. — These  furnish  most  that  is  serious  in 
the  disease,  and  of  these  the  most  frequent  and  dangerous  is  catarrhal  pneu- 
monia or  bronchopneumonia,  the  bronchitis  creeping  into  the  smaller  air- 
tubes.  The  occurrence  of  this  form  of  pneumonia  seems  to  be  favored  by 
bad  hygiene.  Collapse  of  the  lung  is  also  prone  to  occur,  caused  by  an  acci- 
dental valve-like  plug  of  secretion.  Bronchopneumonia  is  recognized  by  the 
persistent  and  aggravated  cough,  the  continued  high  temperature,  and  physi- 
cal signs  of  a  circumscribed  pneumonia,  ^lore  rarely  lobar  pneumonia  super- 
venes and  is  recognized  even  more  easily.  In  view  of  these  possible  compli- 
cations, frequent  physical  examinations  of  the  chest  should  be  made. 

Among  the  complications  may  be  mentioned  laryngitis,  catarrh  of  the 
middle  ear  leading  to  suppuration  and  perforation  of  the  drum,  and  chronic 
or  intractable  ophthalmic  trouble.  Ulcerative  and  even  gangrenous  stoma- 
titis are  met  under  unfavorable  hygienic  conditions. 

Xephritis,  although  not  often  a  complication  of  measles,  does,  how- 
ever occur,  and  I  have  met  serious  instances  of  such.  Tuberculosis  has  long 
been  recognized  as  a  sequel  of  measles,  yet  it  is  not  a  very  frequent  one.  Any 
of  the  varieties  of  pulmonary  tuberculosis  may  be  present.  Even  nervous 
lesions  are  reported,  such  as  hemiplegia,  paraplegia,  neuritis,  and  myelitis.* 

Diagnosis. — Measles  is  easy  of  diagnosis ;  but  the  physician  must  not 
be  too  precipitate.  Allusion  has  already  been  made  to  the  possibility  of  mis- 
taking it  for  smallpox,  on  account  of  the  similarity  of  the  eruption  in  the 
early  stage,  an  error  which  a  few  hours'  delay  would  have  averted.  Koplik's 
spots  should  be  helpful  here,  as  they  are  said  to  appear  at  least  twenty-four 
hours  before  the  skin  eruption.  From  scarlet  fever  there  is  sometimes  diffi- 
culty, as  there  is  occasionally  slight  sore  throat  and  the  eruption  may  be 
diffuse,  while  the  difficulty  is  increased  if  there  be  glandular  swelling  in 
measles :  but  the  catarrhal  symptoms  of  measles  are  essential  to  it.  The 
mildest  cases  are  probably  those  that  give  most  trouble.  The  distinction 
between  measles  and  rubella  is  sometimes  more  difficult,  but  this  will  be 
considered  when  treating  of  rubella. 

Typhus  fever  and  measles  have  been  confounded,  and  it  must  be 
admitted  that  in  the  asthenic  variety  of  measles  the  eruption  may  resemble 
that  of  typhus  fever.  It  will  be  remembered  that  the  eruption  of  typhus  is 
described  as  '"  rubeoloid."  Confusion  is  further  favored  by  the  fact  thai 
the  eruption  occurs  at  about  the  same  time  in  each  disease. 

Prognosis. — The  vast  majority  of  cases  of  measles  get  well.  It  is  only 
in  epidemics  of  the  malignant  form,  in  hospitals,  cam.ps.  and  foundling 
asylums,  that  death  occurs  as  a  direct  result  of  the  disease.  In  these  the 
mortality  is  sometimes  very  high.  Epidemics  among  the  aborigines  in 
Xorth  and  South  America,  in  the  ^Mauritius  and  Feejee  Islands,  and  in  the 
Confederate  Army  in  the  War  of  the  Rebellion  in  America  were  of  signal 
fatality.  Other  deaths  are  due  to  complications,  especially  pneumonia. 
Out  of  24  fatal  cases  collected  by  Pot't.  21  died  of  bronchopneumonia  and 
pneumonia,  and  3  of  croup. 

*  See  a  pappr  by  Imogene  Bassette  entitled  "  The  Paralyses  in  Children  which  Occur  during  and 
after  Infectious  Diseases,"  "  Jour.  Xerv.  and  Ment.  Dis.,"  vol.  xix.,  1902. 


122  INFECTIOUS  DISEASES. 

Treatment. — After  surrounding  the  patient  by  a  uniformly  warm  tem- 
perature, best  secured  in  bed,  the  treatment  of  measles  is  mainly  that  of  the 
fever  and  the  cough.  The  former  is  sufficiently  treated  by  the  simple 
diaphoretics  and  febrifuges,  such  as  citrate  of  potash  and  sweet  spirit  of 
niter,  or  tincture  of  aconite.  The  latter  is  efficient  and  tasteless.  The 
coal  tar  derivatives,  acetanilid,  antipyrin,  thermol,  and  phenacetin  may 
be  used. 

The  cough  calls  for  positive  anodyne  measures,  of  which,  for  chil- 
dren, paregoric  is  the  best  because  the  safest.  Laudanum  or  deodorized 
tincture  of  opium  may  be  used  in  smaller  doses,  but  not  morphin.  They 
may  be  combined  with  the  febrifuges  just  mentioned.  It  is  comparatively 
rare  that  cool  sponging  is  needed  to  reduce  the  temperature,  but  cold  water 
drinking  should  be  allowed  ad  libifuin.  I  recently  knew  a  case  of  measles  to 
receive  the  cold  tub-bath  treatment  under  the  impression  that  it  was  typhoid 
fever.  The  rash  came  out  brilliantly  at  the  proper  time  and  the  case  did 
splendidly.  Complications  should  be  treated  as  they  arise.  Stimulants  and 
tonics  are  necessary-  in  the  adynamic  form.  When  the  cough  is  prolonged, 
cod-liver  oil  is  a  valuable  remedy.  Watchfulness  during  convalescence  is 
more  important  than  is  supposed  by  many,  and  carelessness  and  indifference 
are  sometimes  responsible  for  unfortunate  results. 

It  occasionally  happens  that  the  eruption  is  "  suppressed,"  or  its  appear- 
ance may  be  delayed.  Under  these  circumstances  the  hot  pack  is  very 
effectual.  The  child  is  wrapped  in  flannel  wrung  out  in  hot  w^ater  and  then 
enveloped  in  a  mackintosh.  Copious  perspiration  soon  sets  in,  the  eruption 
appears,  and  general  reaction  begins. 

I  have  never  seen  any  good  reason  for  isolating  measles  as  usually 
occurring  in  families.  The  disease  is  so  mild  in  children,  and  so  much  more 
serious  in  adults,  that  I  believe  it  is  desirable  that  all  the  children  of  a  family 
should  have  it  as  soon  as  possible. 


RUBELLA. 

Synonyms. — Rdthehi;  Rubeola;^   German   Measles;  Rubeola  notha;  Epi- 
demic Roseola;  False  Measles;  Hybrid  Measles;  Hybrid  Scarlet  Fever. 

Definition. —  Rubella  is  a  mild,  acute,  contagious  disease,  characterized 

by  a  punctiform  rash  that  fuses -into  patches  less  plainly  crescentic  than  those 

of  measles.     There  is  often  slight  sore  throat,  more  rarely  mild  catarrhal 

symptoms,  and  trifling  fever.     ]\Iany  so-called  second  attacks  of  measles  and 

scarlet  fever  are  attacks  of  rubella. 

Historical.— The  existence  of  rubella  as  an  independent  and  separate  infectious 
disease  was  for  a  long  time  disputed,  some  regarding  it  as  a  variety  of  measles  and 
others  as  a  mild  form  of  scarlet  fever,  although  as  far  back  as  1752  Bergen,  a  German 
phvsician,  claimed  for  it  a  distinct  individualitv.  A  sufficient  foundation  for  such 
claim  was  not.  however,  advanced  until  1815,  'when  Maton.  an  English  phj-sician, 
substantiated  that,  while  one  attack  protected  ordinarily  against  its  own  recurrence, 
it  did  not  protect  its  victim  either  from  measles  or  scarlet  fever,  while  an  attack  of 
either  of  the  latter  diseases  did  not  protect  from  rubella.  A  few  held  out  for  the 
original  views,  among  whom  was  the  eminent  Hebra,  but  there  seems  to  be  no  one  at 
the  present  day  who  denies  that  it  is  an  independent  disease.  The  name  "rubella" 
was  first  suggested  by  Veale  in  1866. 


*  It  is  unfortunate  that  the  Germans  have  selected  for  their  technical  term  for  this  affection  the 
word  Rubeola,  which  is  the  word  used  in  English  for  measles. 


RUBELLA.-  123 

Etiology. — The  relation  of  the  disease  seems  rather  closer  to  measles 
than  scarlet  fever,  and  may  be  said  to  bear  -to  the  former  the  same  relation  as 
varicella  to  variola.  Though  contagious,  it  is  much  less  so  than  measles  or 
scarlet  fever.  It  affects  children  chiefly,  very  rarely  adults,  sucklings  less 
frequently  than  school  children,  because  the  latter  are  more  exposed  to  con- 
tagion. Isolated  cases  occur,  but  it  is  apt  to  prove  in  large  cities  epidemic. 
Such  epidemics  are  sometimes  widespread. 

Symptoms. — After  a  period  of  incuhation  ranging  from  two  to  three 
weeks,  the  disease  sets  in,  as  a  rule,  with  no  distinctive  symptoms  of  inva- 
sion prior  to  the  eruption.  There  may  be  chilliness,  moderate  muscular 
pain,  mild  catarrh,  and  slight  fever,  with  temperature  barely  reaching  100" 
F.  (37.8°  C),  for  a  day  or  two  previous  to  the  eruption.  ]\Iore  frequently, 
an  indistinct  macular  eruption  of  a  pale  rose  color  is  first  noted.  The 
papules  are  scarcely  elevated,  and  vary  in  size  from  a  pinhead  to  a  split  pea, 
the  smaller  being  more  numerous,  much  smaller  than  the  papules  of  measles. 
They  may,  however,  fuse  and  form  large,  irregular  patches,  with  little  or  no 
disposition  to  form  small  crescent-shaped  groups  like  those  of  measles.  The 
rash  may  appear  as  late  as  the  second  day,  rarely  on  the  third,  after  the  indis- 
tinct symptoms  of  invasion  mentioned. 

Two  types  of  the  spread  of  the  eruption  are  possible.  In  the  one  it 
appears  almost  simultaneously  all  over  the  body,  reaching  its  maximum  by 
the  second  day,  after  which  it  rapidly  fades.  In  the  second  mode  of  invasion 
the  rash  appears  first  on  the  face,  and  extends  rapidly  thence  all  over  the 
body,  reaching  the  hands  and  feet  last,  and  beginning  to  fade  on  the  face  and 
tnmk  before  attaining  its  maximum  on  the  extremities,  or  even  before  it 
appears  there  at  all.  Thus  it  has  a  wave-like  course,  reaching  its  maximum 
in  twenty-four  hours,  when  it  begins  to  decline  rapidly.  It  is,  therefore,  of 
shorter  duration  than  the  eruption  either  of  measles  or  of  scarlet  fever.  It 
may  terminate  in  a  branny  desquamation,  less  evident  even  than  that  of 
measles. 

The  most  constant  symptom  after  the  eruption  is  the  sore  throat.  It 
varies  in  severity,  but  is  for  the  most  part  mild,  never  becoming  ulcerative. 
It  is  really,  perhaps,  the  eruption  in  the  throat.  Somewhat  less  constant 
than  the  sore  throat,  though  varying  somewhat  in  different  epidemics,  is 
szvelling  of  the  lymphatic  glands  of  the  neck,  especially  the  superficial  cer- 
vical, postcervical,  and  postauricular  glands.  This  swelling  is  present  dur- 
ing the  eruptive  stage  and  may  occur  even  earlier.  Its  possible,  though 
rarer,  occurrence  in  measles  also  is  to  be  remembered. 

The  remaining  symptoms  of  rubella  are  not  marked  nor  distinctive 
There  is  little  or  no  constitutional  disturbance,  and,  as  already  mentioned, 
rarely  any  fez^er  above  100°  F.  (37.8"  C),  although  102°  F.  (38.9°  C.)  and 
even  103°  F.  (39.4°  C.)  have  been  noted.  There  may  be  sligb"  catarrh, 
watering  of  the  eyes,  and  running  at  the  nose,  all  much  less  marked  than  in 
measles.  There  are  no  complications,  as  a  rule,  though  albuminuria, 
nephritis,  pneumonia,  colitis,  and  icterus  have  been  reported,  but  it  would 
seem  as  though  measles  or  scarlatina  must  have  been  mistaken  for  rubella  in 
these  cases. 

Diagnosis.— Such  are  the  symptoms  of  a  typical  case.  Unfortunately, 
there  are  many  deviations,  some  approximating  measles  and  some  scarlet 
fever,  differing  from  either  mainly  in  mildness.  The  absence  of  decided 
catarrhal  symptoms,  the  earlier  appearance  of  the  eruption,  its  more  diffuse 
character,  and  the  swelling  of  the  lymphatic  glands  are  its  chief  difterencea 


124  INFECTIOUS  DISEASES. 

from  measles.  The  careful  studies  of  J.  P.  C.  Griffith  *  show  the  latter  of 
less  significance  than  has  been  usually  supposed.  The  course  of  the  erup- 
tion differs  also,  that  of  measles  lasting  longer.  The  absence  of  Koplik's 
sign  must  hereafter  be  helpful  in  distinguishing  it  from  measles.  The  same 
mildness  and  absence  from  fever,  with  the  more  distinct  mottling,  distinguish 
it  from  scarlet  fever.  In  rubella  the  symptoms  of  invasion  are  all  very  much 
milder  than  in  either  measles  or  scarlet  fever,  even  mild  cases  of  the  latter. 

Prognosis. — The  prognosis  of  rubella  is  invariably  favorable. 

Treatment. — Very  little  if  any  is  required,  except  rest  in  bed.  A  simple 
febrifuge  with  potassium  chlorate  may  be  useful. 


SCARLET  FEVER. 

Synonym. — Scarlatina. 

Definition. —  Scarlet  fever  is  an  acute  contagious  disease,  especially 
characterized  by  faucitis  and  a  diffuse  scarlet  eruption,  terminating  in  more 
or  less  membranous  desquamation. 

Historical. — Although  it  has  been  claimed  that  the  pestilence  of  Thebes,  600  B.  C, 
and  the  plague  at  Athens,  430  B.  C,  were  each  epidemics  of  scarlet  fever,  no  accu- 
rate knowledge  of  this  affection  as  a  separate  disease  was  obtainable  prior  to  the 
seventeenth  century,  v^^hen  Sydenham  and  his  contemporaries  described  it  in  a  manner 
which  permits  its  easy  recognition  as  the  scarlet  fever  of  to-day.  It  pervades  the  Old 
World  everywhere,  having  been  recognii^ed  in  England  in  1661,  Scotland  in  1716,  Ger- 
many and  Italy  in  1717,  Denmark  in  1740,  and  was  introduced  into  North  America  by 
shipping  in  the  year  1735.  It  did  not,  however,  reach  South  America  until  1829,  Ice- 
land 1827,  and  spread  to  Greenland  as  late  as  1847. 

Etiology. — The  organism  that  causes  scarlet  fever  has  not  been  iso- 
lated. Streptococci  have  been  found  in  the  blood  and  postmortem  in  the  lym- 
phatic glands  and  kidneys. f  Whatever  the  agency,  it  is  the  most  tenacious  of 
all  the  contagia,  retaining  its  power  to  infect  for  at  least  a  year  after  the 
occurrence  of  a  case.  It  is  especially  difficult  to  dislodge  from  organized 
substances,  such  as  bedding,  clothing  or  straw,  letters  and  books,  and  the 
disease  has  been  communicated  to  newcomers  even  after  an  infected  apart- 
ment has  been  thoroughly  cleaned  and  fumigated  with  sulphur.  Physicians 
have  doubtless  conveyed  it,  and  the  beard  and  hair  are  contagium-bearers 
more  frequently  than  is  suppos,ed.  Hence,  physicians  should  not  wear  long- 
beards,  and  nurses,  before  passing  from  one  case  to  another,  should  disinfect 
their  hair  as  well  as  the  rest  of  their  body. 

While  the  contagium  itself  has  never  been  isolated,  there  is  every  reason 
to  believe  that  the  bearer  is  the  exfoliated  epithelium.  Hence,  it  is  not  until 
desquamation  takes  place  that  the  disease  is  communicable,  and  the  ease  with 
which  the  scaly  particles  are  disseminated  through  the  air  and  the  tenacity 

*  "  Differential  Diagnosis  of  Rubeola  and  Rubella,  with  Special  Reference  to  Enlargement  of  the 
Glands  of  the  Neck,"  "  Universaty  Med.  Magazine,"  Tune,  1892. 

t  Dr.  William  ].  Class  ("  Monthly  Bulletin  of  the  Chicago  Dept.  of  Health,"  March,  i8gg)  claims  to 
have  found  a  diplococcus  which  fulfills  the  conditions  that  make  it  reasonable  to  believe  it  is  the 
bacterium  responsible  for  scarlet  fever.  His  observations  are  confirmed  by  Calvin  G.  Page,  in  a 
"Preliminary  Report  on  the  Diplococcus  of  Scarlet  Fever"  ("  Journal  Boston  vSociet)'  of  Medical 
Sciences."  March  24,  T_goo~),  by  R.  H.  B.  Gradwohl  f"  Philadelphia  Med.  Jour.,"  March  24,  igoo,  p.  683), 
and  W.  K.  Jaques  (  Ibid.,  March  10,  igoo.  p.  552).  The  diploccocus  was  found  in  the  throat,  blood,  and 
desquamative  scales  in  a  lar.ge  proportion  of  cases  by  all  these  observers.  In  a  further  paper  in  the 
"  Philadelphia  Med^  Jour.,"  June  23,  igoo,  Dr.  Class  describes  his  efforts  to  obtain  an  antitoxin.  The 
bacillus  of  Class  is,  however,  not  regarded  by  the  best-trained  pathologists  as  the  cause  of  scarlet 
fever. 


SCARLET  FEVER.  125 

with  which  they  adhere  to  textures  readily  explain  the  communicability  of 
scarlet  fever  and  the  difificulty  in  destroying  its  cause.  On  the  other  hand, 
until  the  eruption  makes  its  appearance  the  disease  cannot  spread.  Accord- 
ingly, it  is  not  likely  to  be  communicated  to  those  exposed  prior  to  this  stage. 
Hence,  children  removed  from  association  with  the  disease  promptly  after 
its  discovery,  and  kept  apart,  generally  escape  it. 

The  route  of  infection  is  mostly  the  respiratory  tract,  although  the 
alimentary  canal  may  also  convey  it.  In  confirmation  of  this  is  the  fact  that 
in  a  number  of  instances  milk  has  been  the  medium  of  infection,  the  milk 
having  been  infected  by  exposure  in  an  apartment  occupied  by  patients.  In 
one  instance  the  disease  appeared  in  six  out  of  twelve  families  supplied  from 
such  a  source.  The  readiness  with  which  milk  absorbs  volatile  substances 
kept  in  the  same  refrigerator  compartment  and  retains  their  flavor  is  quite  in 
accord  with  such  transmission. 

Children  of  either  sex  are  more  subject  to  the  disease,  because  a  single 
attack,  as  a  rule,  protects  against  a  second.  Infants,  however,  even  under 
exposure,  are  less  liable  to  the  disease,  and  it  would  seem,  too,  that  adults 
who  have  escaped  exposure  during  childhood  are  less  liable.  I  have  never 
had  scarlet  fever,  and  have  been  exposed  many  times  to  the  most  virulent 
forms.  The  primary  attack  is  not  always  protective ;  second  and  third 
attacks  are  reported.  But  here,  again,  careless  diagnoses  and  defective 
memory  are  responsible  for  a  certain  number.  In  my  own  experience  the 
disease  is  most  common  about  the  age  of  seven. 

Morbid  Anatomy. — There  is  no  morbid  anatomy  peculiar  to  scarlet 
fever.  The  eruption  fades  after  death,  unless  there  happens  to  be  hemor- 
rhagic extravasation.  There  may  be  lesion  the  result  of  ulcerative  destruc- 
tion in -the  neighborhood  of  the  throat.  The  intensity  of  the  fever  sometimes 
produces  granular  fatty  change  in  muscles,  which  is  pronounced  in  the  case 
of  the  heart ;  also  cloudy  swelling  in  the  cells  of  the  kidney  and  liver. 
Glandular  swellings  present  at  death  maintain  themselves  afterward.  The 
morbid  anatomy  of  the  complications  and  sequelae  is  appropriately  considered 
under  the  diseases  constituting  them. 

Symptoms. — The  period  of  incubation  varies  greatly.  It  is  sometimes 
as  short  as  twenty- four  hours,  and  again  as  long  as  twelve  days ;  more  fre- 
quently, perhaps,  from  two  to  four  days.  At  the  end  of  this  time  there  is 
usually  a  very  short  prodrome,  sometimes  none  at  all.  Vomiting,  occurring 
either  as  an  initial  symptom  or  a  couple  of  hours  later,  is  often  present ; 
more  rarely  a  convulsion,  still  more  rarely  a  chill.  Sore  throat  is  early  com- 
plained of,  and  high  fever  is  conspicuous.  There  is  early  fever,  the  face 
is  flushed,  and  the  temperature  rapidly  rises  to  103°  F.  (39.4°  C),  105°  F. 
(40.5°  C),  and  even  108°  F.  (42.2°  C),  and  the  pulse  to  no,  120,  or  more. 

The  eruption  appears,  as  a  rule,  on  the  second  day,  and  it  generally 
happens  that,  if  it  is  not  present  at  the  physician's  first  visit,  it  is  sure  to  be 
found  at  his  second.  Its  striking  character  is  its  uniform  redness.  It  is 
like  a  dififuse,  broadly  spread  blush,  appearing  first  upon  the  neck  and  chest, 
and  extending  thence  rapidly  over  the  whole  body,  so  that  at  the  end  of  the 
third  day  it  has  completed  its  invasion.  The  appearance  of  a  child  covered 
with  a  frank  scarlet-fever  eruption  is  very  characteristic.  It  has  been  well 
compared  with  that  of  a  boiled  lobster  in  its  bright  redness.  It  is  further 
characterized  by  the  readiness  with  which  it  disappears  on  pressure  and  the 
promptness  with  which  it  returns  after  the  pressure  is  removed.  It  is.  hov/- 
ever,  no  sooner  complete  than  it  begins  to  fade,  and  does  so  with  great 


126  INFECTIOUS  DISEASES. 

rapidity  in  the  order  of  invasion.  The  eruption  is  not,  however,  always 
thus  typical,  and  presents  every  degree  between  that  described  and  that 
which  is  barely  recognizable.  It  is  also  at  times  more  "  patchy,"  but  never 
presents  the  crescentic  or  otherwise  irregular  edges  or  mottled  appearance 
of  the  eruption  of  measles.  In  the  lower  and  more  malignant  forms  the 
redness  is  of  a  darker  or  dusky  hue,  and  in  the  worst  of  these,  petechise  are 
present.  \>sicles  are  even  found  with  turbid  contents,  producing  scarlatina 
miliayis.  The  eruption  is  sometimes  entirely  absent  from  the  face ;  hence  no 
conclusion  should  be  based  upon  inspection  only.  The  thorax  and  inner 
surface  of  the  thighs  are  more  favorable  sites.  The  eruption,  when  severe, 
is  constantly  accompanied  by  an  itching  or  burning  more  or  less  intense,  and 
there  is  a  feeling  of  slight  roughness  at  times. 

The  tongue  is  red  at  the  edges  and  tip,  furred  at  the  center,  but  through 
the  fur  the  papillae  stand  out  in  distinct  points,  producing  an  appearance  that 
is  regarded  as  more  or  less  characteristic.  This  has  been  called  by  some 
the  strazvbcrry  tongue.  So  I  did  in  my  first  edition,  but  further  examma- 
tion  into  the  subject  leads  me  to  adopt  the  view  that  the  strawberry  tongue 
is  the  red  and  raw-looking  tongue  with  enlarged  papillae,  as  originally  held 
by  the  late  Dr.  Flint,*  who  wrote  as  follows :  "  In  the  progress  of  the  dis- 
ease the  coating  exfoliates,  leaving  the  surface  of  the  tongue  reddened ;  and 
the  papillae  being  enlarged,  the  appearance  is  strikingly  like  that  of  a  ripe 
strawberry."  The  term  raspberry  tongue  is  also  applied  to  this  condition. 
The  rest  of  the  mouth,  including  the  roof  and  the  palate  and  tonsils,  is  bright 
red,  as  though  the  eruption  extended  to  it,  as  it  doubtless  does. 

With  the  abatement  of  the  eruption  comes  desquamation,  and  it  is  gen- 
erally proportionate  to  the  intensity  and  extent  of  the  former.  It  sets  in 
about  the  tenth  day,  and  continues  in  bad  cases  for  two  or  three  weeks  and 
even  longer.  When  the  eruption  is  slight,  the  little  scales  are  scarcely 
noticeable,  and  the  closest  examination  is  necessary  to  discover  them,  while, 
where  there  is  a  vivid  and  extensive  eruption,  the  amount  of  desquamation  is 
enormous.  Glove-like  casts  of  the  fingers,  including  the  nails,  are  some- 
times exfoliated,  and  the  bed  contains  each  day  numerous  flakes  of  epiderm 
that  have  come  off,  while  many  days  are  required  for  complete  separation  of 
the  dead  skin.  Great  care  should  be  taken  in  gathering  it  up,  for  in  the 
desquamation  resides  the  contagium.  On  the  other  hand,  when  slight  it 
should  be  carefully  sought  for,  as  it  has  great  diagnostic  value.  At  the 
same  time  it  should  not  be  regarded  as  something  peculiar  and  confined  to 
scarlet  fever,  for  every  dermatitis  is  followed  by  desquamation,  as  especially 
exemplified  in  the  exfoliation  that  follows  an  attack  of  erysipelas  on  the  face 
or  irritation  by  iodin  or  mustard. 

The  urine  from  scarlet  fever  proper  is  like  that  of  fever  cases  generally 
— scanty,  high-colored,  and  precipitating  uric  acid  and  urates  on  cooling. 
The  chlorids  are  diminished  during  active  fever. 

The  duration  of  simple  uncomplicated  scarlet  fever  ranges  from  three 
to  fourteen  days,  according  to  the  degree  of  severity.  Its  decline  is,  how- 
ever, gradual  as  compared  with  the  suddenness  of  onset. 

Such  is  a  general  picture  of  scarlet  fever  in  its  simple,  uncomplicated 
form,  so  characteristic  that  early  in  its  history  it  received  the  name  scarla- 
tina simplex;  owing  to  further  combinations  of  symptoms,  there  have  been 


*  For  an  interesting  paper  containing  the  views  of  various  authors  on  this  subject  see  he 
Strawberry  Tongue  in  Scarlet  Fever,"  by  M.  H.  Fussell,  M.  D.,  "  University  Med.  Magazine,  Phila- 
delphia, May,  1897. 


SCARLET  FEVER. 


127 


128  INFECTIOUS  DISEASES. 

added  three  other  varieties;  the  anginose  form,  or  scarlatina  anginosa;  the 
malignant  form,  or  scarlatina  maligna,  and  the  hemorrhagic  form. 

In  the  angi)iosc  variety  the  throat  symptoms  are  conspicuous  and  severe. 
In  no  well-developed  case  is  there  an  absence  of  throat  redness.  On  the 
other  hand,  there  may  be  intense  soreness  with  swelling  of  the  fauces  and 
tonsils,  giving  rise  to  extreme  dysphagia.  The  neck  may  be  so  swollen  as 
to  fill  up  the  depression  beneath  the  jaw.  There  may  be  a  false  membrane 
involving  the  fauces,  the  posterior  pharynx,  the  nasal  cavities,  the  trachea,  and 
the  bronchi.  The  throat  may  present  all  the  features  of  a  severe  diphtheria. 
Abscess  and  destructive  ulceration  ma}'  result,  which  may  proceed  even  to 
perforation  of  the  carotid  artery,  and  rapid  death  ensue  therefrom.  The 
inflammation  almost  certainly  ascends  the  Eustachian  tubes,  producing 
severe  ear  symptoms.  The  false  membrane  is  usually  the  result  of  the 
intensity  of  the  inflammatory  process,  due  to  the  specific  cause  of  the  disease 
and  not  to  that  of  diphtheria,  but  there  may  be  true  diphtheritic  membrane 
containing  the  Loefller  bacillus.  Especially  is  this  true  of  the  cases  in  hos- 
pitals for  infectious  diseases.  The  streptococcus  pyogenes  is  perhaps  the 
most  frequent  cause  of  the  throat  inflammation.  It  has  been  found  also  in 
the  skin,  the  blood,  and  the  glandular  organs  in  fatal  cases.  Scarlet  fever 
has,  indeed,  been  called  a  streptococcus  infection.  Follicular  tonsillitis  may 
also  be  one  of  the  forms  of  sore  throat. 

In  the  malignant  variety  there  is  an  overwhelming  intensity  of  the  cause 
which  may  result  in  almost  immediate  prostration  and  death  of  the  patient, 
giving  no  time  for  the  development  of  the  usual  symptoms,  or  these  may  be 
so  feebly  manifested  that  they  present  no  distinctness.  When  the  disease  is 
not  immediately  fatal,  there  is  intense  adynamia,  the  heart  and  pulse  sharing 
it.  The  breath  is  rapid ;  the  capillary  circulation  is  feeble ;  the  skin  dusky ; 
the  eruption  is  imperfectly  developed ;  the  temperature  is  very  high,  reaching 
105"  to  108°  F.  (40.5°  to  42.2°  C.)  ;  there  is  delirium,  which  may  pass  over 
into  coma,  and  convulsions  may  occur.     The  pulse  ranges  from  120  to  150. 

In  the  honorrhagic  form  there  are  more  or  less  extensive  hemorrhagic 
extravasation,  epistaxis,  and  hematuria.  It  attacks,  for  the  most  part,  the 
feeble  and  badly  nourished,  and,  like  the  previous  variety,  is  almost  invari- 
ably fatal. 

Epidemics  of  scarlet  fever  vary  greatly  in  severity.  In  some  all  the 
cases  appear  to  be  mild,  in  others  all  are  of  extreme  severity.  Families  of 
children  may  be  exterminated.  Again,  a  mild  case  may  give  rise  to  one  of 
the  most  intense  forms.  ^ 

Complications. — Acute  nephritis  is  the  most  frequent  complication  of 
scarlet  fever.  It  makes  its  appearance  usually  after  desquamation  is  more 
or  less  complete — in  the  second,  third,  or  fourth  week.  A  slight  album.i- 
nuria.  which  is  common  at  the  height  of  the  fever,  is  not  to  be  confounded 
with  that  of  nephritis,  and  probably  does  not  predispose  to  it,  although  the 
cells  lining  the  tubules  are  at  this  stage  in  a  state  of  cloudy  swelling.  The 
rationale  of  its  production  is  not  precisely  understood.  It  used  to  be 
ascribed  to  cold  or  a  draft  of  air  upon  the  skin,  w^hich  is  young  and  tender 
after  the  desquamation.  But  vdien  it  is  remembered  that  the  mildest  cases 
are  as  susceptible  as  the  most  severe,  and  probably  more  so,  and  that  chil- 
dren have  been  found  barefoot  in  the  street  with  the  eruption  upon  them, 
and  yet  have  escaped  Bright's  disease,  it  must  be  admitted  that  we  do  not 
know  all  about  it.  The  fact  that  the  complication  is  usually  more  severe  the 
earlier  it  appears,  would  go  to  show  that  the  specific  toxin  or  bacillus  has 


SCARLET  FEVER. 


129 


something  to  do  with  it.  It  is  true,  too,  that  with  the  skin  functionally  dead 
the  complemental  work  thrown  upon  the  kidney  increases  its  susceptibility 
to  the  ordinary  causes  of  nephritis,  of  which  cold  is  one.  It  is  to  be  remem- 
bered also  that  other  diseases  in  which  the  skin  is  seriously  affected  predis- 
pose to  nephritis.     This  is  pre-eminently  true  of  burns  and  scalds. 

However  it  may  be  brought  about,  the  result  is  generally  a  typical 
example  of  parenchymatous  or  tubal  nephritis,  although  instances  of  acute 
interstitial  inflammation  are  also  found.  Every  grade  of  severity  is  met, 
but  early  recognition  increases  our  power  to  control  this  severity.  The 
majority  of  cases  thus  recognized  get  well,  and  I  have,  known  recovery 
to  take  place  after  suppression  of  urine  has  lasted  for  a  week.  The  clinical 
picture  is  that  of  acute  nephritis  otherwise  caused,  and  its  consideration 
may  be  deferred  until  that  disease  is  studied.  This  complication  was  for- 
merly often  overlooked,  but  in  modern  times  cases  are  more  closely  watched 
for  it.  The  possibility  of  Bright's  disease  without  albuminuria  must  be 
borne  in  mind. 

Adenitis  producing  a  moderate  degree  of  glandular  enlargement  occurs 
in  almost  all  cases  of  scarlet  fever,  but  in  severe  cases  it  becomes  a  painful 
and  grave  complication.  A  majority  of  cases  subside,  but  some  go  on  to 
extensive  and  destructive  suppuration,  of  which  I  have  known  ulceration 
through  the  carotid  artery  a  consequence. 

Arthritis  ensues  in  a  certain  number  of  cases,  and  closely  resembles  that 
of  acute  rheumatism.  The  term  rheumatism  is  justified  as  much  as  the  term 
gonorrheal  rheumatism,  and  no  more.  Each  is  the  result  of  the  specific 
cause  of  the  disease,  and  not  of  the  cause  of  rheumatism.  It  occurs  usually 
at  defervescence,  and  recovery  is  almost  invariable.  Suppuration  in  the 
joint  has,  however,  occurred. 

Otitis  is  one  of  the  most  serious  and  permanently  harmful  of  the  com- 
plications. It  is  commonly  considered  the  result  of  an  extension  of  inflam- 
mation from  the  throat  through  the  Eustachian  tube  to  the  middle  ear,  and  is 
associated  with  the  streptococcus.  I  have  known  it  to  occur  after  recover}^ 
was  supposed  to  have  taken  place,  immediately  after  a  child  had  been  sitting 
on  a  cold  step.  On  the  other  hand,  it  sometimes  happens  quite  early  in  the 
disease.  Suppuration  and  perforation  of  the  membrane  of  the  tympanum 
are  common,  and  more  rare  is  destructive  suppuration  of  the  mastoid  cells. 
As  a  consequence  of  one  or  both  of  these,  it  almost  always  leaves  impaired 
hearing  or  total  deafness.  The  facial  nerve  may  become  involved  in  the 
disease  of  the  labyrinth,  producing  facial  palsy,  while  thrombosis  of  the 
lateral  sinuses  may  be  another  result  of  the  same  condition.  Meningitis 
and  death  may  be  later  consequences. 

Meningitis  may  arise  independently  of  otitis ;  in  fact,  scarlet  fever  is 
the  most  frequent  cause  of  meningitis,  after  cerebrospinal  fever,  tubercu- 
losis, and  syphilis. 

Various  other  nervous  affections  develop  as  rare  complications. 
Among  these  may  be  mentioned  chorea,  convulsions,  hemiplegia ;  and  Osier 
mentions  two  cases  of  progressive  paralysis  of  the  limbs  due  to  ascending 
spinal  paralysis  or  multiple  neuritis  and  subacute  ascending  paralysis  as 
coming  under  his  observation.  ' 

Of  thoracic  complications  endocarditis  and  pericarditis  not  infrequently 
develop  during  convalescence  from  scarlet  fever.  Endocarditis  is  nor 
always  discovered,  and  a  few  unexplained  chronic  valvular  defects  may  have 
originated  in  this  way  and  thus  be  accounted  for.     Pericarditis  is  less  likely 


I30  INFECTIOUS  DISEASES. 

to  be  overlooked.  Malignant  endocarditis  is  not  so  frequent  as  might  be 
expected  from  the  virulence  and  widespread  character  of  the  responsible 
germ.     Pleurisy  may  also  occur,  and  more  rarely  pneumonia. 

Diagnosis. —  The  diagnosis  of  scarlet  fever  is  easy  if  the  symptoms  are 
well  developed,  for  it  is  the  mild  cases  that  escape  detection.  In  the  absence 
of  the  eruption  in  a  distinctive  form,  it  is  sometimes  impossible  to  aver  the 
presence  of  the  disease.  If  there  be  a  doubt  as  to  the  eruption,  close  watch- 
ing will  sometimes  discover  signs  of  desquamation  in  the  shape  of  branny 
scales  beneath  the  underclothing  or  in  the  stockings.  In  the  absence  of  this 
the  question  must  occasionally  remain  forever  unsettled.  At  others 
the  unfortunate  development  of  a  nephritis  sets  the  matter  at  rest. 
If  there  has  been  exposure  to  the  contagion,  it  is  best  to  regard  every 
case  of  sore  throat  as  a  possible  case  of  scarlet  fever,  and  treat  it  accord- 
ingly. While  the  throat  affection  of  diphtheria  closely  resembles  at 
times  that  of  scarlet  fever,  where  this  symptom  is  at  all  conspicuous 
in  scarlet  fever  the  eruption  is  not  generally  wanting,  or  is,  at  least,  present 
to  such  extent  as  to  permit  recognition  of  the  disease.  The  fact  that 
the  one  or  the  other  of  the  two  diseases  is  prevailing  may  settle  the  ques- 
tion. It  must  be  admitted,  too,  that  the  two  aft'ections  may  succeed  each 
other,  and  even,  perhaps,  coexist,  both  events  being,  however,  exceed- 
ingly rare.  The  diagnosis  of  diphtheria  is  rendered  certain  by  obtaining  a 
successful  culture  of  the  Klebs-Loefifler  bacillus.  The  facilities  furnished 
at  the  present  day  by  the  municipal  laboratories  to  this  end  make  it  easy  to 
obtain  this  test. 

The  coryza  and  cough  in  measles  characterize  the  stage  of  invasion, 
while  the  eruption  occurs  later  than  in  scarlet  fever.  When  it  does  come 
it  is  very  different,  being  at  first,  at  least,  in  patches  bounded  by  irregular 
and  crescentic  outlines,  more  uneven  and  elevated,  and  is  conspicuous  in  the 
face,  where  the  scarlet  fever  eruption  is  faintest.  The  absence  of  sore 
throat  is  distinctive  of  measles,  though  its  occasional  presence  in  mild 
degree  must  be  admitted  in  the  latter  disease. 

Rofheln,  or  rubella,  has  an  eruption  more  like  that  of  scarlet  fever  than 
is  the  typical  measles  eruption,  but  it  is  not  usually  followed  by  desquama- 
tion. There  are  no  uncomfortable  throat  symptoms,  and  the  constitutional 
disturbance  is  much  less.  It  is  also  of  much  shorter  duration.  It  is  pos- 
sible, too,  that  these  affections  may  succeed  each  other,  as  is  true  of  real 
measles  and  scarlatina. 

Acute  exfoliating  dermatftis  resembles  scarlet  fever  during  the  eruption, 
but  the  exfoliation  in  the  former  is  not  like  that  of  scarlet  fever.  As  in 
erysipelas,  it  has  more  the  appearance  of  scales  and  crusts  before  it  is  thrown 
off,  and  there  is  more  apt  to  be  a  moist  surface  left  behind,  followed  by  a 
second  exfoliation.  There  are  no  throat  symptoms,  and  the  tongue  char- 
acteristic of  scarlet  fever  is  wanting.  The  eruption  caused  by  belladonna, 
both  on  the  skin  and  throat,  resembles  that  of  scarlet  fever,  but  it  is  of  short 
duration  and  without  constitutional  symptoms. 

Prognosis. — The  prognosis  of  scarlet  fever  varies  greatly  in  different 
epidemics.  There  are  epidemics  of  great  severity,  in  Avhich  the  mortality  is 
large,  and  certain  fulminating  cases  are  beyond  treatment.  Yet  most  physi- 
cians of  large  experience  in  surveying  their  work  will  recall  that  the  per- 
centage of  deaths  in  their  scarlet  fever  cases  has  not  been  large,  and  that  it 
has  been  greatest  among  the  very  young.  The  percentage  of  deaths  is  put 
down  at  from  5  to  10  per  cent,  in  mild  epidemics,  and  20  to  30  per  cent,  in 


SCARLET  FEVER.  131 

severe  ones.  The  mortality  is  greater  in  hospitals  than  in  private  practice. 
In  the  fulminating  cases  death  takes  place  before  a  chance  for  treatment  is 
offered ;  but  in  the  next  grade  of  cases,  characterized  by  high  temperature 
and  severe  throat  symptoms,  a  survival  of  five  or  six  days  generally  means 
recovery,  unless  the  supervening  complications  carry  off'  the  patient. 
Among  these,  nephritis  and  glandular  swelling  passing  over  to  abscess  are 
conspicuous,  but  even  of  those  so  afflicted  a  majority  recover. 

Treatment. — After  isolation  and  protection  in  bed  against  changes  of 
temperature,  the  treatment  of  scarlet  fever  is,  in  the  main,  a  symptomatic 
one,  associated  with  a  vigilant  nursing  that  will  guard  against  complications. 
The  patient  should  be  isolated,  if  possible  at  the  top  of  the  house,  and  all 
communication  with  those  of  the  family  who  have  not  had  the  disease  inter- 
dicted. The  temperature  of  the  room  should  be  uniform,  while  effective 
ventilation  should  be  secured.  The  diet  should  be  liquid  as  long  as  the  fever 
persists,  and  the  best  of  all  liquids  is  milk,  though  light  broths  are  allowable 
and  an  abundance  of  water. 

If  the  fever  is  high,  say  above  103°  F.  (39.4°  C),  cool  sponging  may  be 
resorted  to,  but  it  is  to  be  remembered  that  high  temperature  in  this  disease 
is  usually  of  short  duration  and  not  likely,  therefore,  to  produce  the  mischief 
it  may  cause  in  long-continued  febrile  diseases  like  typhoid  fever.  Very 
high  temperature,  such  as  105°  F.  (40.5''  C),  with  meningeal  symptoms,  may 
require  the  tub-bath  or  cold  pack,  but  the  temperature  of  the  tub-bath  should 
not  be  so  low  as  that  used  in  typhoid  fever.  It  is  safer  to  put  a  patient  in  a 
bath  at  90°  F.  (32.2°  C.)  and  gradually  reduce  the  temperature.  The  warm 
bath  allays  the  itching  of  the  skin,  but  this  is  as  well  accomplished  by  inunc- 
tion with  cold  cream  or  sweet  oil,  and  this  unguent  is  important  for  another 
purpose  as  soon  as  desquamation  takes  place,  to  keep  the  scales  from  flying 
about  and  spreading  the  contagium.  An  ice-cap  may  be  applied  to  the  head 
if  the  temperature  be  high,  and  especially,  if  there  are  head  symptomis. 
While  cool  applications  are  allowable  during  fever,  they  are  positively  con- 
tra-indicated in  its  absence,  as  they  may  act  in  the  development  of  complica- 
tions of  nephritis  and  otitis. 

Fever  is  best  controlled  by  these  measures,  but  it  is  desirable  to  give 
medicines  which  tend  to  the  samic  purpose,  especially  if  they  dispose  to  diure- 
sis as  well.  Hence,  the  officinal  solution  of  citrate  of  potassium  or  of  the 
acetate  of  ammonium  combined  with  the  spirit  of  nitric  ether,  or  a  couple  of 
drops  of  aconite  with  a  little  flavoring  syrup,  is  useful.  Constipation  should 
be  guarded  against. 

The  throat  symptoms  require  to  be  treated  according  to  the  degree  of 
their  severity.  Iron  and  potassium  chlorate  may  be  added  to  the  above 
mixture.  If  more  active  local  measures  are  needed,  the  throat  may  be 
sprayed  frequently  with  peroxid  of  hydrogen  (i  to  3)  or  with  a  weak 
bichlorid  of  mercury  solution  (i  to  5000)  or  carbolic  acid  spray  (i  to  60). 
The  first  is  the  best.  Cold  water  applications,  and  even  ice  to  the  exterior  of 
the  throat,  are  very  comforting  to  the  patient.  Very  efficient  and  soothing  is 
a  bandage  for  the  throat  with  pockets  opposite  to  the  tonsils,  into  which  pieces 
of  ice  are  placed  and  the  whole  covered  with  a  dry  towel ;  or  little  india- 
rubber  ice-bags  may  be  similarly  usedt  In  adynamic  cases  stimulants  and 
restorative  treatment  in  general  are  indicated.  Due  regard  should  be  had  to 
the  tendency  of  the  disease  in  severe  forms  to  produce  degeneration  of 
muscle  and  the  liability  of  the  heart  to  share  in  this. 

The  proper  treatment  of  the  throat  tends  to  save  the  ear,  but  should  the 


132  INFECTIOUS  DISEASES. 

middle  ear  become  involved,  the  membrane  should  be  watched  daily,  and  if 
the  tension  be  extreme,  perforation  practiced,  even  more  than  once,  if 
needed.  Too  little  attention  has  been  paid  to  this  complication,  and  if  cir- 
cumstances permit,  an  aural  surgeon  should  be  called  in. 

The  prophylaxis  against  nephritis  should  be  most  careful.  Whatever 
may  be  the  immediate  cause  of  the  renal  involvement,  it  is  certain  that  cold 
often  becomes  its  exciting  cause.  Hence,  the  patient  should  be  scrupulously 
guarded  against  drafts,  and,  tedious  as  it  may  sometimes  seem  to  mother 
and  child,  "  six  weeks  in  the  room  "  is  a  precaution  which  will  avert  many 
a  case  of  nephritis.  In  addition  to  the  milk  diet,  which  is  an  efficient  prophy- 
lactic against  nephritis,  I  am  in  the  habit  of  giving  a  moderate  dose  of  digi- 
talis, say  three  to  five  minims  (0.333  to  0.666  gm.),  tw^o  or  three  times  a  day, 
to  aid  in  maintaining  a  free  movement  of  the  blood  through  the  kidney. 

The  treatment  of  complicating  nephritis  is  the  treatment  of  that  afiPec- 
tion  under  other  circumstances,  and  the  reader  is  referred  to  the  appropriate 
section  on  it. 

Serum  Treatment. — An  important  addition  to  the  treatment  of  scarlet 
fever  has  been  made  by  Paul  Moser  *  who  suggested  the  use  of  antistrep- 
tococcic serum,  not  with  a  view  to  combating  the  disease  itself,  but  the 
complications  which  are  the  result,  not  of  the  scarlatinous,  but  of  the  strep- 
tococcic infection.  G.  A.  Charlton,t  of  Montreal,  and  W.  R.  Hubbert,  of 
Detroit,  have  reported  Moser's  treatment  with  gratifying  results.  Dr.  Charl- 
ton says  that  he  employed  it  in  15  cases,  the  majority  of  which  would,  in  his 
judgment,  under  ordinary  treatment,  have  termdnated  fatally,  or,  at  leasts 
have  suffered  from  lingering  and  troublesome  complications.  There  were 
thirteen  prompt  recoveries  and  two  deaths,  one  case  having  been  in  a  dying 
condition  and  the  other  complicated  by  pneumonia  wdien  they  came  under 
treatment.  The  frequency  of  mixed  infection  is  shown  by  Moser's  state- 
ment that  in  99  cases  of  scarlet  fever  streptococci  were  obtained  from  blood 
63  times.  The  injections  should  be  made  early  in  the  disease.  The  usual 
dose  is  20  c.  c,  but  in  those  cases  in  which  the  severity  of  the  attack  would 
seem  to  indicate  a  larger  quantity,  the  dose  may  be  repeated.  After  the 
injection  of  the  serum  a  rapid  subsidence  of  the  pyrexia  supervenes,  also  a 
corresponding  decrease  in  the  pulse  rate,  with  improvement  in  its  tension  and 
rhythm.  This  seemingly  harmless  treatment  demands  a  prompt  trial  for 
the  relief  of  the  dangers  of  this  serious  disease. 

"  DIPHTHERIA. 

Synonyms. — Membranous  Croup;  Angina  nmligna;  Angina  membranacea; 
Cynanche  contagiosa;  Diphtheria  faucium. 

Definition. —  Diphtheria  is  an  acute,  contagious,  inflammatory  disease, 
caused  by  inoculation  with  the  Klebs-Loeffler  bacillus,  and  especially  char- 
acterized by  the  formation  of  false  membrane  and  by  secondary  constitu- 
tional infection.  It  may  attack  any  mucous  membrane,  and  even  the  skin, 
but,  as  usually  employed,  the  term  means  diphtheritic  inflammation  of  the 
oral,  faucial,  nasal,  laryngeal,  tracheal,  or  bronchial  mucous  membrane. 
The  term  diphtheroid  is  applied  to  such  membranous  inflammations  as  are 
not  due  to  the  Klebs-Loeffler  bacillus. 

*  "Ueber  die  Behandlting  des  Schaiiachs  mit  einen  Scharlachsstreptococcenserum,"  "Wiener 
klinische  Wochenschrift,"  October  g,  igo2. 

t  "Montreal  Medical  Journal,"  October,  igoa. 


DIPHTHERIA.  133 

Historical. — Diphtheria  has  prevailed  endemically  and  epidemically  since  the 
days  of  Hippocrates  (406  B.  C).  D'Hauvanture,  an  East  Indian  physician  living  at 
the  time  of  Pythagoras  (probably  500  B.  C),  described  a  disease  bearing  strong  re- 
semblance to  diphtheria.  The  first  tracheotomy  is  said  to  have  been  performed  by 
Asclepiades,  who  lived  probably  more  than  a  century  before  Christ.  Diphtheria  was 
recognized  hj  Aret<£us  of  Cappadocia  (100  A.  D.),  who  has  left  the  oldest  clear  and 
concise  description  of  this  disease,  which  he  called  "  Syriac  ulcer."  Galen  also  de- 
scribed the  disease  in  the  latter  part  of  the  second  century.  Paralysis  of  the  soft  palate 
was  recognized  as  one  of  the  consequences  of  diphtheria  in  the  fourth  century  by 
Coelius  Aurelianus,  and  in  the  fifth  or  sixth  century  by  ^tius.  During  the  Middle 
Ages  no  accurate  descriptions  were  given,  although  important  epidemics  are  recorded 
that  no  doubt  were  diphtheria.  Ballonius,  of  Paris,  in  1659,  gives  the  earliest  re- 
corded/eference  to  the  pseudo-membrane  of  diphtheria. 

The  disease  appeared  in  this  country,  in  New  England,  in  the  seventeenth  century. 
The  earliest  American  literature  on  the  subject  appears  to  be  a  reference  to  a  number 
of  children  that  "died  from  bladders  in  the  windpipe,"  found  in  the  work  of  Sibley, 
of  New  England,  in  1659.  An  admirable  account  by  Samuel  Bond  was  published  in  the 
"  Transactions  of  the  American  Philosophical  Society,"  at  Philadelphia,  in  1770.  The 
disease  was  epidemic  for  the  first  time  in  New  York  city  in  1771.  Samuel  Bard,  in  a 
paper  written  at  that  time,  described  it  under  the  name  of  "Angina  suffocativa," 
known  in  common  parlance  as  "  sore  throat  distemper." 

We  owe  the  name  by  which  the  disease  is  now  generally  known  to  Bretonneau,  who 
applied  it  in  a  paper  read  before  the  French  Academy  of  Medicine  in  1821,  wherein 
he  declared,  also,  that  "  Angina  suffocativa,"  "  Cynanche  maligna,"  "putrid"  and 
other  forms  of  sore  throat  were  one  and  the  same  thing.* 

The  first  distinction  between  catarrhal,  croupous,  and  necrobiotic  types  of  laryn- 
geal diphtheria  was  made  by  Virchow  in  1847. 

Etiology. — The  specific  organism  which  by  common  consent  at  the 
present  day  is  the  cause  of  diphtheria  is  the  so-caUed  Klebs-Loeffler  bacillus, 
•a  bacillus,  non-motile,  slightly  bent,  with  rounded  ends,  2.5  to  3  microns  f 
in  length,  and  from  0.5  to  0.8  micron  in  thickness.  It  stains  readily 
by  Loeffler's  methylene  alkaline  blue  in  cover-glass  preparations  and 
in  sections.  Its  cultures  in  blood-serum  are  small,  round,  grayish-white 
colonies  that  are  characteristic.  These,  with  the  clubbed  ends  of  the 
bacillus  and  clear  spaces  in  its  interior,  giving  it  an  appearance  as  if 
broken,  suffice  for  its  recognition.  It  grows  on  all  the  usual  culture- 
media,  but  ceases  to  grow  at  a  temperature  below  20°  C.  (68°  F.). 
If  inoculation  cultures  are  practiced  on  the  lower  animals,  the  nature  of 
the  virus  is  declared  by  the  exudation,  the  bacilli,  the  swelling  of  adjacent 
h'mphatic  glands,  and  the  invariably  fatal  results  of  such  inoculation. 
The  bacillus  produces  in  its  growth  a  potent  toxic  substance,  or  tox- 
albumin,  the  absorption  of  which  from  the  seat  of  local  infection  causes 
the  general  symptoms  of  the  disease,  which  are  therefore  due  to  this  toxin 
and  not  to  an  invasion  of  the  blood  by  the  organism  producing  it.  The 
toxin  is  an  albuminous  substance,  but  its  composition  is  unknown.  When 
injected  into  animals,  it  produces  paralysis,  nephritis,  and  albuminuria. 
Roux  and  Yersin  were  the  first  to  show,  in  1888,  the  pathogenic  property  of 
cultures  that  had  been  filtered  through  porcelain. 

The  successful  implantation  of  the  bacillus  of  diphtheria  is,  however, 
dependent  on  various  circumstances.  Certain  temporary  states  of  the  indi- 
vidual doubtless  favor  it,  while  others  retard  it.  While  general  weakness 
or  feeble  resisting  power  may  be  one  of  these  conditions  it  is  likely  also  that 
purely  local  states,  such  as  uncleanness  of  the  mouth,  teeth,  and  fauces,  as 
well  as  chronic  inflammatory  conditions,  may  act  as  predisposing  causes. 
Enlarged  tonsils  and  nasopharyngeal  catarrh  predispose.  It  has  been  shown 
that  there  are  different  degrees  of  virulence  in  the  contagious  organism  itself. 

The  bacillus  of  diphtheria  is  associated  with  other  pathogenic  bacteria, 

*  The  history  of  diphtheria  is  one  of  the  most  interesting- chapters  in  medicine,  and  isrnore  fully 
■considered  in  the  classic  paper  of  Abraham  Jacobi  in  the  "System  of  Medicme  by  American 
Authors,"  Philadelphia,  1885. 

t  A  micron  is  a  xijVi)  millimeter,  or  TiSiiss  inch. 


134  INFECTIOUS  DISEASES. 

such  as  streptococcus  pyogenes  and  stapJiyloeocciis  albiis  and  aureus,  micro- 
coccus lanceolatus,  and  bacillus  coli  communis,  which  are  probably  responsi- 
ble for  suppurative  processes  often  associated,  as  well  as  for  certain  deep- 
seated  inflammatory  conditions  and  certain  forms  of  pseudo-diphtheria, 
which  often  complicate  the  disease  and  are  sometimes  mistaken  for  it.  The 
streptococcus  is  probably  the  most  active. 

It  was  formerly  believed  that  defective  drainage,  and  to  a  less  extent 
also  the  upturning  of  soil,  were  conditions  favoring  the  production  of  diph- 
theria, but  such  views  are  not  sustained  by  modern  studies.  On  the  other 
hand,  army  statistics  seem  to  show  that  foul  air  causes  simple  follicular  sore 
throat,  which  in  seasons  of  epidemics  makes  an  excellent  nidus  for  the 
growth  of  the  diphtheria  bacillus.  The  contagion  is  communicated,  as  a 
rule,  through  the  air  and  not  by  fluids  ingested,  although  epidemics  have 
been  traced  to  milk,  in  which  the  bacillus  multiplies.  In  the  vast  majority 
of  instances  the  source  of  the  contagion  is  the  throat  or  nose  of  another 
individual  affected,  whence  it  is  propelled  by  acts  of  coughing  or  expecto- 
ration. Hence  it  happens  that  the  physician  and  nurse  are  not  infrequently 
infected.  Perhaps  in  this  disease,  more  than  any  other,  excepting  typhus, 
are  doctors  and  nurses  the  victims  of  contagion.  Much  may,  however,  be 
done  to  secure  protection  by  caution  during  such  ministrations,  as  by  keep- 
ing the  mouth  closed  and  carefully  cleansing  the  hands  after  contact.  The 
practice  of  examining  throats  through  a  plate  of  clear  glass  is  a  further  pro- 
tection against  inoculation  of  the  examiner.  The  contagion  is  less  tenacious 
than  that  of  scarlet  fever,  but  is  still  highly  so,  having  been  found  to  live  on 
blood-serum  for  one  hundred  and  fifty-five  days ;  dried  on  silk  threads,  one 
hundred  and  seventy-two  days ;  and  in  gelatin,  for  eighteen  months.  It  has 
been  found  on  a  child's  toy  that  had  been  kept  in  a  dark  place  for  five  m.onths, 
and  in  the  hair  of  nurses.  It  resides  also  in  the  healthy  throats  of  immune 
persons,  in  simple  catarrhal  angina  without  membrane,  and  in  simple 
lacunar  tonsillitis ;  whence  it  is  plain  how  the  disease  may  arise  without 
apparent  cause  in  certain  sporadic  cases. 

It  is  believed  by  some  that  diphtheria  affects  the  lower  animals,  espe- 
cially the  cat,  and  may  be  transmitted  from  them  tO'  children.  It  is  said, 
also,  that  such  an  affection  attacks  calves  and  heifers,  and  is  from  them  com- 
municable to  man. 

The  disease  is  much  more  common  in  children  than  in  adults,  though  no 
age  is  exempt.  It  is  rare  in  very  young  children,  and  more  girls  are  attacked 
than  boys.  Abraham  Jacobi,  ^whose  experience  has  been  very  large,  has 
seen  only  three  cases  in  the  newly  born.  Several  cases  in  children  about 
six  months  old  have  come  under  my  notice.  Epidemics  vary  in  severity, 
and  winter  is  the  season  in  which  the  disease  is  most  prevalent.  While 
crowding  in  cities  favors  it,  it  is  often  widespread  and  virulent  in  the 
country. 

Morbid  Anatomy. — The  morbid  anatomy  of  diphtheria  consists,  on 
the  one  hand,  in  the  presence  of  the  false  membrane  and  of  the  more  ordi- 
nary phenomena  of  inflammation,  most  of  which  latter  disappear  after  death ; 
in  the  deep-seated  ulcerative  processes  that  sometimes  result ;  and  in  the 
results  of  the  complications  and  sequelae  to  be  considered  later.  The 
paralyses  do  not  furnish  palpable  morbid  products. 

Under  morbid  anatomy  the  constitution  of  the  false  membrane  is  suit- 
ably considered.  At  its  first  appearance  it  is  yellowish-white,  but  later  may 
assume  a  grayish  hue.     Whether  superimposed  on  a  mucous  membrane  or 


DIPHTHERIA. 


135 


set  into  it  as  in  a  frame,  depends  much  upon  the  character  of  the  epitheUum 
with  which  the  surface  is  normally  covered.  To  squamous  epithelium  the 
membrane  is  more  deeply  and  thoroughly  attached;  to  columnar  epithelium, 
such  as  lines  the  larynx  or  bronchi,  it  is  more  loosely  adherent;  but  in  both 
situations  it  tends  to  become  looser  with  the  lapse  of  time. 

The  membrane  itself  is  to-day  considered  a  product  of  what  is  known 
as  coagulation-necrosis,  our  knowledge  of  which  is  based  on  the  studies  of 
Wagner,  Weigert,  and  especially  of  Oertel.  The  mechanism  of  its  produc- 
tion is  as  follows :  The  diphtheritic  poison,  probably  admixed  with  fibrin 
from  the  blood,  infiltrates  the  wandered-out  leukocytes  and  the  epithelial 
cells  of  the  part,  especially  the  more  superficial,  causing  first  their  death  and 
then  a  hyaline  transformation,  and  simultaneously  coagulation.  The  result- 
ant, is  a  plate  of  necrotic  tissue  and  coagulated  fibrin.  Hence  the  word 
"  coagulation-necrosis."  The  membrane  presents,  also,  a  laminated 
structure,  probably  due  to  the  involvement  of  successive  layers  of  tissue  and 
wandering  cells.  If  forcibly  separated,  especially  when  recent,  it  is  apt 
to  leave  a  bleeding  surface,  on  which  new  membrane  is  generally  promptly 
deposited.  The  process  proceeds  from  without  inward,  and.  though  usually 
superficial,  may  extend  more  deeply,  invading  lymphatic  glands  and  adjacent 
tissue,  producing  foci  of  necrosis,  which  may  be  extensive.  Blood-vessels 
may  also  be  invaded,  especially  capillaries.  Bacilli  are  everywhere  present, 
but  they  do  not  directly  produce  the  mischief.  It  is  caused  by  the  toxin 
they  generate.     The  same  results  may  be  produced  experimentally. 

Inflammatory  membrane  of  this  kind  is  not  the  product  of  the  toxin  of 
diphtheria  only.  Any  intense  irritant  is  capable  of  producing  it.  Such  are 
corrosive  poisons  like  nitric  acid  and  ammonia,  although  the  necrotic 
product  is  here  partly  the  result  of  the  direct  action  of  the  agent  itself  on  the 
tissue.  Similar  in  its  effect  is  the  organism  of  scarlet  fever,  whatever  it 
may  be,  which  often  produces  a  pseudo-membranous  angina  difficult  to  dis- 
tinguish in  its  coarser  characters  from  that  of  diphtheria,  but  in  which  is  not, 
as  a  rule,  found  the  Klebs-Loefiler  bacillus.  In  this  membrane  have  been 
found  streptococci,  staphylococci,  and  diplococci.  The  microccus  of 
sputum-septicemia,  and  the  oidium  albicans  may  produce  such  false  mem- 
brane. The  streptococcus  is  probably  the  most  frequent  cause.  Such  false 
membranes  may  be  called  diphtheroid. 

Symptoms. — ^The  period  of  incubation  varies  from  two  days  to  twelve, 
seldom  exceeding  one  week. 

According  to  what  may  be  the  primary  or  principal  seat  of  invasion  we 
may  speak  of  the  pharyngeal,  laryngeal,  and  nasal  forms  of  diphtheria. 

In  the  pharyngeal  variety,  fever  and  sore  throat  appear  simultaneously, 
sometimes  preceded  by  a  chill  or  chilliness.  Both  increase  rapidly.  There 
may  be  aching  or  a  sense  of  weariness.  More  rarely  a  convulsion  ushers  in 
the  attack.  At  times  at  the  beginning,  at  others  on  the  second  or  third  day, 
an  erythematous  eruption  more  or  less  extensive  appears  on  the  skin  and 
may  lead  to  the  diagnosis  of  scarlet  fever.  Usually,  as  soon  as  attention  is 
called  to  the  throat,  white  patches  are  found  on  one  or  both  tonsils,  which 
spread  with  varying  rapidity.  It  is  this  spread  from  the  original  focus  by 
which  the  disease  is  especially  characterised  as  something  distinct  from  fol- 
licular tonsillitis.  Commonly,  the  extension  is  anterior,  over  the  anterior 
half-arches  to  the  uvula,  and  to  the  palate  or  up  into  the  nasal  passages,  or 
both.  With  the  invasion  of  the  uvula  and  palate,  commonly  reached  about 
the  fourth  dav,  the  diagnosis  becomes  certain,  even  without  the  bacteno- 


136  IXFECTIOUS  DISEASES. 

logical  examination.  ^lore  serious  is  the  extension  backward  into  the 
larynx,  producing  croup. 

The  temperature  rises  to  103'  or  104°  F.  (39.4^  or  40°  C.J,  but  is  not 
characterized  by  extreme  or  persistent  elevation.  The  pulse,  which  ranges 
from  120  to  140,  is  never  very  full  and  strong,  but  tends  early  to  smallness 
and  w^eakness.  Delirium  is  rarely  present.  Deglutition  becomes  more  and 
more  painful,  and  is  increased  by  external  glandular  szcclling,  involvmg  the 
Ivmphatic  and  salivary  glands,  although  this  swelling  is  not  invariably 
present.  As  the  nasal  passages  become  involved,  breathing  becomes  more 
and  more  obstructed,  until,  finally,  it  is  possible  through  the  mouth  onl}\ 
The  Eustachian  tube,  middle  ear,  and  even  the  antra  may  be  invaded.  So, 
also,  there  may  be  diphtheritic  conjunctivitis,  and  even  keratitis,  and,  though 
rarely  .indeed,  dermatitis.  Sh.ould  there  be,  however,  excoriations  or 
■wounds,  these  may  be  invaded  by  the  diphtheritic  pseudo-membrane.  Such 
false  membrane  may,  however,  be  due  to  the  streptococcus,  which  requires 
a  bacteriological  examination  for  its  recognition. 

As  intimated  under  the  head  of  morbid  anatomy,  the  ulcerative  process 
may  extend  much  more  deeply,  producing  destruction  of  tissue  and  even 
gangrene,  resulting,  as  in  scarlet  fever,  in  a  fatal  erosion  of  blood-vessels. 
Usually,  the  membrane  gradually  disappears  from  the  fauces  as  convales- 
cence is  established,  or  is  coughed  up  if  deeper  in  the  respiratory  passages. 
Sometimes,  on  the  other  hand,  it  remains  on  the  tonsils  for  some  days  after 
all  constitutional  disturbance  has  disappeared. 

If  the  inflammation  and  membrane  formation  extend  downward, 
laryngeal  cough  and  the  signs  of  laryngeal  obstruction  become  superadded 
— in  a  word,  the  sym.ptoms  of  pseudo-membranous  croup  supervene.  Or  if 
the  process  begins  in  the  larynx — primary  laryngeal  diphtheria — we  have 
croup  at  the  outset,  which  differs  from  spasmodic  croup  in  being  less  sudden 
in  its  onset.  The  seriousness  of  the  disease  is  greatly  aggravated  by  the  pos- 
sibility of  complete  obstruction  and  suffocation  unless  averted  by  operative 
interference.  Not  the  larynx  alone,  but  the  trachea  and  bronchi  may  be 
invaded  by  false  membrane,  ^\'hile  the  onset  is  slov."er  than  that  of  pharyn- 
geal diphtheria,  the  course  is  more  rapid.  To  the  phenomena  of  congestion 
and  membrane  formation  with  resulting  obstruction  are  added  those  of 
spasm,  which  brings  on  at  intervals  the  alarming  paroxysms  that  add  to  the 
terrors  of  this  horrible  aft'ection. 

Nasal  diphtheria,  in  which  the  nares  are  especially  invaded  by  the  false 
membrane,  requires  special  allusion.  It  is  more  apt  to  succeed  upon  acute 
nasal  catarrh  with  little  secretion  than  on  chronic  catarrh.  The  eft'ect  of  the 
invasion  is  to  increase  any  previous  discharge,  which  is  also  rendered  acrid 
and  irritating.  In  this  form  glandular  swelling  of  the  deep  faucial  glands  at 
the  angle  of  the  jaw  is  particularly  prone  to  occur,  probably  on  account  of 
the  richness  of  this  locality  in  lymphatics,  and  persists  as  induration,  while 
a  chronic  pharyngeal  and  nasal  catarrh  may  persist  a  long  time  after  disap- 
pearance of  the  membrane.  Jacobi,  who  also  especially  emphasized  the 
diagnostic  value  of  this  peculiar  glandular  swelling,  called  attention  to  the 
fact  that  this  form  of  catarrh  is  not  only  liable  to  be  a  focus  of  fresh  attacks, 
but  may  also  be  a  source  of  spread  to  others.  Suppuration  in  these  enlarged 
glands  rarely  occurs. 

In  three  to  five  days  after  the  onset,  if  the  case  is  one  of  ordinary 
severity,  the  phenomena  of  constitutional  infection  m.ake  their  appearance  in 
extreme  adynamia,  feebleness  of  pulse  and  heart-beat,  while  a  sense   of 


DIPHTHERIA. 


137 


intense  zveariness  is  complained  of.  From  this  time  a  new  period  of  danger 
begins,  the  danger  of  death  from  heart  failure.  This  is  a  distinct  and 
separate  cause  from  heart  paralysis  due  to  neuritis  of  cardiac  nerves.  At 
times  in  diphtheria,  as  in  scarlet  fever,  the  signs  of  constitutional  poisoning 
appear  at  the  outset,  and  the  patient  is  struck  down  as  by  a  blow,  but  this  is 
less  common  than  in  scarlet  fever.  In  such  cases  the  temperature  may  not 
rise,  and  may  even  be  subnormal.  Constitutional  poisoning  is  not  so  prone 
to  take  place  in  primary  laryngeal  croup  as  in  secondary  croup.  This  lesser 
tendency  to  constitutional  poisoning  together  with  the  more  gradual  onset, 
the  spasm,  the  slighter  contagion,  the  shorter  duration,  and  more  serious 
mortality,  constitute  the  chief  clinical  features  of  the  laryngeal  variety. 

Complications  and  Sequelae. — The  most  frequent  complication  of 
diphtheria  is  nephritis,  which  pursues  a  course  somewhat  similar  to  the 
nephritis  of  scarlet  fever,  but  is  less  frequently  accompanied  by  dropsy,  and 
generally  terminates  more  favorably.  On  the  other  hand,  albuminuria  is 
present  in  almost  every  severe  case.  There  may  be  the  other  signs  of 
nephritis — viz.,  blood-casts,  epithelial  casts,  scanty  and  even  suppressed 
urine.  Capillary  bronchitis  and  hronchopneumonia  are  serious  complica- 
tions, especially  if  the  results  of  inflammation  of  the  virulently  laden  mem- 
brane.    Endocarditis  and  arthritis  sometimes  occur. 

The  most  important  sequel  of  diphtheria  is  paralysis.  This  is  now  gen- 
erally regarded  as  the  result  of  a  toxic  neuritis.  It  may  come  on  as  early  as 
the  seventh  or  eighth  day,  or  as  late  as  the  second  and  third  w'eek,  when  con- 
valescence is  apparently  established.  It  is  quite  as  likely  to  follow  mild  cases 
as  severer  ones.  It  may  even  follow  wound-diphtheria.  It  most  frequently 
affects  the  palate,  producing  nasal  speech  and  permitting  the  passage  of 
fluids  into  the  posterior  nares  and  through  the  nose.  There  is  simultaneous 
anesthesia  of  the  pharyngeal  mucous  membrane,  destroying  reflex  excita- 
bility. Next  in  frequency  of  involvement  are  the  muscles  of  deglutition; 
more  rarely,  the  eye  muscles,  especially  those  of  accommodation,  which  is 
thereby  rendered  defective.  There  may  be  also  ptosis  and  strabismus,  or 
paralyses  of  the  distribution  of  the  facial  nerves.  Still  more  rarely  the  nerves 
of  the  lower  extremities  are  involved,  producing  paralysis,  partial  recovery 
from  which  leaves  lameness  that  may  last  through  life.  Generally,  however, 
recovery  takes  place  in  the  order  of  involvement,  usually  in  two  or  three 
weeks.  Sometimes  there  are  ataxic  synvptoms,  with  loss  of  the  tendon 
reflexes,  and  no  involvement  of  sensation. 

The  most  serious  of  the  local  palsies  is  that  of  the  heart,  due  to  neuritis 
of  the  cardiac  nerves.  In  this  there  may  be  bradycardia  and  tachycardia,  but 
the  most  frequent  result  is  the  sudden  cessation  of  the  heart's  action,  and 
this  tragic  termination  may  take  place  during  convalescence.  Indeed,  the 
event  is  more  frequent  during  convalescence,  and  is  often  as  late  as  the  sixth 
or  seventh  week.  At  other  times  the  phenomena  of  heart  failure  are  more 
slow  in  their  development.  The  pulse  may  become  weak  and  rapid,  or  more 
rarely  become  slow,  while  the  extremities  become  cold,  the  temperature  falls, 
and  there  supervene  in  a  few  hours  all  the  signs  of  collapse.  A  most  strik- 
ing instance  of  bradycardia  in  diphtheria  was  met  by  Baumgarten,  wherein, 
toward  the  close,  the  pulse  fell  to  25,  though  very  regular. 

Diagnosis. — The  only  two  conditions  with  which  diphtheria  is  liable  to 
be  confounded  are,  first,  the  different  forms  of  diphtheroid  faucitis,  includ- 
ing follicular  tonsillitis,  and,  the  faucitis  of  scarlet  fever.  The  difficulty  in 
deciding  between  the  former  condition  and  diphtheria  at  the  outset  is  some- 


138  INFECTIOUS  DISEASES. 

times  extremely  great,  and  time  or  the  bacteriological  investigation  may  alone 
settle  it.  The  primary  fever,  constitutional  disturbance,  and  dysphagia  are 
often  equally  as  great  in  follicular  tonsillitis  due  to  streptococcus  or  some  other 
cause  of  infection.  As  a  rule,  however,  the  follicular  exudate  remains 
limited  in  size — it  does  not  spread,  and  in  the  second  or  third  twenty-four 
hours  is  apt  to  drop  out,  leaving  a  clean-cut  ulcer  that  heals  rapidly,  while 
the  constitutional  symptoms  disappear  with  equal  rapidity.  In  the  form  of 
follicular  tonsillitis  attended  by  multiple  white  spots  on  the  tonsils  the  local 
resemblance  to  diphtheria  is  even  greater,  but  the  white  spots  remain  isolated, 
while  those  of  diphtheria  spread. 

Sometimes,  however,  the  mass  of  desquamated  epithelium,  fibrin,  and 
fungous  filaments,  which  make  up  the  contents  of  the  follicles  in  follicular 
angina  extend  outside  of  the  follicles  and  over  the  surface  of  the  tonsils. 
Then  it  becomes  more  difficult  to  decide.  It  does  not,  however,  pass  the 
boundary  of  the  tonsils.  The  follicular  fungi  are  said  to  stain  bluish-red 
with  an  iodopotassic  iodin  solution.  Further  certainty  is  secured  by  mak- 
ing cultures  from  the  membrane,  a  small  portion  being  removed  by  the 
sterilized  platinum  loop  or  cotton  swab,  and  planted  in  gelatinized  blood- 
serum.  In  the  course  of  twenty-four  hours  characteristic  colonies  will 
develop,  and  the  microscope  will  confirm  the  diagnosis. 

From  scarlet  fever,  diphtheria  is  usually  easily  distinguished  by  the 
absence  of  eruption,  although  this  aid  is  wanting  in  those  few  cases  of  scarlet 
fever  in  which  there  is  no  eruption,  and  in  those  of  diphtheria  where  there 
is  an  erythematous  redness.  Under  these  circumstances  the  distinction 
becomes  more  difficult  if  the  throat  symptoms  be  similar,  as  they  sometimes 
are.  The  prevalence  of  an  epidemic  of  one  or  the  other  disease  aids  in  the 
decision.  Later  on,  the  desquamation  that  takes  place  in  scarlet  fever,  but 
not  in  diphtheria,  also  settles  the  question. 

Diagnosis  is  sometimes  delayed  or  the  disease  entirely  overlooked  by 
concealment  of  the  membrane  in  localities  not  easily  open  to  examination,  as 
in  the  nasal  chambers.  Hence,  in  all  obscure  cases  these  should  be  examined. 
Indeed,  it  is  not  impossible  that  diphtheria  may  exist  without  membrane,  as 
evidenced  by  prompt  recovery  after  the  use  of  antitoxin  in  certain  obscure 
throat  cases  with  continued  adynamia  and  fever. 

The  larger  cities  in  the  United  States  now  offer,  through  their  health 
bureaus,  to  make  bacteriological  examinations  for  physicians  in  all  cases  of 
possible  diphtheria.  Outfits  ^are  left  at  stations.  They  consist  of  a  box 
containing  a  tube  of  blood-serum  and  another  containing  a  sterilized  swab. 
The  following  directions  are  issued  by  the  Philadelphia  Board  of  Health : 

"  Inoculations  should  be  made  by  rubbing  the  cotton  swab  attached  to 
the  end  of  the  wire  contained  in  the  test-tube  gently,  but  freely,  against  any 
visible  exudate,  and  then  drawing  it  over  the  surface  of  the  culture-medium 
without  breaking  the  surface  of  the  latter.  The  swab  should  then  be 
replaced  in  the  tube  from  which  it  was  taken,  and  both  tubes  be  replugged 
and  put  back  into  the  box.  Return  the  box  to  the  station  from  which  it  was 
obtained  as  soon  as  possible,  or  bring  it  directly  to  the  laboratory.  The  tubes 
will  be  collected  every  afternoon,  examined  the  following  morning,  and 
reports  will  be  mailed  by  one  o'clock  p.  m.  The  attending  physician  can 
obtain  information,  however,  by  telephoning  directly  to  the  laboratory  after 
that  hour." 

PrognosiSo — The  introduction  of  the  serum  treatment  for  diphtheria, 


DIPHTHERIA.  139 

which  may  be  dated  April,  1893,  when  the  first  30  cases  treated  by  Behring's 
normal  serum  w'ere  reported,*  marks  an  era  prior  and  subsequent  to  which 
the  prognosis  of  diphtheria  presents  very  different  aspects.  Even  prior  to 
1893,  while  the  prognosis  was  so  unfavorable  as  to  justify  a  wholesome  dread 
of  the  disease  the  world  over,  many  moderately  severe  and  most  mild  cases 
got  well.  Allowing  for  the  great  variation  in  the  percentage  of  fatal  cases 
in  different  epidemics,  and  especially  at  dift'erent  ages,  the  verv  careful  and 
reliable  studies  of  Professor  William  H.  \\'elch,t  of  Johns  Hopkins  Hospital, 
make  it  safe  to  put  such  mortality  at  a  minimum  of  40  per  cent.  Where  the 
larynx  was  involved,  it  amounted  to  almost  100  per  cent.  Of  the  remaining 
non-laryngeal  cases  probably  one-third  died.  Since  the  introduction  of  the 
antitoxin  treatment  the  studies  of  the  same  observer  (Welch)  show  a  reduc- 
tion in  mortality  of  between  50  and  60  per  cent.  This  improvement  affects 
all  classes  of  cases,  including  those  operated  upon  as  well.  As  near  as  it 
ma)'  be  possible  to  put  it,  the  mortality  since  the  introduction  of  antitoxin 
has  been  from  8  to  25  per  cent.  This  is  attested  from  many  sources.  For 
example,  in  the  report  of  collective  investigation  by  the  American  Pediatric 
Society  w^e  have  the  following:  "  Formerly,  2j  per  cent,  approximately  repre- 
sented the  recoveries,  while  now  27  per  cent,  represents  the  rate  of  mor- 
tality " ;  also  "  Formerly,  only  10  per  cent,  of  laryngeal  cases  did  not  require 
operation,  while  now  vrith  antitoxin  treatment  17  per  cent,  do  not  require 
this  procedure."  Finally,  the  most  remarkable  results  are  shown  in  the 
"  Bulletin  of  the  Departmicnt  of  Health,'"  city  of  Chicago,  for  February,  1899, 
which  reports  that  out  of  4071  cases  of  bacterially  verified  diphtheria,  3705 
recovered  and  276  died,  giving  a  mortality  rate  of  but  6.77  per  cent.  In 
New  York  City  for  1899  there  were  8240  cases  reported  with  a  mortality  of 
1087,  or  13  per  cent. 

During  thirteen  months  ending  October,  1896,  1972  patients  w^ere 
treated  with  antitoxin  at  the  Boston  City  Hospital,  and  of  this  number  post- 
diphtheritic paralysis  occurred  in  5.8  per  cent.,  which  percentage  is  smaller 
than  that  of  cases  not  treated  wdth  antitoxin.  A  fair  ratio  of  the  causes  of 
death  in  25  fatal  cases  prior  to  the  use  of  antitoxin  was  given  in  a  paper  by 
William  P.  ]\Iunn  ±  as  follows :  from  septic  intoxication  8,  laryngeal  stenosis 
7,  cardiac  paralysis  6,  hemorrhage  from  the  bow^els  i,  nephritis  i,  unknown 
2 ;  total  25.  Thus  the  chief  causes  of  death  are  adynamia,  laryngeal  obstruc- 
tion, heart  paralysis,  or  suft"ocation  from  paralysis  of  deglutition ;  more  rarely, 
nephritis  and  bronchopneumonia.  Hemorrhage  from  an  eroded  blood- 
vessel is  a  possible  cause  of  death.  ]\Iorse  analyzed  366  deaths  occurring  in 
1972  consecutive  cases  treated  since  1895  in  the  Boston  City  Hospital,  and 
"found  the  miortality  only  18.5  per  cent.  Seventy  of  these  cases  died  on  the 
day  of  admission,  and  38  on  the  following  day;  in  other  words,  100  were 
moribund  on  admission.  The  following  are  the  causes  of  death:  sepsis,  107; 
bronchopneumonia,  91;  cardiac  complications,  52:  exhaustion,  13;  tubercu- 
losis, i;  empyema,  i;  typhoid  fever,  i;  moribund  when  adiiiitted,  100; 
total.  366. 

Under  the  use  of  antitoxin  the  average  duration  of  an  ordinary  case  may 
be  put  down  at  about  five  days  and  of  a  very  bad"  case  ten  days.     It  is  impor- 


*The  prior  trials  of  immune  serum  in  the  treatment  of  human  diphtheria,  made  in  v.  Ber?- 
mann's  clinic  in  Berlin  in  iSgi.  and  by  Henoch  and  Huebnerin  Berlin  in  iSg2,  were  tentative  and  made 
^vith  weak  serum  and  in  insufficient  doses.  ,       ,  ■   ^• 

+  "  The  Treatment  of  Diphtheria  bv  Antitoxin."  Reprint  of  paper  read  before  the  Association 
of  American  Phvsicians,  Mav  .^i,  183=;.  and  published  in  the  "  Transactions  "  for  that  3-ear. 

t  "Diphtheria:  a  Clinical  Studv,"  "  Medical  News,"  Philadelphia,  JIarch  25,  1893. 


I40  IXFECTIOUS  DISEASES. 

tant  to  remember,  however,  that  actively  growing  bacilH  can  be  cultivated 
from  the  throat  of  cases  treated  early  with  antitoxin,  two  weeks  after  the 
membrane  has  disappeared. 

Treatment. — In  the  management  of  every  case  of  diphtheria  there  are 
two  principal  indications :  first,  to  combat  the  toxin  and  thereby  neutralize 
constitutional  infection;  second,  to  co-operate  with  this  object  by  suitable 
supporting  treatment. 

I.  To  combat  the  toxin  and  to  prevent  constitutional  infection.  This  is 
accomplished  (a)  by  serum  therapy,  that  is,  by  antitoxin;  {b)  by  local  anti- 
septic measures. 

(a)  Antitoxin. — The  treatment  of  diphtheria  by  antitoxin  should  be 
associated  with  the  general  and  local  treatment  to  be  described.  It  is  based 
on  the  facts  that  animals  may  be  made  immune  to  diphtheria  by  the  injection 
of  diphtheria  toxin,  and  that  the  serum  from  such  animals  is  antitoxic  to 
the  toxin  of  diphtheria.  This  was  shown  by  Behring  in  1891,  after  some 
preliminarv  experiments  had  been  made  by  Frankel  in  the  same  year.  In 
1892  Behring  and  Wernicke  employed  this  method  successfully  in  immu- 
nizing sheep,  and  also  ascertained  the  second  important  fact  mentioned 
that  blood-serum  from  an  immune  animal  could  be  used  with  success  m 
arresting  diphtheritic  infection  in  susceptible  animals.  To  this  was  added 
the  further  important  fact  that  a  smaller  amount  of  serum  is  required  to 
produce  innnunity  than  is  necessary  for  the  cure  of  an  animal  already  in- 
fected. If  the  injection  be  made  immediately  after  infection,  from  one 
and  a  half  to  tzvic'e  as  much  is  required;  eight  hours  after,  three  times  as 
much,  and  tzcenty-four  to  thirty-six  hours  after  infection  the  dose  required 
is  eight  times  the  immuni::ing  dose. 

In  obtaining  a  uniform  standard  of  strength  Behring  produced  first 
his  normal  therapeutic  serum,  which  when  injected  into  guinea-pigs,  in  the 
proportion  of  i  to  5000  of  body  weight,  saves  the  animal  from  the  fatal 
efifects  of  ten  times  the  minimum  dose  of  a  two-day-old  culture  fatal  to 
a  control  animal  not  thus  treated.  One  cubic  centimeter  of  this  nornml 
serum  he  calls  an  antitoxin  unit.  The  serum  prepared  by  this  method 
he  labeled  three  strengths :  Xo.  i  is  60  times  the  strength  of  the  normal 
serum :  Xo.  2,  100  times  as  strong ;  and  Xo.  3,  140  times  as  strong.  Behr- 
ing claims  that  10  c.  c.  of  his  Xo.  i  serum  is  sufficient  to  arrest  the 
progress  of  the  disease  in  a  child  under  ten  years,  and  effect  a  cure  if  given 
within  two  or  three  days  after  the  onset  of  the  attack.  This  older  method 
of  Behring  has  been  replaced-  by  other  modern  methods.* 

One  of  the  objections  to  the  serum  treatment  at  first  was  the  necessar 
rily  large  bulk  of  the  injection.  This  has,  however,  been  reduced  by  in- 
creasing the  strength  of  the  serum,  so  that  the  dose  now-  injected  gives  no 
more  discomfort  than  a  hypodermic  injection  of  morphin.  Reliable  prepa- 
rations are  now  made  in  this  country,  notably  by  the  ]\Iulford  Company, 
in  Philadelphia,  and  by  Parke,  Davis  &  Co.,  in  Detroit,  ]\Iich.,  and  in 
some  cities  by  the  official  authorities  under  direction  of  the  city  board  of 
health.  Two  strengths  of  serum  are  made  by  these  firms,  the  "  standard  " 
and  "  concentrated  "  serum.     The   latter  is  more  bulky,    1000  units  being 

*  The  method  of  the  Mulford  Co.  is  briefly  as  follo^\'s: 

Determine  by  trial  on  a  larure  number  of  gruinea  piars  the  smallest  sureU'  fatal  dose  of  toxin. 
Take  other  guinea  pigs  and  determine  the  smallest  fraction  of  a  cubic  centimeter  of  serum  that  will 
protect  the  guinea  pig  against  loo  times  the  fatal  dose  of  toxin.  This  fraction  of  a  cubic  centimeter 
■will  then  contain  one  unit,  and  there  are  in  one  cubic  centimeter  as  many  units  as  the  fraction  will 
go  into  the  ^vhole  cubic  centimeter.  Thus  if  ji^  of  i  c.c.  is  the  smallest  quantity  that  ■p'ill  protect, 
then  the  serum  has  250  units  per  c.c. 


DIPHTHERIA.  141 

represented  by  5  to  10  c.  c,  while  1000  units  of  the  concentrated  are  rep- 
resented by  2  c.  c. 

Technique  of  the  Aduiinisfraiion  of  Antitoxin. — Antitoxin  should 
be  administered  at  once  if  there  is  a  reasonable  probability  of  the  presence 
of  diphtheria,  without  waiting  for  the  bacteriological  diagnosis.  Antitoxin 
does  no  harm  where  the  disease  is  not  diphtheria,  and  delay  in  a  true  case 
may  be  fatal. 

The  begmning  dose  is  1000  units  for  ordinary  pharyngeal  diphtheria. 
The  "  concentrated  "  form  is  preferred  on  account  of  its  small  bulk,  which 
gives  no  more  pain  than  a  hypodermic  injection  of  morphin.  If,  for  any 
reason,  the  concentrated  form  cannot  be  procured,  the  "  standard  "  may  be 
used,  which  is  cheaper  and  just  as  efficacious,  but  gives  much  more  pain 
because  of  its  greater  bulk.     One  thousand  units  of  this  is  indicated  also. 

The  bulk  of  1000  units,  concentrated  form,  is  2  c.  c. ;  1000  units,  stan- 
dard form,  4  c.   c. 

A  large  hypodermic  syringe  is  used  for  the  administration.  The 
syringe  must  be  made  sterile  by  boiling  for  five  minutes  just  before  being 
used.  Always  test  the  syringe  with  water  before  filling  with  serum.  After 
the  administration  the  syringe  should  be  washed  out  with  clean  cold  water. 

The  injection  is  given  in  the  back  just  below  the  scapula  or  in  the 
flank  or  buttock,  the  skin  being  cleaned  with  soap  and  water  followed  by 
alcohol.  It  is  pinched  up  and  the  injection  made  immediately  beneath  it. 
If  the  smaller  bulk  be  used,  it  can  be  injected  quickly.  If  the  larger  bulk 
be  used,  inject  slowly  in  order  to  avoid  injury  to  the  underlying  tissues  by 
too  rapid  stretching.  Immediately  after  the  injection  there  is  an  occasional 
rise  of  temperature,  which  need  give  no  concern. 

In  favorable  cases,  after  twenty-four  hours  have  passed,  the  tempera- 
ture will  not  have  risen ;  the  pulse  will  be  slower ;  the  membrane  will  not 
have  spread ;  the  mucous  membrane  at  the  edge  of  the  exudation  will  be 
bright  red  in  color.  There  will  be  a  feeling  of  diminished  discomfort  and 
revival  of  spirits.  These  are  favorable  signs,  and  a  second  dose  need  not 
be  administered.  A  second  dose  is  administered  after  twenty-four  hours 
if  the  temperature  has  risen,  if  the  membrane  is  spreading,  and  if  the  gen- 
eral condition  of  the  patient  is  not  so  good  as  at  the  previous  injection. 
As  might  be  expected,  improvement  is  more  rapid  in  mild  cases. 

In  laryngeal  diphtheria  (membranous  croup)  the  initial  dose  is  2000 
units.  The  same  beginning  dose  is  also  given  in  bad  cases  of  the  pharyngeal 
or  nasal  form  that  have  lasted  some  days.  In  these  forms  a  second  dose 
should  also  be  administered,  if  there  is  not  improvement  in  twehe  hours. 

For  Immunisation. — For  producing  immunity  to  those  subject  to  infec- 
tion from  diphtheria,  immunizing  doses  should  be  administered.  These 
range  from  200  to  500  units,  according  to  the  age  of  the  person  to  be  pro- 
tected. Infants  and  very  young  children  are  easily  protected  by  the  smaller 
dose.  Adults,  especially  those  in  attendance  upon  the  sick,  should  receive 
the  larger  dose.  Persons  who  have  been  exposed  and  probably  are  already 
infected  should  receive  500  units.  The  throat  irritation  so  common  in  those 
who  are  attending  diphtheria  is  said  to  have  yielded  promptly  to  a  dose  of 
500  units.  If  suspicious  symptoms  have  appeared,  not  less  than  loco  units 
should  be  given. 

Immunization  cannot  be  too  strongly  insisted  upon.  The  protection 
afiforded  by  one  dose  will  last  for  at  least  three  or  four  weeks,  at  most 


142  IXFECTIOUS  DISEASES. 

not  more  than  eight  or  ten  weeks ;  within  which  time,  with  proper  means 
of  disinfection,  the  source  of  infection  should  be  ehminated. 

Behring  and  others  declare  that  the  diphtheria  antitoxin  has  no  injuri- 
ous effect  upon  animals  in  the  largest  dose  in  which  it  has  been  employed, 
and  that,  aside  from  its  antitoxic  powers,  its  properties  are  entirely  negative, 
as  far  as  human  beings  are  concerned.  This  is  essentially  true ;  yet  there  is 
evidence  to  the  contrary,  notably,  a  fatal  case  reported  in  the  "  Journal  of 
the  American  Aledical  Association,"'  April  4,  1896,  that  of  a  healthy  boy, 
five  years  old,  who  received  an  injection  of  Behring's  fresh  serum  as  a  proph- 
ylactic and  died  within  five  minutes :  also  another  case,  in  Berlin,  referred 
to  in  the  "  ^Medical  Xews,"  April  18,  1896,  page  443.  The  daughter  of 
a  friend  of  the  author  died  suddenly  in  Switzerland  after  receiving  an 
injection  of  antitoxin. 

{b)  Antiseptic  Local  Treatment  to  Prevent  Constitutional  Infection. — 
Germicides  and  disinfectants  are  best  applied,  when  possible,  by  the  spraying 
apparatus  at  intervals  of  an  hour,  or,  at  most,  every  two  hours.  If  the 
spraying  apparatus  cannot  be  used,  as  is  often  the  case  with  children,  a  swab 
of  cotton  wool  or  a  soft  sponge  may  be  employed.  The  most  satisfactory 
solution  in  my  hands  for  this  purpose  has  been  equal  parts  of  pcroxid  of 
hydrogen  and  Dohell's  solution.  The  spraying  should  be  continued  five 
minutes,  if  possible.  Bichlorid  of  mercury  is  also  a  suitable  solution  for 
spraying,  of  strengths  of  i  to  4000,  or  even,  in  extreme  cases,  i  to  2000. 
The  most  efficient  bichlorid  solution  is  that  with  tartaric  acid  i  to  500,*  with 
which  the  throat  ma}-  be  swabbed  once  in  six  hours,  or  even,  in  severe  cases, 
once  in  three.  The  objection  to  the  corrosive  sublimate  solution  is  its 
extremely  unpleasant  taste.  Carbolic  acid  may  also  be  used  in  2  1-2  to  3  per 
cent,  solution,  in  equal  parts  of  glycerin  and  water.  The  stronger  soltttions 
are  better  applied  by  a  swab  than  by  the  spray  apparatus,  while  with  chil- 
dren it  is  often  impossible  to  use  the  spray.  Solutions  of  albumin  solvents 
are  also  highly  recommended  by  some,  such  as  trypsin  and  papoid,  in  the 
strength  of  30  grains  to  i  ounce  (2  gm.  to  30  c.  c.)  or  lactic  acid  in  the  same 
proportion.  Salicylic  acid,  i  to  200:  thymol,  i  to  2000;  chlorin  li'ater; 
boric  acid  in  saturated  solution ;  saturated  solution  of  iodoform  in  ether  or 
5  per  cent,  suspended  in  equal  parts  of  glycerin  and  water,  are  all  useful 
local  applications.  Loefl^er's  toluol  solution  is  highly  praised.  It  is  com- 
posed of  menthol,  10  gm.  dissolved  in  enough  toluol  to  make  36  c.  c. ;  sesqui- 
chlorid  of  iron,  4  c.  c,  and  absolute  alcohol,  60  c.  c.  Still  another  solu- 
tion is  tincture  of  the  perchlorid  of  iron,  i  1-2  drams  (6  gm.)  ;  glycerin  and 
water,  each  i  ounce  (30  c.  c.)  ;  carbolic  acid,  15  to  20  minims  (i  to  1.3  c.  c). 
Where  there  is  laryngeal  diphtheria,  the  patient  should  breathe  an  atmos- 
phere saturated  with  the  vapor  of  slaking  lime.  The  comfort  derived  from 
such  breathing  is  often  very  great. 

\^^hile  iron  and  the  chlorate  of  potash  have  lost  some  of  their  former 
reputation,  they  are  still,  in  my  judgment,  indispensable,  and  I  always  comi- 
bine  them  with  any  other  treatment  I  may  care  to  use.  As  held  by  Jacobi, 
they  are,  at  least,  useful  in  the  conctirrent  pharyngitis  and  stomatitis  that 
invariably  attend  the  disease.  The  chlorate  of  potash  in  saturated  solution 
may  be  used  as  a  simple  mouth-wash.  Gargling  is  an  ineffectual  method 
of  reaching  the  throat,  and  has  given  place  to  spraying.     Still  it  may  be 

*A  tablet  consisting  of  3.75  grains  C0.25  gm.")  bichlorid  of  mercury  to  1Q.25  grains  (1.25  gm.)  of 
tartaric  acid,  dissolved  in  4  ounces  (120  c.c.)  of  water,  makes  a  i  to  500  solution- 


DIPHTHERIA.  143 

used  with  advantage  by  adults.  i\Iuch  depends  upon  a  certain  facility  in 
using  it,  which  may  be  cultivated. 

Jacobi  recommends  that  in  children  too  young  to  use  the  gargle  the 
local  effect  of  the  chlorate  of  potash  be  secured  by  frequent  administration 
of  small  doses.  Thus,  regarding  i  1-2  to  2  drams  (6  to  8  gm.)  as  a  suit- 
able twenty-four  hours'  quantity  for  an  adult,  30  grains  (2  gm.)  for  a  child 
two  or  three  years,  and  20  grains  (1.33  gm-)  for  a  baby  a  year  old,  he  pre- 
fers the  whole  amount  to  be  given  in  50  or  60  doses  rather  than  8  or  10, 
giving  the  weaker  dose  every  hour  or  half-hour,  or  every  fifteen  or  twenty 
minutes,  being  careful  to  give  no  water  immediately  afterward,  for  obvious 
reasons.  But  I  have  seen  the  thing  overdone :  I  have  seen  a  little  child, 
exhausted  for  want  of  sleep,  aroused  every  fifteen  minutes  for  the  adminis- 
tration of  medicine,  when  what  it  wanted  was  sleep  more  than  medicine. 

11.  The  second  object  includes  measures  which  also  have  for  their 
purpose,  first,  checking  the  spread  of  the  membrane,  its  loosening  and 
solution,  and,  second,  maintaining  the  strength  of  the  patient  against  the 
depressing  action  of  the  absorbed  toxin,  (a)  The  former  is  accomplished 
by  the  preparations  of  mercury.  Of  these,  I  prefer  the  bichlorid  of  mer- 
cury in  doses  of  1.48  grain  (0.0027  gm.)  to  1.12  grain  (0.005  S'l'^-)  for  an 
adult,  in  conjunction  with  tincture  of  the  chlorid  of  iron  and  the  chlorate 
of  potassium,  every  two  hours,  taken  freely  diluted.  The  former  dose  makes 
1.4  grain  (0.0162  gm.)  of  the  bichlorid  in  twenty-four  hours,  but  as  much 
as  one-half  (0.032  gm.)  may  be  given  in  that  period.  These  doses  are  given 
to  adults,  and  they  need  not  be  much  reduced  for  children.  There  need  be 
little  fear  of  poisonous  effects  from  the  bichlorid,  as  bowel  irritation,  pain, 
and  loose  movements  give  a  warning  before  any  more  serious  consequences 
supervene.  When  these  symptoms  appear,  the  bichlorid  should  be  dis- 
continued or  the  dose  decidedly  diminished.  The  calomel  treatment  is 
preferred  by  some.  The  drug  is  given  in  hourly  doses  of  1.6  or  1.8  grain 
(0.016  or  0.008  gm.)  until  spawn-like  stools  are  produced.  Both  remedies 
are  supposed  to  have  the  effect  of  loosening  the  membrane. 

(h)  Iron  is  also  useful  in  supporting  the  strength  of  the  patient.  For 
this  purpose  quinin  is  indispensable  in  doses  of  10  to  24  grains  (0.65  to  1.5 
gm.)  in  the  twenty-four  hours.  Stimulating,  nourishing,  and  easily  assimi- 
lated food  is  necessary.  Milk  is  to  be  preferred  to  all  else,  fortified 
with  full  doses  of  whisky  or  brandy,  2  drams  to  i  ounce  (8  to  30  c.  c), 
every  two  hours,  being  required  in  all  cases  of  severity,  and  propor- 
tional doses  for  children.  The  milk  may,  of  course,  be  alternated  with 
nutritious  animal  broths  or  beef-peptonoids.  In  extreme  cases  of  difficult 
deglutition  nutrient  enemas  may  be  useful,  but  nourishment  by  the  stomach- 
tube,  if  possible,  is  more  efficient.  For  enemas,  peptonized  milk  is  the 
most  suitable.  To  this  brandy  or  whisky  may  be  added,  if  needed.  Rectal 
alimentation  has  som.etimes  to  be  discontinued  because  the  enema  is  made 
too  large  and  is  too  frequently  administered.  Once  in  four  hours  is  often 
enough,  and  4  ounces  at  a  time  are  as  much  as  the  rectum  will  commonly 
bear.     Smaller  quantities  should  be  used  for  children. 

Treatment  Demanded  by  Special  Forms. — Where  laryngeal  obstruction 
is  imminent,  intubation  or  tracheotomy ,  should  be  performed.  Lives  have 
been  saved  by  both  of  these  operations.  Intubation  may  precede  tracheotomy, 
as  its  use  does  not  preclude  the  more  serious  operation  at  a  later  date,  if  the 
obstruction  increases.  Such  cases  should  breathe  an  atmosphere  charged 
with  the  vapor  of  slaking  lime. 


144  INFECTIOUS  DISEASES. 

In  the  nasal  variety  of  diplitJicria  special  means  must  be  employed  to 
disinfect  and  cleanse  the  nasal  passages.  The  solutions  recommended  to 
spray  the  throat  may  be  used  for  such  cleansing.  Gentle  injections 
into  the  nostril  may  be  more  efficient  than  the  spray,  precaution  being 
taken  to  keep  the  mouth  open,  by  which  the  entrance  of  fluid  into  the 
Eustachian  tube  is  guarded  against.  The  injections  should  be  continued 
until  the  fluid  has  free  exit  either  by  the  other  nostril  or  th:  ough  the 
mouth.  Jacobi  has  seen  cases  where  he  has  been  compelled  to  bore  a  pas- 
sage with  a  silver  probe  through  a  mass  of  membrane  filling  the  nasal  cavi- 
ties, and  then  apply  carbolic  acid  to  remove  the  denser  portions  before 
injecting.  He  recommends  that  when  about  to  bring  the  injection  to 
a  close,  the  nasal  cavities  should  be  pressed  together  for  an  instant  with  the 
fingers,  as  in  this  way  the  fluid  is  forced  backward  into  the  pharynx  and 
swallowed  or  ejected  through  the  mouth,  thus  washing  both  at  the  same 
time. 

The  Treatment  of  Complications  and  Sequelae. — Complications  are 
treated  as  the  same  conditions  under  other  circumstances,  and  the  paralysis 
so  frequently  succeeding  upon  diphtheria  alone  requires  special  allusion. 
The  prognosis  is,  on  the  whole,  good,  and  time,  under  favorable  circum- 
stances, mainly  effects  the  cure,  and  during  this  the  most  important  meas- 
ures are  those  that  save  the  patient  from  accident.  Thus  if  there  is 
paralysis  of  the  muscles  of  deglutition,  liquid  food  only  should  be  used,  and 
it  may  be  necessary  to  nourish  for  a  time  by  the  rectum  or  by  means  of  the 
stomach-tube.  So,'  too,  undue  exertion  should  be  avoided.  Electricity  and 
tonics,  especially  strychnin,  are  indicated.  The  former  is  applied  to  wast- 
ing muscles,  and  may  be  advantageously  associated  with  massage.  Strych- 
nin should  be  given  in  full  doses,  ascending  gradually  to  1-20  grain  (0.003 
gm.)  three  and  four  times  a  day,  with  appropriate  reduction  for  children. 
Iron  and  quinin  should  also  be  given. 

The  electrical  treatment  for  paralysis  of  the  pharyngeal  muscles  is 
applied  in  the  following  manner :  An  electrode  is  placed  at  the  back  of  the 
neck  and  a  very  small  electrode  is  touched  to  the  velum  palati,  and  a  rapidly 
interrupted  faradic  current  of  moderate  strength  applied.  Galvanism  may 
be  similarly  used.  A  specially  constructed  electrode  is  also  applied  to  the 
throat. 

Prophylaxis  Against  Diphtheria. — Most  important  are  the  precau- 
tions necessary  to  prevent  a  spread  of  the  disease.  To  this  end  the  patient 
should  be  isolated,  all  carpe,ts  and  unnecessary  furniture  and  hangings 
should  be  removed  from  the  room,  and  all  utensils  used  in  treatment  should 
be  kept  apart  and  separate  for  the  patient's  own  use.  Spoons  and  tongue 
depressors  should  be  kept  in  carbolic  acid  solution,  or,  better,  thrown  into 
water  kept  boiling.  All  bed  linen  and  clothing  removed  from  the  patient 
should  be  boiled,  being  immersed  in  water  before  removal  from  the  room. 
Mattresses,  pillows,  and  woolen  garments  too  good  to  be  destroyed  should  be 
exposed  to  superheated  steam  in  establishments  provided  for  the  purpose  in 
the  cities ;  or  they  may  be  disinfected  at  the  same  time  with  the  apartment  oc- 
cupied by  the  patient.  They  should  be  opened  and  suspended  in  this  apart- 
ment, of  which  all  the  doors  and  windows  must  be  closed  tightly  and  the 
room  fumigated  with  formaldehyd  gas,  of  2  to  4  per  cent,  volume  strength, 
for  not  less  than  twelve  hours.  Suitable  lamps  are  provided  for  this  pur- 
pose. If  formaldehyd  is  not  available,  sulphur  may  be  used.  The  sulphur, 
in  the  amount  of  2  pounds  to  every  10  feet  (2  kilos  to  every  2.5  meters) 


SMALLPOX. 


H5 


square,  should  be  placed  in  iron  pans  and  these  supported  by  bricks  in 
washtubs  containing  a  little  water.  The  sulphur  is  then  ignited  by  glowing 
coals  or  by  burning  alcohol.  The  room  should  be  kept  closed  for  twenty- 
four  hours.  After  this  fumigation  the  articles  of  clothing  should  be  hung 
out  in  the  open  air  for  several  hours,  and  the  doors  and  woodwork  washed 
well  with  a  solution  of  corrosive  sublimate,  i  to  looo,  while  the  walls 
should  be  wiped  down  with  a  similar  solution. 

Finally,  physicians  and  nurses  in  attendance  on  the  patient  should 
carefully  wash  their  hands  before  leaving  the  room,  first  in  soap  and  water, 
and  finally  rinse  them  in  corrosive  sublimate  solution,  i  to  lOOO.  Nurses 
in  constant  attendance  should  wear  an  overdress  of  washable  material, 
vvhich  should  be  slipped  off  before  leaving  the  room,  and  the  physician 
while  in  the  room  should  be  similarl}'  covered  and  should  treat  his  hands 
as  described. 

As  the  bacillus  has  been  found  to  multiply  in  milk,  it  is  safer  to  use 
sterilized  milk  during  an  epidemic. 

The  convalescent  patient  should  also  be  kept  isolated  until  thorougiily 
disinfected.  This  is  accompHshed  by  giving  first  a  hot  water  and  soap 
bath,  then  washing  the  body  of  the  patient  with  a  solution  of  bichlorid  of 
mercurv,  i  to  2000,  or  2  per  cent,  solution  of  carbolic  acid,  or,  what  is  m.ore 
agreeable,  25  to  50  per  cent,  alcohol.  This  should  be  done  two  or  three 
days  in  succession.  The  hair  should  be  cut  or  similarly  washed  with  these 
solutions.  The  regulations  of  the  Board  of  Health  of  Philadelphia  do  not 
permit  the  children  of  a  family  In  which  diphtheria  has  been  present  to 
return  to  school  until  thirty  days  after  the  Board's  physician  has  declared 
the  patient's  recovery 


SMALLPOX. 

SvxoxYM.— Fan'o/cr. 

Definition. —  Smallpox  is  an  acute  contagious  disease  especially  char- 
acterized by  an  eruption  which  passes  through  the  successive  stages  of  pap- 
ule, vesicle,  pustule,  desiccation,  and  desquamation. 

Historical. — Smallpox  Avas  first  accurately  described  by  Rhazes.  an  Arabian  pby- 
sician,  in  the  nintli  century  of  the  Christian  era,  anddistin.c:uishedby  him  from  measles; 
but  it  is  believed  to  be  the  same  as  t\\e pesf a  mag-7ta  descriheAhy  Galen  (A.  D.  130-200.) 
Itprevailed  also  in  China  many  centuries  before  the  Christian  era.  It  isknown  tohave 
prevailed  in  the  sixth  centurv  and  again  during  the  Crusades.  The  disease  is  believed 
tohave  been  introduced  into  America  by  the  Spaniards,  having  first  appeared  most 
fatally  in  :Mexicto  in  1520.  and  in  Massachusetts  in  1633.  I^i  evidence  of  the  virulence 
of  the  disease  it  mav  be  mentioned  that  in  Iceland  in  1707,  18.000  perished  out  of  a 
population  of  50.000'.  In  Mexico  three  and  a  half  millions  v/ere  suddenly  smitten. 
Svdenham's  classic  description  Avas  made  in  the  seventeenth  century. 

The  imraunitv  secured  bv  a  previous  attack  suggested  to  Lady  Mary  Wortley 
Montagu  the  idea  of  inoculation  for  the  purpose  of  protection,  the  practice  of  which 
was  introduced  in  England  in  171S  Long  before  this  the  Brahmins  had  discovered 
that  the  inoculation  of  smallpox  produced  the  true  disease  in  a  milder  form,  so  that 
the  maladv  proved  fatal  onlv  to  i  in  ico,  or  under  most  favorable  circumstances,  i  m 
300.  It  was.  moreover,  practiced  for  centuries  in  China  and  other  Asiatic  countries. 
The  effect  of  inoculation  was.  however,  to  spread  the  disease,  though  in  a  milder- 
form, and  it  was  not  until  the  discovery  of  vaccination  by  Jenner  in  1798,  that  control 
over  the  disease  was  obtained. 

In  I7g6  Juncker  wrote  that  400.000  lives  were  Tost  vearlv  in  Europe  by  smallpox. 
In  1803  King  Frederick  William  of  Prussia,  in  an  edict,  stated  that  40.000  die  annually 
in  Prussia  of  the  disease.     As  already  mentioned,  inoculation  of  smallpox  was  mtro- 


146  INFECTIOUS  DISEASES. 

duced.  into  England,  in  171S,  by  Lady  Mary  AVortley  Montagu,  the  wife  of  the  British 
Ambassador  to  Turkey  ;  into  Germany  in  1721.  but  was  not  popular  until  1740.  The 
peasantry  in  various  parts  of  the  world,  particularly  in  England,  believed  that  sores  on 
the  hands  of  persons  who  milked  cows  affected  with  cowpox  conferred  immunity  from 
the  disease.  It  is  said  that  a  Dorsetshire  English  farmer  successfully  vaccinated  his 
wife  and  two  sons  as  early  as  1774  from  a  cowpock  on  himself.  In  1791  Plett,  a  Holstein 
schoolmaster,  vaccinated  three  children,  in  one  case  on  the  finger-tips,  which  caused  in- 
flammation of  the  arm  and  deterred  him  from  repeating  the  expveriment.  These  three 
children  escaped  the  epidemic  in  1794.  Edward  Jeuner,  while  a  student,  learned  of  the 
traditions  on  this  subject  and  mentioned  them  to  his  preceptor,  John  Hunter.  He 
settled  the  question,  Maj'  14,  1796,  when  he  vaccinated  a  boy,  James  Phipjis,  with  matter 
from  akinepock  on  the  hand  of  a  dairymaid.  Sarah  Nelmes,  and  on  July  ist  intro- 
duced into  this  boy  pus  from  a  smallpox  pustule  without  effect.  Two  years  later — 
Tune,  1798 — he  published  "An  Inquiry  into  the  Causes  and  Effects  of  the  Variolae 
Vaccinae,"  illustrated  by  four  plates,  and  within  a  year  or  two  vaccination  became 
general  over  the  continent  of  Europe. 

Vaccination  was  introduced  into  the  United  States  July  S,  1800,  b}'  Benjamin 
Waterhouse,  Professor  ofPhysick  at  Harvard  Universitj',  who  vaccinated  his  own 
children,  and  into  Philadelphia  b\'  John  Redman  Coxe,  who  vaccinated  his  oldest 
child  about  the  same  time,  and  then  tested  the  experiment  by  exposing  him  to  the 
influence  of  smallpox.  The  reliance  on  the  protective  power  of  vaccination  in 
America  was  strengthened  materially  by  this  bold  act.  President  Jefferson  was 
instrumental  in  introducing  vaccination  in  Southern  United  States. 

Once  introduced,  the  practice  spread  rapidly,  but  not  without  some  opposition, 
some  of  which  prevails  even  at  the  present  da}^,  although  it  is  as  certain  as  an}"- 
demonstrable  fact  that  thousands  of  lives  have  been  saved  by  vaccination,  and  that 
a  thorough  and  continuous  practice  of  the  operation  would,  sooner  or  later,  blot  out 
smallpox  from  the  face  of  the  earth. 

Publications  in  connection  with  the  Jenuer  Centenary  in  iSgS  have  added  greatly 
to  the  literature  on  vaccination,  especially  the  centenary  number  of  the  "  British  ^ledi- 
cal  Journal."  See  the  Report  of  the  Royal  Commission  on  Vaccination,  the  compre- 
hensive article  by  T.  D.  Ackland  and  Copeman  in  "  Allbutt's  System,"  and  the  mono- 
graph by  Cory.  Also  "  Facts  about  Smallpox  and  Vaccination,"  leaflets  issued  bj- 
the  British  Medical  Association  ("  British  Medical  Journal,"  189S,  vol.  i.  p.  632).  See, 
also.  Moore's  "  History  of  Smallpox,"  London,  1S15. 

It  is  impossible  to  follow  the  history  of  numerous  epidemics  of  smallpox  which 
have  prevailed  from  time  to  time,  even  since  the  ravages  of  the  disease  have  been  ar- 
rested by  the  agencj^  of  vaccination.  The  latest  epidemic  characterized  on  the  one 
hand  by  its  widespread  distribution,  and  its  comparative  mildness  on  the  other,  is  that 
which  commenced  in  the  L^nited  States,  at  the  close  of  the  Spanish-American  Avar  in 
1899,  spread  over  almost  every  State  of  the  L'nion,  and  is  not,  at  this  writing,  com- 
pletely arrested  Soon  after  the  period  above  mentioned  there  appeared  in  the 
Southern  States  and  elsewhere  a  disease  which  did  not  accord  with  the  classic  descrip- 
tions of  smallpox,  and  was  variously  regarded  as  chicken-pox,  smallpox,  impetigo 
contagiosa,  Cuban  itch,  and  as  an  hitherto  undescribed  dermatosis. 

In  manj^  cases  the  mildness  of  the  illness  was  such  that  the  patient  could  pursue 
his  usual  occupation.  As  a  consequence  of  failure  to  recognize  the  true  nature  of 
the  disease,  it  spread  widely.  Thus,  there  were  reported  in  the  L'nited  States  to  the 
Surgeon  General,  Public  Health,  and  Marine  Hospital  Services  in 

YE.\R 
1898, 
1899, 
1900, 
I9OI, 
1902, 

Total 135,668  4514 

The  mildness  of  the  epidemic  is  shown  by  the   fact   that  the    mortality  for  this 
period,  and  enormous  number  of  cases,  was  only  3.3  per  cent. 
In  the  city  of  Philadelphia  there  were  in  the 

YEAR  CASES  DEATHS 

1900,    ......     27  O 

I9OT, II59  156 

1902,     ......     1342  231 

Etiology. — The  contagmm  of  smallpox,  probably  the  most  unfailing 
of  all  the  contagia  in  its  effect  tipon  the  unprotected  victim,  has  not  yet 
been  isolated.  It  is  conveyed  in  the  secretions  and  exhalations  of  the  body, 
including  those  of  the  lungs.     The  pus  of  the  pustule  is  its  most  fertile 


CASES 

DEATHS 

2,633 

27 

10,453 

458 

20.362 

819 

48,206 

II27 

54,014 

2083 

SMALLPOX. 


147 


source,  and  the  dust  derived  from  the  dried  pus  scales  is  the  more  usual 
medium  of  its  distribution.  No  other  pathogenic  organisms  than  those 
of  suppuration  have  been  isolated  from  the  disease.  The  degree  of  mild- 
ness or  severity  of  a  case  does  not  influence  that  of  another  caused  by  it; 
the  severest  cases  being  at  times  followed  by  the  mildest,  and  vice 
versa.  The  contagium  is  very  tenacious,  and  may  be  dormant  for  months 
in  clothing  or  furniture  or  hangings.  No  age  nor  sex  nor  race  is  exempt, 
but  the  number  of  cases  in  successive  decades  diminishes  because  of  the 
immunity  furnished  by  a  previous  attack.  The  foetus  in  utcro  may  acquire 
the  disease  from  the  mother,  and  the  child  may  be  born  with  the  eruption 
on  it.  Certain  individuals  are  invulnerable  even  though  unprotected  by 
vaccination,  while  the  mortality  in  aboriginal  races  is  very  great.  Many 
alleged  immunes  respond  to  a  proper  vaccination. 

Some  difference  of  opinion  exists  as  to  the  period  at  which  smallpox 
is  contagious.  Welsh  and  Schamberg,  in  their  forthcoming  book  on  Con- 
tagious Diseases,  make  the  following  statement,  which  may  be  considered 
as   embodying  the   most   recent   views : 

"  Smallpox  is  undoubtedly  infectious  in  all  stages  characterized  by 
symptoms.  It  is  alleged  by  some  that  the  disease  is  even  infectious  during 
the  period  of  incubation,  but  we  think  there  is  very  little  reason  to  believe 
that  such  is  the  case. 

"  The  disease  is  least  infectious  during  the  initial  stage,  and  most 
highly  so  during  the  suppurative  and  early  period  of  the  desiccative  stages." 

Morbid  Anatomy. — The  essential  morbid  anatomy  of  smallpox  is  that 
of  the  eruption  as  represented  by  its  various  stages  and  modifications,  in- 
cluding hemorrhagic  infiltration.  To  the  anatomy  of  the  eruption  is  added 
that  of  the  complications  that  may  occur. 


.  15, — Temperature  Chart  of  Smallpox — {Eu'/ikorsf). 


The  histology  of  the  pustule  shows  that  it  starts  in  the  rete  mucosum, 
close  to  the  true  skin.  The  center  is  a  focus  of  coagulation  necrosis,  and- 
about  it  the  reticular  spaces  are  filled  with  serum,  leukocytes,  and  fibrin 
filaments.  As  long  as  the  process  does  not  extend  deeper,  healing  takes 
place  without  a  scar.  In  the  more  severe  cases  the  papillae  of  the  true  skin 
are  invaded  to  various  depths  and  destroyed  by  the  infiltration,  producing 
a  loss  of  tissue  constituting  the  pit.  Among  other  morbid  phenomena  may 
be  mentioned  a  hardness  and  firmness  of  the  spleen.  Cloudy  swelling  of 
the  secreting  cells  of  the  liver  and  kidney  occur,  as  in  other  fevers  with 
high  temperature.     True  nephritis  is  rarely  present. 


J 48  INFECTIOUS  DISEASES. 

Symptoms. — After  a  period  of  incubation  of  from  seven  to  twelve  clays, 
and  sometimes  longer,  the  victim  is  seized  with  violent  muscular  pain, 
especiallv  in  the  back.  Often  a  cliill  or  chills  usher  in  the  disease,  and  in 
children  a  convulsion  may  be  the  initial  symptom.  Intense  headache  is  also 
present.  Fever  sets  in  rapidly  and  the  temperature  reaches  103°  to  104"^ 
F.  (39.4°  to  40°  C.)  the  first  day.  The  pidse  is  rapid,  hard,  and  strong  at 
this  stage.     Delirium  may  be  present  and  is  sometimes  very  violent. 

About  the  second  day  the  initial  rashes  make  their  appearance.  These 
have  been  especially  studied  by  Theodore  Simon, '^'  Knecht,  f  Scheby- 
Busch,  J:  and  William  Osier,  §  although  they  are  mentioned  by  some  of  the 
older  authors,  including  Sydenham,  Wood,  Watson,  Niemeyer,  Trousseau, 
Marson,  Munro,  and  others. 

Thev  include  a  diffuse  scarlatinous  rash  and  a  macular  or  measly  form, 
dark  red  in  color  and  occupying  a  variable  extent  of  surface.  Either  ma)- 
be  associated  with  petechial  ecchymoses.  Sometimes  they  are  general,  but 
as  a  rule  they  are  limited  to  the  abdomen,  the  inner  surface  of  the  thighs, 
or  the  lateral  region  of  the  thorax  and  axilla.  Among  Osier's  cases  was 
one  of  a  true  urticarial  prodrome.  While  it  is  to  be  remembered  that  the 
coexistence  of  smallpox  and  measles  and  of  smallpox  and  scarlet  fever  is 
possible,  it  is  more  than  likely  that  the  eruptions  on  which  the  diagnosis 
was  based  were  really  the  initial  rashes  of  uncomplicated  smallpox. 

On  the  fourth  day  of  the  disease,  the  distinctive  eruption  makes  its 
appearance  in  the  shape  of  snmll  red  spots,  first  on  the  forehead  and 
wrists,  whence  it  extends  rapidly  over  the  face  and  extremities,  becom- 
ing quite  general  in  the  first  twenty-four  hours.  At  this  stage  the 
eruption  is  not  unlike  measles,  but  in  another  twenty-four  hours  it  is 
decidedly  different.  The  papules  have  acquired  shot-like  hardness.  With 
the  appearance  of  the  eruption  the  fever  falls  and  the  patient  feels  com- 
fortable. On  the  fifth  or  sixth  day  a  clear  or  slightly  turbid  scrum  makes 
its  appearance.  Coincident  with  this  a  depression  is  seen  in  the  middle 
of  each  vesicle.  It  is  umbilicated,  and  this  umibilication  is  the  most  char- 
acteristic feature  of  the  eruption.  Frequently,  a  hair  follicle  passes  up 
through  the  center  of  it.  By  the  eighth  day  the  turbidity  has  increased 
until  it  is  bright  3'ellow  and  the  umbilicus  has  disappeared.  The  pustule 
is  complete.  The  maturation  takes  place  in  the  same  order  as  the  eruption 
appeared.  With  the  appearance  of  suppuration  the  fever  again  returns, 
knovvn  as  the  secondary  fever,  and  with  it  elevation  of  temperature 
and  other  signs  of  fever.  There  is  a  good  deal  of  pain  in  the  inflamed 
parts  because  of  the  tension.  On  the  tenth  or  eleventh  day  the  pustules 
become  dry,  and  by  the  fourteenth  are  converted  into  crusts,  which  drop 
ofif,  leaving  in  mild  cases  a  simple  discoloration,  in  severe  a  more  or  less 
deep  ulcer,  or,  if  cicatrization  be  complete,  a  simple  pit.  The  eruption 
may  be  found  on  the  tongue  and  buccal  mucous  membrane  and  even  in 
the  pharynx,  larynx,  and  esophagus,  and  pustules  have  been  found  in  the 
stomach  and  rectum.  In  the  trachea  and  bronchi  there  may  be  ulcers ;  also 
on  the  cornea.  Sore  throat,  nausea,  hoarseness,  vomiting,  and  diarrhea  may 
be  consequences.     With  the  drying  of  the  eruption  the  fever  disappears. 

This  description  is  typical  of  the  course  of  the  eruption  in  the  simple 

=■■  "Das  Prodromal-Exanthema  der  Pocken."   "Arch.  f.   Dermatol,    und  Syph.,"  Prag.  Ileft   iii. 
iZ-jn.  7.6;  1871.  Heft  ii.  242;  Heft  iii.  30Q;  1872.  Heft  iv.  541. 
+  "  Arch.  f.  Dermatol,   und  Svph.."  Heft  iii.  75:72,  372. 
i  "  Arch.  f.  Dermatol,  und  Sj-ph.,"  Heft  iv.  1872.  ;o6 
5  "  The  Initial  Rashes  of  .Smallpox,"  "  Canada  Med.  and  Surg-.  Jour.."  187J. 


SMALLPOX. 


149 


discrete  variety.  It  may  be  variously  modified.  The  attack  may  be  so 
virulent  that  the  patient  dies  before  the  eruption  makes  its  appearance,  or  it 
may  be  arrested  at  any  stage.  Sometimes  blood  forms  the  contents  of  the 
pustule,  and  there  may  be  subcutaneous  infiltration  of  blood  in  addition. 
Along  with  this  there  may  be  hemorrhage  from  the  mucous  surfaces  of  the 
nose,  stomach,  or  bowels,  or  there  may  be  hematuria. 

The  pustules  may  be  so  close  to  each  other  that  they  join,  when  the 
case  is  confluent ;  or  they  may  be  separate  and  distinct,  producing  the  discrete 
form..  The  variety  with  bloody  infiltration  is  called  hemorrhagic.  The 
diagnosis  as  to  whether  the  confluent  or  discrete  form  is  present  is  generally 
made  by  an  examination  of  the  face,  for  it  is  an  interesting  fact  that  nowhere 
are  the  pock-marks  more  abundant  than  upon  the  face. 

Sydenham  early  called  attention  to  the  fact  that  in  the  confluent  variety 
the  eruption  appears  earlier  (on  the  third  day),  and  its  early  appearance, 
according  to  him,  is  an  indication  that  the  case  will  be  one  of  that  variety. 
All  the  symptoms  are  much  more  severe.  There  is  not  the  abatement  of 
fever  described  as  occurring  on  the  appearance  of  the  eruption.  The  face, 
hands,  and  feet  present  an  almost  continuous  pus-vesicle,  which  often  bursts 
in  places,  and  the  pus  partly  drying,  there  results  a  picture  which  is  revolting. 
Such  pronounced  morbid  changes  must  produce  wide  systemic  exhaustion, 
as  is  manifested  on  the  tenth  or  the  eleventh  day  by  the  growing  weakness  of 
the  patient,  an  adynamia  that  frequently  terminates  in  death.  When  recovery 
takes  place,  the  secondary  fever  is  the  more  prolonged  the  more  widespread 
the  suppuration. 

The  hemorrhagic  variety  of  smallpox  is  still  more  severe.  Two  forms 
of  it  are  described :  One,  the  purpura  variolosa,  or  hemorrhagic  variola,  in 
which  the  hemorrhagic  symptoms  appear  early  in  the  shape  of  a  hemorrhagic 
rash  while  hemorrhage  takes  place  from  the  mucous  surfaces,  generally 
on  the  evening  of  the  second  or  third  day.  The  patient  dies  in  from  two  to 
six  days,  sometimes  before  the  eruption  makes  its  appearance.  In  the 
second  form,  variola  h(smorrhagica  pustnlosa,  the  case  progresses  at  first 
like  any  other,  and  it  is  not  until  the  vesicular  or  pustular  stage  that  blood 
makes  its  appearance  in  the  pocks. 

Varioloid. — A  third  variety  of  smallpox  is  varioloid,  which  is  variola 
modified  by  vaccination  or  a  previous  attack  of  smallpox.  In  general, 
varioloid  is  smallpox  bereft  of  all  its  serious  features,  each  symptom  being 
milder.  The  initial  fever  is  less,  the  eruption  is  less  general  and  may  abort 
-in  its  development,  the  secondary  fever  is  less  marked,  and  convalescence 
sets  in  earlier.  Yet  it  has  happened  that  both  classes  of  individuals  referred 
to,  those  having  had  smallpox  and  those  having  been  vaccinated,  have  had 
very  severe  attacks,  from  which,  indeed,  the  patients  have  perished.  Gen- 
erally, the  longer  the  interval  between  the  attack  and  vaccination,  the  more 
severe  the  former  is.  Similar  is  the  mildness  which  characterizes  a  small- 
pox produced  by  the  direct  inoculation  of  an  individual  from  the  pus  of 
another,  though  the  attack  thus  caused  is  more  severe  than  that  which 
follows  vaccination. 

Other  names  given  to  less  important  varieties  are  variola;  sine  varioUs, 
or  variolous  fever  without  eruption ; '  the  crystalline  pock,  in  which  the 
eruption  continues  vesicular ;  and  the  "  stone  pock,"  "  horn  pock,"  and  ''  wart 
pock,"  in  which  the  vesicles  dry  up  into  tuberculated  or  warty  elevations. 

Complications. — Among  complications  of  smallpox  may  be  mentioned 
laryngitis   with   fatal   edema    of   the   glottis,   bronchopneumonia,   parotitis. 


I50  INFECTIOUS  DISEASES. 

vomiting,  diarrhea,  albuminuria,  but  rarely  nephritis.  Prolonged  delirium, 
and  even  insanity,  have  supervened,  while  neuritis  may  occur  during  con- 
valescence ;  so  may  arthritis.  On  the  skin  may  be  boils  and  painful  acne. 
A  troublesome  and  painful  conjunctivitis  used  to  be  the  result  of  indifferent 
care  of  the  eyes,  but  it  is  now  less  common  because  of  greater  care  in  this 
respect.  Myocarditis  and  pericarditis  sometimes  occur,  and  most  rarely 
endocarditis. 

Diagnosis. — With  the  appearance  of  the  perfect  papule  all  doubt  in 
the  diagnosis  of  smallpox  generally  ceases.  Ignorance  of  the  initial  rashes, 
measly  and  scarlatinal,  has  often  led  to  errors  of  diagnosis.  On  the  other 
hand,  the  resemblance  of  the  eruption  of  measles  to  smallpox  has  also  given 
rise  to  errors  the  result  of  which  has  been  no  less  serious,  because  in  conse- 
quence cases  of  measles  have  more  than  once  been  sent  to  smallpox  hospitals 
with  disastrous  results.  Never  in  measles  is  there  such  severe  pain  in 
in  the  back  as  in  smallpox,  while  the  early  cough  and  coryza  are  found  only 
in  measles.  The  lesson  taught  is  to  defer  a  positive  diagnosis,  because  less 
serious  mischief  can  result  from  an  error  thus  occasioned  than  as  the  result 
of  an  opposite  course.  The  possibility  of  relapsing  fever  being  taken  for 
smallpox  has  been  alluded  to  in  considering  the  former  disease.  Cerebro- 
spinal  fever  may  also  be  simulated  by  the  hemorrhagic  form  of  smallpox. 
Pustular  syphilids  and  accidental  croton-oil  eruption  have  been  mistaken  for 
smallpox,  as  has  also  chicken-pox. 

Prognosis. —  Smallpox  is  a  serious  disease,  and  the  death-rate  is  always 
relatively  large.  It  varies,  however,  at  different  ages,  in  different  races, 
and  in  different  epidemics.  The  young  die  almost  always.  Thus,  in  the 
Montreal  epidemic  of  1885,  86  per  cent,  of  the  deaths  were  children  under 
ten  years.  The  African  and  American  Indian  and  native  Mexican  have 
perished  by  thousands.  The  range  of  the  mortality  in  different  epidemics 
is  put  down  at  25  per  cent,  to  35  per' cent.  The  recent  epidemic  in  the 
United  States  was  an  especially  mild  one,  the  mortality  being  but  3.3  per  cent. 
The  hemorrhagic  cases  are  always  serious;  those  of  purpura  variolosa  all 
die,  and  although  some  cases  of  variola  pustulosa  hemorrhagica  get  well,  the 
majority  are  usually  fatal  on  the  seventh,  eighth,  or  ninth  day.  The  preg- 
nant woman  usually  aborts  and  perishes,  but  not  always.  The  complications 
of  pneumonia  and  laryngitis  are  serious. 

From  the  statistics  of  Dr.  Gregory,  based  Upon  London  hospital  prac- 
tice, most  die  on  the  eighth  day ;  but  in  private  practice,  according  to  the 
experience  of  the  late  George  B.  Wood,  the  greatest  number  of  deaths  occur 
between  the  twelfth  and  eighteenth  da)'s. 

Treatment. — ^It  is  not  possible  to  cut  short  a  case  of  smallpox.  The 
patient  should  be  isolated  and  taken  to  a  smallpox  hospital,  if  possible.  If 
at  home,  an  uppermost  room  should  be  selected,  all  hangings  and  carpet 
removed,  and  communication  with  the  rest  of  the  house  cut  off  by  closed 
doors  fortified  by  a  sheet  dampened  with  a  solution  of  carbolic  acid,  i  to  60. 
Separate  dishes  and  utensils  should  be  provided,  and  nurses  should  hold  no 
communication  with  other  members  of  the  family.  All  clothing  removed 
from  the  patient  should  be  put  in  scalding  water,  and  sweepings  should  be 
burned.  The  nurse  should  wear  an  overall,  to  be  removed  on  leaving  the 
room,  and  her  head  should  be  covered  with  a  close-fitting  cap. 

The  treatment  must  consist  in  combating  the  symptoms.  Morphin,  or 
or  in  less  severe  cases  phenacetin,  acetanilid,  or  antipyrin,  must  be  given  to 
control  the  pain  in  the  back.     Nourishing  liquid  food  and   stimulants  are 


SMALLPOX.  151 

required  in  adynamic  cases.  The  fever  is  treated  by  sudorifics  including 
acetanilid,  antipyrin,  phenacetin,  and  thermol,  and  by  aconite,  or  by  cool 
sponging  or  even  by  cold  baths,  as  in  typhoid  fever,  if  the  temperature  be 
high.  Cool  drinks  should  be  permitted  ad  libitum.  The  complications 
must  receive  the  treatment  appropriate  to  them.  Tracheotomy  may  be 
demanded  by  edema  of  the  larynx. 

It  has  always  been  the  object  of  the  physician  to  find  some  means  of 
preventing  the  disfiguring  scars  which  so  invariably  remain  after  very 
severe  cases.  No  one  method  is  always  successful.  It  has  long  been  thought 
that  the  absence  of  light  favored  healing  without  pits.  For  the  painful  oph- 
thalmia that  so  often  attends  smallpox,  darkness  is  certainly  a  comfort,  but 
that  it  diminishes  tlie  pitting  I  have  much  doubt.  It  is  a  comforting  fact 
that  even  the  deepest  and  ugliest  pits  gradually  lose  their  distinctness  as  time 
passes,  and  that  much  of  the  marking  disappears  in  the  course  of  a  few  years. 
The  surface  should,  however,  be  anointed  with  vaselin,  cold  cream,  or 
similar  substance,  as  they  allay  the  burning  and  itching,  keep  the  scabs  moist, 
and  prevent  the  contagium  from  spreading  through  the  air.  The  odor, 
which  is  often  intolerable,  is  perhaps  best  covered  by  adding  carbolic  acid  to 
the  vaselin  or  other  unguent  employed,  say  10  grains  (0.666  gm.)  to  the 
ounce  (30  gm.)  ;  or  a  watery  solution  of  carbolic  acid  may  be  made  of  the 
same  strength  and  applied  on  cloths.  Bichlorid  of  mercury,  i  to  2000,  may 
be  used  in  the  same  way.  These  preparations  appHed  cold  on  lint  are  sooth- 
ing and  comforting.  Dr.  Schamberg,  the  assistant  physician  to  the  small- 
pox hospital  in  Philadelphia,  says  that,  as  the  result  of  his  experience  in  the 
epidemic  of  1901-1902  in  Philadelphia,  painting  with  iodin  seems  to  be 
more  efficient  in  averting  pitting  than  any  other  treatment.  J.  F.  Romero 
claims  to  have  used  with  most  satisfactory  results  picric  acid  as  a  local 
measure  to  prevent  pitting.  He  advises  a  lotion  made  mth  2  grams  (30 
grains)  picric  acid,  15  grams  (half  an  ounce)  alcohol,  and  185  grams  (six 
and  a  half  ounces)  water.  An  ointment  may  be  made  instead.  He  suggests 
that  the  picric  acid  may  destroy  the  pyogenic  germs  that  may  find  their  way 
into  the  pustules. 

The  eyes,  nose,  mouth,  and  throat  should  be  kept  clean,  all  crusts  being 
carefully  removed.  This  may  be  accomplished  for  the  eyes  by  cold  com- 
presses frequently  changed,  while  the  nose,  mouth,  and  throat  should  be 
cleansed  with  borated  gargles  and  lotions.  As  soon  as  convalescence  is 
established  the  patient  should  bathe  daily,  using  carbolic  soap,  the  bathing 
being  kept  up  until  the  skin  is  perfectly  smooth,  because  only  then  does  the 
patient  cease  to  be  a  source  of  infection. 

Special  Modes  of  Treatment. — As  in  the  case  of  the  other  infectious 
diseases,  smallpox  offers  encouragement  to  similar  specific  modes  of  treat- 
ment. The  bacterium  of  smallpox,  whatever  it  may  be,  does  not  seem  to 
develop  a  toxic  substance  so  virulent  as  that  of  diphtheria.  The  exhaustive 
effect  on  the  system  is  that  of  the  extensive  inflammation  and  suppuration  of 
the  skin.  The  internal  administration  of  antiseptics  has  been  recom- 
mended, but  seems  to  have  furnished  no  results  that  particularly  commend  it. 
The  substances  tried  are  the  usual  ones — namely,  sodium  salicylate,  salol, 
mercuric  chlorid,  carbolic  acid,  creasote,' the  sulphites,  and  sulpho-carbolates. 

Upon  the  same  plan  as  the  serum  treatment  for  diphtheria,  serum 
from  vaccinated  subjects,  both  human  beings  and  lower  animals,  and  from 
smallpox  patients  in  the  advanced  stage  of  the  disease,  has  been  used  by 
Kinyoun,    Lundmann,    and    Beclere.      Analogy    would    lead    us    to    expect 


152  INFECTIOUS  DISEASES. 

similar  results  to  those  obtained  b}'  antitoxin  in  diphtheria,  but  such  has  not 
been  the  case  as  yet. 

Special  modes  of  external  treatment,  as  by  baths  impregnated  witli 
antiseptics,  have  also  been  used  and  brilliant  results  claimed.  Galewouski  '•' 
used  solutions  of  potassium  permanganate  of  such  strengths  as  to  make  the 
baths  a  rose-red  color.  He  claims  reduction  of  temperature,  disappearance 
of  pustules,  and  speedy  recovery.  Talamon  j  recommends  external  applica- 
tion of  mercuric  chlorid  spray  to  the  skin,  using  a  solution  made  up  of  cor- 
rosive sublimate  and  tartaric  acid,  each  i  gm.  (15  grains)  ;  90  per  cent,  alco- 
hol 5  c.  c.  (fo  1.25)  ;  ether,  enough  to  make  50  c.  c.  (f5  1.33)  ;  spray  three 
or  four  times  daily  for  a  minute,  being  careful  to  protect  the  eyes.  The 
treatment  is  commenced  on  the  first  day  of  the  eruption,  being  preceded  b\' 
thorough  washing  of  the  face  with  soap,  which  is  rinsed  off  with  boric  acid 
solution,  and  the  skin  then  dried  with  absorbent  cotton.  After  the  spray 
lias  been  used  the  face  should  be  covered  with  a  layer  of  50  per  cent,  of 
glycerolate  of  mercuric  chlorid  to  keep  the  skin  antiseptic.  After  the  fourth 
day  the  number  of  spra3-ings  is  gradually  diminished,  and  after  the  seventh 
day  they  are  discontinued,  though  the  glycerolate  dressings  are  kept  up. 
Talamon  also  recommended  in  the  confluent  and  grave  forms  of  the  disease 
mercuric  chlorid  baths  lasting  from  three-quarters  of  an  hour  to  an  hour, 
Vv^ith  internal  treatment  including  tlie  usual  supporting  measures.  These 
treatments  commend  themselves  to  reason  and  common  sense,  and  as  being 
disinfectant  and  cleansinsr  at  least. 


VACCINE  DISEASE. 

Synoxyms. — Vaccinia;  Vaccina;  Cozvpox:  Kincpox. 

Definition. — A'accinia  is  an  infectious  disease  produced  by  inoculation 
of  man  with  lymph  from  the  vesicle  of  Idnepox.  It  is  characterized  by  local 
and  general  sj-mptoms.  Persons  successfully  vaccinated  are,  in  the  vast 
majority  of  cases,  immune  from  smallpox.  The  local  product  of  such  vac- 
cination is  the  vaccine  vesicle,  the  contents  of  which,  when  again  inoculated, 
are  capable  of  producing  the  same  disease  with  immunity  in  another  person 
not  previously  vaccinated.  It  is  pre-eminently  characteristic  of  vaccine  dis- 
ease that  it  can  be  communicated  only  when  introduced  directly  into  the 
blood. 

Historical. — See  History  of  Smallpox. 

There  can  be  no  doubt  that,  if  vaccination  were  thoroughly  carried  out, 
smallpox  could  be  stamped  out.  This  is,  however,  not  done,  and  in  point 
of  fact,  a  few  cases  occur  annualh'-  everywhere  except  in  Germany,  while  at 
intervals  an  epidemic  of  greater  or  less  severity  occurs.  A  false  sense  of 
security  leads  to  indifference  about  vaccination  and  revaccination,  and  thus 
gradually  accumulate  a  number  of  susceptible  persons  who  are  liable  to  the 
disease. 

Nature  of  Vaccinia. — Two  views  as  to  the  true  nature  of  vaccinia  are 
held — the  English,  that  it  is  smallpox  modified  by  transmission  through  the 
cow ;  the  second,  or  French  view,  that  it  is  a  separate  disease  distinct  from 

*  '•  >red.  Press  and  Circular,"  1850. 

+  ''Jour.  Ol  Cutaneous  and  Venereal  Diseases,"  February,  iSgi,  "  Gazetta  medica  Lombarda," 
i8go. 


VACCINE  DISEASE.  153 

smallpox.  Each  side  claims  that  its  own  view  is  sustained  by  experiment. 
The  form.er  view  is  probably  correct — that  vaccinia  is  smallpox  modified  by 
passing"  through  the  cow. 

Lymph  in  Use. — At  the  present  time  it  is  almost  the  universal  practice 
to  use  animal  lymph  or  the  lymph  directly  from  the  cow,  although  human- 
ized lymph,  that  from  another  person  having  vaccine  disease,  can  also  be 
successfully  used.  The  chief  reason  for  using  animal  lymph  is  that  all  dan- 
ger of  communicating  other  affections,  especially  syphilis,  is  thus  avoided, 
although  there  is  reason  also  to  believe  that  protection  is  more  certainly 
secured  by  animal  lymph.  For  securing  the  cow-lymph  numerous  farms 
exist  in  this  country  and  in  Europe,  where,  under  the  most  perfect  sanitary 
precautions,  inoculation  is  practiced  on  the  udder  of  heifers,  whence  the 
lymph  is  gathered  and  distributed.  In  Belgium  the  heifers  are  slaughtered 
after  the  lymph  is  taken,  and  if  they  are  found  diseased,  the  lymph  is  not  used- 
In  this  country  the  m.ore  usual  method  is  to  allow  the  lymph  to  dry  on  ivor}* 
points  or  quills,  or  to  collect  it  in  capillary  tubes.  Before  the  use  of  animal 
lymph  became  general  the  crusts,  or  scabs,  from  vaccinated  arms  were  pre- 
served and  iiYoistened  to  the  consistence  of  pus  before  inoculation. 

Bacteriology. — The  inoculating  element  of  vaccine  virus  has  not  been 
isolated.  Analogy  leads  us  to  expect  some  organism  will  ultimately  be 
found  in  the  fluid  of  the  pock.  Quist  has  cultivated  micrococci  from  vac- 
cine lymph,  which,  he  claims,  produced  in  the  child  a  typical  vesicle ;  while 
Harold  Ernst  and  Martin,  of  Boston,  have  isolated  from  bovine  lymph  a 
germ  which  grows  on  culture-media  and  produces,  when  inoculated  in  the 
heifer  or  children,  characteristic  vesicles.  Klein  and  Copeman  have  each 
found  a  bacillus,  and  Pfeiffer  and  Ruffer  bodies  regarded  as  psorosperms. 
Peculiar  ameboid  bodies  have  been  niet  in  the  blood  of  vaccinated  persons. 

Operation. — The  operation  of  vaccination  is  variously  performicd.  I 
prefer,  after  thorough  cleansing,  to  scrape  the  skin  of  the  arm  or  forearm 
with  a  lancet  until  the  cuticle  is  removed  and  a  moist  surface  results,  due  to 
the  transuded  lic[Uor  sanguinis.  On  this  is  expressed  from  the  capillary  tube 
the  virus,  or  the  ivory  point  is  rubbed,  slightly  moistened.  Prolonged  fric- 
tion is  desirable  to  secure  success.  I  am  confident  I  have  been  more  invari- 
ably successful  since  I  have  used  capillary  tubes  instead  of  ivory  points.  It 
is  a  disadvantage  to  have  the  surface  bleed  much,  as  it  interferes  with 
absorption.  Another  method,  handed  down  by  the  late  Professor  George  B. 
Wood  from  his  predecessors,  and  available  only  with  liquid  lymph,  is  to 
make  three  slight  punctures  obliquely  under  the  cuticle  and  work  the  lymph 
into  each.  The  punctures  should  be  about  a  line  apart  and  at  the  angles  of 
an  equilateral  triangle.  Very  convenient  instruments  of  various  kinds  are 
made  to  scratch  the  surface,  which  are  especially  useful  when  a  large  number 
of  vaccinations  is  to  be  made  and  celerity  is  desirable.  At  the  present  day 
it  is  quite  the  fashion  to  inoculate  on  the  leg,  especially  in  the  case  of  girls, 
in  order  to  avoid  an  unsightly  scar  on  the  arm.  In  infants  there  is  no  objec- 
tion to  this,  but  I  have  known  young  girls  to  be  very  seriously  disabled  for  a 
time  by  vaccination  upon  the  leg.  Another  advantage  of  inoculation  on  the 
leg  of  infants  is  that  there  is  less  liability  to  injure  the  afifected  limb  in  nurs- 
ing or  carrying.  The  same  thing  is  nearly  as  well  accomplished  by  vacci- 
nating the  forearm,  but  this  makes  the  resulting  scar  needlessly  conspicuous. 
Another  favorite  situation  is  the  region  of  the  insertion  of  the  deltoid  muscle. 

The  Phenomena  of  Vaccination. — Immediately  succeeding  the  opera- 
tion a  slight  inflammatory  redness  appears,  which  usually  subsides  rapidly, 


1  5  4  ^ A^^^£ C  TI 0  US  DISEA  SES. 

and  sometimes  has  entirely  passed  away  before  the  tirst  phenomenon  of  the 
vaccine  disease  appears.  Thus,  there  is  a  true  period  of  incubation,  after 
which,  usually  on  the  third  day,  but  often  two  or  three  days  later,  a  slight 
red  elevation  makes  its  appearance.  By  the  iifth  or  sixth  day  this  has 
already  become  an  umbilicated  vesicle  tilled  with  a  transparent  viscid  fluid, 
surrounded  by  a  delicate  red  areola.  The  vesicle  presents  a  shining"  silvery 
appearance;  by  the  eighth  day  it  becomes  a  lustrous  silver-gray,  and  by 
the  tenth  day  the  vesicle  and  areola  have  both  reached  their  maximum. 
The  pock  is  by  this  time  1-3  inch  in  diameter  (about  i  an.),  one  to 
two  lines  in  height,  umbilicated  at  its  center,  and  presenting  frequently  a 
minute  brown  spot  or  scab  in  the  same  situation.  The  areola  is  quite  angry 
looking,  often  two  inches  (5  cm.)  or  more  in  diameter,  and  shows  under  a 
magnifying  glass  numerous  minute  vesicles  on  its  surface.  At  this  stage, 
too,  it  itches  and  burns  to  a  degree  which  causes  in  adults  an  almost  irre- 
sistible desire  to  scratch,  while  in  the  child  it  gives  rise  to  fretfulness  and 
peevishness  and  to  slight  fever.  Even  in  the  adult  there  is  slight  rise  of 
temperature.  On  the  eleventh  or  tzvelftJi  day  the  disease  begins  to  decline. 
The  areola  narrows  and  becomes  less  bright,  the  lymph  more  turbid  and 
begins  to  dry.  By  the  end  of  tzvo  -weeks  the  vesicle  has  been  converted 
into  a  dry,  brown  scab,  which  generally  drops  off  on  the  twenty-iirst  to 
twenty-fifth  day.  A  scar  remains,  which  is  very  distinct  at  first,  but  gradu- 
all}'  assumes  even  a  whiter  hue  than  the  surrounding  integument. 

The  course  described  is  the  typical  one  in  a  healthy  vaccinated  child. 
In  other  cases  the  amount  of  local  irritation  is  much  greater,  with  a  cor- 
responding degree  of  constitutional  disturbance.  There  is  often  adenitis  in 
adjacent  glands.  Sometimes,  in  ill-conditioned  children,  deep,  tmhealthy 
ulcers  supervene  that  are  very  slow  to  heal,  while  erysipelas  and  gangrenous 
ulcerations  have  even  occurred  and  been  followed  by  death.  Even  tetanus 
has  succeeded  upon  vaccination  and  it  has  been  claimed  that  the  bacillus  of 
tetanus  has  been  inoculated  with  the  germ  of  vaccine  resulting  in  the  simul- 
taneous development  of  tetanus,  but,  so  far  as  I  know,  none  of  the  claims  as 
to  this  combined  inoculation  have  been  substantiated.  Tetanus  resulting 
from  simultaneous  inoculation  should  appear  5  to  9  days  after  its  introduc- 
tion, whereas,  in  tlie  cases  commonly  reported,  3  to  4  weeks  have  elapsed 
before  tetanus  developed.  This  seems  to  have  been  the  case  witli  the  epi- 
demic in  Camden,  N.  J.,  in  the  fall  of  1901. 

Since  the  incubation  period  of  vaccination  is  shorter  than  that  of  small- 
pox, the  prompt  vaccination  bf  a  person  exposed  to  smallpox  may  protect 
him,  or  at  least  modify  the  disease. 

Vaccination  Rashes. — In  certain  cases,  especially  when  vaccination  is 
done  with  the  liquid  lymph  from  the  cow,  a  general  eruption  of  vesicles  takes 
place,  constituting  vaccinia  bullosa;  associated  with  miliary  vesicles  it  is 
called  vaccinia  miliaria.  At  times  a  roseolar  eruption  is  associated, — roseola 
vaccinalis, — not  unlike  the  roseolar  eruptions  of  syphilis.  The  vesicles  may 
be  filled  with  blood — vaccinia  hcenwrrhagica. 

Revaccination. — Should  a  considerable  time  elapse  after  vaccination,  a 
revaccination  will  generally  be  more  or  less  successful.  Usually,  the  entire 
set  of  phenomena  is  less  characteristic,  although  it  sometimes  happens  that 
the  same  typical  course  is  repeated.  Such  successful  vaccination  is  regarded 
as  evidence  that  immunity  from  smallpox  is  no  longer  present,  and  the  per- 
son, if  exposed  to  smallpox  before  vaccination,  would  have  taken  it.  Such 
an  attack  is  almost  invariably  less  severe,  and  presents  the  modified  symptom- 


VACCINE  DISEASE. 


155 


atology  known  as  that  of  varioloid.  The  period  of  exemption  after  vac- 
cination varies  greatly.  It  is  often  perpetual.  More  frequently,  it  lasts 
from  ten  to  twelve  years,  and  every  person  should  be  revaccinated  at  ten  to 
fifteen  years,  and  thereafter  whenever  an  epidemic  of  smallpox  is  raging, 
unless  he  happen  to  have  been  successfully  vaccinated  within  a  few  years. 

At  times,  even  in  first  vaccinations,  an  abortive  result  obtains,  the  vesicle 
drying  and  dropping  off  much  too  early.  Should  this  occur,  the  operation 
should  be  repeated. 

Possibility  of  Transmitting  Disease  by  Humanized  Lymph. — It 
has  already  been  said  that  the  possibility  of  transmitting  disease  by  vacci- 
nating with  humanized  lymph  has  been  a  potent  influence  in  stimulating  the 
employment  of  animal  lymph.  Syphilis  seems  the  only  disease  that  can  be 
thus  transmitted,  although  it  has  been  claimed  also  for  tuberculosis.  It  is, 
nevertheless,  important  that  every  precaution  should  be  taken  against  such 
accidents.  If  humanized  lymph  be  used,  as  it  sometimes  must  be,  only  that 
from  children  of  healthy  parents,  free  from  syphilis  or  tuberculosis,  should 
be  selected,  and  under  all  circumstances  lymph  admixed  luith  blood  should 
be  rejected.  Lymph  should  be  taken  from  fully  matured  and  perfect  vesicles 
on  the  eighth  day. 

It  is  exceedingly  important  that  the  physician  should  have  at  hand  the 
data  of  discriminating  between  the  ulcer  of  vaccinosyphilis  and  of  vaccina- 
tion ;  and  between  secondary  vaccinosyphilis,  the  vaccination  rashes,  and 
hereditary  syphilis  occurring  about  the  tim.e  of  vaccination.  Such  data  are 
found  in  the  following  table  compiled  by  C.  S.  Shelly  from  Fournier,  in 
Fowler's  "  Dictionarv  of  Medicine  "  : 


Vaccinosyphilis    or   Vaccino-Chancre. 

Chancre  developed  on  the  site  of  usually 
one  or  two  only  of  the  vaccination 
punctures. 

Inflammation  is  slight. 

Loss  of  substance  superficial  only. 

Suppuration  scanty  or  absent,  scabs,  or 
crusts. 

Border  of  chancre  smooth,  slightly  ele- 
vated, gradualljr  merging  into  floor. 

Surface  of  floor  smooth. 

Induration"parchment-like,"  and  specific, 
not  merely  inflammatory. 

Inflammatory  areola  very  slight. 

Gland  swelling  constant,  indolent  [syph- 
ilitic] bubo. 

Complications  rare. 

Chancre  never  developed  before  the  fif- 
teenth day  after  vaccination;  usually 
not  until  after  three  to  five  weeks;  it 
is  still  in  its  earlier  stage  twenty  daj'S 
after  vaccination. 

Secondary  Syphilitic  Eruption  due  to 
Vaccinosy'philis. 


Appears,  at  the  earliest,  nine  or  ten  weeks 
after  vaccination. 

Requires,  in  every  case,  the  pre-existence 
of  a  specific  ulcer  [chancre]  at  the  site 
of  vaccination. 


Vaccination    Ulcers. 

Ulceration  affects  all  the  punctures,  as 
a  rule. 

Inflammation  and  ulceration  severe. 
Ulcer  deeply  excavated. 
Much  suppuration. 

Margin  of   iilcer    irregular,  as   in    "  soft 

chancre." 
Floor  of  ulcer  uneven,  suppurating. 
Induration  inflammatory  only. 

Areola  inflammatory  and  er3'sipelatous. 

Gland  swelling  often  absent;  if  present, 
merely  inflammatory. 

Complications — sloughing,  erysipelas,etc. 
— often  present. 

Ulceration  is  present  twelve  to  fifteen 
days  after  vaccination  and  is  fully 
developed  the  twelfth  day  after  vacci- 
nation. 

Vaccination  Rashes. 

[Including  roseola  vaccinalis, miliaria  vac- 
cinalis,  vaccinia  bullosa,  vaccinia 
hsemorrhagica;  also  accidental  erup- 
tions— rubeola,  scarlatina,  lichen, 
,    urticaria,   etc.] 

A  true  vaccinal  rash  appears  between  the 
ninth  and  fifteenth  day  after  vacci- 
nation. 

Absence  of  inoculation  chancre. 


J  50  IXFECTIOi'S  DISEASES. 

Exhibits  the  character  of  a  true  specific  Eruption  does  uot  exhibit  specific  char- 
eruption,  acters. 

Fever  often  slight.  Fever  always  present. 

Lasts  for   a  long  time.     Usually  acconi-  Evanescent, 
panied   by   specific    appearances    on 
mucous  membranes. 

Vaccinosyphilis  Hereuitary    Syphilis,     Showing    Iisel? 

AJoUT  THE  Ti.Mi-:  of  Vacclnaiiox. 

Begins  with  local  infection  chancre  and       No   chancre;   begins   with   general    phe- 

indolent  bubo.  noniena. 

Typical  development  in  four  stages — viz..       Has  no  typical  development  in  connection 
incubation,  chancre,    second  incuba-  with  vaccination, 

tion,  generalization  [secondary  erup- 
tion], etc. 
Never  appears  earlier  than  the  ninth  or       Time  of  development  quite  independent 
tentii  week  after  vaccination.  of   vaccination.     Is   attended  by  the 

characteristic  syphilitic  bodily  as- 
pects. Other  manifestations  of  he- 
reditary syphilis  may  be  present. 
The  history  may  indicate  syphilis. 

Some  idea  of  the  efficiency  of  vaccination  may  be  obtained  from  the  faci: 

that    through    it    smallpox    has    been    blotted    from    the    German    army, 

P\irther,  it  was  early  shown  by  Marson  that  of  those  who  have  acquire  J 

smallpox  after  vaccination,  the  disease  is  vastly  less  severe  than  in  those  who 

have  primary  smallpox.     This  is  confirmed  also  by  the  statistics  of  \Y.  jM. 

Welch,    Physician-in-charge    of    the    ^Municipal    Hospital    of    Philadelphia, 

From  a  study  of  5000  cases,  he  showed  that  where  there  were  good  cicatrices, 

only  8  per  cent,  died ;  with  fair  cicatrices,  14  per  cent. ;  with  poor  cicatrices, 

27  per  cent. ;  unvaccinated  cases,  58  per  cent. 


CHICKEX-POX. 
S  vxox  YM. — [  'aricella. 

Definition. —  Varicella  is  an  acute  contagious  disease  of  children,  char- 
acterized by  an  eruption  of  vesicles  with  pearly  contents  and  attended  with 
little  or  no  constitutional  disturbances. 

Etiology, — The  disease  is  eminently  contagious,  but  no  specific  causal 
organism  has  been  isolated.  It  is  almost  purely  a  disease  of  chUdhood, 
occurring  most  frequently  between  the  second  and  sixth  year.  It  is  a  dis- 
tinct and  separate  disease  from  smallpox,  an  attack  bringing  no  exemption 
from  that  (lisease. 

Symptoms. — The  period  of  incubation  is  from  ten  to  fifteen  days.  So 
slight  is  the  constitutional  disturbance  that  very  commonly  the  appearance 
of  the  eruption  is  the  first  notification  of  the  child's  illness.  At  tiir.es  there 
are  slight  prodromal  peevishness,  restlessness,  and  fcverishness;  at  others 
there  is  a  slight  chill  followed  by  fever.  Some  muscular  pain  may  be 
present. 

A  prodromal  scarlatinal  rash  may  rarely  present  itself,  but  for  the  most 
part  the  suddenness  of  the  eruption  is  distinctive.  It  presents  itself  m  the 
shape  of  isolated  pimples  scattered  over  the  body  within  the  first  twenty- 
four  hours  after  constitutional  disturbance.  They  may  then  appear  first  on 
the  trunk,  but  are  apt  to  be  seen  first  on  the  face.  In  another  twenty-four 
hours  they  are  pearly  pustules,  as  a  rule,  without  um.bilication  or  areola ; 
and  by  the  end  of  the  third  day  they  begin  to  dry  up,  and  in  another  day  are 


WHOOPING-COUGH. 


157 


converted  into  clark-brownish  crusts,  which  drop  off,  usually  leaving  no  scar. 
Sometimes,  however,  a  distinct  pit  is  left,  especially  if  the  pock  be  scratched 
by  the  child,  as  it  sometimes  is,  because  of  the  irritation  it  excites.  Occa- 
sionally, too,  the  pustule  is  distinctly  umbilicated  and  may  also  have  a  pink 
areola.  The  pustules  appear  in  crops,  so  that  on  the  fourth  day  they  can 
be  seen  in  all  stages,  but  at  the  end  of  a  week  again  all  have  disappeared. 
Rarelv  are  there  more  than  half  a  dozen  on  the  face,  though  they  may  be 
quite  numerous  and  the  victim  well  dotted  over.    They  occur  also  on  the  scalp. 

I  have  never  seen  any  complications  with  varicella,  and  in  most  cases 
under  my  observation  the  disease  would  have  been  overlooked  but  for  the 
eruption.  It  is  said,  however,  that  hemorrhagic  pocks  sometimes  occur 
accompanied  by  hemorrhage  from  the  mucous  membranes;  that  nephritis 
and  even  gangrene — varicella  gangrccnosa — have  occurred,  and  infantile 
paralysis  has  developed  during  an  attack  of  the  disease. 

Diagnosis. — The  diagnosis  should  not  detain  one  long.  The  trifling 
constitutional  disturbances,  the  rapid,  almost  sudden,  development  of  the 
pustules,  the  absence  of  umbilication  and  of  areola — all  distinguish  the  dis- 
ease from  smallpox. 

Prognosis. — This  is  invariably  favorable,  except  in  rare  cases  of  vari- 
cella gangrenosa. 

Treatment. — Usually  none  is  needed  save  the  application  of  a  simple 
lotion  or  ointment  to  allay  the  itching.  The  principal  need  of  the  physician 
is  to  make  the  diagnosis. 

I  conclude  the  section  on  the  eruptive  diseases  with  the  following  table, 
somewhat  modified,  from  T.  M.  Rotch,  wdiich  may  be  helpful  in  diagnosis : 


Scarlet 
Fever. 

Measles. 

Variola. 

Varicella. 

Rubella. 

Incubation,  .     .     . 

Prodrome,    .     .     . 
Efflorescence,   .     . 

Two  to  four 
days. 

Two  da^-s. 
Erythema. 

Seven       1 0 
fourteen 
days. 

Three  daj-s. 
Papules. 

Seven    to 
twelve    days. 

Three    days. 
Macules,    pap- 

Ten   to    fif- 
teen days. 

A  few  hours. 
Vesicles. 

Fourteen  to 
t  wen  tj'- 
one  da^'^s. 

Afewhours. 

Papules. 

Desquamation, 

Lamellar. 

Furfurace- 

ules,  vesicles, 
pustules. 
Lar^e  crusts. 

Small  crusts. 

Complications  and 
sequelae,    .     .     . 

Kidney, ear, 
and  heart. 

Eve       and 
lung. 

Larynx,  lungs, 
eyes. 

WHOOPING-COUGH. 

Synonyms. — Pertussis;  Hooping-cough. 

Definition. —  Whooping-cough    is   an    infectious   disease,   characterized 

by  spells  of  coughing  accompanied  by  a  long-drawn  inspiration  producing 

the  "  whoop,"  whence  the  disease  is  named. 

Historical. — While  the  writings  of  Hippocrates,  Galen,  and  Avicenna  containex- 
pressions  that  point  to  the  existence  of  a  specific  disease  like  whooping-cough,  it  is 
still  disputed  as  to  whether  this  disease  was  known  to  the  Greeks.  The  fi_rst  pub- 
lished account  appears  to  be  bv  Baillou,  in  1578.  He  described  an  epidemic  occurring 
in  Paris  and  spoke  of  it  as  a  disease  not  previously  known.  A  hundred  years  later, 
Willis  wrote  of  /ussz's  pnerorum  coiivjilshia,  evidently  the.  disease  under  consider- 
ation, which  has  since  become  omniprevalent. 


158  INFECTIOUS  DISEASES. 

Etiology. —  It  is  interesting  to  note  that  Linnaeus  ascribed  whooping- 
cough  to  the  larvae  of  insects  in  the  nose.  No  specific  organism  has  been 
generally  agreed  upon,  though  a  number  of  candidates  for  this  important 
role  have  been  brought  forward.  Thus,  in  1887,  Afanassieff  found  in 
sputum  from  the  disease  a  short  bacillus,  of  which  he  has  succeeded  in  mak- 
ing cultures,  inoculations  from  which  into  the  tracheae  of  animals  have  pro- 
duced catarrhal  conditions.  Letzerich  also  found  a  micrococcus  in  the 
sputum  with  which  he  claimed  he  was  able  to  produce  the  disease  in  animals 
by  introducing  the  sputum  into  the  trachea.  Koplik's  bacillus  seems  better 
accredited,  and  is  apparently  the  same  as  that  described  by  Czaplewski  and 
Hensel,  as  found  in  mucous  clumps  in  the  sputum.*  Koplik  found  it  in  13 
of  16  cases.  It  is  faculative  anaerobic,  and  is  not  stained  by  Gram's  method 
except  in  pure  culture,  in  which  it  can  be  separated  from  other  bacilli  found 
with  it.  It  is  pathogenic  for  mice.  It  is  found  free  and  in  pus-cells  of 
mucus.     It  is  not  found  in  sputum  during  the  prodromal  stage. 

Whooping-cough  attacks  children  of  all  ages  not  rendered  immune  by 
previous  attacks,  though  it  is  most  usual  between  the  first  and  second  denti- 
tions ;  nor  is  it  a  very  rare  affection  in  adults,  in  whom  it  may  become  serious. 
It  is  said  to  be  more  frequent  in  girls.  Its  epidemics  are  more  common  in 
the  spring  and  winter,  and  often  precede  or  follow  those  of  scarlet  fever  and 
measles.  The  disease  is  generall}^  communicated  from  one  child  to  another, 
and  few  escape  who  are  exposed.  Sporadic  cases  also  occasionally  occur. 
The  delicate  and  those  suffering  with  bronchial  and  nasal  catarrh  are  more 
vulnerable.     Some,  persons  are  immune. 

Morbid  Anatomy. — There  is  no  morbid  anatomy  peculiar  to  whoop- 
ing-cough beyond  the  catarrhal  inflammation.  According  to  Myer-Huni 
and  V.  Heroff,  this  is  most  marked  in  the  mucous  membrane  of  the  nose, 
larynx,  and  trachea  down  to  the  bifurcation,  but  especially  on  the  posterior 
wall  of  the  pharynx,  and  in  the  interarytenoid  region — the  so-called  "  cough 
region."  The  morbid  states  found  after  death  are  those  of  the  complica- 
tions— viz.,  bronchitis,  bronchopneumonia,  and  collapse  of  the  lung. 
Vesicular  and  interstitial  emphysema  are  sometimes  present,  the  former 
from  over-distention  of  the  air-vessels,  and  the  latter  from  their  rupture. 

Symptoms. —  Whooping-cough  has  a  period  of  incubation  of  from 
seven  to  ten  days.  There  is  no  prodrome  separable  from  the  preliminary 
stage,  beginning  with  cough  which  is  in  no  way  peculiar,  being  that  of  an 
ordinary  cold  with  slight  fever  and  without  expectoration.  There  may  be 
corysa  and  injection  of  the  conjunctiva.  This  cough  may  go  on  for  a  couple 
of  weeks  and,  if  there  be  nothing  in  the  history  to  suggest  the  nature  of  the 
disease,  may  occasion  no  suspicion.  Toward  the  end  of  this  period,  how- 
ever, the  observing  mother  will  have  noted  that  the  cough  is  gradually  grow- 
ing worse  and  becoming  paroxysmal,  that  it  occurs  "  in  spells."  Then  sud- 
denly a  "  whoop  "  is  noted  and  the  nature  of  the  disease  is  suspected. 

The  paroxysmal  stage  has  replaced  the  catarrhal,  and  soon  the  diag- 
nosis is  plain.  The  paroxysms  become  more  frequent  and  more  severe. 
Each  one  begins  in  a  succession  of  short  expiratory  coughs,  which  grow  in 
intensity.  All  efforts  lie  in  the  direction  of  expiration,  and  all  the  expiratory 
muscles  are  brought  into  play  to  this  end.  The  chest  is  compressed  laterally, 
and  bulges  in  the  sternal  region.  As  the  result  of  such  efforts,  the  face  is 
flushed,  the  eyes  are  injected  and  bulging,  the  tears  start,  and  the  nose  dis- 

*  For  an  exhaustive  review  of  this  siihiect  with  some  original  observations  pointing:  to  this  con- 
clusion, see  a  paper  on  "  The  Etiologfy  of  Pertussis,"  by  Joseph  Walsh,  in  "  Contributions  from  the 
William  Pepper  Laboratory  of  Clinical  Medicine,"  Philadelphia,  iqoo,  p.  450. 


WHOOPING-COUGH.  159 

charges.  Finally,  the  paroxysm  termmates  or  is  interrupted  by  a  loud, 
whooping  inspiration— -that  is,  it  may  end  for  the  time  or  be  immediately 
succeeded  by  another  similarly  concluded  paroxysm.  Severe  paroxysms 
commonly  terminate  in  an  act  of  vomiting,  which  brings  up  considerable 
mucus,  which  often  collects  before  the  paroxysm  begins  and  seems  to  be  its 
exciting  cause.  The  number  of  paroxysms  in  the  twenty-four  hours  varies 
greatly.  They  may  be  as  often  as  every  half-hour  or  only  four  or  five  times 
in  the  day.  Emotion  will  precipitate  a  paroxysm,  as  will  the  inhalation  of 
irritant  matters.  The  little  patient  resists  the  paroxysms  as  long  as  possible, 
and  when  the  inevitable  comes  it  will  run  to  the  basin  or  bowl,  knowing  full 
well  what  is  to  happen.  The  demure  method  pursued  by  little  children 
under  these  circumstances  is  often  at  once  touching  and  amusing.  I  have 
known  each  one  of  a  family  of  a  half-dozen  children  to  have  its  own  cup 
ready  for  seizure  at  a  moment's  notice.  Rupture  of  a  conjunctival  or  nasal 
blood-vessel  sometimes  occurs  and  occasionally  an  involuntary  urination. 
An  ulcer  may  form  at  the  frenum  of  the  tongue,  said  to  be  due  to  the  press- 
ure of  that  part  of  the  organ  against  the  incisor  teeth.  The  termination  of 
the  paroxysm  is  followed  by  temporary  relief. 

The  paroxysmal  stage,  if  uncomplicated,  is  unattended  by  fever,  and 
physical  examination  of  the  chest  is  barren  of  results  as  compared  with  the 
severity  of  the  cough.  The  percussion  note  is  clear,  clearer  during  inspira- 
tion. Auscultation  may  discover  a  few  moist  rales  soon  after  a  paroxysm ; 
but  during  it,  nothing.  Even  during  the  whoop  the  vesicular  murmur  may 
be  absent,  because  of  the  slowness  with  which  the  air  enters  the  chest. 

The  length  of  the  paroxysmal  stage  is  usually  from  four  to  six  zveeks, 
although  in  mild  cases  it  may  be  shorter.  Indeed,  there  are  mild  cases  of 
whooping-cough  in  which  the  paroxysms  are  scarcely  noticeable  and  would 
not  be  noted  except  for  an  occasional  "  whoop."  Toward  the  end  of  this 
period  the  paroxysms  become  less  severe  and  less  frequent,  and  soon  the 
stage  of  decline  or  convalescence  is  established.  In  the  course  of  it  the 
paroxysms  become  still  milder  and  less  frequent,  and  finally  subside  alto- 
gether. They  are,  however,  liable  to  be  renewed  for  a  time  if  the  patient 
takes  cold,  and  even  digestive  disturbances  are  said  to  have  a  similar  effect. 
The  other  phenomena  of  the  stage  of  convalescence  are  return  of  appetite, 
weight,  and  strength.  The  period  of  convalescence  occupies  another  four 
weeks,  so  that  the  entire  length  of  an  ordinary  attack  of  whooping-cough  is 
from  ten  to  twelve  weeks,  and  even  longer. 

Complications  and  Sequelae. — The  complications  that  attend  whoop- 
ing-cough are  bronchitis,  bronchopneumonia,  collapse  of  the  lung,  pleurisy, 
and  interstitial  emphysema.  The  bronchopneumonia  is  apt  to  be  of  the 
insufflation  kind.  Collapse  of  the  lung  may  succeed  it.  Interstitial 
emphysema  and  even  pneumothorax  may  result  from  rupture  of  the  air- 
vesicles,  and  it  is  apt  to  become  general  and  serious.  In  a  case  of  this  kind 
under  the  care  of  my  friend,  Horace  Williams,  which  terminated  fatally,  an 
abscess  formed  at  each  point  at  which  the  emphysema  approached  the  sur- 
face. Cerebral  palsy  and  death  from  subdural  hemorrhage  are  said  to  have 
occurred  in  whooping-cough.  Among  sequelae  may  be  mentioned,  as  a  rare 
event,  tubercular  consumption ;  also  permanent  changes  in  the  shape  of  the 
chest  including  the  so-called  pigeon  breast,  sometimes  the  result  of  a  pro- 
longed attack  of  whooping-cough. 

Diagnosis. — The  diagnosis  cannot  be  delayed  after  the  appearance  of 
the  whoop,  and  it  is  scarcely  possible  without  it.     Spasmodic  cough  may 


i6o  INFECTIOUS  DISEASES. 

occur  from  other  causes,  but  it  is  not  whooping-cough  unless  there  be  the 
Avhoop. 

Prognosis. — Xotwithstanding  the  enormous  number  of  children  who 
have  whooping-cough  and  get  well  of  it,  many  of  them  without  any  treat- 
ment whatever,  it  is  not  so  harmless  a  disease  as  many  suppose.  At  the 
same  time  I  cannot  believe  that  the  position  assigned  to  whooping-cough  by 
Thomas  AI.  Dolan,*  of  being  third  among  the  fatal  diseases  of  children  in 
England,  is  true  of  this  country.  The  chief  danger  is  from  the  complica- 
tion of  bronchopneumonia.  The  younger  the  child,  the  greater  the  danger. 
As  already  stated,  cases  in  which  interstitial  emphysema  occurs  from  rupture 
of  the  air-vesicles  may  terminate  fatally.  The  disease  is  more  serious  in  the 
negro  race — more  than  twice  as  fatal  as  in  whites. 

Treatment. — The  treatment  of  whooping-cough  is  one  of  the  opprobria 
of  medicine.  Xotwithstanding  the  claims  of  many  to  the  contrary,  it  remains 
a  fact  that  we  possess  no  means  of  cutting  it  short.  We  may,  however,  pal- 
liate the  disease  by  diminishing  both  the  freciuency  and  the  severity  of  its 
paroxysms.  The  remedies  to  this  end  are  the  opiates,  chloral,  and  antispas- 
modics. The  former  two,  as  a  rule,  should  be  reserved  for  night,  though  in 
severe  cases  chloral  in  doses  sufficient  to  secure  somnolence  is  recom- 
m.ended  by  Willoughby.f  Of  the  latter,  the  most  efficient  are  belladonna, 
the  bromids,  and  asafetida.  Belladonna  should  be  given  in  full  doses.  It  is 
difficult  to  name  them,  and  they  must  for  the  most  part  be  arrived  at  by  trial. 
We  may  begin  with  i  minim  (0.066  gm.)  of  the  tincture  every  tw^o  hours  to 
a  child  of  six  months,  or  1-12  grain  (0.0055  ^'^•)  of  ^^^^  extract,  and  increase 
the  dose  until  the  characteristic  redness  of  the  skin  is  produced. 

The  bromids,  preferably  of  sodium,  should  be  given  as  often,  in  doses 
of  I  or  2  grains  (0.066  to  0.132  gm.)  for  every  year  of  age.  I  am  confi- 
dent, too,  asafetida  is  useful.  I  use  it  in  the  shape  of  a  freshly  spread  plas- 
ter, large,  so  as  to  cover  the  whole  of  the  front  or  back,  and  bandaged  to 
keep  in  place.  It  should  be  renewed  often.  The  odor  is  soon  endured. 
Antipyrin  has  acquired  some  reputation  and  has  been  especially  recom- 
mended by  F.  J.  Taylor.J  and  \"on  Genser.  The  former  says  in  many  cases 
its  action  is  little  short  of  marvelous.  He  recomniends  beginning  with  a 
small  dose,  increased  until  a  child  of  two  years  is  taking  two  or  three  grains 
every  three  hours.  The  bromids  of  potassium,  sodium,  and  ammonium  may 
be  combined  with  it.  The  same  writer  recommends  alum  to  check  excessive 
secretion  in  the  later  stages,  three  grains,  every  three  or  four  hours,  to  a 
child  two  years  old.  Von  Genser  recommends  two  grains  a  day  for  each  year 
of  age  and  reports  recovery  m  24  davs. 

The  intervals  between  the  paroxysms  at  night  may  be  prolonged  by  the 
judicious  use  of  paregoric,  deodorized  tincture  of  opium  or  codein  com- 
bined with  the  antispasmodics,  including  belladonna  and  the  bromids. 

The  inhalation  of  germicidal  solutions  suggested  by  the  probable  germ 
origin  of  the  disease  has  not  as  yet  produced  any  results.  Carbolic  acid.  5 
to  1000,  corrosive  sublimate,  i  to  4000,  and  the  peroxid  of  hydrogen  diluted 
with  two  parts  of  Dobell's  solution  may  be  used  in  this  way.  The  remedies 
pr°  better  used  with  the  steam  atomizer,  as  the  steam  itself  has  a  soothing 
effect. 

*  "  WhooDini^-congh.'"  London.  1882. 

+  "Am.  Joiir.  Obstetrics."  Jiir.e,  tSoS. 

i  "  Annals  of  Gvnaecolog-y  and  Paediatrics  "  Tulv.  i8oq.  See  also  very  full  paper,  giving:  the  ex- 
pori"°nce  of  many  phvsicians',  in  "Gazette  Hebdom'.  de  TMed.  et  Chirurg.","  October  22,  1896,  bv  Le 
Goff.     Abstracts  in  "  New  York  Med.  Jour.,"  November  14,  1896. 


MUMPS,  i6i 

Parents  should  be  enjoined  to  protect  their  children  from  undue  expo- 
sure, because  it  is  this  that  causes  complications,  and  it  is  the  complications 
that  are  dangerous.  Such  complications,  and  other  symptoms  which  arise 
in  the  course  of  the  disease,  should  be  treated  by  appropriate  remedies. 

The  possibilities  of  serum  therapeutics  extend  to  the  treatment  of 
whooping-cough,  and  Dr.  Walsh,  in  the  paper  alluded  to,  refers  to  results 
■obtained  by  him  which  encourage  further  trial. 


MUMPS. 

Synonym. — Epidemic  Parotitis. 

Definition. — Mumps  is  an  acute  infectious  disease  characterized  by 
inflammation  of  the  parotid  gland,  sometimes  of  the  submaxillary. 

Etiology. — Although  a  bacillus  parotidis  has  been  described,  it  is  gen- 
erally conceded  that  the  real  contagium  of  mumps  has  not  been  isolated. 
Children  and  adolescents  are  its  favorite  subjects,  the  very  young  as  well  as 
adults  being  equally  exempt.  More  boys  are  attacked  than  girls.  The 
disease  is  more  common  in  the  spring  and  fall.  It  is  more  commonly  epi- 
demic, but  may  be  sporadic.  It  may  be  associated  with  measles  and  whoop- 
ing-cough.    One  attack  protects  against  a  second. 

Morbid  Anatomy. — The  swollen  and  hardened  salivary  gland  is  the 
sole  morbid  product.     The  swelling  is  mainly  due  to  serous  infiltration. 

Symptoms. — From  seven  to  fourteen  days  intervene  between  exposure 
and  the  invasion,  which  is  ushered  in  by  moderate  fever,  rarely  exceeding 
101°  F.  (38.33°  C),  although  103°  and  104°  F.  (39.44°  and  40°  C.)  have 
been  noted.  The  first  symptom  is  usually  pain  helozv  and  in  front  of  the 
ear,  but  pain  in  swallowing  may  be  first  experienced.  Simultaneously,  there 
may  be  sivelling  about  the  ear,  which  extends  rapidly  in  front  of  the  ear 
and  below  it  until  the  entire  neck  in  this  vicinity  is  involved. 

The  maximum  swelling  is  reached  in  about  forty-eight  hours,  after 
which  the  involvement  of  the  other  side  begins  and  extends  with  equal 
rapidity.  The  most  prominent  point  is  in  front  of  the  ear!  The  swelling 
does  not,  however,  subside  as  fast  as  it  comes  on,  but  persists  from  seven 
to  ten  days. 

At  the  height  of  the  disease  the  pain  and  difficulty  in  swallowing  are 
extreme,  the  former  extending  often  to  the  interior  of  the  ear,  producing 
earache,  and  the  hearing  may  be  affected.  The  parts  are  so  tense  and 
swollen  as  to  make  opening  of  the  mouth  almost  impossible,  mastication 
equally  difficult.  Suppuration  is  an  exceedingly  rare  event.  In  cases  of 
great  severity  delirium  is  sometimes  present  for  a  short  time. 

Complications. — The  most  frequent  complication  is  orchitis,  and  occur- 
ring, as  it  commonly  does,  after  inflammation  of  the  salivary  glands  has  sub- 
sided, it  has  been  regarded  as  a  metastasis ;  but  this  is  probably  not  the  case, 
since  both  conditions  may  be  the  result  of  the  same  cause,  as  originally  held 
by  Niemeyer.  The  swelling  may  affect  one  or  both  testicles,  the  duration 
being  longer  in  the  bilateral  form.  The  organs  are  heavy  and  painful,  but 
not  so  much  so  as  in  gonorrheal  orchitis.'  The  inflammation  lasts  for  three 
or  four  days  and  then  subsides  gradually.  Usually,  the  gland  itself  is 
involved,  but  occasionally  there  occurs  acute  epididymitis  with  acute 
"hydrocele . and  edema  of  the  scrotum.     Atrophy  is  said  to  have  supervened. 


i62  LYFECTIOUS  DISEASES. 

Inflammation  of  the  mammary  glands  and  of  the  vulva  sometimes  occurs 
in  girls,  and  more  rarely  of  the  ovaries. 

Otitis  media  with  resulting  deafness,  meningitis,  and  facial  palsy  are 
occasional  complications. 

Diagnosis. — The  diagnosis  usually  presents  no  difficulties,  and  any 
doubt  is  commonly  cleared  up  by  the  acuteness  of  the  attack.  Certain 
enlargements  of  the  cervical  lymphatic  glands  resemble  contagious  parotitis, 
and  in  scrofulous  children  the  swelling  in  mumps  is  sometimes  pro- 
longed, but  the  physiognomy  in  this  disease  is  different  and  distinctive. 
There  is  more  swelling  in  front  of  the  ear  in  parotitis,  and  in  the  first  stage  a 
triangular  shape  is  produced  with  the  apex  downward,  while  the  lobe  of  the 
ear  is  raised  in  a  characteristic  manner. 

Prognosis. — The  prognosis  is  favorable,  no  fatal  cases  of  uncompli- 
cated mumps  being  recorded. 

Treatment. — No  means  of  shortening  the  duration  of  the  disease  exists. 
The  patient  should  be  kept  uniformly  warm,  and  to  this  end  the  bed  is  desir- 
able. It  is  usual  to  anoint  the  gland  with  some  simple  ointment,  as  cold 
cream,  and  it  may  be  that  the  feeling  of  drawing  and  tension  is  thus  relieved. 
No  commensurate  advantage  results  from  leeching.  It  is  thought  by  some 
that  the  so-called  metastasis  is  occasioned  by  exposure  to  cold,  and  if  this  be 
true,  there  is  even  better  reason  for  keeping  the  patient  warm.  Warm 
applications  are  generally  better  borne  than  cold.  Cotton  or  wool  or  flannel,, 
warmed  and  greased,  gives  a  sense  of  comfort.  Fever  should  be  treated  by 
appropriate  remedies  and  other  symptoms  met  as  they  arise. 

Secondary  Parotitis. — This  term  is  applied  to  parotitis  occurring  as  a 
complication  in  acute  infectious  diseases,  typhoid  fever,  typhus  fever,  and 
pneumonia  being  the  most  frequent.  It  may  be  a  complication  of  pyemia, 
phthisis,  and  carcinoma.  Except  in  pyemia,  when  it  is  metastatic,  it  is  proba- 
bly caused  by  the  bacteria  of  decomposing  matters  in  the  mouth,  which  reach 
the  gland  through  the  duct  of  Steno. 

It  is  a  much  more  serious  affection  than  mumps,  and  often  terminates 
in  suppuration.  Facial  paralysis  may  result  from  destruction  of  the  facial 
nerve,  or  there  may  be  deafness  from  invasion  of  the  middle  ear. 

The  treatment  of  secondary  parotitis  is  that  of  phlegmonous  inflamma- 
tion elsewhere. 

INFLUENZA. 

Synonyms. — Cdtarrhal  Fever;  Grip ;  Fr.,  La  Grippe: 

Definition. — Influenza  is  an  acute  infectious  disease  characterized  by  fever, 
by  catarrhal  irritation  of  any  or  all  of  the  mucous  tracts,  especially  the  respira- 
tory, by  muscular  pain,  and  by  great  prostration.     It  is  commonly  epidemic. 

Historical. — Although  influenza  appears  to  have  prevailed  as  early  as  1173  in  Italy, 
Germany  and  England,  it  was  not  until  15 10  that  it  was  recognized  in  its  true  light  as 
an  epidemic  or  pandemic  disease.  Since  that  date  it  has  recurred  at  intervals  of 
from  four  years  to  one  hundred  3'ears.  Up  to  1870  more  than  a  hundred  epidemics 
had  been  described.  It  first  appeared  in  the  United  States  in  1627,  in  Massachusetts 
and  Connecticut,  and  extended  thence  over  South  America  as  far  as  Chili.  Since  i88(^ 
there  has  been  an  epidemic  extending  almost  around  the  world.  It  usually  begins  in 
the  east  and  travels  westward.  The  last  epidemic  started  in  Bokhara,  in  May,  i88q, 
reached  St.  Petersburg  in  October,  Berlin  in  November.  London  in  December,  and 
the  eastern  cities  of  the  United  States  by  the  middle  of  December.  While  its  rate  of 
travel  is  rapid,  it  is  not  more  so  than  travel  itself.  Its  spread  is  not  influenced  b}?-  the 
direction  of  prevailing  winds.  It  travels  as  rapidly  against  the  wind  as  with  it.  some 
observers  say  more  rapidly.  A  district  invaded  in  the  fall  of  the  year  is  apt  to  be  in- 
fected more  or  less  for  several  months.  Since  the  epidemic  of  1S89  there  has  been 
some  influenza  each  winter  in  the  epidemic  form  in  many  American  cities. 


INFLUENZA. 


i6- 


Etiology. — In    1892    Pfeiffer   discovered   in   the   pus-cells   of   tracheal 
mucus  an  organism  which  he  regarded  as  that  of  influenza.     It  is  0.8  to  i 

GRAPHIC   CLINICAL   CHART. 


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Fig.  lb. — Chart  of  a  Case  of  Influenza — Medical  Student. 

micron  long  and  o.i  to  0.2  micron  broad — i.  e.,  about  the  same  width  as  the 
bacillus  of  mouse  septicemia  and  half  as  long.  It  forms  colonies  on  glycerin 
agar  twenty-four  hours  after  inoculation,  visible  under  the  microscope  as 
clear,  water-like  drops.  These  drops  do  not  coalesce,  but  remain  separate. 
The  bacilli  are  best  stained  in  dilute  Ziehl-Neelsen  solution  of  carbol  fuchsin 
or  hot  Loeffler  methylene  blue  solution.  Later  studies  tend  to  sustain 
Loeffler's  claim.  The  bacilli  are  very  numerous  in  the  nasal  and  bronchial 
mucus,  whence  they  are  conveyed  to  others,  constituting  a  true  contagiura. 
P.  Canon  has  even  found  them  in  the  blood.  The  contagious  nature  of 
mfluenza  is  further  sustained  by  the  fact  that  it  travels  only  as  fast  as 
people  travel,  even  contrary  to  the  direction  of  prevailing  winds.  The  fact 
that  inoculations  have  thus  far  been  unsuccessful  in  transmitting  the  disease 


i64  INFECTIOUS  DISEASES. 

is,  however,  against  its  contagious  nature.  The  compHcations  and  sequelae  of 
the  disease — pneumonia,  pleurisy,  endocarditis — may  be  the  result  of  a  toxin, 
or  the  bacillus  may  be  transmitted  in  the  blood  to  the  seat  of  secondary 
infection.  One  attack  does  not,  however,  protect  against  a  second,  and  I 
know  persons  who  have  had  an  attack  each  winter  for  several  winters. 

Varieties. — There  is  much  carelessness  at  the  present  day  in  the  appli- 
cation of  the  word  "  grippe."  Commonly,  when  a  person  is  said  to  have 
"  grippe  "  it  means  that  he  has  a  bad  cold  in  the  head,  with  more  or  less 
bronchial  catarrh.  This  seemingly  is  what  Leichtenstern  calls  endemic 
inUuensa  nostras,  pseudo-influenza,  or  catarrhal  fever,  a  special  disease  of 
unknown  etiology,  which  bears  the  same  relation  to  the  true  influenza  as 
cholera  nostras  to  Asiatic  cholera.  In  addition,  Leichtenstern  makes  two 
other  divisions — (i)  epidemic  inflnenza  vera,  caused  by  Pfeiffer's  bacillus; 
(2)£'ndemic  influenza  vera,  which  often  develops  for  several  years  in  suc- 
cession after  a  pandemic,  also  due  to  Pfeiffer's  bacillus. 

Morbid  Anatomy. — The  anatomical  changes  are  those  of  the  compli- 
cations. Whatever  alterations  are  the  direct  result  of  the  disease  itself  for 
the  niost  part  promptly  disappear  after  death. 

Symptoms. — Influenza  has  a  period  of  incubation  of  from  two  to  three 
days  or  longer.  It  attacks  all  ages,  infancy  less  commonly,  more  frequently 
persons  from  twenty  to  fifty  years  old.  The  mode  of  onset  is  by  no  means 
the  same.  The  attack  may  be  ushered  in  by  a  chill  or  continued  chilliness. 
Most  frequently,  perhaps,  there  are  coryza  and  sneezing,  with  or  without 
watering  of  the  eyes.  To  this  succeeds  cough,  to  which  is  commonly 
added,  very  soon,  copious  expectoration.  The  cough  may  be  paroxysmal 
and  be  attended  with  prostration  at  the  end  of  the  spell.  It  is  often  per- 
sistent, while  the  bronchitis  may  pass  into  bronchopneumonia  or  a  croupous 
pneumonia  may  supervene.  Less  frequently,  there  may  be  faucitis,  simple, 
however,  and  not  accompanied  by  ulceration  or  white  patches.  These  symp- 
toms are  more  or  less  associated  with  muscular  pain,  although  not  invariably. 
At  other  times  the  attack  begins  with  severe  pain  in  the  back  or  back  of  the 
head,  the  chest  zvalls,  the  extremities,  or  throughout  the  muscular  system. 
Such  pain  is  sometimes  severe  and  sudden.  Severe  headache  may  be 
associated. 

Another  mode  of  onset  is  by  an  extreme  and  sudden  prostration.  I 
have  known  a  man  to  step  from  a  railroad  station,  apparently  well,  and  in 
the  course  of  a  few  hundred  yards  become  so  weak  as  to  have  to  take  a  car 
to  reach  his  home,  though  not  distant.  This  prostration  is  apt  to  be  pro- 
longed even  in  mild  cases  far  beyond  what  seems  reasonable.  Mental 
depression  is  a  frequent  symptom,  and  suicide  and  even  manslaughter  have 
been  said  to  be  its  terminal  acts. 

There  is  always  more  or  less  fever.  Commonly,  it  is  slight  at  first,  but 
sometimes  very  high,  ushering  in  the  febrile  variety  of  the  disease.  I  have 
known  it  to  be  106.2°  F.  (41.2°  C.)  at  the  first  observation  of  a  patient. 
More  frequently,  it  does  not  exceed  103°  F.  (39.4°  C),  and  it  is  often  but 
slightly  above  normal.  During  convalescence  the  temperature  may  become 
subnormal,  and  in  the  patient  alluded  to  there  was  a  fall  from  106°  F. 
(41.1°  C.)  to  96°  F.  (35.6°  C.)  in  a  very  short  space  of  time.  Further,  the 
temperature  chart  may  exhibit  fantastic  changes,  as  seen  in  that  of  the 
case  of  a  medical  student  who  made  a  good  recovery  after  twenty-eight 
days'  illness  (see  Fig.  16).  Delirium  is  sometimes  associated  with  the 
fever,  and  may  come  on  suddenly  and  actively.     The  pulse  is  usually  cor- 


INFLUENZA.  165 

responding!}'  frequent,  but  some  cases  of  uncommonly  slow  pulse  have  fallen 
under  my  observation. 

While  pulmonary  catarrh  is  perhaps  the  most  frequent  catarrhal  mani- 
festation, it  is  by  no  means  always  present,  even  when  there  are  pulmonary 
symptoms.  I  recall  an  obstinate  case  of  bronchial  spasm  without  any  secre- 
tion whatever.  In  the  epidemic,  especially  of  1893-94,  in  Philadelphia  and 
vicinity,  gastric  catarrh  was  frequent,  producing  distressing  nausea  with 
vomiting,  and  adding  greatly  to  the  physical  weakness.  Severe  vomiting  may 
even  usher  in  the  attack,  especially  in  children.    More  rarely  there  is  diarrhea. 

Herpes  is  sometimes  present.  According  as  one  or  another  set  of 
symptoms  predominates,  the  disease  is  said  to  belong  to  the  respiratory,  nerv- 
ous, gastro-intestinal,  or  febrile  form  of  influenza. 

Complications. — The  most  serious  complication  is  pneumonia.  It  is 
often  invited  by  exposure  during  convalescence  or  in  the  attempt  of  a 
patient  to  fight  out  the  disease  without  giving  up.  In  these  events  it  is 
usually  ushered  in  by  a  chill  and  extends  rapidly  through  the  whole  of  one 
lung  or  even  both  lungs.  When  a  part  of  the  primary  attack,  the  pneumonia 
is  more  apt  to  be  catarrhal  and  circumscribed,  creeping  from  the  bronchi 
into  the  air-vesicles,  and  is  less  serious,  although  it  may  also  be  fatal,  espe- 
cially in  old  persons.  At  other  times  the  inflammation  is  confined  to  the 
minute  bronchioles,  and  we  have  the  physical  signs  of  a  capillary  bronchitis. 
It  may  be  associated  with  pleurisy.  Of  cardiac  and  vascular  complications 
endocarditis,  pericarditis,  irregularity  of  the  heart  unassociated  with  evident 
endocarditis  or  pericarditis,  may  arise.  Sudden  heart  failure  is  to  be  remem- 
bered as  a  possible  cause  of  death,  as  I  have  reason  to  know  from  experience. 

Of  nervous  lesions  meningitis  and  encephalitis  have  been  noted,  even 
abscess  of  the  brain ;  also  neuritis  and  optic  neuritis ;  in  fact,  almost  every 
form  of  nervous  disease,  though  some  of  the  conditions  must  be  referred  to 
errors  of  diagnosis,  cerebrospinal  fever  being  probably  responsible  for  some. 
Herpes,  when  present,  is  probably  a  result  of  neuritis.  Mention  should  not 
be  omitted  of  venous  thrombosis — phlegmasia  alba  dolens — as  a  complication 
of  influenza,  Leyden  and  Guttmann  having  collected  28  cases.* 

A  most  important  fact  to  be  remembered  in  this  connection  is  the  tend- 
ency of  influenza  to  develop  latent  disease  into  active  disease,  and  to  make 
slight  grades  of  organic  affections  more  serious.  This  is  particularly  seen 
in  connection  with  heart  disease  and  kidney  disease.  A  small  albuminuria 
with  no  other  symptoms  may  become,  after  an  attack  of  influenza,  an  in- 
curable and  rapidly  fatal  Bright's  disease.f  A  mild  cardiac  affection, 
scarcely  noticeable  by  its  symptoms,  may  become  a  grave  illness  with 
degeneration  of  muscular  substance  and  dilatation  of  the  cavities. 

Diagnosis. — The  diagnosis  is  ordinarily  easy,  although  doubtless 
during  an  epidemic  many  cases  are  called  influenza  that  are  cases  of  simple 
bronchitis,  faucial  angina,  or  nasal  catarrh.  The  diagnostic  features  in  addi- 
tion to  the  catarrhal  factor  are  the  suddenness  of  attack,  fever  of  short  dura- 
tion, extreme  disproportional  prostration.  Muscular  rheumatic  pains  are 
characteristic,  but  not  always  present.  Cerebrospinal  fever  and  inUiienza  are 
sometimes  confounded.  The  distinction  will  be  considered  when  treating  of 
the  former.  I  have  more  than  once  tjhought  of  a  case  in  its  incipiency 
that  it  was  going  to  be  one  of  typhoid  fever,  but  the  suddenness  of  onset, 
absence  of  the  typical   temperature  of  typhoid,   of  epistaxis,   of   diarrhea, 

*  "  Deutsche  med.  WochenschriEt,"  No.  6,  iSgy. 

t  See  a  paper  by  G.   Baumgarten  on  "  Renal  Affections  Following  Influenza,"    in  "  Transaction 
of  the  Association  of  American  Physicians,"  vol.  x.,  1895. 


i66  INFECTIOUS  DISEASES. 

together  with  the  shorter  duration  of  the  iUness,  turned  the  scale  in  favor 
of  influenza. 

Prognosis. — The  prognosis  is  generally  favorable,  especially  if  the 
patient  goes  to  bed  at  once,  or  at  least  houses  himself.  Such  a  one  is 
almost  sure  to  be  well  in  three,  four,  or  five  days.  It  is  possible,  however, 
for  one  attacked  to  fight  through  the  disease  without  losing  a  day's  time. 
But  especially  unfortunate  is  he  if  he  fails  in  this  attempt  because  of  taking 
cold  or  inability  to  hold  out  longer  against  the  debilitating  effect  of  the  dis- 
ease. In  the  former  he  is  apt  to  have  pneumonia,  in  the  latter  he  has  to 
contend  with  extreme  prostration.  The  prostration  of  the  epidemic  variety 
is  something  peculiar.  The  weakness  is  extreme,  and  the  slightest  effort, 
physical  or  mental,  promptly  convinces  the  patient  of  this.  The  duration 
of  the  weakness  may  be  greatly  prolonged,  months  being  sometimes  neces- 
sary to  overcome  it. 

Treatment. — The  treatment  in  the  majority  of  cases  is  very  simple. 
Rest  in  bed,  without  medicine,  answers  for  a  large  number.  Beyond  this 
the  treatment  is  mainly  symptomatic,  phenacetin,  acetanilid,  or  antipyrin 
being  generally  sufficient  to  subdue  the  pains  when  present.  Quinin  is 
necessary  in  many  cases  to  keep  up  the  strength.  In  ordinary  cases  requir- 
ing such  treatment  I  am  in  the  habit  of  giving  5  grains  (0.324  gm.)  of 
phenacetin  every  four  hours,  alternating  with  2  grains  (0.120  gm.)  of 
quinin  as  often,  omitting  the  former  when  the  pain  has  disappeared,  but 
continuing  the  quinin.  When  the  pains  are  very  severe,  the  phenacetin 
may  be  given  more  frequently  and  even  in  larger  doses.  When  headache 
is  present  caffein  should  be  added  in  doses  of  i  1-2  to  3  grains  (o.i  to  0.3 
gm.).  Larger  doses  of  quinin  may  be  needed.  A  favorite  prescription  at 
the  Hospital  of  the  University  of  Pennsylvania  is  a  capsule  of  2  1-2  grains 
(0.16  gm.)  each  of  Dover's  powder,  salol,  and  phenacetin,  every  two  or  three 
hours.  Another  prescription  is  phenacetin  and  salol,  of  each  21-2  grains 
(0.16  gm.),  and  pilocarpin,  1-12  grain  (0.005  g^i-)-  Still  another  is  phe- 
nacetin and  salicin,  of  each  21-2  grains  (0.16  gm.)  and  powdered  camphor, 
1-2  grain  (0.035  gm.). 

The  cough  may  be  treated  with  turpentine  stupes  and  sinapisms  to 
the  chest ;  and  when  there  are  positive  laryngeal  symptoms,  "  Dobell's  solu- 
tion," sprayed  into  the  larynx,  is  very  useful.  It  may  also  be  sprayed  into 
the  nasal  passages,  or  cocain  may  be  applied  locally.  Internally,  the 
officinal  solution  of  citrate  of  potassium  in  half  fluid  ounces  (15  c.  c.)  doses 
every  two  or  three  hours,  is-.helpful.  When  the  cough  is  disturbing,  small 
doses  of  morphin  or  heroin  may  be  necessary ;  and  if  secretion  has  set  in, 
ammonium  chlorid  in  5-  to  lo-grain  (0.324  to  0.648  gm.)  doses,  with  15 
minims  (i  gm.)  of  syrup  of  squills  and  2  drams  (7.4  c.  c.)  of  compound 
licorice  mixture  are  sufficient  to  answer  the  purpose.  If  more  stimulating 
effect  is  required  on  the  secretion,  the  aromatic  spirit  of  ammonium  in  half- 
dram  doses  (2  gm.),  or  carbonate  of  ammonium  in  doses  of  5  to  10  grains 
(0.324  to  0.648  gm.)  may  be  substituted.  Opium  may  be  given  in  large 
doses,  or  morphin  in  corresponding  doses,  to  relieve  pain,  if  required. 

For  the  prostration,  supporting  measures  are  necessary,  and  stimulants 
may  be  called  for.  Whisky  and  milk  are  efficient.  The  entire  absence  of 
appetite  and  the  complaint  that  all  things  taste  alike  are  to  be  ignored, 
and  the  patient  must  be  encouraged  to  take  food,  which  should  be  made  as 
attractive  as  possible.  Strychnin  is  an  admirable  heart  tonic,  and  may  be 
given,  1-30  grain  (0.00216  gm.),  every  six  hours,  increased,  if  necessary. 


CEREBROSPINAL  FEVER.  167 

Treatment  for  the  pneumonia,  often  so  grave  a  complication,  is  at  times 
-extremely  difficult.  In  a  few  cases  "  pneumonia  fulminans  "  strikes  the 
patient  down  so  suddenly  and  violently  as  to  make  all  treatment  unavail- 
ing. Referring  the  reader  for  details  to  the  section  on  pneumonia,  it  may 
be  said  that,  as  a  rule,  in  the  pneumonia  of  influenza,  stimulating  and  restor- 
ative measures  of  a  very  positive  character,  rather  than  depressing  agents, 
are  indicated.  The  free  use  of  alcohol  and  ammonia  is  especially  necessary. 
Dry-cupping  is  never  out  of  place,  for  it  can  do  no  harm,  if  no  good.  It 
may  be  repeated  and  should  be  followed  during  convalescence  by  a  jacket 
of  wool,  to  maintain  warmth  and  a  uniform  temperature,  but  this  is  of 
doubtful  propriety  during  the  height  of  fever  when  we  need  measures  to 
dissipate  heat  rather  than  to  retain  it. 

One  need  not  wait  for  the  physical  signs  of  pneumonia  to  present 
themselves  before  beginning  the  treatment.  Given  a  chill  after  exposure, 
with  no  other  cause  to  explain  it,  a  pneumonia  is  almost  inevitable.  Often- 
times a  pneumonic  focus  in  the  center  of  a  lung  does  not  furnish  any 
physical  signs,  while  to  wait  until  it  approaches  the  surface  causes  a  fatal 
delay  in  the  treatment. 

Other  complications  of  influenza  are  treated  as  when  they  are  simple 
diseases.     Overmedication  should  be  avoided. 


CEREBROSPINAL   FEVER. 

Synonyms. — Epidemic  Cerebrospinal  Meningitis;  Spotted  Fever;  Petechial 

Fever. 

Definition. — An  infectious  disease  of  sporadic  and  epidemic  occur- 
rence, microbic  in  origin  and  especially  characterized  by  inflammation  of 
the  membranes  of  the  brain  and  spinal  cord. 

Historical — Cerebrospinal  fever  is  a  disease  of  modern  recognition,  for  a  long 
time  confounded  with  typhus  fever,  and  even  with  our  present  knowledge  at  times 
difficult  to  distinguish  from  it.  Its  distinct  recognition  dates  back  no  farther  than 
1805,  when  Vieusseux,  in  Geneva,  pointed  it  out  as  a  separate  disease,  under  the  name 
fievre  cerebrale  ataxigtie,  although  there  can  be  little  doubt  that  it  existed 
previously.  Sir  John  Pringall  describes  in  his  work  on  "  Diseases  of  the  Army," 
published  in  1752,  a  hospital  or  jail  fever  that  resembled  cerebrospinal  meningitis. 
In  his  history  of  "  Epidemic  Pestilences  "  Bascome  speaks  of  a  local  epidemic  in  the 
autumn  of  1802  at  Roettinggen  m  Franconia.  Symptoms  that  almost  conclusively 
point  to  this  disease  are  described  in  the  histories  of  the  great  epidemics  of  Europe 
from  the  thirteenth  century  on.  It  appeared  in  1806  in  this  countr}-  as  an  epidemic  at 
Medfield,  Mass.;  in  Canada  in  1807  ;  in  Virginia,  Kentucky,  and  Ohio  in  1808  ;  in  New 
York  and  Pennsylvania  the  year  after  ;  at  Grenoble  and  Paris,  France,  in  1814  ;  again 
at  Metz  in  181 5.  '  It  disappeared  on  both  sides  of  the  Atlantic  in  1816.  It  reappeared 
at  Vesoul,  France,  in  1822-23,  prevailing  more  particularly  in  barracks,  whence  it 
extended  to  other  places  more  or  less  until  1849.  It  prevailed  in  Italy  from  1839  to 
1845,  and  in  Algiers  from  1839  to  1847.  In  1844  a  short  epidemic  visited  Gibraltar  ;  a 
longer  one,  Denmark  in  1845-48.  It  occurred  in  a  mild  form  in  Great  Britain  in  1846, 
and  malignantly  in  Sweden  in  1854  ;  in  Norway  in  1859-60  ;  in  Holland  brief!)' 
in  1860-61.  Northern  Germany  was  again  invaded  in  1863,  Southern  Germanj'  in 
1864,  and  Baden  and  Hesse  in  the  sarne  year  ;  Austria  and  Russia  mildly  a  year  or 
two  later,  and  in  18&8  Turkev  and  its  adjacent  possessions  mildly. 

In  the  United  States  another  visitation  occurred  in  1822-23  in  Middletown,  Conn., 
and  in  1828  at  Trumbull,  Ohio  ;  again  in  Middletown  in  1842  ,  since  whichtime  it  has 
prevailed  more  or  less  in  all  the  States,  being  especiallj-  severe  in  1863-65  in  Philadel- 
phia and  throughout  the  State  of  Pennsylvania.  It  has  lingered  in  Philadelphia  ever 
since,  isolated  cases  being  annuall^^  reported.  The  number  of  deaths  in  thatcity 
from  1863  to  iSgi  inclusive,  as  collected  by  Alfred  Stille  and  completed  by  William 
Pepper,  was  2575.  Since  i8(_|i  cases  have  occurred  each  year  as  follows  :  1S92,  22 
cases  ;  1893,  35  cases  ;  1894,  18  cases  ;  1895,  17  cases  ;  1896,  7  cases  ;  1897.  10  cases  ; 
1898,  24  cases  ;  1899,  146  cases;  in  1900,  29  cases;  in  1901,  9  cases;  1902,  4  cases.  An 
epidemic  prevailed  in  Maryland  in  1892,  in  New  York  in  1S93,  and  in  Boston  in  1897. 


i68  INFECTIOUS  DISEASES. 

Etiology. — The  direct  cause  of  cerebrospinal  fever  is  believed  to  be  a 
micro-organism  not  altogether  undisputed,  possibly  of  more  than  one 
variety.  It  includes  a  special  lancet-shaped  diplococcus  resembling  the 
pneumococcus  discovered  by  Weichselbaum  in  1887,  and  called  by  him  nien- 
ingococcus  or  diplococcus  intmcellitlaris  meningitidis.  It  lies  within  the 
polynuclear  leukocyte.  Weichselbaum's  observations  were  confirmed  by 
Heubner  *  in  1891,  by  Jaeger  in  1895,  and  by  Councilman,!  Mallory,  and 
Wright  in  1898,  and  Osier  %  in  1899.  In  general  these  observers  favor 
the  view  that  this  organism  is  the  exciting  cause  of  the  disease.  On  the 
other  hand,  A.  Xetter  takes  strong  exception,  and  says  (volume  xvi.,' 
"Twentieth  Century  Practice  of  Medicine,"  p.  191):  "The  pneumococcus- 
can,  without  doubt,  cause  meningitis,  and  in  spite  of  Heubner's  experience, 
tlie  role  of  the  pneumococcus  has  been  most  surely  established  experi- 
mentally." He  regards  the  meningococcus  as  a  degenerate  form  of  the 
pneumococcus.  Osier  §  also  says :  "  That  a  primary  cerebrospinal  menin- 
gitis may  be  due  to  the  pneumococcus  is  universally  acknowledged." 
Mixed  infections  undoubtedly  occur  as  attested  by  all  observers.  Other 
bacteria  found  with  it  are  staphylococcus  pyogenes,  aureus,  citreus,  and  albus, 
the  streptococcus  pyogenes,  pneumococcus,  the  bacillus  coli  communis,  and 
bacillus  lactis  aerogenes.  While  the  disease  may  be  regarded  as  contagious, 
it  is  not  highly  so,  being  somewhat  like  tuberculosis  in  this  respect.  That 
the  infectious  agent  is  always  derived  from  an  infected  person  is  at  least 
doubtful,  the  disease  not  being,  as  a  rule,  traceable  to  another  having  it,, 
but  appearing  to  arise  rather  in  certain  houses  or  localities  where  the  neces- 
sary conditions  prevail.  Xeisser  has  shown  that  the  bacillus  is  transmissible 
by  feeble  atmospheric  currents.  || 

Predisposing  causes  are — cold,  moisture,  exposure,  defective  sanitation. 
Crowded  buildings,  barracks,  and  tenements  have  been  favorite  localities, 
especially  in  Europe.  Depressing  influences  and  the  fatigue  of  long  marches 
favor  it.  During  the  Civil  War  in  America  both  armies  suffered  from  the 
disease,  but  the  mortality  was  not  large.  Sometimes  the  diseasee  prevails 
in  the  country  rather  than  in  the  city.  It  is  more  common  in  the  young, 
attacking  even  infants  of  less  than  a  year  old.  Sex  and  race  seem  to  have 
no  influence  on  the  etiology. 

Morbid  Anatomy. — The  external  appearance  of  the  body  after  death 
is  not  peculiar.  Most  characteristic  are  the  remnants  of  the  eruption, 
petechial  or  herpetic,  but  they  are  not  constant.  The  brain  and  spinal  cord 
are  naturally  the  seats  to  which  we  look  for  morbid  changes,  and  we  find 
every  degree  of  inflammatory  condition,  from  slight  hyperemia,  such  as  may 
be  found  in  any  form  of  infectious  disease,  to  intense  congestion  with 
injection  of  the  pia-arachnoid,  and  finally  a  stage  in  which  pus  and  fibrinous 
deposits,  more  particularly  in  connection  with  the  pia  mater,  are  abundantly 
present.  Higher  degrees  of  hyperemia  involve  even  the  calvarium  as 
well  as  the  dura.     The  arachnoid  spaces  may  contain  serum  and  pus,  but 

*  "Jahrbuch  fur  Kinderlieilknnde,"  i8qi.  and  "Deutsche  med.  Wochenschrift."  iSg?- 

+  "  Epidemic  Cerebrospinal  Meningitis,"  "Report  of  the  State  Board  of  Health  of  Massachu- 
setts, Boston.  18:8." 

i  Cavendish  Lecture,  "  On  the  Etiology  and  Diagnosis  of  Cerebrospinal  Fever,"  "  West  London 
Med.  Tour.,"  iSgg. 

§  Ibid. 

i|  The  follovsring  are  the  characteristic  features  of  this  bacillus  :  It  occupies  a  position  within  the 
polynuclear  leukocytes,  whence  the  adjective  term  intracelliilaris.  It  takes  the  usual  stains,  and  is 
decolorized  by  the  "Gram  method.  It  "forms  on  Loeffler's  blood-serum  "round,  whitish,  shining, 
viscid-looking  colonies,  w^ith  smooth,  sharplv  defined  outlines,  which  attain  a  diameter  of  i  to  i  1-2 
mm.  in  twenty-four  hours  "  (Councilman).  It  is  found  in  the  cerebrospinal  exudate,  and  has  been 
isolated  from  blood,  from  pus  from  the  joints,  from  pneumonic  areas  in  the  lungs,  and  from  nasal 
mucus. 


CEREBROSPINAL  FEVER.  169 

it  is  under  the  pia  mater  that  we  look  for  the  inflammatory  products — 
serous,  fibrinous,  or  purulent,  especially  at  the  bottom  of  the  sulci  in  the 
longitudinal  and  Sylvian  fissures  and  at  the  base  over  the  pons,  the  chiasm, 
and  cerebellum.  To  a  less  degree  the  convexity  of  the  brain  is  also  involved, 
and  even  the  brain  substance  may  share  in  the  hyperemia,  while  actual 
softening  has  been  noted.  Adhesions  between  the  pia  and  the  cortex  are 
common,  removal  of  the  pia  carrying  the  substance  of  the  cortex  with  it. 
More  rarely  there  is  an  effusion  into  the  ventricles  and  the  choroid  plexus  is 
congested.  The  walls  of  the  ventricles  may  be  softened,  and  in  cases  of  long 
standing  there  is  even  hydrocephalus. 

The  cranial  nerves,  especially  the  auditory  and  optic,  may  be  the  seat 
of  a  neuritis,  or  bathed  in  pus  infiltrating  the  lyrnph-sheaths.  The  muscular 
and  trophic  phenomena  resulting  from  such  involvement  may  be  per- 
manent. 

The  spinal  membranes  are  similarly  hyperemic,  even  to  the  extent  of 
extravasation  of  blood  at  times.  The  same  inflammatory  products  are 
found  upon  them  as  on  the  meninges  of  the  brain.  They  are  more  fre- 
quently seen  on  the  posterior  aspect  of  the  cord,  but  may  be  general. 
Ounces  of  pus  have  been  removed  from  the  spinal  canal.  Even  the  central 
spinal  canal  has  been  found  dilated  and  filled  with  pus.  There  may  be 
likewise  inflammation  of  the  substance  of  the  cord.  The  roots  of  the 
spinal  nerves  may  be  compressed  by  exudate,  producing  localized  paralysis, 
or  may  be  themselves  the  seat  of  a  neuritis,  whence  the  characteristic  clonic 
muscular  contractions  often  present,  while  the  irritation  of  the  sensory 
roots  gives  rise  to  more  or  less  intense  pain.  Certain  malignant  cases  are  of 
so  short  duration  that  there  is  no  time  for  morbid  changes  to  occur.  In 
such  the  results  of  necropsy  are  negative. 

Minutely  examined,  the  exudate  consists  of  polynuclear  leukocytes 
inclosed  in  a  fibrinous  mass  in  which  also  diplococci  are  found.  The  brain 
and  cord  may  also  be  infiltrated  with  pus-cells.  In  the  more  chronic  cases 
there  is  thickening  of  the  meninges,  with  scattered  yellow  patches  represent- 
ing exudate. 

As  to  other  organs,  there  is  no  characteristic  involvement.  The  spleen 
may  be  normal  in  size  or,  if  the  illness  has  lasted  some  time,  it  may  be 
slightly  enlarged.  There  may  be  congestion  of  the  liver,  kidney,  stomachy 
and  intestines,  and  even  extravasation  of  blood.  The  same  is  true  of  the 
lungs,  in  which  there  may  be  bronchitis  or  pneumonia,  the  latter  not  very 
rarel3^     Endocarditis  and  pleurisy  are  sometimes  found. 

Symptoms. — Cerebrospinal  fever  does  not  present  an  unvarying  pic- 
ture in  its  symptomatology,  and  to  attempt  to  portray  every  unusual  symp- 
tom would  occupy  undue  space.  Several  varieties  are  described,  viz.,  (i)  the 
ordinary  form,  (2)  the  malignant  form,  (3)  the  mild  form,  (4)  the  abortive 
form,  (5)  the  intermittent  form,  (6)  the  chronic  form.  Only  the  most  char- 
acteristic symptoms  will  be  given,  first  of  the  ordinary  form  and  then  of 
the  most  important  modifications  of  it. 

I.  The  Ordinary  Form.  No  definite  time  of  incubation  is  known. 
A  prodromal  period  of  short  duration  with  headache  and  pain  in  the  back  or 
headache  and  vertigo  may  precede,  but, sudden  onset  is  characteristic,  often 
associated  with  a  decided  chill.  Projectile  vomiting  is  also  a  frequent  early 
symptom.  Headache  and  pain  in  the  hack  of  the  neck  and  back  promptly 
appear.  Though  usually  severe,  this  pain  is  sometimes  so  slight  as  to  cause 
the  real  condition  to  be  overlooked.     It  is  sometimes  so  sudden  and  severe- 


170  INFECTIOUS  DISEASES. 

as  to  be  compared  to  the  sting  of  a  bee.  The  muscles  are  rigid,  and  pain  is 
increased  on  motion. 

There  is  fever,  but  the  temperature  does  not  usually  exceed  102°  F. 
(38.9°  C).  There  is  nothing  characteristic  in  the  fever,  and  the  graphic 
chart  shows  no  regular  evening  rise  and  morning  fall.  On  the  other  hand, 
it  is  extremely  irregular.  Hpyeresthesia  of  the  skin  is  a  characteristic 
symptom.  It  is  sometimes  extreme,  and  as  the  disease  increases  in 
severity  rigidity  of  the  muscles  of  the  neck  and  back  becomes  more 
marked.  This  muscular  contraction  may  cause  backward  curvature  of 
the  head  and  even  opisthotonos.  Clonic  spasm  may  also  occur,  though 
less  frequent  than  tonic  contraction.  It  is  more  common  in  children, 
in  whom  it  may  amount  to  convulsion  and  take  the  place  of  the  chill. 
Spasm  of  the  muscles  of  the  face  may  occur,  and  of  the  eye-muscles,  causing 
strabismus.  Strabismus  in  any  febrile  case  of  doubtful  nature  should  always 
lead  to  suspicion  of  meningitis.  On  the  other  hand,  there  may  be  paralysis 
of  the  face  and  eye-muscles,  producing  inequality  of  pupils,  nystagmus,  di- 
plopia, and  ptosis.  More  rarely  there  are  paralysis  and  wasting  of  trunk 
muscles,  including  those  of  respiration.  The  auditory  nerves  may  be  involved, 
affecting  the  hearing,  and  intolerance  of  sound  is  a  characteristic  symptom, 
as  is  also  photophobia  due  to  hyperemia  of  the  retina. 

Delirium  is  very  frequent,  occurs  early  in  the  disease,  and  may  pass 
into  stupor  or  coma.  The  delirium  may  be  maniacal,  considerable  effort 
being  necessary  to  control  the  patient. 

It  has  been  stated  of  the  temperature  in  this  disease  that  it  is  rarely 
high.  In  some  of  the  earliest  descriptions  of  the  disease — and  there  have 
been  most  interesting  ones  written  almost  a  century  ago — the  writers  speak 
of  the  skin  as  being  cool.  This  was  before  the  days  of  the  clinical  ther- 
mometer and  the  accurate  measurement  of  temperature  growing  out  of 
it.  High  temperatures  do  occur,  though  rarely,  105°  F.  and  106°  F.  (40.5° 
and  41.1°  C.)  being  noted,  and  others  even  higher  just  before  death.  There 
is,  however,  no  constant  type.  The  temperature  chart  of  the  intermittent 
form  resembles  somewhat  that  of  remittent  fever,  while  sometimes  the  chart 
resembles  that  of  the  fastigium  of  typhoid  fever  in  its  spike-like  delineation. 

The  pulse  goes  hand  in  hand  with  the  temperature — that  is,  it  is  not 
very  frequent  at  first,  at  least  in  adults.  As  the  disease  advances  it  grows 
more  feeble  and  more  frequent  as  the  result  of  increasing  debility  of  the 
patient.  So,  too,  the  breathing  rate  is  not  apt  to  be  markedly  influenced 
unless  there  be  a  lung  computation. 

The  urine,  as  in  other  infectious  fevers,  may  be  scanty  and  albuminous ; 
but  it  may  also  be  increased  because  of  the  involvement  of  the  nervous 
system.  For  a  like  reason  there  is  sometimes  glycosuria,  and  occasionally  in 
^severe  cases  Cheyne-Stokes  breathing. 

Another  characteristic  symptom  is  the  eruption,  although  it  is  not 
present  in  more  than  one-half  the  cases.  It  is  of  at  least  two  kinds — 
herpetic  and  petechial.  Herpes  labialis,  although  not  always  present,  is 
nevertheless  more  frequent  than  in  pneumonia.  The  herpes  may  be  noted 
elsewhere  than  on  the  face — viz.,  on  the  trunk  and  extremities,  extending 
exceptionally  even  to  the  ends  of  the  fingers.  The  contents  of  the  vesicles 
may  be  purulent ;  they  may  coalesce  and  break  and  dry,  forming  crusts. 
The  petechial  eruption  is  more  general.  It  is  an  extravasation,  and,  like  the 
similar  eruption  in  typhus,  does  not  disappear  on  pressure.  The  number 
of  spots  varies  greatly ;  there  may  be  only  a  few,  or  they  may  be  very 


CEREBROSPINAL  FEVER.  171 

numerous,  fully  justifying  one  of  the  names  of  the  disease — spotted  fever. 
It  will  not  do,  however,  to  exclude  the  disease  by  reason  of  the  absence 
of  these  skin  symptoms.  The  petechial  eruption  seems  less  common  in 
the  sporadic  than  in  the  epidemic  form. 

Other  eruptions,  as  erythema,  urticaria,  sudamina,  rose-colored  spots 
like  those  of  typhoid  fever,  pemphigus  and  ecthyma,  have  been  noted. 
Gangrene  of  the  skin  has  occurred  as  the  result  of  pressure.  Some  trophic 
influence  may,  however,  be  responsible  for  it. 

Arthritis  is  not  infrequent,  varying  in  different  epidemics,  reaching 
nearly  20  per  cent,  of  the  severe  cases  in  the  epidemic  described  by  S.  Flexner 
and  L.  S.  Barker.*  The  arthritis  is  deforming  and  is  analogous  to  the 
arthropathies  more  or  less  common  in  spinal  cord  diseases. 

Sometimes  the  disease  sets  in  with  diarrhea,  though  more  commonly 
there  is  constipation.  The  tongue  is  less  apt  to  be  dry  than  in  typhus,  prob- 
ably because  the  patient  is  less  disposed  to  breathe  through  his  mouth. 
Jaundice  has  been  met  with,  and  may  be  due  to  infectious  inflammation  of  the 
bile-ducts. 

Leukocytosis  is  a  constant  symptom,  increase  being  chiefly  of  the  mul- 
tinuclear  variety  of  white  cells.  Vacuolation  of  blood  cells  has  also  been  noted. 

Kernig's  Sign. — Kernig,  of  St.  Petersburg,  called  attention  to  a  symp- 
tom which  is  at  times  a  valuable  aid  to  diagnosis  in  meningitis  where 
the  spinal  membranes  are  involved.  It  is  tested  for  in  the  following 
way :  The  patient  is  propped  up  in  bed  in  a  sitting  posture,  with  the  thighs 
flexed  upon  the  abdomen  and  the  legs  partially  flexed  upon  the  thighs, — a 
position  commonly  assumed  by  patients  with  prolonged  spinal  meningitis. 
An  attempt  is  then  made  to  extend  the  leg,  when  it  will  be  found  to  be 
resisted  by  contraction  of  the  flexor  muscles,  preventing  its  full  straight- 
ening. In  the  recumbent  position  the  leg  can  be  straightened.  When 
the  patient  cannot  sit  up  in  bed,  the  thigh  may  be  flexed  upon  the  abdomen 
and  then  an  attempt  made  to  extend  the  leg,  which  again  fails  if  meningitis 
be  present.  Friis  found  the  sign  in  53  out  of  63  cases,  Netter  in  45  out  of 
50,  and  J.  B.  Herrick  in  17  out  of  19.  f  It  is  said  to  be  present  in  all  cases 
of  spinal  meningitis,  but  is  especially  characteristic  of  the  acute  cerebro- 
spinal form.  It  is  apparently  no  measure  of  the  degree  of  intensity  of  the 
disease.  Netter  explains  it  as  follows :  "  In  consequence  of  the  inflamma- 
tion of  the  meninges  the  roots  of  the  nerves  become  irritable,  and  the  flexion 
of  the  thighs  upon  the  pelvis  when  the  patient  is  in  the  sitting  posture  elon- 
gates and  consequently  stretches  the  lumbar  and  sacral  roots,  and  thus 
increases  their  'irritability.  The  attempt  to  extend  the  knee  is  insufficient 
to  provoke  a  reflex  contraction  of  the  flexors  while  the  patient  lies  on  his 
back  with  the  thighs  extended  upon  the  pelvis,  but  it  does  so  when  he 
assumes  a  sitting  posture." 

The  Babinski  or  extension  toe  reflex  (see  p. 849) may  be  sought,  though 
it  is  inconstant  and  occurs  in  hemiplegia  and  other  results  of  lesions  of 
the  motor  tract. 

II.  Malignant  Form. — The  malignant  form  of  cerebrospinal  fever  is 
characterized  by  the  suddenness  of  its  onset  and  severity  of  its  cardinal 
symptoms, — the  chill,  headache,  coma,  ,collapse, — followed  by  early  fatal 
termination.  There  is  little  or  no  fever;  indeed,  the  temperature  may  be 
subnormal.    The  pulse  is  feeble  and  slow,  falling  to  50  or  60  a  minute,  increas- 

*  "  Am.  Jour,  of  the  Med.  Sci.,"  i8q4,  vol.  cvii. 
t  '■  Am.  Jour,  of  the  Med.  Sci.,"  July,  iSgg. 


172  INFECTIOUS  DISEASES. 

ing,  however,  in  frequency  as  the  disease  progresses.  The  breathing  is 
labored.  The  urine  is  scanty  and  albuminous.  But  for  the  prevalence  of 
the  epidemic  such  fulminating  cases  could  not  be  distinguished  from  like 
attacks  of  other  infectious  diseases.  Such  cases  may,  however,  occur  even 
sporadically.  They  may  last  but  a  few  hours.  They  are  more  frequent 
in  the  beginning  of  an  epidemic.  The  malignant  form  of  smallpox  is 
similar,  and  the  presence  of  an  epidemic  of  one  or  other  disease  must  settle 
the  question. 

11 L  The  mild  form  presents  a  corresponding  mildness  of  symptoms, 
and  only  the  presence  of  an  epidemic  leads  to  its  recognition. 

IV.  The  abortive  form  terminates  abruptly  after  a  sharp  development 
of  characteristic  symptoms. 

V.  The  intermittent  form  is  characterized  by  remissions  and  exacer- 
bations in  the  fever  every  day  or  second  day,  without,  however,  the  reg- 
ularity of  intermittent  fever,  for  which  it  is  sometimes  mistaken.  The  fever 
resembles  rather  that  of  pyemia. 

VI.  Finally,  the  term  chronic  form  is  applied  to  cases  prolonged  beyond 
the  usual  duration,  in  which  the  headache,  gastric  irritability,  and  vague 
neuritic  pains  reduce  the  patient  to  such  an  extremity  of  exhaustion  and 
emaciation  that  he  welcomes  death  as  a  relief  to  his  suffering ;  or  partial 
recovery  may  take  place  with  crippled  motion,  defective  senses,  and  severe 
pains,  which  are  a  source  of  constant  discomfort.  On  the  other  hand,  some 
remarkable  recoveries,  even  in  these  advanced  stages,  are  reported,  so  that 
one  should  not  be  discouraged  from  continuing  therapeutic  effort. 

Complications  and  Sequelae. — Of  the  complications  of  cerebrospinal 
fever,  croupous  pneumonia  has  already  been  mentioned  as  not  infrequent 
as  well  as  that  it  is  sometimes  difficult  to  say  which  disease  is  primary. 
The  initial  chill  and  herpes  are  characteristic  of  both  affections,  and  close 
attention  to  other  conditions  must  be  given,  such  as  the  presence  or  absence 
of  an  epidemic,  the  order  of  appearance  of  the  symptoms,  the  nervous  and 
muscular  preceding  in  cerebrospinal  fever,  and  coming  on  later  in  pneu- 
monia. Other  complications  are  those  which  not  infrequently  accompany 
infectious  diseases,  including  pleurisy,  endocarditis,  pericarditis,  polyarthritis 
with  possible  suppuration,  and  others. 

Of  the  sequelae  the  most  important  are  blindness  due  to  optic  neuritis' 
and  more  rarely  keratitis,  deafness  from  disease  of  the  labyrinth,  paralysis 
more  or  less  extensive,  invading  especially  groups  of  muscles,  including 
those  of  the  face.  There  may  be  aphasia  and  defective  articulation.  There 
may  be  also  persistent  headache,  shooting  muscular  pains,  and  mental 
weakness.  Next  to  scarlet  fever  cerebrospinal  meningitis  is  the  most  fre- 
quent cause  of  deafness.  Even  chronic  hydrocephalus  and  abscess  of  the 
braiih  are  included  among  sequelae.  Von  Ziemssen  says  the  former  is  indi- 
cated by  "  paroxysms  of  severe  headache,  pain  in  the  neck  and  extremities, 
without  vomiting,  loss  of  consciousness,  convulsions,  and  involuntary  dis- 
charges of  feces  and  urine."  He  also  says  that  of  the  deaf  and  dumb  in 
the  institutions  of  Bamiberg  and  Nuremberg,  in  1874,  a  majority  of  the 
pupils  had  become  deaf  from  cerebrospinal  meningitis. 

N'asal  catarrh  may  be  an  early  symptom,  and  Striimpell  suggests  it 
may  precede  and  be  the  starting  point  of  the  invasion.  The  discharge  often 
contains  the  meningococcus,  as  in  ten  out  of  fifteen  cases  in  the  Boston  epi- 
demic alluded  to. 

Diagnosis. — The  diagnosis  in  epidemic  cases  is  usually  easy,  although 


CEREBROSPINAL  FEVER.  173 

it  is  more  than  probable  that  under  such  circumstances  some  cases  are 
classified  as  cerebrospinal  fever  when  they  are  really  something  else.  Dur- 
ing epidemics  typhus  fever  is  the  disease  with  which  it  is  most  frequently 
confounded,  especially  as  epidemics  of  typhus  and  cerebrospinal  fever 
sometimes  prevail  jointly.  The  difficulty  is  greatest  at  the  beginning  of 
the  attack,  for  as  time  passes  the  diseases  diverge  in  symptoms.  Typhus 
fever  is  not  characterized  by  the  severe  pains  in  the  head  and  back  of  the 
neck,  nor  by  opisthotonos,  both  of  which  may,  however,  be  absent  in 
cerebrospinal  fever,  or  be  so  slight  as  not  to  attract  attention.  In  typhus 
fever  the  spots  are  more  constant  and  numerous  than  in  cerebrospinal  fever. 
Herpes  does  not  occur  in  typhus.  The  typhoid  state  may  be  equally  pro- 
nounced in  both,  but  in  general  it  may  be  said  to  be  more  marked  in  typhus. 
The  two  diseases  differ  in  their  duration,  typhus  having  a  pretty  definite 
duration  of  about  two  weeks,  whereas  cerebrospinal  fever  is  either  shorter 
or  longer. 

Among  the  diseases  which  embarrass  is  muscular  rheumatism;  more 
frequently  than  with  typhus  fever,  perhaps,  is  it  confounded  at  the  onset 
with  this  disease.  The  muscular  pains  are  similar,  but  the  headache  in 
cerebrospinal  fever  is  a  point  of  difference.  Hence,  too,  as  the  disease 
advances,  the  diagnosis  becomes  plainer.  The  joint  complications  not  infre- 
quently associated  also  cause  a  resemblance  to  articular  rheumatism,  which 
may  lead  to  confusion  at  first. 

The  isolated  cases  give  most  trouble.  Typhoid  fever,  especially  the 
meningeal  form  of  typhoid,  in  which  there  is  extreme  headache  and  active 
delirium,  simulates  cerebrospinal  fever  in  the  beginning  not  a  little,  and  I 
have  known  consultants  to  hold  different  views  for  some  days.  With  the 
lapse  of  time,  however,  the  diagnosis  may  generally  be  made.  The  onset  of 
typhoid  is  also  slow ;  as  a  rule,  there  is  no  vomiting  nor  severe  muscular  pain. 

Pneumonia  is  another  source  of  confusion,  especially  as  the  two 
•diseases  are  sometimes  associated,  and  it  is  almost  impossible  to  say  which 
is  primary.  Should  it  prove  that  the  meningococcus  is  the  sole  cause  of 
primary  cerebrospinal  fever,  and  the  pneumococcus  characterizes  only  the 
secondary  form  associated  with  pneumonia  or  one  of  the  sporadic  primary 
forms,  the  bacteriological  examination  will  be  of  great  assistance.  The 
meningeal  complications  in  pneumonia  are  more  apt  to  invade  the  convexity, 
whence  there  arise  muscular  contraction  and  tremor,  but  not  retraction  of 
the  head. 

Tubercular  meningitis  presents  some  resemblance  to  cerebrospinal 
fever.  While  usually  less  sudden  in  its  development,  it  is  not  always  so. 
Delirium  and  stiffness  of  the  neck,  retraction,  and  even  opisthotonos  occur. 
It  is,  however,  scarcely  ever  primary,  and  there  are  no  skin  symptoms. 
The  termination  of  tubercular  meningitis  is  invariably  fatal.  The  presence 
of  a  focus  of  tuberculosis  is  a  great  aid  to  diagnosis. 

Influensa,  too,  in  one  of  its  many  forms  occasionally  simulates  cere- 
"brospinal  fever,  at  times  very  closely.  Extreme  muscular  pain  is  character- 
istic of  both,  and  when  influenza  is  associated  with  actual  cerebrospinal 
meningitis,  with  delirium  and  stupor,  as  it  sometimes  is,  one  may  be  excused 
for  being  in  doubt.  Although  both  ai;e  diseases  of  short  duration,  influ- 
enza spends  its  fury  earlier,  and  is  thus  a  shorter  disease  unless  prolonged 
lay  one  of  its  complications.  This  feature,  if  other  characteristic  symptoms 
are  wanting,  may  help  us  to  a  decision. 

Quincke's  lumhat'  punctw'e  may  be  necessary  to  establish  a  diagnosis. 


174 


INFECTIOUS  DISEASES. 


The  operation  is  done  with  the  patient  lying  on  the  right  side,  with  knees 
drawn  up,  and  the  left  shoulder  turned  forward.  The  needle  of  a  large 
h}-poderniic  syringe  or  antitoxin  syringe  is  introduced  midway  between  the 
third  and  fourth  or  the  fourth  and  fifth  lumbar  vertebrae,  below  the  spinous 
process,  a  little  to  one  side  of  the  median  line,  the  thumb  of  the  left  hand  of  the 
operator  being  placed  between  the  spinous  processes  as  a  guide.  The  needle 
should  enter  one  centimeter  from  the  median  line  on  a  level  with  the  thumb. 


Fig.  17. — Method  of  Puncture  for  Spinal   Drainage.     A.  Quincke's  site.     B. 
Maxfan's  site.    C.  Chipault's  site. — {Chipault.) 

and  be  directed  slightly  upward  and  inward.  At  the  depth  of  two  centi- 
meters in  infants  and  four  to  six  in  adults  it  should  enter  the  canal.  The 
syringe  should  be  unscrewed  and  the  fluid  allowed  to  fall,  drop  by  drop,  into 
a  sterilized  test-tube,  care  being  taken  not  to  allow  it  to  run  down  the  side  of 
the  tube.  Five  to  fifteen  cubic  centimeters  should  be  withdrawn,  for 
chemical,  bacteriological,  and  microscopical  examination.  A  faint  trace  of 
albumin  is  found  in  normal  cerebrospinal  fluid.  It  may  be  increased  in  cere- 
brospinal meningitis.  A  cloudy  fluid  is  almost  always  present  in  epidemic 
meningitis ;  rarely,  it  may  be  clear,  or  the  fluid  from  an  upper  puncture  may 
be  clear,  and  from  a  lower  turbid.  In  tuberculous  meningitis  it  is  clear. 
Blood  may  be  present  in  the  former. 

Prognosis. — Cerebrospinal  fever  is  a  grave  disease,  but  the  mortality 
varies  greatly  in  different  epidemics,  ranging  from  20  to  75  per  cent, 
according  to  Hirsch,  while  v.  Ziemssen  places  it  for  mild  epidemics  at  30 
per  cent.,  and  for  severe  ones  at  70  per  cent.  The  death-rate  is  higher  for 
children,  those  under  two  years  almost  invariably  perishing,  while  few  under 
five  survive.     The  old  likewise  succumb  easily. 

Of  few  diseases  is  the  course  more  variable  and  uncertain.  From  a 
duration  of  two  to  three  days  only  it  may  be  prolonged  to  weeks  and  even 
months,  and  its  consequences  may  be  permanent.  Usually,  ho\\^ver, 
improvement  may  be  looked  for  if  the  patient  survives  five  days,  more  than 
half  the  deaths  occurring  within  this  period.  A  remission  of  symptoms 
may  take  place  on  the  third  day,  to  be  followed  after  a  very  short  time  by 
a  relapse.     This  often  misleads  and  gives  the  illusive  hope  of  permanent 


CEREBROSPINAL  FEVER.  175. 

improvement.  Convalescence  is  characteristically  slow,  the  symptoms, 
yielding  gradually.  If  the  termination  be  fatal,  the  cardinal  symptoms  like- 
wise gradually  subside,  but  are  replaced  by  growing  debility  and  exhaus- 
tion. 

Relapses  are  prone  to  occur,  prolonging  the  case  indefinitely,  while  a. 
chronic  or  protracted  form,  to  which  reference  has  been  made,  is  probably 
due  to  the  presence  of  one  of  the  persistent  or  progressive  lesions  above 
referred  to. 

Sporadic  Cerebrospinal  Fever. — This  form  of  cerebrospinal  fever 
requires  a  separate,  though  brief,  consideration.  It  has  been  already  said 
that  such  cases  occur  at  intervals,  and  more  especially  at  odd  times  succeed- 
ing the  prevalence  of  an  epidemic  in  a  city.  Osier,  in  his  Cavendish  lec- 
ture, 1899,  has  taken  some  pains  to  analyze  the  cases  of  cerebrospinal 
meningitis  treated  at  the  Johns  Hopkins  Hospital,  Baltimore,  with  a  view 
to  ascertaining  what  proportion  was  strictly  sporadic  and  non-complicating. 
He  finds  that  after  eliminating  pneumococcic  meningitis  complicating  pneu- 
monia and  pneumococcic  meningitis  due  to  local  infection  and  streptococcic 
cases  of  the  same  class  (surgical  cases),  there  remained  a  few  primary  cases, 
due  to  the  pneumococcus,  a  few  of  miscellaneous  meningitis — i.  e.,  caused  by 
unidentified  bacilli — and  a  few  due  to  the  diplococcus  intracellularis.  The 
whole  question  is,  however,  unsettled  because  of  the  confusion  that  has. 
existed  until  more  lately  of  the  pneumococcus  with  the  diplococcus  intra- 
cellularis. 

Treatment. — The  treatment  of  cerebrospinal  fever  is  symptomatic 
and  supporting.  Quiet  and  the  absence  of  disturbing  causes,  such  as  excess, 
of  light,  too  much  company,  are  absolutely  essential.  The  food  should  be 
simple  and  liquid,  with  an  abundance  of  water.  The  symptom  demanding 
the  promptest  relief  is  pain,  and  for  this  there  is  no  substitute  for  opiates^ 
and  of  these  the  best  preparation  is  morphin,  and  the  best  mode  of  adminis- 
tration is  by  hypodermic  injection.  Doses  sufficient  to  accomplish  their 
purpose  should  be  given,  say  1-4  grain  (0.016  gm.)  to  1-2  grain  (0.032- 
gm.),  night  and  morning,  for  an  adult.  The  tolerance  for  the  drug  is. 
great.  It  may  be  combined  with  1-150  grain  (0.00054  gm.)  to  i-ioo  grain 
(0.00064  gm.)  of  atropin.  The  same  preparation  may  be  given  by  the 
mouth  if  the  hypodermic  administration  is  not  convenient,  but  the  deodorised 
tincture  of  opium  may  be  better  borne,  and  where  the  more  frequent  admin- 
istration of  opiates  is  necessary,  as  hourly  or  bihourly,  this  preparation  is 
to  be  preferred  because  of  the  possible  harmful  effects  of  the  too  frequent 
use  of  the  hypodermic  syringe.  The  action  of  the  drug  is,  of  course,  to 
be  carefully  watched.  Phenacetin,  antipyrin,  salicylic  acid,  and  this  class 
of  drugs  are  no  substitute  for  opium  in  this  painful  malady.  Hot  baths 
may  be  employed  for  the  same  purpose. 

When  there  are  spasms  or  convulsions  there  is  no  remedy  equal  to 
chloral.  If  it  cannot  be  administered  by  the  mouth,  a  dram  (4  gm.)  dis- 
solved in  2  ounces  (60  c.  c.)  of  water  may  be  given  to  an  adult,  without 
hesitation,  per  rectum.  In  extreme  cases  chloroform  or  ether  may  be 
inhaled  for  the  same  purpose.  The  bromids  may  be  used  as  adjuvants  in 
mild  cases,  but  of  themselves  are  altogether  inefficient. 

Cold  may  be  applied  to  the  head  for  the  headache  and  other  meningeal 
symptoms,  and  is  best  used  in  the  shape  of  an  ice-cap  or  ice-bladder  or 
Leiter's  coil.  Cold  may  also  be  applied  to  the  back  of  the  neck  and  spine, 
and  according  to  James  Barr  over  the  splanchnic  region.     These  measures 


176  INFECTIOUS  DISEASES. 

must  be  discontinued  when  the  temperature  falls  to  normal.  Counter  irrita- 
tion to  the  back  of  the  neck  and  spine  has  long  been  employed,  chiefly  by 
blisters.  At  the  present  day  it  is  regarded  as  of  doubtful  value.  The 
Paquelin  cautery,  which  has  been  of  late  much  recommended  as  a  substitute 
for  the  blister,  can  do  no  harm  applied  to  the  back  of  the  neck.  The  incon- 
venience is  less  than  is  commonly  supposed,  and  the  ulcer  heals  rapidly. 
Cupping  and  leeching  in  the  same  localities,  followed  by  warm  fomentations, 
may  be  useful.  They  relieve  the  pain  for  a  time  at  least.  General  bleeding 
is  not  recommended.  Free  movements  of  the  bowels  must  be  maintained  by 
castor  oil  or  calomel,  and  the  bladder  watched. 

Qninin  may  be  given  in  tonic  doses  of  six  to  eight  grains  (3.8  to  5.9 
gm.),  but  not  for  any  specific  end,  while  large  doses  are  harmful,  causing 
cerebral  irritation.  Measures  of  a  very  decided  character  to  reduce  the  tem- 
perature are  not,  as  a  rule,  needed.  Simple  sponging  suffices  for  the  most 
part.  Should  this  be  insufficient,  however,  tub  bathing  may  be  used  as  in 
typhoid  fever. 

The  nourishment  should  be  of  the  best,  including  animal  broths  and 
milk,  and  where,  as  is  frequently  the  case  in  the  early  stages,  they  cannot 
be  tolerated  by  the  stomach,  they  may  be  given  peptonized  per  rectum,  not 
more  than  4  ounces  (120  c.  c.)  at  one  time.  I  have  thus  nourished  for 
several  days  until  the  stomach  became  retentive  a  case  despaired  of,  which 
ultimately  recovered.  Forced  alimentation  by  the  stomach-tube  is  recom- 
mended by  Heubner.  Alcohol  is  contra-indicated  in  the  early  stages  unless 
there  be  unusual  adynamia.  Later,  when  exhaustion  begins  to  show  itself, 
it  may  be  used  and  pushed  as  under  similar  conditions  in  other  diseases. 

There  are  no  specifics  that  have  sustained  the  efficiency  claimed  for 
them.  The  bichlorid  of  mercury  and  iodid  of  potassium  have  been  most 
praised,  and  the  former  drug  may  be  administered  from  the  onset  with  some 
reasonable  expectation  that  it  may  be  useful  in  doses  that  need  not  be  harm- 
ful if  not  beneficial.  Such  doses  would  be  1-24  grain  (0.0027  gm.)  every 
two~  or  three  hours  for  an  adult,  suitably  reduced  for  children.  Mercurial 
inunctions,  which  have  been  much  used,  are  still  recommended  by  v.  Ziems- 
sen,  although  he  admits  them  to  be  of  doubtful  efficacy.  Inunctions  of  iodo- 
form ointment,  10  per  cent.,  are  advised  by  D.  R.  Brower.*  The  iodids 
and  mercury  are  indicated  in  the  later  stages  when  there  are  symptoms 
of  exudation. 

The  lumbar  puncture  is  strongly  recommended  by  Williams,  Brower, 
W.  Cuthbertson,  t  and  others,  as  a  curative  measure ;  Wentworth  is  doubt- 
ful ;  Osier  admits  possible  benefit  therefrom.  Laminectomy  and  local 
therapeutics,  including  drainage,  have  not  furnished  encouraging  results  at 
the  Johns  Hopkins  Hospital.:}: 

The  resulting  paralyses  should  be  treated  by  massage  and  electricity, 
and  as  already  suggested  we  should  not  be  discouraged  from  persisting,  as 
remarkable  cures  have  been  accomplished. 

Recently  I  have  used  with  the  most  satisfactory  results  the  subaqueous 
treatment  recommended  by  Goldscheider  §  to  which  my  attention  was 
called  by  Dr.  William  G.  Spiller.  It  consists  in  active  movements  by  the 
patient  while  submerged  in  a  bath  at  a  comfortable  temperature.  The  move- 
ments are  not  passive,  but  active  and  voluntary. 

*  "Clinical  Rev.,"  September,  i8og. 
t  "Chicago  Med.  Recorder,"  June.  i8qq. 
t  Osier,  "Cavendish  Lecture,"  June,  iSqo. 

§  "Ueber  Bewegungstherapie  bei  Erkrankungen  des  Nervensystems,"  Goldscheider,  "  Deutsche 
tnedicini.sche  Wochenschr.,"  January  27,  1898. 


ERYSIPELAS  ly-j 

ERYSIPELAS. 
Synonyms. — The  Rose ;  St.  Anthony's  Fire. 

Definition. — An  acute,  contagious,  primarily  local  disease,  character- 
ized by  dermatitis  with  the  usual  signs  of  inflammation — swelling,  heat, 
pain,  redness,  and  a  peculiar  disposition  to  spread. 

Historical — Erj^sipelas  was  described  b}'  Hippocrates  (B.  C.  480),  who  had  a 
remarkably  clear  conception  of  the  disease.  Its  parasitic  origin  was  first  maintained 
by  Henle  (1840).  Trousseau  first  asserted,  in  184S,  that  an  abrasion  of  the  skin  is  an 
invariable  condition  of  its  origin.  Hueter,  in  1S76,  was  especially  conspicuous  in 
claiming  that  the  disease  owes  its  existence  to  a  micro-organism  residing  in  the  blood. 
Billroth  and  Klebs  held  similar  views,  but  it  was  reserved  for  Koch,  in  1880,  to  settle 
the  question  by  finding  the  specific  streptococcus  in  the  lymph-vessels  and  lymph- 
;spaces  of  the  skin,  though  not  in  the  blood.  Fehleisenmade  the  same  discovery  inde- 
pendently of  Koch  in  18S1,  isolating  and  cultivating  the  erysipelococcus  and  inoculat- 
ing man  with  it.     Orth  had  previousl}'  made  experiments  of  the  same  kind  on  animals. 

Etiology.— The  streptococcus  erysipelatis  of  Fehleisen  is  a  minute,  cleft 
fungus,  a  micrococcus  in  the  narrow  sense,  three  to  four  microns  in  diam- 
•eter,  arranged  in  pairs  (diplococci)  or  chains  (streptococci)  of  from  six  to 
twelve  cells.  The  erysipelococcus  resembles  very  closely  the  streptococcus 
pyogenes  of  Rosenbach — in  fact,  cannot  be  distinguished  from  it  micro- 
scopically, while  even  the  cultures  of  the  two  organisms  resemble  each  other 
very  closely.  The  streptococcus  pyogenes  grows  more  slowly  and  less 
uniformly,  according  to  Hofifa,  than  that  of  erysipelas,  and  presents  also  a 
brownish  discoloration  in  the  middle  of  its  colony.  They  behave  very  simi- 
larly when  inoculated  in  animals.  Simon  asserts  that  the  micrococcus  of 
■erysipelas  is  identical  with  that  of  pyemia.  Klebs  suggests  that  more  than 
one  organism  may  be  concerned  in  the  causation  of  erysipelas. 

The  organism  probably  operates  as  a  local  irritant  producing  the  der- 
matitis. From  this  as  a  focus  constitutional  infection  is  set  up,  as  in  diph- 
theria, probably  through  the  influence  of  a  toxin  generated  by  the  micrococ- 
■cus.  The  bacterium  is  found  in  the  lymph-vessels  and  lymph-spaces  of  the 
periphery  of  the  inflamed  area,  and  not  in  the  center,  by  which  fact  the 
peripheral  spread  of  the  disease  is  explained. 

The  organism  is  transferred  from  one  person  to  another  by  direct  con- 
tact, or  by  the  intermediation  of  a  third  person,  or  through  the  atmosphere. 
It  cannot  be  said,  however,  that  the  disease  is  highly  contagious  in  the 
•absence  of  surgical  injury,  for  in  my  early  experience  as  a  hospital  interne 
■at  the  Pennsylvania  Hospital,  and  later  as  a  visiting  physician  in  the  Phila- 
delphia Hospital,  though  it  was  the  custom  to  keep  the  erysipelas  cases  in  the 
ordinary  medical  wards,  I  cannot  recall  a  single  instance  where  the  disease 
was  communicated  to  another  patient  in  the  ward.  It  was  very  different, 
however,  in  the  surgical  wards,  where  the  disease  would  spread  rapidly  from 
i3ne  patient  to  another,  showing  the  importance  of  the  open  surface  as  a  con- 
dition of  the  spread.  The  lying-in  woman  is  very  readily  inoculated,  so  that 
no  physician  should  attend  a  case  of  labor  while  attending  one  of  erysipelas. 
Certain  kinds  of  wounds,  as  lacerated  wounds  and  scalp  wounds,  are  espe- 
cially prone  to  erysipelas.  Clean-cut  wounds  in  other  locations  suft"er  less 
frequently.  Leech-bites,  vaccination  punctures,  the  wounds  of  the  cupping 
scarificator  and  of  the  subcutaneous  syringe,  are  also  favorable  starting 
points.  Chronic  inflammatory  processes  and  skin  diseases  may  also  have 
erysipelas  engrafted  upon  them. 

Erysipelas  is  prone  to  occur  in  the  epidemic  form,  more  especially  in 

12 


178  INFECTIOUS  DISEASES. 

the  spring  *  of  the  year  in  old  and  unclean  hospitals,  but  such  epidemics  have 
become  much  rarer  in  the  last  twenty  years.  This  is  doubtless  one  of  the 
results  of  antisepsis,  now  so  generally  practiced.  The  feeble,  the  intem- 
perate, and  those  having  Bright's  disease  or  other  affections  weakening- 
natural  resistance,  are  more  prone  to  the  disease.  An  interesting  case  of 
Bright's  disease  under  my  care  in  the  Philadelphia  Hospital  had  frequent 
attacks  of  facial  erysipelas,  always  accompanied  by  hematuria.  Relapses 
and  recurrences  of  erysipelas  are  prone  to  occur,  and  a  person  once  attacked 
by  erysipelas,  far  from  being  protected,  is  rather  predisposed  to  a  second 
attack.     A  family  predisposition  to  erysipelas  may  exist. 

Morbid  Anatomy .^Like  all  acute  inflammatory  states  of  the  skin,^ 
erysipelas  fades  away  after  death  and  leaves  Httle,  if  anything,  to  be  seen 
unless  it  has  proceeded  to  the  formation  of  blebs  or  abscesses.  Swelling  and 
corresponding  deformity  of  the  part,  especially  of  the  face,  when  extensive,, 
may  remain,  but  even  this  subsides  with  the  lapse  of  time  after  death  and 
may  totally  disappear. 

Minute  examination  finds  the  cocci  in  the  lymph-vessels  and  spaces  at 
the  periphery  of  the  inflamed  area,  as  already  stated,  and  even  in  the  unin- 
flamed  tissue  beyond  the  margin. 

Various  complications  attend  erysipelas  and  add  their  morbid  anatomy 
to  that  which  is  more  essentially  that  of  the  disease.  The  most  important 
of  these  are  pyemic  abscesses  of  internal  viscera  and  hemorrhagic  infarcts  of 
the  lung,  spleen,  and  kidneys.  The  kidneys  are  especially  apt  to  be  con- 
gested, and  the  lesions  of  acute  or  subacute  nephritis  are  sometimes  found. 

Symptoms. — The  form  of  erysipelas  which  more  particularly  concerns 
the  physician  is  the  so-called  idiopathic  erysipelas,  which  arises  inde- 
pendently of  any  apparent  traumatic  lesion,  but  since  all  erysipelas  implies 
some  lesion,  however  minute,  the  term  is  a  misnomer.  The  fact  remains, 
however,  that  the  physician  is  most  frequently  called  upon  to  treat  the  form 
of  erysipelas  in  which  there  is  no  discoverable  local  lesion. 

There  is  a  period  of  incubation  of  from  one  to  eight  days,  after  which 
this  variety  of  erysipelas  begins  at  times  with  a  chill  or  succession  of  chills 
associated  with  a  loss  of  appetite  and  feeling  of  general  discomfort.  At 
other  times  the  chill  is  wanting.  In  either  event  there  soon  appears  a  small, 
red,  burning  spot  a  few  lines  in  diameter,  usually  on  the  face,  oftenest  on 
the  bridge  of  the  nose  or  on  the  chin.  It  spreads  rapidly,  and  as  soon  as 
sufficient  size  is  attained  there  is  a  very  characteristic  elevation  of  the  patch 
above  the  surrovmding  tissue^^which  can  be  recognized  by  carrying  the  finger 
across  it.  This  is  of  diagnostic  value.  The  future  extension  of  the  process 
is  upward  over  the  forehead  and  laterally  toward  the  ears  until  the  whole 
face,  and  more  rarely  also  the  neck,  is  invaded.  The  eyes  become  closed  by 
szvelling,  the  features  are  distorted,  and  the  sum  of  changes  produces  an 
appearance  not  soon  to  be  forgotten.  In  other  parts  of  the  body,  as  the 
arms  and  legs,  the  same  process  may  go  on,  but  there  is  not  the  unsightly 
distortion  found  as  in  the  case  of  the  face  and  head.  In  some  cases  the 
process  proceeds  to   suppuration,  and  deep-seated  abscesses  form.     These 

*  The  influence  of  the  seasons  is  very  well  set  forth  by  James  M.  Anders  in  a  paper  on  "Seasona 
Influences  in  Erysipelas,  with  Statistics,"  wherein  he  has' shown,  as  the  result  of  an  analysis  of  2010- 
cases  collected  from  different  sources,  that  the  various  seasons  of  the  year  exercise  a  potent 
influence  upon  the  frequency  of  this  affection.  Thus,  month  by  month  the  cases  increase,  in  slightly 
varying  ratio,  from  August  to  April,  the  latter  montli  giving  the  greatest  number,  and  then  there  is 
a  rapid  decrease  from  April  to  August,  when  we  find  the  smallest  number.  Again,  one-half  of  all 
the  cases  occur  during  the  months  of  February,  March,  April,  and  May  ;  and  15.9  per  cent,  during  the 
month  of  April  alone.  It  was  found  that  a  low  barometer  and  mean  relative  humidity  invariably 
correspond  with  the  annual  period  in  which  the  greatest  number  of  cases  occur,  and  that  the  highest 
percentage  of  relative  humidity  corresponds  with  the  months  affording  the  fewest  cases. 


ERYSIPELAS.  iy(^ 

must  result  from  mixed  infection  with  other  pyogenic  organisms,  unless 
indeed  the  organism  be  the  same  as  that  of  suppuration.  Blehs  form,  par- 
ticularly oq  the  lobes  of  the  ears  and  on  the  eyelids,  while  little  vesicles  are 
always  visible  through  a  lens.  From  these  a  serum  may  exude  and  dry  on 
the  skin.  As  the  dermatitis  extends  to  new  areas,  the  earlier  spots  dry  up 
and  desquamate.  The  disease  seldom  lasts  more  than  four  days  in  one  spot, 
although  it  may  revisit  the  same  spot  during  one  attack. 

There  may  be  erysipelas  of  the  mucous  membranes,  which  may  extend 
to  the  skin,  or  the  reverse  may  take  place-^extension  from  the  skin  to  the 
mucous  membrane. 

Fever  probably  always  precedes,  though  not  noted  in  the  beginning, 
and  it  rapidly  becomes  higher,  reaching  as  high  as  105°  F.  (40.5°  C).  There 
is  a  corresponding  frequency  of  pulse,  associated  with  headache  and  some- 
times delirium.  The  fever  continues  as  long  as  the  disease  continues  to 
spread.  Often  a  sudden  drop,  a  crisis,  occurs  on  the  fifth  to  the  seventh 
day,  followed  by  another  rise  if  the  disease  takes  a  fresh  start. 

In  more  serious  cases  fever  and  delirium  may  be  followed  by  drozmi- 
ness  and  stupor  and  a  coated,  dry  tongue — all  the  symptoms,  in  fact,  of  a 
typhoid  state.  The  urine  is  scanty  and  a  febrile  albuminuria  may  be  present, 
— in  fact,  to  a  degree,  may  be  said  to  be  constant,* — and  nephritis  sometimes 
results,  while  a  pre-existing  nephritis  may  have  an  acute  exacerbation 
engrafted  upon  it.  Mention  has  already  been  made,  under  the  head  of 
etiology,  of  hematuria  occurring  in  these  cases. 

Gangrene  may  be  associated  with  the  deep-seated  varieties,  constitut- 
ing gangrenous  erysipelas. 

Complications  and  Sequelae.— The  possible  complications  are  numer- 
ous, but  in  practice  are  really  not  often  encountered.  The  most  frequent 
is  meningitis,  the  result  of  extension  by  continuity  through  the  openings  of 
the  cribriform  plate  of  the  ethmoid  bone  or  by  contiguity  from  the  scalp 
through  emissary  veins  of  the  skull,  but  I  have  never  seen  such  a  case.  Wil- 
liam Osier,  however,  traced  the  extension  from  the  face  along  the  fifth  nerve  to 
the  meninges,  causing  an  acute  meningitis  and  thrombosis  of  the  lateral  sinus. 

Edema  of  the  glottis  is  the  result  of  extension  of  the  disease  to  the 
mucous  membrane  of  the  glottis.     It  is  promptly  fatal,  unless  relieved. 

Malignant  ulcerative  endocarditis  is  also  with  comparative  frequency 
secondary  to  erysipelas,  three  cases  out  of  twenty-three  being  sequelae  of 
this  disease.  Of  cardiac  complications,  pericarditis,  endocarditis,  and  myo- 
carditis;  of  pulmonary,  bronchitis,  pneumonia,  and  pleurisy  may  be  men- 
tioned as  possible ;  also  jaundice,  dysentery,  and  hemorrhages  from  the  nose 
and  bowels.  Purpura  is  an  occasional  complication.  Nephritis  of  hemor- 
rhagic variety  has  already  been  mentioned,  and  even  glycosuria  has  been 
noted,  possibly  an  accidental  association.  Septic  and  pyemic  complications 
do,  however,  occur  and  are  among  the  causes  of  death. 

Among  the  sequelse  may  be  mentioned  a  loss  of  hair.  Cicatricial  nezv 
formations  replace  the  parts  destroyed  by  gangrene  and  may  produce 
deformity  by  their  contraction.  On  the  other  hand,  hyperplastic  new  forma- 
tions resembling  elephantiasis  Arabum  may  result.  Hyperesthesia  and 
neuralgia  of  the  involved  areas,  anesthesia  with  which  atrophy  of  the  skin 
may  be  associated,  symmetrical  gangrene  of  the  fingers,  and  painful  affections 
of  the  joints  have  all  occurred  as  sequelae. 

*  See  paper  by  J.  M.  Da  Costa  on  "The  Internal  Complications  of  Acute  Erysipelas,"  "  Am.  Jour, 
of  the  Med.  Sci.,"  October,  1877. 


1 80  IX  f  EC  nous  DISEASES. 

Erysipelas  may  be  associated  with  other  infectious  diseases,  such  as 
tvphoid  and  typhus  fevers,  diphtheria,  scarlet  fever,  and  the  hke. 

Diagnosis. — The  diagnosis  of  erysipelas  is  usually  not  difficult, 
although  many  conditions  are  called  erysipelas  by  the  ignorant  which  are 
not  of  this  nature.  The  acuteness  of  the  disease,  the  rapidity  of  its  spread, 
the  constitutional  disturbance  and  fever  distinguish  it  from  other  conditions 
that  superficially  resemble  it. 

Prognosis. — The  prognosis,  in  the  vast  majority  of  instances,  is  fav- 
orable. Onlv  in  the  aged,  the  intemperate,  and  those  of  broken  health  from 
other  causes  does  it  prove  fatal,  as  a  rule.  Complications,  especially  menin- 
gitis and  septic  states,  are  causes  of  death.  On  the  other  hand,  erysipelas  is 
said  to  exert  a  favorable  influence  on  certain  acute  diseases,  such  as  acute 
rheumatism,  choroiditis,  and  even  morbid  growths.  It  has  even  been  sug- 
gested to  inoculate  erysipelas  for  the  cure  of  such  affections. 

Treatment.— The  patient  should,  of  course,  be  isolated.  It  is  more 
than  likely  that  a  decided  majority  of  cases  of  idiopathic  erysipelas  would 
get  well  without  any  treatment  whatever.  In  other  words,  the  disease  is 
self-limiting.  As  the  disease  is  exhausting,  internal  treatment  should  be 
restorative  and  supporting.  Quinin.  iron,  nutritious  food,  and  stimu- 
lants are  indicated,  while  the  patient  should  be  kept  at  rest.  The  tinc- 
ture of  the  chlorid  of  iron  is  used  throughout  Xorth  America  because  of  some 
supposed  specific  influence  over  the  disease,  and  doses  as  large  as  a  dram 
every  three  or  four  hours  have  been  given.  I  have  always  given  iron,  but 
never  in  such  doses,  and  I  am  doubtful  whether  it  exerts  any  specific  eflfect 
of  the  kind  claimed.  The  natural  duration  of  the  disease  is  short,  and  the 
eitect  claimed  from  the  iron  is  no  prompter  than  that  which  nature  brings. 
Ten  minims  (0.666  gm.)  every  two  or  three  hours  are  a  sufficient  dose,  and 
it  is  exceedingly  doubtful  whether  larger  quantities  than  this  are  absorbed. 
Where  debility  is  marked,  alcohol  in  some  of  its  forms  should  be  freely 
administered. 

J.  M.  Da  Costa  first  suggested  the  use  of  pilocarpin  in  the  treatment  of 
erysipelas,  more  particularly  in  the  early  stages.  J.  L.  Salinger,*  A.  A. 
Eshner,  and  S.  D.  Barr  also  report  favorably  on  the  same  treatment,  which 
should,  how-ever,  be  employed  cautiously.  It  is  recommended  that  1-6  grain 
(o.oi  gm.)  be  administered  hypodermically  every  three  hours  until  free 
sweating  ensues.     After  this  the  interval  is  increased  to  four  or  six  hours. 

Of  late,  evidence  is  accumulating  to  show  that  diphtheria  antitoxin  pos- 
sesses curative  properties  for  diseases  other  than  diphtheria.  Among  these  is 
erysipelas.  In  all,  five  cases  of  successful  treatment  have  been  reported  by 
Russian  physicians.     Presumably  it  is  used  as  in  diphtheria,  which  see. 

An  infinite  variety  of  local  measures  has  been  suggested  to  arrest  the 
spread  of  the  disease,  all  of  which  are  useless  to  this  end,  although  some  of 
them  are  useful  in  allaying  the  burning.  For  this  purpose  I  know  noth- 
ing better  than  the  old-fashioned  mixture  of  lead-water  and  laudanum  in 
the  proportion  of  four  parts  of  the  liquor  plumbi  subacetatis  dilutus,  U.  S. 
P.,  to  two  of  laudanum.  Or  a  mixture  may  be  made  of  acetate  of  lead 
I  9  (1.3  gm.),  powdered  opium  90  grains  (6  gm.),  and  water  6  f  ^  (180 
c.  c. ) .  Lead-water  alone  is  an  efficient  local  application  for  this  purpose ; 
so  is  cold  water.  In  the  military  hospitals  in  Philadelphia  during  the  late 
Civil  War  a  cranberry  poultice  was  a  favorite  application,  and  it  was  cer- 
tainly a  pleasant,  cooling  measure,  but  a  waste  of  a  useful  fruit.     Dusting  the 

*  "  Therapeutic  Gazette,"  March  15,  1894. 


SEPTICEMIA   AND  PYEMIA.  i8i 

surface  with  finely  levigated  oxid  of  zinc  or  subnitrate  of  bismuth  also  has 
a  soothing  effect.  Of  late,  ichthyol  has  become  a  popular  local  dressing. 
It  should  be  added  to  glycerin  or  collodion  in  the  proportion  of  2  drams 
(8  c.  c.)  to  the  ounce  (30  c.  c.)  of  glycerin  or  collodion. 

A  rational  measure  would  be,  as  has  been  suggested  by  Heuter,  the 
hypodermic  injection  of  a  2  per  cent,  solution  of  carbolic  acid,  or  a  weak 
solution,  say  i  to  4000,  of  corrosive  sublimate,  just  beyond  the  edge  of  the 
advancing  dermatitis,  but  it  has  never  seemed  to  me  necessary,  while  it  is 
painful  and  annoying  to  the  patient.  There  can,  however,  be  no  objection 
to  using  these  antiseptics  as  dressings  to  the  part. 


SEPTICEMIA  AND   PYEMIA. 
Synonym. — Bacteriemia. 

Definition. — Pyemia  and  septicemia  are  general  febrile  conditions 
caused  by  the  entrance  into  the  blood  of  pathogenic  micro-organisms.  They 
are  distinguished  from  sapremia,  which  is  the  condition  of  local  develop- 
ment of  micro-organisms  associated  with  the  entrance  of  their  toxic 
products  into  the  circulation  but  not  of  the  organisms  themselves.  Septi- 
cemia and  pyemia  are  sometimes  included  under  the  single  designation  of 
bacteriemia.  They  are  in  man  caused  usually  by  the  entrance  of  pyogenic 
organisms — streptococcus  pyogenes  and  staphylococcus  pyogenes  aureus  or 
albus — into  the  blood.  In  septicemia  the  development  of  the  organisms  is 
not  associated  with  a  special  localization  of  the  micro-organisms  in  the  inter- 
nal organs  with  the  production  of  abscesses,  whereas  in  pyemia  the  presence 
of  secondary  pus  foci  in  different  organs  of  the  body  constitutes  the  distin- 
guishing characteristic  of  the  condition. 

Etiology, — While  the  pus  organisms  have  been  heretofore  held  respon- 
sible for  the  majority  of  intoxications  of  the  blood  by  their  pathogenic 
products  or  toxins,  from  the  medical  standpoint  the  term  septicemia  may  be 
applied  to  the  toxic  condition  produced  by  any  of  the  pathogenic  bacteria 
which  invade  the  blood  and  tissues  with  or  without  a  visible  site  of  infection. 
The  proportion  of  these  last  has  of  late  enormously  decreased,  because  of  the 
antisepsis  practiced  by  surgeons,  while  the  medical  septicemias  have  not  much 
diminished. 

Illustrative  cases  of  the  more  usual  form  of  septicemia  are  puerperal 
fever  following  retained  placenta,  infection  by  scarlet  fever  or  erysipelas  or 
during  difficult  labor  involving  laceration,  and  the  poisoning  by  a  dissecting 
wound.  Among  medical  septicemias  may  be  mentioned  those  arising  from 
typhoid  fever,  pneumonia,  diphtheria,  and  gonorrhea.  These  are  all  pri- 
marily local  infections.  The  symptoms  set  in  in  from  three  to  four  hours 
to  three  or  four  days,  more  frequently  within  twenty-four  hours. 

The  same  essential  cause  lies  at  the  bottom  of  pyemia  as  of  septicemia, 
but  associated  with  the  former  as  important  etiological  factors  are  thrombosis 
and  embolism.  To  this  association  Virqhow  first  drew  attention,  and  it  is  to 
thrombosis  or  embolism  that  the  pyemic  abscesses  are  due.  Fragments  of 
a  venous  thrombus  due  to  phlebitis  at  the  seat  of  putrid  inflammation  are 
broken  off  and  carried  in  the  circulation  until  a  lodgment  is  effected.  These 
fragments  swarm  wdth  bacteria,  causing  intense  inflammation  which  goes 


1 82  INFECTIOUS  DISEASES. 

on  to  abscess  formation,  prodncing  the  metastatic  or  embolic  abscess.  Emboli 
may  be  multiple  and  there  will  be  as  many  abscesses  as  lodged  emboli.  A 
frequent  source  of  multiple  abscesses  is  the  interesting  disease,  malignant 
or  ulcerative  endocarditis,  itself  a  specific  inflammation  caused  by  some 
pathogenic  organism  floating  in  the  blood  and  lodging  on  the  heart 
valves,  where  it  excites  a  septic  valvulitis.  The  vegetations  produced 
by  this  may  be  broken  off  and  become  emboli.  These  are  carried  through 
the  arterial  system  to  points  of  lodgment  and  constitute  the  arterial 
pyemia  of  Wilks.  Osteomyelitis  is  also  a  cause  of  pyemia.  The  term 
idiopathic  pyemia  is  applied  to  that  form  in  which  multiple  abscesses  coexist 
with  the  other  symptoms  of  pyemia,  but  no  infective  focus  is  discoverable. 
It  will  be  remembered  that  the  non-infectious  embolus  produces  simple 
hemorrhagic  infarct. 

The  scats  of  election  for  abscess  in  pyemia  in  their  order  of  frequency 
are  as  follows :  The  lungs,  liver,  spleen,  kidneys,  brain,  and  joints,  the  sub- 
cutaneous connective  tissue,  and  subperitoneal  connective  tissue,  including 
pelvic  connective  tissue.  The  marrow  of  long  bones  and  the  parts  about  the 
cavity  of  the  middle  ear  are  also  seats. 

Abscesses  occur  in  the  lungs  when  the  septic  emboli  originate  in  osteo- 
myelitis or  in  inflammatory  affections  of  the  periphery;  in  the  liver,  when 
they  arise  from  septic  foci  in  the  portal  area,  especially  in  the  intestines ;  the 
pelvic  connective  tissue,  when  they  start  in  the  uterus  and  its  appendages ;  in 
the  spleen,  kidneys,  and  brain,  if  the  emboli  arise  in  the  left  heart,  or  are  so 
small  that  they  can  pass  from  the  right  heart  through  the  lungs  to  the  left 
heart. 

Suppuration  is  not  limited  to  the  agency  of  streptococci  and  staphylo- 
cocci. The  gonococcns,  the  bacillus  coli  communis,  the  typhoid  bacillus,  the 
bacillus  laiiccolatns,  and  others  are  equally  capable  of  producing  suppuration. 

Symptoms. — A  rapidly  rising  fez'cr  is  the  first  symptom  of  pyemia  and 
septicemia,  often  so  closely  followed  by  a  chill  that  its  pre-existence  is 
not  suspected.  The  severity  of  the  chill  corresponds  with  the  intensity  of 
the  infection  and  the  degree  of  inflammation  resulting  from  it.  The  tem- 
perature during  the  chill  reaches  103°  to  104°  and  105°  F.  (39.4°  to  40°  and 
40.5°  C.)  and  is  followed  by  a  szveat  and  fall  of  temperature,  after  which 
the  latter  again  rises  to  a  point  even  higher  than  that  first  attained.  Then 
follows  another  sweat  and  fall  and  thereafter  a  succession  of  intermissions, 
variable  but  quite  characteristic.  The  rise  is  generally  toward  evening,  and 
thus  there  is  a  certain  resemljlance  to  typhoid  fever,  while  the  rigors  and 
sweats  suggest  malaria.  The  evening  rise  is  by  no  means  constant,  and 
irregular  fluctuations  in  the  temperature  are  characteristic.  There  are 
other  symptoms  of  fever — viz.,  thirst,  loss  of  appetite,  and  nausea.  The 
strength  of  the  patient  rapidly  wanes,  he  soon  sinks  into  a  condition 
of  exhaustion  and  semiconsciousness,  from  which,  however,  he  may  be 
aroused  to  take  medicine  and  nourishment. 

The  various  local  involvements  cause  localised  symptoms.  Emboli  in 
the  lungs  cause  cough  and  hurried  breathing,  but  there  may  be  no  dis- 
tinctive physical  signs ;  in  the  liver,  they  may  cause  tenderness  and  enlarge- 
ment with  jaundice ;  if  in  the  kidney,  there  may  be  no  sign  or  there  may  be 
albuminuria  and  hematuria ;  if  in  the  intestines,  diarrhea ;  if  in  the  skin, 
superficial  abscesses ;  if  in  the  joints,  swelling,  tenderness,  and  fluctuation ; 
if  in  the  brain,  little  is  added  to  the  existing  nervous  symptoms.  There  may 
also  be  secondary  abscesses  of  the  parotid  gland  and  pancreas,  the  former 


SEPTICEMIA   AND  PYEMIA.  183 

producing  hard,  painful  swelling  and  the  latter  deep-seated  pain  in  the  epi- 
gastric and  umbilical  regions. 

The  abscesses  contain  the  pyogenic  bacteria,  which  are  responsible  for 
them. 

Diagnosis. — The  diagnosis  is  not  usually  difficult,  though  sometimes 
the  disease  is  overlooked  and  the  symptoms  ascribed  to  some  other  cause. 
Reference  has  already  been  made  to  its  resemblance  to  typhoid  fever  and 
malarial  fever,  but  the  physician  should  not  be  long  in  doubt.  A  careful 
study  of  the  case  will  show  marked  differences  in  history,  while  the  status 
prcesens  exhibits  only  a  superficial  resemblance.  There  are  no  rigors  fol- 
lowed by  sweats  in  typhoid  fever,  as  a  rule,  and  the  temperature  chart  in 
pyemia  is  much  more  irregular.  The  suddenness  of  the  pyemia  is  char- 
acteristic, though  it  is  by  no  means  invariable.  In  remittent  fever  the  chill, 
fever,  and  sweat  are  more  regular,  the  prostration  is  not  so  extreme,  and, 
above  all,  it  is  promptly  cured  with  quinin.  The  plasmodium,  if  found, 
definitely  settles  the  question  as  to  the  malarial  fever,  and  the  Widal  test 
that  of  typhoid  fever.  There  should  be  no  confounding  of  pyemia  with 
simple  intermittent  fever.  The  complete  absence  of  symptoms  between 
paroxysms  is  in  no  way  comparable  to  the  evident  desperate  illness  despite 
the  temporary  absence  of  fever  in  pyemia. 

Among  the  causes  of  pyemia  that  have  been  overlooked  is  osteomyelitis. 
Gunshot  injuries  of  bones  and  compound  fractures,  if  followed  by  suspicious 
symptoms,  should  lead  to  investigation.  Malignant  or  ulcerative  endocar- 
ditis is  often  overlooked,  and  not  without  reason,  as  it  is  so  often  over- 
shadowed by  other  symptoms.  A  cardiac  murmur,  with  irregular  temperature 
and  sweating  and  unusual  prostration,  should  excite  suspicion. 

Gonorrhea  and  prostatic  abscess  are  occasionally  causes,  as  are  also 
tuberculosis  of  the  kidney  and  calculous  pyelitis,  the  last  two,  perhaps,  more 
frequently  than  the  first  two. 

Prognosis. — The  prognosis  is  very  grave.  Even  when  recovery  takes 
place  in  comparatively  mild  cases,  it  is  with  shattered  health.  Alore  fortu- 
nate are  the  rarer  instances  of  recovery  after  puerperal  pyemia,  which,  when 
they  do  occur,  are  more  apt  to  be  complete.  When  calculous  pyelitis  and 
even  tuberculous  pyelitis  are  causes,  operation  often  furnishes  prompt  relief 
more  or  less  complete. 

Not  all  fatal  cases  are  promptly  so.  There  is  a  form  of  chronic  pyemia 
lasting  for  months,  in  which  the  symptoms  are  less  distinctive  and  in  the 
history  of  an  infected  wound  may  be  the  only  cue  to  its  real  nature.  One 
such  case  came  under  my  observation,  that  of  a  young  physician  who 
received  a  dissecting  wound  from  which  the  symptoms  started  and  which 
terminated  fatally  with  meningitis  after  many  months'  illness. 

Treatment  of  Septicemia  and  Pyemia. — First  remove,  if  possible,  the 
primary  surgical  focus  and  relieve  secondary  foci  as  they  appear.  After 
that  the  symptoms  are  to  be  combated  and  the  strength  supported  to  the 
utmost.  To  the  latter  end  the  most  nutritious  and  easily  assimilable  food, 
quinin  in  liberal  doses,  alcohol  freely,  and  strychnin  are  the  sheet  anchors. 
To  these  may  be  added  sponging  to  lower  the  temperature.  To  check 
sweating,  atropin,  oil  of  erigeron  in  do^es  of  10  to  30  minims  (0.65  to  2  gm.) 
in  a  capsule  or  on  sugar ;  ergot  15  to  30  minims  (i  to  2  gm.)  ;  agaricin  i  to 
2  grains  (0.06  to  0.13  gm.)  ;  the  dilute  mineral  acids,  15  to  30  minims  (i  to 
2  c.  c. ) .  Antipyretics  may  be  used  to  reduce  temperature,  but  it  is  better  to 
accomplish  the  same  thing  by  hydrotherapy. 


i84  INFECTIOUS  DISEASES. 

Among  the  more  favorable  cases,  in  which  operative  treatment  is  fol- 
lowed by  prompt  and  sometimes  more  than  temporary  relief,  are  cases  of 
septicemia  originating  in  vesical  and  prostatic  disease  and  calculous  and 
tuberculous  pyelitis.  "  In  tuberculosis  of  the  kidney,  as  tuberculosis  else- 
where, especially  illustrated  in  the  peritoneum,  exposure  to  the  air  seems  to- 
have  a  destructive  influence  upon  the  bacillus.  If  the  source  of  the  infec- 
tion cannot  be  reached  by  surgical  measures,  antistreptococcic  serum  should 
be  used  without  hesitation.  Twenty  to  30  cubic  centimeters  should  be 
injected  every  six  to  eight  hours  until  decided  improvement  in  symptoms 
takes  place  daily,  after  which  the  interval  between  injections  should  be  in- 
creased.    Smaller  doses  may  be  injected  in  milder  degrees  of  the  poisoning. 

Prophylaxis  is  much  more  efficient  than  treatment,  and  with  modern 
aseptic  surgery  and  antiseptic  obstetrics  septicemia  and  pyemia  are  becom-^ 
ing  much  more  infrequent. 

HYDROPHOBIA. 

Synonyms. — Rabies;  Lyssa. 

Definition. — Hydrophobia   is  an  acute  infectious   disease  of  animals,. 

communicable  to  man,  and  characterized  by  intense  tonic  spasm  beginning 

in  the  larynx. 

Historical. — The  disease  was  known  to  the  ancients,  including  the  East  Indians, 
Egyptians,  and  Israelites,  but  is  not  mentioned  by  Hippocrates  (B.  C.  4^30-357),  though 
Democritus.  living  about  the  same  time  (B.  C.  470-362).  is  said  to  have  considered 
it  a  nervous  affection  allied  to  tetanus.  Aristotle  (B.  C.  384-322),  however,  rec- 
xjgnized  it  in  dogs.  According  to  Celsus,  who  wrote  about  the  date  of  the  Christian 
era,  it  was  named  i^pu^oSia^hy  the  Greeks.  The  Latin  poets,  Virgil,  Horace,  and 
Ovid,  mentioned  it,  as  did  also  the  historian,  Plutarch  (about  A.  D.  50-106).  and  Galen 
(A.  D.  130-200),  while  Ctelius  Aurelianus  (fourtli  century  A.  D.)  discussed  it.  William 
Youatt  first  described  it  with  accuracy  in  the  lower  animals  and  man.*  Pasteur  first 
showed  its  infectious  character,  and  ascribed  it  to  a  toxin  developed  by  a  micro-organ- 
ism as  yet  undiscovered.  The  disease  is  rare  in  this  country  and  Germany,  not 
infrequent  in  England  and  France,  and  common  in  Russia. 

Etiology. — All  animals  are  subject  to  the  disease.  The  dog  is  the 
most  frequent  victim,  and  it  is  from  him  that  it  is  almost  invariably  com- 
municated to  man.  The  wolf,  cat,  and  skunk  are  also  frequent  subjects, 
and  may  communicate  the  disease  to  human  beings  by  their  bites,  that  of  the 
wolf  being  especially  virulent.  In  such  cases,  whatever  the  contagium  may 
be,  its  bearer  is  conceded  to  be  the  saliva  of  the  animal.  The  contagium  is 
a  fixed  and  not  a  volatile  one.  ^The  researches  of  Pasteur  go  to  show  that 
it  is  also  contained  in  the  central  nervous  system,  especially  the  medulla  and 
brain.  Klebs  suggested  that  the  disease  is  caused  by  a  bacterium  found  in 
the  salivary  glands  of  those  affected  with  hydrophobia.  Gibier,  Fol,  and 
Babes  claim  to  have  found  micrococci  in  the  brain-substance,  but  these 
claims  have  not  been  confirmed  by  others,  though  their  experiments  have- 
been  repeated.  There  can  scarcely  be  a  doubt  that  an  organism  is  the 
medium  of  infection. 

The  period  of  incubation  is  extremely  variable,  ranging  from  one  week 
to  two  months  or  longer.  Even  two  years  are  said  to  have  elapsed  before 
symptoms  set  in.  The  average  may  be  put  down  at  from  six  weeks  to  two 
months ;  but  by  no  means  all  persons  bitten  take  the  disease,  a  most  impor- 
tant point  to  be  remembered  in  estimating  the  efficacy  of  supposed  curative 

*  "  Canine  Madness,"  being  a  series  of  papers  published  in  "  The  Veterinarian,"  1828,  1829,  1830.. 
London,  1830. 


HYDROPHOBIA.  185 

measures.  Not  more  than  15  per  cent,  of  those  bitten  by  dogs,  according 
to  Horsley,  become  affected.  Various  causes  contribute  to  this.  Thus,  the 
saHva  may  be  wiped  off  in  the  transit  of  the  tooth  through  the  clothing,  and 
such  removal  of  virus  may  reduce  the  danger  of  the  second  bite  of  the  same 
animal,  even  though  it  be  on  the  unprotected  skin.  Again,  the  young  are 
more  susceptible.  Bites  on  the  face  and  hands  are  more  frequently  followed 
by  infection  than  those  on  the  lower  extremities  and  remainder  of  the  body. 
Statistics  by  Watson,  in  America,  and  by  Bollinger,  in  Germany,  show  more 
cases  to  have  resulted  from  bites  in  the  upper  extremities,  while,  according 
to  Horsley,  wounds  about  the  face  and  head  are  more  apt  to  cause  the  disease 
than  those  on  the  hands,  which  are  second  in  order,  and  after  these  come 
bites  on  other  parts  of  the  body.  A  much  larger  proportion  of  those  bitten 
by  wolves  perish,  from  40  to  80  per  cent.,  according  to  different  authorities. 

To  a  very  important  practical  cjuestion,  How  long  after  a  bite  may  the 
dreaded  suspense  of  an  expected  outbreak  last?  accurate  answer  seems- 
scarcely  possible.  Yet,  notwithstanding  the  fact  that  cases  are  recorded  of 
an  outbreak  after  an  interval  of  two  years,  it  may  be  said  with  confidence 
that  if  three  months  have  elapsed,  the  victim  may  feel  assured  that  he  is  safe. 

Morbid  Anatomy. — The  morbid  anatomy  of  rabies,  so  far  as  recog- 
nized, is  limited  to  the  upper  spinal  cord,  medulla,  pons,  and  cortex  of  the 
brain,  and  is  revealed  only  by  the  microscope.  The  blood-vessels  are  dilated 
and  congested,  the  perivascular  sheaths  are  invaded  with  leukocytes,  and 
there  are  even  small  hemorrhages.  There  is  hyperemia  of  the  pharynx, 
larynx,  trachea,  bronchi,  and  even  of  the  mucous  membrane  of  the  stomach, 
which  may  be  covered  with  blood-stained  mucus.  Often  there  are  no  dis- 
coverable changes. 

During  the  year  1900,  important  discoveries  in  the  minute  morbid 
anatomy  of  rabies  were  announced  by  Van  Gehucten  and  Nelis.  The  changes, 
were  found  in  the  peripheral  ganglia  of  the  cerebrospinal  and  sympathetic 
systems,  and  are  especially  marked  in  the  plexiform  ganglion  of  the  pneumo- 
gastric  nerve  and  Gasserian  ganglion.  In  the  normal  state  these  ganglia  are 
composed  of  a  framework  of  tissue  in  the  meshes  of  which  lie  the  nerve  cells, 
each  one  inclosed  in  a  capsule  made  up  of  a  single  layer  of  endothelial  cells. 
The  rabic  virus  stimulates  these  cells  to  proliferation  leading  to  the  ultimate 
destruction  of  the  normal  ganglion  cell  and  replacing  it  by  a  collection  of 
round  cells.  The  ganglion  cells  are  sometimes  only  slightly  altered,  at  others 
destroyed,  the  extent  of  the  process  varying  in  different  animals,  being  most 
pronounced  in  the  dog  and  less  so  in  man  and  rabbit. 

These  changes  are  claimed  to  be  especially  valuable  in  diagnosis,  since 
the  examination  can  be  completed  within  six  hours  after  the  death  of  the 
animal.  It  is  important,  however,  that  the  animal  should  be  allowed  to  die 
and  not  be  killed  prematurely.  The  ganglion  selected  for  examination  is  by 
preference  that  of  the  pneumogastric  nerve.  The  laboratory  of  the  State 
Live  Stock  Sanitary  Board  of  Pennsylvania  was  the  first  in  this  country  to 
take  up  this  method,  under  the  direction  of  Dr.  Mazyck  P.  Ravenel,  bacteri- 
ologist to  the  Board.  Fifty-two  cases  were  examined  between  May,  1900, 
and  July,  1901,  without  a  single  failure. 

Symptoms. — Rabies  is  usually  diyided,  corresponding  to  the  promi- 
nence of  symptoms,  into  two  varieties — furious  or  convulsive  and  dumb  or 
paralytic  rabies.  Professor  W.  H.  Welch,  of  Johns  Hopkins  University, 
suggests  a  third  form  of  mixed  rabies,  representing  a  combination  of  con- 
vulsive   and    dumb    rabies.     The    variety    common    to    human    beings    is 


1 86  INFECTIOUS  DISEASES. 

the  furious  or  convulsive,  though  paralytic  rabies  also  occurs  in  man,  espe- 
cially after  bites  on  the  lower  extremities,  and  would  seem  to  be  increasing 
in  proportion  to  the  convulsive  form.  So,  too,  in  dogs  furious  rabies  is  the 
more  usual,  while  in  rabbits  the  paralytic  form  is  more  common. 

It  is  true,  also,  that  a  sharp  distinction  cannot  always  be  made  between 
the  two  forms,  while  a  stage  of  excitation  and  a  stage  of  paralysis  may  be 
made  out  in  the  same  case,  and  it  amounts  largely  to  this :  that  in  the  furious 
form,  the  stage  of  paralysis  may  be  short  or  wanting,  while  in  the  paralytic 
form  the  stage  of  excitement  may  be  short  and  may  be  manifested  only  by 
acceleration  of  breathing,  elevation  of  temperature,  and  symptoms  referable 
to  irritation  of  the  vagus  nerve.  The  most  reliable  observations  go  to  show 
that  there  is  no  difference  in  the  quality  of  the  virus  producing  the  two 
forms,  but  that  the  differences  are  due  rather  to  peculiarities  in  the  individual, 
the  seat  of  inoculation,  or  perhaps  the  quantity  of  the  virus. 

The  iirst  or  premonitory  stage  succeeds  upon  the  period  of  incubation 
and  lasts  about  twenty-four  hours.  The  cicatrix  of  the  bite,  wdiich  has 
been  for  some  time  healed,  may  become  painful  or  the  seat  of  radiating  pain, 
or  become  livid,  or  even  break  out  again.  The  patient  is  morbidly 
depressed  or  irritable,  is  feverish,  loses  appetite,  and  is  sleepless;  there 
is  hoarseness  or  huskiness  of  voice.  A  feeling  of  intense  anxiety  and  a 
moodiness  are  very  characteristic,  his  probable  fate  being  the  sole  subject  of 
contemplation.  There  is  an  increased  excitability,  as  a  result  of  which  the 
banging  of  a  door  or  a  flash  of  light  causes  the  patient  to  start. 

The  second  or  'spasmodic  stage  is  the  true  hydrophobic  stage,  setting  in 
usually  after  the  first  twenty-four  hours.  It  is  also  called  the  furious  stage. 
The  sum  of  its  symptomatology  depends  upon  an  exalted  irritability  of  the 
imtscles  of  the  larynx,  as  the  result  of  which  they  contract  upon  the  slightest 
irritation  in  their  vicinity,  the  act  of  swallowing  being  the  most  frequent 
exciting  cause.  Attempt  at  swallowing  is  followed  by  the  most  potverful 
contraction  associated  with  dyspnea,  even  when  the  glottis  is  open  or 
tracheotomy  has  been  performed ;  whence  the  fear  of  zuater,  the  contact  of 
which  with  the  throat  is  followed  by  such  frightful  spasm  of  the  muscles  of 
the  larynx  and  elevators  of  the  hyoid  bone.  Even  the  saliva,  which 
is  secreted  in  increased  quantity,  cannot  be  swallowed  without  exciting  parox- 
ysms. Hence  it  is  discharged  from  the  mouth,  sometimes  forcibly,  giving 
rise  to  the  popular  idea  that  the  patient  is  frothing  at  the  mouth.  A  breath 
of  air  or  the  slamming  of  a  door  may  produce  a  paroxysm. 

The  paroxysm  may  be  associated  with  maniacal  excitement  in  which 
the  patient  is  sometimes  uncontrollable,  rolling  his  eyes,  striking  about  with 
his  arms,  and  making  snapping  noises  with  the  mouth,  which  are  compared 
to  the  biting  of  dogs.  These  noises  are  altogether  due  to  uncontrollable 
spasmodic  shutting  of  the  mouth.  On  the  other  hand,  between  the  parox- 
ysms, when  the  mind  is  clear  and  the  reason  sound,  there  is  often  found  a 
touching  concern  on  the  part  of  the  patient  lest  he  does  some  harm  to  those 
whom  he  loves.  There  is  more  decided  feverishness  in  this  stage,  the  tem- 
perature rising  as  high  as  103°  F.  (39.4°  C),  while  the  pulse  is  frequent 
and  sometimes  irregular.  Albuminuria  and  glycosuria  have  both  been 
found  in  this  stage.  The  second  stage  lasts  from  one  to  three  days,  some- 
times a  little  longer. 

In  the  third  or  paralytic  stage  the  patient  has  become  exhausted.  There 
are  no  more  paroxysms  and  he  is  quiet.  His  heart  gradually  fails,  and  he 
dies  by  syncope,  although  he  may  die  in  a  convulsion  or  in  asphyxia.     This 


HYDROPHOBIA.  187 

stage  usually  lasts  from  six  to  eighteen  hours.  Happily,  the  disease  is  one 
of  short  duration,  ranging  from  two  to  six  days,  notwithstanding  its  long 
period  of  incubation. 

Diagnosis. — Hydrophobia  most  resembles  tetanus.  Yet  the  diseases 
are  very  different.  Hydrophobia  has  a  long  period  of  incubation,  while 
tetanus  has  a  short  one,  from  three  to  ten  days.  Tetanus  begins  with 
trismus  and  is  associated  with  opisthotonos.  Neither  of  these  symptoms  is 
present  in  hydrophobia.  Tetanus  has  no  laryngeal  symptoms,  no  spasms  in 
swallowing.  The  mental  depression  so  characteristic  of  hydrophobia  is 
wanting  in  tetanus. 

More  difficult  is  it  to  distinguish  hydrophobia  from  the  imaginary  con- 
dition known  as  pseudophohia  or  lyssopJwbia,  numerous  cases  of  which  have 
been  reported,  and  the  occurrence  of  which  doubtless  furnished  the  founda- 
tion for  the  belief  by  some  that  there  is  no  such  disease  as  hydrophobia,  and 
that  all  cases  are  lyssophobia.  The  resemblance  is  often  very  close,  especially 
the  depression  and  mania,  and  it  is  even  said  that  strong  men  have  been  so 
overcome  by  this  fear  that  they  die  as  a  consequence.  The  condition,  how- 
ever, generally  passes  away.  Especially  is  this  the  case  when  it  transpires 
that  the  biting  dog  was  not  rabid.  Hence,  the  usual  practice  of  immediately 
killing  the  dog  supposed  to  be  rabid  is  not  a  wise  one,  since  it  makes  it  impos- 
sible to  settle  the  question  conclusively  as  to  its  madness.  It  is  better  to  con- 
fine the  animal  until  the  possibility  of  recovery  is  settled.  If  the  dog  be 
killed,  inoculations  from  the  medulla  should  be  made  under  the  dura  mater 
of  rabbits  and  results  awaited.  If  true  rabies,  the  paralytic  form  of  the  dis- 
ease will  be  developed  in  from  fifteen  to  twenty  days.  A  much  more  rapid 
method  of  diagnosis  is  that  recently  announced  by  A'an  Gehucten  and  Xelis, 
for  which  see  Morbid  Anatomy. 

Prognosis. — The  prognosis  once  established  of  hydrophobia,  is,  unfor- 
tunately, totally  unfavorable.  The  possibility  of  spontaneous  recoverv  can- 
not be  denied,  but  it  is  certainly  exceptional.  The  preventive  treatment  is 
more  successful.  The  claims  of  Pasteur  will  be  considered  under  treatment. 
Youatt's  success  by  cauterization  with  nitrate  of  silver  is  also  there  referred 
to.  Bollinger's  statistics  go  to  show  that  out  of  134  cases  in  which  the  bite 
was  cauterized,  92,  or  69  per  cent.,  were  attacked,  while  42,  or  31  per  cent., 
died  of  the  disease ;  of  66  not  cauterized  83  per  cent,  died  of  the  disease. 

Treatment. — The  curative  treatment  consists  first  in  prompt  measures 
to  eliminate  the  poison.  Suction  is  the  promptest  measure  available  and 
should  be  practiced,  if  possible,  by  the  victim  himself,  as  it  is  not  without 
danger  to  a  second  person.  An  abrasion  in  the  mouth  or  a  carious  tooth 
may  be  the  medium  of  inoculating  such  person  with  the  dreaded  virus.  If 
suction  be  practiced,  the  mouth  should  be  promptly  rinsed.  It  is  doubtful 
if  the  cupping-glass  is  as  efficient,  even  if  at  hand. 

Next  in  availability  is  cauterisation,  which  should  be  practiced  by  a 
glozving  hot  poker  or  other  instrument  of  the  kind,  a  galvanocautery  or 
Paquelin's  cautery.  In  the  absence  of  such  means  silver  nitrate  or  caustic 
soda  should  be  used  and  thoroughly  applied.  Youatt  considered  nitrate  of 
silver  amply  sufficient,  having  failed  once  only  out  of  400  times,  and  in  this 
instance  he  declared  that  the  patient  died  of  fright.  He  himself  was  bitten 
seven  times  and  in  each  instance  used  this  agent.  In  the  absence  of  these 
caustics  pure  carbolic  acid  may  be  used  or  corrosive  sublimate,  i  to  500  or 
to  1000.  When  the  symptoms  once  set  in,  palliation  alone  is  possible.  The 
sore  should  be  kept  open. 


1 88  INFECTIOUS  DISEASES. 

The  paroxysms  should  be  controlled  by  inhalations  of  chloroform,  and 
averted  as  far  as  possible  by  full  doses  of  opium,  preferably,  as  a  rule,  mor- 
phin  hypodermically.  Chloral  may  at  first  suffice.  As  light  and  noise 
excite  paroxysms,  the  patient  should  be  kept  quiet  and  secluded,  and  even 
in  a  dark  room  with  two  attendants.     Water  and  nourishment  may  be  given 

by  enema. 

Pasteur's  Treatment  by  Attenuated  Virus. — This  is  of  the  nature  of 
preventive  treatment.  Pasteur  discovered  that  the  virus  of  hydrophobia  is 
located  in  the  nervous  system,  especially  in  the  brain,  medulla,  and  spinal 
cord.  He  then  ascertained  that  inoculations  by  virus  from  this  source  in 
rabbits  produced  a  virus  of  such  increased  virulence  that  after  25  successive 
inoculations  there  resulted  a  virus  that  acted  after  a  period  of  incubation  of 
eight  davs ;  and  after  25  additional  inoculations  in  seven  days.  The  virus 
from  the  medulla  of  rabbits,  with  this  short  period  of  incubation,  is  called, 
"  fixed  "  virus  as  contrasted  with  the  "  street  "  virus.  Now,  although  the 
spinal  cords  of  such  animals  contain  the  virus  in  a  state  of  great  intensity 
Pasteur  ascertained  that  its  intensity  was  greatly  reduced  by  preserving  the 
cords  in  dry  air.  and  that  it  disappeared  altogether  in  two  weeks.  The  desic- 
cation is  practiced  in  sterilized  glass  vessels  in  which  are  placed  pieces  of 
caustic  potash.  If.  now,  dogs  are  inoculated  with  an  emulsion  of  such 
medullas  of  reduced  virulence,  say,  cords  preserved  from  twelve  to  fifteen 
days,  and  then  with  the  cord  preserved  for  a  shorter  period — that  is,  with 
progressivelv  stronger  virus — they  acquire  immunity  from  inoculation  by 
the  fresh  cord  of  the- rabid  rabbit. 

Pasteur  availed  himself  of  these  facts  to  inoculate  human  subjects  who 
had  been  bitten.  He  used  an  emulsion  of  rabbits'  cords  that  had  been  kept 
fourteen  days,  and  on  successive  days  made  12  more  inoculations  from  cords 
preserved  a  shorter  time,  until  those  only  one  day  old  were  used,  after  which 
immunity  was  secured.  Later. — that  is,  in  1886, — Pasteur  reported  to  the 
Academv  of  Sciences  the  so-called  "  intensive  method,"  consisting  in  inocu- 
lations from  cords  of  increasing  virulence  in  more  rapid  succession,  which 
is  the  method  now  commonly  adopted  in  the  various  institutes.  A  careful 
examination  of  the  results  of  this  treatment  by  the  most  exact  and  conscien- 
tious observers,  such  as  Victor  Horsley,  of  London,  and  William  H.  Welch, 
of  Johns  Hopkins  University,  as  well  as  the  records  of  the  numerous  Pas- 
teur institutes  throughout  the  world,  goes  to  show  that  the  treatment  is  a 
powerful  agent  in  saving  life.  In  illustration  it  may  be  said  that  the  treat- 
ment was  commenced  at  the  Pasteur  Institute  in  Paris  in  1886,  at  the  end  of 
which  year  the  percentage  of  deaths  was  0.94,  while  by  the  end  of  1891  it 
had  been  reduced  to  0.25  per  cent.,  and  for  1895  it  was  0.13  per  cent.,  or  a 
mortality  of  2  out  of  1520  inoculations.  In  consequence  of  the  difficulties 
in  the  way  of  carrying  out  the  treatment  it  is  practically  available  only  at 
the  Pasteur  institutes  referred  to.  of  which  there  is  one  in  New  York  City., 
one  in  Baltimore,  and  in  almost  all  the  large  cities  in  Europe. 

In  the  Xew  York  Pasteur  Institute  1608  cases  were  treated  in  the 
12  years  expiring  January  i.  1902,  of  which  10  died — a  percentage  of 
0.62. 

At  the  Pasteur  Institute  of  Lyons  372  cases  were  treated  from  Novem- 
ber I.  1897.  to  November  i.  1899;  26  persons  had  been  bitten  on  the  face 
(6  per  cent.)  ;  203.  on  the  hands;  143.  on  other  parts  of  the  body.  In  58 
cases  (15.5  per  cent.)  the  animal  had  been  proved  rabid;  in  207  cases  (55.6 
per  cent.)   it  was  very  probably  rabid:  in  107  cases  hydrophobia  was  sus- 


HYDROPHOBIA  189 

pected.     Among  the  372  persons  treated  there  was  but  one  death  (0.27  per 

cent.)- 

At  the  Institute  of  Marseilles  1460  persons  have  been  treated  since  its 
•opening,  five  years  ago.  Six  deaths  occurred  (0.40  per  cent.).  In  307 
cases  (21  per  cent.)  the  animal  inflicting  the  bite  had  been  proved  rabid;  it 
was  very  probably  so  in  789  cases  (54  per  cent.). 

At  the  Athens  Institute  797  persons  were  treated  from  August,  1894, 
to  the  end  of  1897.  Two  deaths  were  recorded  (0.25  per  cent.).  Further- 
more, the  treatment  failed  in  one  case  when  a  w^olf  had  inflicted  the  bite. 
Among  people  not  treated  at  the  latter  institute,  40  died  of  hydrophobia.  In 
2y  cases  the  period  of  incubation  was  from  twenty  to  one  hundred  and  twenty 
days ;  in  two  cases  it  was  from  five  to  six  months,  seven  months  in  one  case, 
and  twelve  months  in  another. 

The  following  directions  have  been  issued  by  Paul  (jibier,  the  Director 
of  the  New  York  Pasteur  Institute,  for  the  benefit  of  persons  bitten: 

Cauterisation. — Theoretically,  the  immediate  application  to  all  the 
recesses  of  the  wound  of  any  agent  that  destroys  protoplasm  should  suffice 
to  kill  any  germs  lodged  therein  and  remove  all  danger  of  a  general  infec- 
tion. Practically,  such  application  cannot  be  made,  and  a  later  cauterization 
not  only  does  no  good,  but  does  harm  in  lending  a  false  sense  of  security  to 
the  minds  of  the  patient  and  of  his  friends. 

Treatment  of  the  Wound. — It  is  best,  then,  to  treat  the  w^ound  as  one 
would  treat  any  infected  wound. 

When  Should  the  Patient  he  Sent  to  the  Pasteur  Institute? — At  once. 
It  is  not  a  hypothesis,  but  a  demonstrated  fact,  that  every  day  of  delay  adds 
to  the  uncertainty  of  a  favorable  prognosis.  It  is  better  to  be  inoculated  for 
a  disease  that  one  has  not  contracted  than  to  wait  for  a  biological  confir- 
mation of  infection,  and  then  find  that  this  delay  is  irremediable.  The 
inoculation  is,  in  itself,  harmless  to  a  non-infected  person,  and  is  also  pro- 
tective (like  vaccination)  for  a  period  of  several  years. 

What  Should  he  Done  zvith  the  Dog  or  Other  Animal? — Whenever  the 
animal  can  be  confined  and  kept  with  perfect  safety  under  observation,  this 
should  be  done  until  he  dies  or  recovers.  As  full  notes  as  possible  should 
be  made  and  forwarded  after  the  patient's  departure  to  the  Pasteur  Institute, 
as  a  valuable  part  of  his  history.  If  keeping  the  animal  is  attended  with 
unavoidable  danger,  it  should  be  killed,  the  head  separated  from  the  body 
with  an  aseptic  knife,  and  with  a  smaller  aseptic  knife  a  small  piece  of  the 
medulla  oblongata  should  be  carefully  extracted  from  the  base  of  the  skull. 
This  should  at  once  be  placed  in  a  clean,  small,  wide-mouthed  bottle,  con- 
taining a  solution  of  equal  parts  of  pure  glycerin  and  water  that  has  been 
sterilized  by  boiling.  The  bottle  should  then  be  sealed  and  forwarded  to 
the  Pasteur  Institute  for  examination  by  animal  inoculation,  the  results  of 
which  may  not  manifest  themselves  before  three  weeks.  In  addition,  the 
stomach  should  be  opened  and  examined  as  to  the  presence  in  it  of  food  or 
■of  foreign  bodies,  and  the  details  of  this  examination  noted  and  forwarded 
as  part  of  the  patient's  history. 

How  to  Reach  the  Pasteur  Institute. — The  Institute  is  situated  at  313 
West  Twenty-third  Street,  New  York  City.  It  is  within  easy  access  of  the 
Sixth  and  Ninth  Avenue  elevated  roads  (nearest  station  at  Twenty-third 
Street)  ;  the  Eighth  Avenue  electric  cars  pass  the  other  end  of  the  block, 
and  the  Twenty-third  Street  cross-town  cars  pass  the  door  from  the  Penn- 
sylvania and  the  Erie  Railroad  Stations  (Hudson  or  North  River). 


iC)o  INFECTIOUS  DISEASES. 

The  Pasteur  Department  of  the  Baltimore  City  Hospital  is  at  the  corner 
of  Saratoga  and  Calvert  Streets. 

Length  of  Treatment.— It  is  necessary  in  all  cases  for  the  patient  to 
remain  under  treatment  for  fifteen  days.  During  this  time  two  inoculations 
are  given  dailv.  If  the  case  is  more  grave— that  is,  if  treatment  has  been 
begim  late— or  if  the  wounds  are  on  the  head  or  face,  from  four  to  six 
inoculations  are  given  daily. 

Beyond  these  measures  th€  treatment  of  the  disease  is  the  treatment 
of  the  symptoms. 

TETANUS. 
Synonym. — Lockjaw. 

Definition. — Tetanus  is  an  infectious  disease  characterized  by  parox- 
ysms of  tonic  spasm,  repeating  themselves  with  increasing  severity.  It  is 
a  disease  of  human  beings  and  lower  animals. 

Etiology. — The  specific  cause  of  tetanus  is  a  bacillus,  which  was 
isolated  by  Nicolaier  in  1884  and  obtained  in  pure  culture  by  Kitasato  in 
1889.  It  is  a  slender  rod  with  rounded  ends,  develops  at  ordinary  tempera- 
tures, and  is  found  in  the  soil,  in  pus,  and  putrefying  fluids  of  wounds, 
sometimes  forming  threads,  sometimes  irregular  masses.  It  is  non-mobile, 
anaerobic,  refusing  utterly  to  grow  in  the  presence  of  oxygen;  develops 
spores  within  itself,  though  when  studied  early  in  pus  is  often  sporeless.  It 
is  one  of  the  most  invulnerable  of  bacilli,  its  spores  resisting  a  temperature 
of  176°  F.  (80°  C),  while  the  bacilli  retain  their  vitality  in  the  dried  con- 
dition for  months.  According  to  G.  M.  Sternberg,  they  resist  a  five  per 
cent,  carbolic  solution  for  ten  hours,  but  will  not  grow  after  fifteen  hours' 
immersion.  If  five  per  cent,  hydrochloric  acid  be  added,  they  are  destroyed 
in  two  hours.  They  are  destroyed  in  three  hours  by  a  i  to  1000  bichlorid 
solution,  but  when  five  per  cent,  hydrochloric  acid  is  added  the  spores  are 
destroyed  in  thirty  minutes.  Exposure  to  passing  steam  for  from  five  to 
eight  minutes  kills  the  spores.  The  toxin,  on  the  other  hand,  is  rapidly 
destroyed  by  heat  and  light,  being  unable  to  resist  a  temperature  above  140° 
to  149°  F.  (60°  to  65°  C).  In  the  dark  in  a  refrigerator  it  can  be  kept 
indefinitely.  Cultures  of  the  tetanus  bacillus  in  all  media  give  off  a  peculiar 
characteristic  odor — a  burnt-onion  smell  with  a  suggestion  of  putrefaction. 

The  bacilli  do  not,  however,  pass  into  the  blood,  but  at  the  site  of  the 
wound  manufacture  with  great  rapidity  a  ptomain  or  toxin,  which  is  ab- 
sorbed and  excites  the  disease.*  This  was  first  shown  in  1890  by  Kitasato, 
who  found  that  the  bacteria-free  filtrates  of  bouillon  cultures  of  the  tetanus 
bacillus  produce  the  same  symptoms  as  inoculation  with  cultures  containing 
the  bacillus,  including  ultimate  death.  Indeed,  Brieger  in  1886  isolated  from 
impure  cultures  three  ptomains,  which  he  called  tetanin,  tetanotoxin,  and 
spasmatoxiu.  The  first  of  these  causes  the  characteristic  symptoms  of 
tetanus ;  the  second,  tremors,  convulsions,  and  subsequently  paralysis ;  and 
the  third,  intense  tonic  and  clonic  spasms.  More  recently,  Kitasato  and 
Weyl  obtained  Brieger's  tetanin  and  tetanotoxin  from  pure  cultures ;  while 
Brieger  himself,  with  Frankel  and  Kitasato,  has  succeeded  in  isolating  from 
tetanus  cultures  a  far  more  deadly  ptomain,  foxalbuinin,  which  was  purified 
by  Brieger  and  Cohn,  who  have  shown  that  it  is  not  a  pure  albuminous  body. 

*  Hochsinger  alone  claims  to  have  found  the  bacilli  or  their  spores  in  the  blood  of  tetanic  cases. 


TETANUS. 


191 


Brieger  has  also  isolated  such  poisons  from  the  organs  of  those  dead  of 
tetanus,  and  Xissen  has  demonstrated  toxin  in  the  blood  of  those  ill  of 
tetanus. 

Further,  it  has  been  shown  by  Behring  and  Kitasato  that  there  exists 
in  the  blood  of  animals  immune  to  tetanus  a  substance  with  opposite  prop- 
erties, therefore  called  antitoxin,  and  by  the  gradual  introduction  of  the 
toxin  into  animals  these  observers  have  been  able  to  produce  in  their  blood 
a  potent  antitoxic  substance.  Such  serum  is  prepared  by  Behring  and  bv 
Roux  abroad,  and  by  the  ^lulford  Company  in  Philadelphia.  The  method 
for  it§  production  is  similar  to  that  for  diphtheritic  antitoxin,  but  slower. 
Tizzoni  and  Cantani  have  successfully  prepared  it  in  a  solid  form,  in  which, 
it  is  claimed,  it  can  be  kept  indefinitely  and  shipped  as  wanted,  and  applied 
it  to  treatment  of  cases  of  traumatic  tetanus  with  success.  Six  cases  have 
been  thus  treated  up  to  December  24,  1892.  "  The  Lancet,"  for  August 
10,  1895,  contains  a  review  of  35  cases  treated  at  all  stages  with  antitoxin, 
23  successfully.  ^^lore  recently,  Gooderich  collected  153  cases  with  63  per 
cent,  of  recoveries. 

Predisposing  Causes. — The  excitation  of  tetanus  is  favored  by  cer- 
tain conditions.  Wounds,  particularly  contused  and  punctured  wounds, 
especially  of  the  hands  and  feet,  are  favorite  foci,  whence  the  term  traumatic 
for  such  cases  of  tetanus,  and  idiopathic  for  cases  not  thus  caused.  A  simi- 
lar focus  is  the  badly  cared-for  umbilical  cord,  whence  tetanus  neonatorum, 
affecting  especially  the  colored  race.  In  certain  parts  of  the  West  Indies  it 
is  said  that  more  than  half  the  deaths  among  negro  children  are  due  to  this 
cause.  It  is  probably  because  the  contused  wound  affords  a  more  favorable 
nidus  for  the  growth  of  the  bacilli  rather  than  that  there  is  any  peculiar 
laceration  of  nerves,  as  formerly  thought.  It  is  more  common,  too,  in  hot 
countries,  and  in  places  and  seasons  where  there  are  decided  alternations  of 
heat  and  cold.  It  affects  both  sexes  and  all  ages,  but  it  is  more  frequent 
in  men  for  obvious  reasons,  the  average  percentage  of  cases,  according  to 
F.  X.  Dercum,*  being  22. 

Idiopathic  tetanus  is  much  more  rare  than  traumatic,  and  it  constantly 
happens  that  close  examination  in  cases  of  apparent  idiopathic  tetanus 
results  in  the  discovery  of  a  previous  undiscovered  trauma.  Exposure  to 
cold,  especially  damp  cold,  is  one  of  the  recognized  causes  of  idiopathic 
tetanus.  It  can  only  produce  a  condition  favorable  to  the  lodgment  and 
multiplication  of  the  bacillus. 

That  tetanus  should  occasionally  prevail  in  epidemics  is  one  of  the 
natural  results  of  its  mode  of  causation. 

Morbid  Anatomy. — There  is  no  essential  morbid  anatomy  of  tetanus. 
There  may  be  congestion,  extravasations,  and  perivascular  exudates  due  to 
impediment  of  the  movement  of  the  blood  during  spasm,  granular  changes 
in  cells  from  modified  nutrition — all  results  rather  than  causes  of  symptoms. 

Symptoms. — A  period  of  incubation  of  from  ten  to  fifteen  days  is 
required  for  the  operation  of  the  specific  cause  of  tetanus.  Occasionally 
only  does  a  chill  precede  the  other  symptoms.  There  appears  first  usually  a 
stiffness  in  the  neck  and  jan's  and  the  patient  opens  his  mouth  with  diffi- 
culty, but  not  with  pain.  Then  the  stiffness  extends  to  the  back  and  abdom- 
inal muscles  and  to  the  legs,  which  may  be  fixed  in  extension,  more  usually 
during  a  paroxysm.  The  result  is  that  the  abdominal  muscles  feel  like  a 
board  and  the  whole  trunk  is  inflexible.     If  an  attempt  be  made  to  flex  the 

*  Article  "  Tetanus,"  Keating's  "  Cyclopedia  of  Diseases  of  Children,"  vol.  iv.  p.  913,  1890. 


192  INFECTIOUS  DISEASES. 

thighs  on  the  abdomen  the  whole  body  comes  up  in  a  single  piece ;  if  the  body 
is  turned  over,  it  is  like  turning  over  a  wooden  man.  There  is,  in  a  word, 
orthotonos.  Again,  as  in  a  striking  case  of  my  own,  the  symptoms  may 
begin  in  the  abdomen  and  by  its  intermittent  character  simulate  cramp.* 

These  symptoms  are  present  in  various  degrees,  less  marked  in  the  mild 
cases,  more  so  in  the  severe  ones.  In  severe  cases  the  jaws  become  locked,  in 
milder  ones  they  may  partly  yield  to  forcible  extension.  The  eyebrows  may 
be  raised  and  the  angle  of  the  mouth  drawn  out,  producing  the  rijus  sar- 
donicus,  or  tetanic  grin.  In  the  so-called  head  tetanus  described  by  E.  Rose, 
there  may  be  paralysis  of  the  facial  muscles  and  difficulty  of  swallowing,  with 
violent  spasm  of  the  pharynx  and  esophagus.  It  is  associated  more  par- 
ticularly with  injuries  to  the  fifth  nerve. 

All  the  symptoms  are  further  increased  during  the  paroxysm,  which  is 
excited  by  various  sensory  impressions,  sometimes  exceedingly  trifling,  as 
a  breath  of  air  or  the  contact  of  a  dress,  a  footfall,  or  the  slamming  of  a  door. 
The  muscles  of  the  trunk  contract  more  strongly,  and  if  the  patient  be  on  his 
back,  the  body  may  be  so  bowed  that  only  the  back  of  the  head  and  heels 
touch  the  bed — opisthotonos ;  or  the  side  of  the  face  and  leg,  producing  pleu- 
rosthotonos ;  or  the  abdominal  muscles  may  bend  the  body  forward — 
emprosthotonos.  Spasmodic  closure  of  the  jaws  sometimes  causes  the 
tongue  to  be  bitten.  The  paroxysm  may  then  relax,  and  during  its  relaxa- 
tion the  patient  will  be  able  to  walk  about.  In  severe  cases  the  spasm  may 
involve  also  the  muscles  surrounding  cavities,  as  the  thorax,  compressing  as 
in  a  vise  their  contents,  causing  extreme  pain.  Indeed,  pain  is  almost  every- 
where an  accompaniment  of  these  spasmodic  contractions,  and  the  perspira- 
tion stands  out  in  great  drops  on  the  face  and  covers  the  body.  An  attempt 
to  speak  is  transformed  into  a  fit  of  crying.  The  frequency  of  the  spasms 
varies  greatly ;  they  may  occur  every  couple  of  minutes  or  almost  incessantly 
or  once  in  several  hours. 

The  temperature  is  generally,  but  slightly,  if  at  all,  elevated,  rising  to 
loi°  F.  (38.3°  C.)  and  more  rarely  to  102°  F.  (38.9°  C).  At  times,  how- 
ever, it  rises  higher,  to  105°  to  106°  F.  (40.5°  to  41.1°  C),  and  it  is  said 
also  in  fatal  cases  to  reach  108°  to  110°  F.  (42.2°  to  43.3°  C).  In  a  case 
reported  by  Joseph  P.  Tunis  f  it  fell  as  low  as  96.6°  F.  (35.5°  C),  reaching 
a  maximum  of  only  101°  F.  (38.3°  C).  The  pulse  is  generally  frequent, 
130  to  150,  respirations  30  to  45.  There  is  often  constipation,  which  is  a 
more  serious  symptom  in  severe  cases,  because  the  efforts  to  relieve  it  are 
apt  to  bring  on  spasm.  Among  the  rare  events  have  been  the  rupture  of 
muscles  and  spasmodic  closure  of  the  glottis,  producing  fatal  asphyxia. 
Generally,  death  is  produced  by  exhaustion,  the  mind  remaining  unclouded 
throughout. 

Diagnosis. — Tetanus  is  liable  to  be  confounded  with  strychnin  poison- 
ing, cerebrospinal  meningitis,  and  hydrophobia.  Strychnin  poisoning  dififers 
from  tetanus  in  the  absence  of  rigidity  between  the  paroxysms  and  of  tris- 
mus, and  in  the  more  marked  involvement  of  the  extremities,  as  well  as  the 
history  of  the  case.  In  hydrophobia  there  is  no  trismus,  and  while  con- 
vulsive dysphagia  occurs  sometimes  in  tetanus,  it  is  very  rare.  As  in  strych- 
nin poisoning,  too,  the  individual  paroxysms  are  more  distinct. 

Cerebrospinal  meningitis  produces  a  rigidity  similar  to  that  of  tetanus, 
T)Ut  the  cerebral  symptoms  give  it  its  stamp,  and  fever  is  a  much  earlier 

*  "  Philadelphia  Med.  Times,"  vol.  i.,  1871.  p.  .<i8. 

+  "Archives  of  Gynecology  and  Pediatry,"  April,  1892. 


TETAXUS.  193 

symptom  than  in  tetanus.     The  stillness  of  the  jaws  in  parotitis  and  severe 
tonsillitis  is  similar  to  that  of  tetanus,  but  there  the  resemblance  ends. 

The  interesting  and  rare  condition  known  as  tetany,  or  intermittent 
tetanus,  characterized  by  the  paroxysmal  tonic  contraction  in  groups  of 
muscles,  more  frequently  in  the  extremities,  is  hardly  likely  to  be  confounded 
with  tetanus. 

Prognosis. — The  prognosis  of  traumatic  tetanus  is  exceedingly  unfav- 
orable, not  less  than  80  per  cent,  perishing,  while  in  the  idiopathic  form  less 
than  one-half  die. 

In  children  the  prognosis  is  more  favorable  than  in  adults,  and  some 
very  severe  cases  get  well.  The  case  of  Joseph  P.  Tunis,  already  referred 
to,  is  a  truly  remarkable  one  of  recovery  in  a  boy  six  years  of  age  after 
seventy  days'  duration.  ^Most  cases  die  within  the  first  six  days,  and  cases 
living  to  the  sixth  day  are  very  much  more  apt  to  get  well ;  the  aphorism  of 
Hippocrates,  that  ''such  persons  as  are  seized  with  tetanus  die  within  four 
days,  or  if  they  pass  these  they  recover,"'  is  frequently  substantiated.  On  the 
other  hand,  a  late  onset  makes  a  case  more  hopeful.  Localization  of  the 
spasm  to  the  muscles  of  the  face,  neck,  and  jaw  is  favorable  to  recovery,  and 
the  so-called  Rose's  head  tetanus  most  commonly  gets  well.  The  cases  in 
which  there  is  very  little  elevation  of  temperature  are  more  apt  to  do  well. 
Convalescence  is  likely  to  be  protracted  even  in  mild  cases. 

Treatment. — Prompt  local  treatment  is  important,  though  it  is  not  often 
thought  of  until  the  mischief  is  done.  The  wound  should  be  excised  and  cau- 
terized by  the  hot  iron  or  nitrate  of  silver,  and  antiseptic  dressings  should  be 
applied.  The  patient  ought  then  to  be  secluded  and  surrounded  by  the 
utmost  quiet.  After  such  seclusion  Gacelli  recommends  the  subcutaneous 
injection  of  a  two  per  cent,  solution  of  carbolic  acid  every  two  or  three  hours. 
He  claims  that  carbolic  acid  gives  better  results  than  the  antitoxin  by 
antagonizing  the  toxin  and  quieting  the  nervous  system.  There  are  many 
difftculties  in  the  way  of  the  antitoxin  treatment  of  tetanus  in  human  beings, 
and  it  has  perhaps  been  a  disappointment  up  to  the  present  time.  The 
amount  needed  in  proportion  to  the  body  w^eight  increases  enormously  with 
the  stage  of  the  disease,  in  consequence  of  its  extremely  rapid  production  by 
the  bacilli — millions  of  times,  where  diphtheria  antitoxin  increases  but  ten- 
fold. Twenty  to  30  c.  c.  of  the  fluid  serum  should  be  injected  early,  and  15 
to  20  c.  c.  every  five  or  ten  hours.  Of  Tizzoni's  solid  antitoxin  2.25  grams 
should  be  the  first  dose,  and  0.6  gram  afterward  at  about  the  same  interval — 
/.  e.,  5  to  10  hours.  The  use  of  antitoxin  in  no  way  precludes  the  employ- 
ment of  spinal  anti-spasmodic  remedies,  such  as  chloral,  bromids,  morphin, 
eserine,  etc. 

The  further  treatment  of  tetanus  must  be  the  treatment  of  the  symp- 
toms. Morphin  is  indispensable  to  control  the  pain  and  defer  the  paroxysms 
or  diminish  their  seventy,  and  anesthesia  by  ether  or  chloroform  may  be 
required  during  the  paroxysm.  The  milder  sedatives,  like  chloral,  may 
suffice  in  mild  cases,  but  they  are  insufficient  in  severe  ones.  Chloral  may  be 
used  as  an  adjuvant  in  not  less  than  15-grain  (1  gm.)  doses  for  adults  when 
the  quantity  of  morphin  otherwise  required  would  be  excessive.  Even 
larger  doses  of  chloral  than  those  named  mav  be  given  in  connection  with  the 
antitoxin  treatment.  Subdural  injection  through  a  trephined  opening  is 
recommended  by  A.  E.  Barker,*  who  injected  7.5  c.  c.  of  antitoxin  at  one 
time,  and  20  c.  c.  subcutaneously  daily  for  the  following  four  days.    In  addi- 

*  "  Philadelpliia  Med.  Jour.,"  December  8,  igoo. 
13 


194  INFECTIOUS  DISEASES. 

tion  massive  doses  of  chloral  were  given.  A  week  later  the  rigidity  com- 
menced to  diminish,  and  in  the  course  of  three  weeks  the  patient  had  com- 
pletely recovered.  The  efficiency  of  chloral  is  also  increased  when  combined 
with  double  the  dose  of  bromid  of  potassium.  To  a  less  degree  phenacetin, 
antipyrin,  and  antifebrin  may  be  useful.  Salicylic  acid  in  large  doses  has 
been  thought  to  be  of  value. 

Reasoning  from  its  physiological  action  on  the  nerve-centers,  calabar 
bean  ought  to  be  a  useful  remedy,  and  it  is  commonly  used  in  doses  of  1-4  to 
1-2  grain  (0.0165  to  0.033  gm.)  three  to  five  times  a  day.  Curare  should 
also  be  useful  for  its  sedative  effect  on  the  terminal  nerves,  but  experience 
has  not  confirmed  expectation  as  yet;  1-25  grain  (0.0026  gm.)  may  be  given 
hypodermically  and  cautiously  increased.  The  strength  of  currare  varies 
greatly.  JVarin  baths  are  serviceable  in  relaxing  spasm  and  often  very  com- 
forting to  the  patient. 

The  most  nourishing  food  in  liquid  form  is  necessary,  and  usually,  also, 
stimulants  are  freely  administered  in  tetanus,  with  a  view  to  sustaining  the 
patient  against  the  exhaustion  that  sooner  or  later  causes  death  unless  the 
disease  is  arrested. 


ANTHRAX. 

Synonyms. — Malignant  Pustule;  Contagions  Carbuncle;  Splenic  Fever; 
Splenic  Apoplexy;  Gangrene  of  the  Spleen;  Carbuncle  Fever;  Blood- 
striking;  Choking  Quinsy  and  Bloody  Murrain;  Wool-sorter's  Disease; 
Rag-sorter's  Disease.  In  France  it  is  known  as  "  Charbon,"  and  in  Ger- 
many as  "  Miltabrand." 

Definition. — An  acute  infectious  disease  of  animals,  especially  affecting 
cattle  and  sheep,  but  transmissible  also  to  man ;  caused  by  the  implantation 
and  multiplication  of  the  bacillus  of  anthrax. 

History. — Anthrax  was  known  to  the  ancients  as  a  destructive  disease  of  ani- 
mals. The  true  poison  was  not,  however,  discovered  until  Pollander  found  it  in  1855. 
Two  years  later  Brauell  also  found  it  independently.  Davaine,  in  1S63,  greatly 
extended  our  knowledge  of  the  whole  subject  by  discovering  the  bacillus  and  inocu- 
lating many  animals,  including  mice,  rats,  guinea  pigs,  cows,  sheep,  goats,  and 
birds,  and  more  recently  Louis  Pasteur  and  Robert  Koch,  1878-81,  studied  the  bacillus 
exhaustively  from  the  "biological  standpoint.  It  was  the  first  micro-organism  recog- 
nized as  the  cause  of  an  infectious  disease.  Mention  should  be  made  of  Toussaint, 
who  was  the  first  to  produce  immunity  by  the  use  of  sterilized  cultures.  His  paper 
on  "  Immunity  from  Anthi'ax  Acquired  as  a  Result  of  Protective  Inoculations  "  was 
published  in  the  "  Proceedings  of  the  French  Academy  of  Sciences,"  July  12,  1880. 
The  disease  is  found  all  over  the  world.  A  number  of  cases  occurred  in  Dubois,  Pa., 
in  1897,  by  infection  from  hides  imported  from  China. 

Etiology. — The  bacillus  of  anthrax,  the  largest  of  the  pathogenic  bacilli, 
is  a  minute  cylinder  5  to  20  microns  in  length  and  i  to  1.25  microns  in 
breadth.  It  is  found  in  enormous  numbers  in  the  blood  and  tissues  of  the 
animal  infected  with  anthrax,  where  it  multiplies  rapidly  by  division.  In 
artificial  cultures  it  grows  in  long  threads,  in  the  interior  of  which  appear 
minute  ovoid  spores,  which  are  loosed  by  disintegration  of  the  bacilli,  which 
have  but  a  transient  existence,  while  the  spores  are  very  tenacious  of  life. 
Their  vitality  may  remain  in  abeyance  for  long  periods  of  time,  and  revive 
with  the  return  of  favorable  conditions  of  heat  and  moisture.  Introduced 
into  the  blood  of  animals  they  develop  into  bacilli.     The  medium  of  their 


ANTHRAX.  195 

transfer  to  others,  including  human  beings,  is  the  blood,  secretions,  flesh,  and 
hair  from  those  infected.  Here,  as  in  glanders  and  hydrophobia,  an 
abraded  surface  is  necessary  for  successful  inoculation,  although  the  pos- 
sibility of  absorption  through  intact  mucous  membrane  and  skin  is  asserted. 
Those  most  frequently  infected  are  herdsmen,  stable-hands,  butchers,  and 
wool-sorters. 

It  is  thought  that  anthrax  bacilli  may  exist  elsewhere  than  in  animals, 
as  in  marshes  and  on  the  banks  of  streams,  whence  they  may  be  carried  by 
freshets  into  pastures  and  so  infect  grazing  animals.  Commonly,  however, 
the  affection  spreads  from  other  animals  having  the  disease.  Pasteur  has 
found  the  bacilli  in  the  herbage  over  the  buried  bodies  of  animals  dead  of  the 
disease.  It  is  primarily  a  disease  of  herbivora,  from  which  it  is  transmitted 
to  carnivora  and  man. 

Hoffa  has  isolated  a  toxin,  which  he  calls  anihracin. 

Morbid  Anatomy. — The  body  after  death  is  cyanotic.  The  blood  is 
dark  and  viscid,  coagulating  slowly ;  the  spleen  is  enlarged  and  soft.  On  the 
skin  are  carbuncular  and  gangrenous  patches,  the  subcutaneous  tissue  is 
infiltrated  with  bloody  serum,  the  blood  is  uncoagulated,  and  all  the  tissues 
and  organs  are  more  or  less  infiltrated  with  blood.  The  gastro-intestinal 
mucous  membrane  is  edematous  and  ecchymotic,  there  are  enlarged  follicles 
and  gangrenous  patches  infiltrated  with  bacilli,  constituting  the  so-called 
■carbiijhcle  of  nuicous  nicmbrane.  Even  the  nervous  tissues  are  the  seat  of 
analogous  lesions. 

Symptoms. — Anthrax  has  a  period  of  incubation  of  about  seven  days, 
after  which  there  are  a  number  of  modes  of  manifestation  of  the  disease,  of 
which  the  chief  are  external  anthrax  and  internal  anthrax. 

External  Anthrax  manifests  itself  as  malignant  pustule  and  malig- 
nant anthrax  edema. 

1.  Malignant  pustule  starts  most  frequently  on  exposed  surfaces  of  the 
skin, — the  arms,  hands,  or  face, — at  the  seat  of  inoculation.  It  begins  as  an 
itching  and  a  burning,  smarting  pain,  resembling  often  that  from  the  bite  of 
an  insect.  The  spot  becomes  red  and  develops  rapidly  into  a  papule,  in  the 
center  of  which  a  vesicle  soon  appears,  which  is  filled  with  clear,  or  at  times 
bloody,  serum.  The  vesicle  bursts,  the  papule  enlarges  and  becomes  indu- 
rated, surrounded  by  a  number  of  small  vesicles.  The  induration  extends, 
while  the  center  becomes  dark  and  discolored.  Within  thirty-six  hours  a 
brown  eschar  makes  its  appearance  and  rapidly  undergoes  disintegration. 
The  vicinity  becomes  edematous,  the  lymphatics  inflamed,  swollen,  and 
painful. 

To  these  local  symptoms  are  added  those  of  general  infection,  with  its 
thirst,  high  temperature,  and  frequent  pulse.  The  tongue  becomes  dry,  the 
liver  and  spleen  enlarged,  the  breathing  rapid,  and  death  supervenes  in  from 
three  to  five  days. 

Occasionally,  recovery  takes  place,  but  it  is  only  in  mild  cases,  in  which 
all  the  symptoms,  local  and  general,  are  less  severe,  that  the  vesicles  dry  up 
into  a  crust  or  scab,  and  the  induration  dies  away. 

2.  Malignant  anthrax  edema  begins  in  the  eyelids  and  passes  thence  to 
the  head,  hands,  and  arms.  The  skin  reddens  and  becomes  edematous,  vesicles 
may  arise,  but  there  are  no  papules,  although  the  edema  may  proceed  to 
extensive  gangrene.  The  local  symptoms  in  this  form  follow  rather  than 
precede  the  constitutional  disturbance,  as  in  the  papular  form,  and  the  termi- 
nation is  even  more  invariably  fatal  than  in  the  latter. 


196  INFECTIOUS  DISEASES. 

Anthrax  presents  an  interesting  contrast  to  hydrophobia  in  the  absence 
of  the  anxious  mental  condition  so  characteristic  of  the  latter. 

Internal  Anthrax  manifests  itself  as  mycosis  intcstinalis  or  intestinal 
anthrax,  and  pulmonary  anthrax.  The  latter  is  also  called  zvool-sorter's 
disease. 

1.  Intestinal  anthrax,  or  mycosis  intcstinalis  is  often  ushered  in  by  chill 
followed  b}-  nausea,  vomiting,  bloody  diarrhea,  and  abdominal  pains  and  ten- 
derness, in  addition  to  these  symptoms  pustules  may  form  on  the  skin.  It 
arises  from  the  ingestion  of  meat  infected  with  anthrax. 

2.  Jl'ool-sortcr's  disease  is  a  form  of  internal  anthrax  acquired  by  inhal- 
ing the  bacilli  into  the  lungs  by  those  engaged  in  sorting  wool,  especially 
that  imported  from  Russia  and  South  America.  It  begins  with  chill,  fever 
with  high  temperature,  pain,  dyspnea,  bronchitis,  and  cough,  together  with 
the  physical  signs  of  lung  involvement.  There  are  rarely  premonitory  symp- 
toms and  often  no  external  lesion.  It  is  rapidly  fatal,  the  patient  often  dying 
in  twenty-four  hours  in  collapse.  Other  cases  are  more  protracted,  and  there 
may  be  vomiting,  diarrhea,  delirium,  and  unconsciousness,  while  the  brain 
may  be  the  chief  seat  of  involvement,  the  capillaries  being  filled  with  bacilli. 
Rag-picker's  disease  is  a  special  etiological  variety,  invading  the  lungs  and 
pleura,  with  general  infection. 

Diagnosis. — The  diagnosis  of  external  anthrax  is  usually  easy  from  the 
symptoms,  in  connection  with  the  history  of  exposure  to  the  cause.  The 
fluid  of  the  pustule  may  be  examined  for  the  bacilli,  which  are  large  and  easily 
recognized.     Cultures  may  be  made  and  a  mouse  or  guinea  pig  inoculated. 

Internal  anthrax  is  more  difficult  of  recognition  and  may  escape  it  alto- 
gether unless  a  knowledge  of  the  occupation  of  the  patient  suggests  it. 

Prognosis. — The  prognosis  is  unfavorable ;  yet  not  all  cases  perish. 
The  intestinal  form  and  wool-sorter's  disease  are  especially  fatal,  though  it 
is  said  also  that  those  who  survive  the  latter  one  week  recover. 

Treatment. — Prophylaxis  is  exceedingly  important.  Animals  dead  of 
the  disease  should  be  cremated — burying  is  not  a  safe  plan ;  their  hides  should 
not  be  used ;  infected  pastures  should  be  shut  ofif ;  disinfectants  should  be 
freely  used  in  the  wake  of  the  disease.  Hides,  wool,  and  rags  should  be  dis- 
infected by  superheated  steam.  In  the  case  of  wool  and  rags  this  is  quite  pos- 
sible, but  the  necessary  temperature  is  so  high  that  hides  are  damaged  by  it. 

The  curative  treatment  consists  in  a  vigorous  attack  on  the  seat  of  the 
infection.  Deep  crucial  incisions  should  be  made,  and  to  these  the  actual 
cautery  or  caustic  potash  or  strong  carbolic  acid  should  be  applied  and  the 
wound  drssed  with  a  strong  solution  of  carbolic  acid,  i  to  20 ;  or  powdered 
bichlorid  of  mercury  diluted  with  calomel  powder,  4  to  15  per  cent.,  may  be 
thrown  into  the  bottom  of  the  incisions.  As  the  sublimate  dissolves  it 
deepens  the  cauterization.  The  treatment  is  very  severe  and  etherization 
may  be  necessary.  Cocain  at  least  should  be  freely  used.  In  the  edematous 
form  numerous  free  incisions  should  be  used  and  treated  as  the  cuts  into  the 
carbuncle. 

With  the  local  treatment  should  be  associated  stimulating  and  restora- 
tive measures,  including  alcohol,  highly  nutritious  food,  quinin,  and  strych- 
nin. Five  to  ten  grains  of  ipecacuanha  powder  every  three  or  four  hours  are 
recommended  by  Davies-Colley. 

Internal  anthrax  must  be  treated  by  the  general  measures  just  alluded  to, 
but  is  generally  incurable.  Free  purgation  is  advised  at  the  outset,  with  a 
view  to  removing  the  infecting  material. 


GLANDERS  AND  FARCY.  197 

GLANDERS  AND  FARCY. 

Synonyms. — Farcy ;  Malleus  humidus. 

Definition. —  Glanders  is  an  infectious  disease  more  especially  of  the 
horse,  communicable  to  man  and  certain  domesticated  animals,  but  not  to 
cows ;  characterized  by  nodular  growths  in  the  nares,  when  it  is  known  as 
glanders,  and  under  the  skin,  when  it  is  called  farcy.  Among  animals  to 
which  it  is  communicable  are  the  lion,  sheep,  rabbit,  guinea  pig,  cat,  dog, 
and  mouse. 

Historical. — Glanders  was  apparently  described  by  Aristotle  (B,  C.  384-322)  as 
occurring  in  the  ass.  It  is  first  mentioned  under  the  name  jiclIlq  and  malleus  by 
Apsyrtus,  a  veterinary  surgeon  under  Constantine  the  Great  (A.  D.  272-337),  who,  how- 
ever, included  under  this  name  a  number  of  affections  of  a  more  or  less  similar  nature, 
and  we  are  indebted  for  our  first  accurate  knowledge  of  the  disease  to  Rayer,  whose 
monograph  appeared  in  1837. 

The  contagious  nature  of  glanders  was  recognized  by  Soleysal  (1664),  Garsault 
(1741),  and  by  the  two  writers  Lafosse  (1754-72);  its  inoculability  and  fatal  character 
were  demonstrated  by  Abeldgaard  in  1795,  while  its  contagiousness  was  experimentally 
established  by  Viborg  (1797).  Notwithstanding  these  facts,  its  contagiousness  was 
long  contested  in  France,  and  it  was  not  until  the  middle  of  the  present  century  that 
finally  it  became  generally  acknowledged  in  that  country,  chiefly  through  the  labors 
of  St.  Cyr.  Lorin  in  1812,  Waldinger  in  1816,  and  Veith  in  1822,  made  researches  on 
the  injurious  effects  of  the  virus  on  man.  Schelling.  of  Berlin,  was  the  first  to  give 
an  exhaustive  description,  in  1821,  of  the  disease  as  it  occurs  in  man. 

Etiology. — Glanders  and  farcy  are  the  direct  result  of  a  bacillus — the 
bacillus  mallei — described  by  Loeffler  and  Schiitz  in  1882.  It  is  a  short, 
non-motile  bacillus  not  unlike  that  of  tubercle  and  leprosy,  but  shorter  than 
either.  It  is  commonly  seen  among  the  cells  of  the  growth,  but  has  also 
been  found  in  the  blood.  The  disease  is  communicated  through  the  discharge 
from  the  infected  animal  to  an  abraded  skin  surface  or  intact  mucous  mem- 
brane. The  human  victims  are  usually  hostlers  or  others  working  about  horses. 

Morbid  Anatomy. — The  infection  presents  itself  in  the  shape  of  nodules 
ranging  in  size  from  that  of  a  lentil  to  that  of  a  fist,  or  it  may  infiltrate  more 
diffusely.  It  is  composed  of  round  cells  which  invade  the  skin,  mucous  mem- 
brane, and  muscles.  Internal  organs,— as  the  lungs,  liver,  spleen,  kidneys, 
and  even  stomach,  the  nervous  system,  bone,  and  cartilage — may  be  invaded. 
The  ulcers  on  the  skin  are  often  serpiginous,  whence  the  name  Wiirm  among 
Germans.  A  few  of  the  cells  develop  into  epithelioid  cells,  but  all  soon 
break  down,  leaving  ulcers  on  mucous  membrane  and  skin,  and  abscesses 
under  the  latter. 

Symptoms. — Glanders  and  farcy  have  a  period  of  incubation  of  from 
three  to  five  days,  rarely  a  week.  There  is  an  acute  and  chronic  form.  The 
acute  terminates  within  three  weeks,  while  the  chronic  may  last  for  months 
and  even  years. 

In  acute  glanders  of  the  nasal  mucous  membrane  there  is,  first,  red- 
ness  and  szvelling  at  the  point  of  inoculation  with  burning  and  dryness  of  the 
adjacent  mucous  membrane.  Intense  pain  in  the  forehead  from  involvement 
of  the  frontal  sinuses  may  also  be  present.  This  is  promptly  followed  by 
nodule-formation  and  the  rapid  breaking  down  of  the  nodules  and  discharge 
of  fetid  hemorrhagic  or  muco-pus.  The  destructive  process  extends  to  the 
nasal  septum,  the  mouth  and  pharynx,  and  even  the  larynx,  lung,  and  other 
organs.  The  submaxillary  glands  swell  and  suppurate.  From  these  lesions 
result  the  usual  symptoms  of  painful  deglutition,  cough,  and  hoarseness,  with 
fetid  expectoration. 


198  INFECTIOUS  DISEASES. 

Chronic  glanders  is  less  easy  of  recognition.  The  symptoms  are  more 
like  those  of  incurable  coryza  and  sometimes  of  chronic  laryngitis.  It  may 
be  necessary  to  make  cultures  and  inoculate  an  animal,  preferably  the  guinea 
pig,  which  perishes  in  thirty  days  and  presents  already  testicles  swollen  and 
suppurating. 

In  acute  farcy,  after  the  period  of  incubation,  a  feverish  state  develops. 
At  the  point  of  infection  on  the  skin  there  appears  a  nodular  swelling,  or  an 
ulcer  which  tends  to  spread  and  discharge  a  fetid  hemorrhagic  pus.  The 
adjacent  tissue  becomes  red  and  edematous  and  the  lymph-vessels  and  lymph- 
atic glands  are  inflamed.  Papules  that  become  pustules  may  also  develop  in 
the  neighborhood.  Such  an  eruption  has  been  mistaken  for  that  of  smallpox, 
but  is  soon  replaced  by  open  ulcers.  The  so-called  farcy  buds  are  nodular, 
subcutaneous  enlargements  along  the  course  of  the  lymphatics,  and  may  sup- 
purate.    The  nose  is  not  involved. 

In  chronic  farcy  the  localized  tumors  form  under  the  skin,  especially  of 
the  extremities,  and  break  down,  but  the  process  is  more  slow,  and  there  is 
no  special  involvement  of  the  lymphatic  glands. 

Further  symptoms  in  both  forms  are :  chilliness,  fever  with  high  tem- 
perature, intense  prostration  and  depression,  muscular  and  joint  pain  and 
soreness,  abscess  formation,  and  finally  typhoid  symptoms  and  death. 

The  spleen  and  liver  may  be  enlarged,  albuminuria  may  be  present,  and 
it  is  said  even  leucin  and  tyrosin  are  found  in  the  urine. 

Diagnosis. — The  diagnosis  in  the  acute  form  is  easy.  It  has,  how- 
ever, been  confounded  with  pyemia  and  smallpox.  Chronic  glanders  is  to 
be  distinguished  from  syphilis  and  tuberculosis.  Xhe  history  of  exposure  is 
helpful.  In  doubtful  cases  cultures  should  be  made.  Especially  character- 
istic is  that  on  the  cooked  potato,  which  by  the  third  day  furnishes  an  amber- 
hued  film,  that  on  the  sixth  to  eighth  day  is  red  and  turbid,  surrounded  with 
a  pale-green  area.  Inoculation  with  "  mallein,"  a  product  of  the  bacillus  of 
glanders,  comparable  to  the  tuberculin  of  tuberculosis,  should  be  made.  It 
causes  a  rise  of  temperature  in  affected  cases  as  do  tuberculosis  cases  with 
tuberculin.  A  reaction  of  3.50°  F.  (2°  C.)  in  horses  is  regarded  as  positive 
proof  of  the  presence  of  the  disease  ;  a  rise  of  1.85°  F.  ( 1.5°  C.)  is  strong  pre- 
sumptive proof,  and  1.25°  F.  (1°  C.)  suspicious. 

Prognosis. — The  prognosis  in  the  acute  variety  is  invariably  fatal;  in 
the  chronic  fomi  50  per  cent,  recover. 

Treatment. —  In  the  cutaneous  form  excision  and  cauterization  should 
be  practiced  as  early  as  possiJDle,  followed  by  antiseptic  dressings.  In  the 
nasal  variety  sprays  of  carbolic  acid  and  bichlorid  of  mercury  and  peroxid  of 
hydrogen  should  be  introduced  into  the  nose  and  throat.  "  Mallein  "  has 
also  been  used  internally  as  a  remedy,  but  its  value  is  not  as  yet  determined. 


ACTINOMYCOSIS. 

Synonyms. — Big  Javj;  Sivelled  Head;  Bone  Tumor. 

Definition. —  An  infectious  inflammatory  disease  of  cattle,  communi- 
cable also  to  man,  and  depending  for  its  existence  on  a  peculiar  fungus 
named  by  Hartz,  a  Munich  botanist,  actinomyces  or  ray-fungus. 

History  and  Etiology. — The  great  German  surgeon,  Langenbeck,  was  the  first  to 
discover,  in  1845,  that  the  disease,  "big-jaw,"  previously  well  known  in  the  slaughter- 
houses of  Germany,  could  be  communicated  to  man.  His  results  were  not,  however, 
published  until  1878,  a  year  after  Bollinger  discovered  that  it  was  due  to  a  fungus. 


ACTINOMYCOSIS.  199 

Bollinger  took  it  to  Hartz,  who  gave  it  its  name.  The  same  year,  1877,  James  Israel, 
of  Berlin,  found  the  fungus  in  man,  but  did  not  recognize  it  as  identical  with  the 
Hartz  fungus.  It  was  reserved  for  Ponfick,  in  1879  .  to  establish  thoroughly  the  iden- 
tity of  the  disease  in  man  and  in  cattle.  Belheld,  of  Chicago,  first  recognized  the 
parasite  in  cattle  in  this  country.  Henry  F.  Formad  and  George  A.  Bodamer  first 
studied  the  disease  in  Philadelpliia,  and  through  them  I  was  able  to  examine  speci- 
mens of  the  swelled-head  from  the  slaughter-houses  of  that  city. 

The  fungus  belongs  to  the  species  Cladothrix,  and  is  known  as  the  ray  fungus. 
As  found  in  the  pus  from  man  and  cattle  affected  with  the  disease,  it  appears  as  a 
small,  yellowish  granule  from  one  to  two  millimeters  {-^-^  to  J^  inch)  in  diameter, 
detectable  by  the  naked  eye.  By  the  microscope  the  granule  is  resolvable  into  conical 
threads,  radiating  from  a  center  to  which  they  are  attached  by  their  small  ends,  the 
other  club-like  ends  being  outward.  This  gives  the  external  surface  a  mulberry 
appearance.  The  center  is  composed  of  a  granular  substance,  containing  numerous 
bodies  resembling  micrococci.  The  disease  has  been  reproduced  by  inoculation  of  the 
fungus  from  a  diseased  animal,  as  well  as  bj'  the  inoculation  of  cultures.  It  is 
thought  to  arise  primarily  in  animals  in  the  course  of  their  feeding  on  vegetable  mat- 
ter. This  is  the  more  reasonable,  because  the  ray-fungus  has  been  isolated  from 
vegetables.     A  similar  origin  is  ascribed  to  it  in  man. 

The  effect  of  the  parasite  is  to  produce  granulomatous  and  fibromatous  new  for- 
mations, which  ultimately  become  the  seat  of  suppuration.  The  former,  like  tubercle, 
is  composed  of  small  round  cells,  epithelioid  cells,  and  giant  cells.  The  fibrous  mat- 
ter consists  of  proliferated  connective  tissue  about  the  granulation  growth,  expanding 
and  enlarging  the  bone  until  it  resembles  an  osteosarcoma,  for  which  it  was  for  a  time 
mistaken. 

The  tendency  to  suppuration  is  more  marked  in  man  than  in  cattle,  where  the 
process  is  a  more  localized  one.  In  man  the  disease  runs  its  course  with  the  formation 
of  multiple  abscesses  and  chronic  pyemia.  Such  course  is  supposed  to  be  due  to  an 
admixture  of  pyogenic  organisms  with  the  true  ray  fungus.  Associated  with  the  sup- 
purative process  m  man  is  a  tendency  to  fatty  degeneration  of  tlie  cells  of  the  granu- 
lation tissue. 

Morbid  Anatomy. — In  addition  to  the  lesions  presently  to  be  described 
about  the  jaw  and  head,  there  are  found  in  the  lungs,  when  the  latter  are 
invaded,  the  miliary  nodules  alluded  to,  made  up  of  groups  of  fungi,  sur- 
rounded by  granulation-tissue.  Bronchopneumonic  areas  and  abscesses  large 
enough  to  be  recognized  by  their  physical  signs  during  life  may  also  be 
present.    Erosion  of  the  vertebrae,  ribs,  and  sternum  may  also  occur. 

Symptoms. — The  route  of  infection  is  generally  the  mouth,  while  the 
special  seats  seized  upon  are  carious  teeth,  whence  the  jaiv  is  invaded  and 
becomes  swollen.  The  swelling  may  extend  thence  to  the  face  and  temporal 
region,  and  even  to  the  neck,  producing  discharging  sinuses  like  those  asso- 
ciated with  dead  bone.  Alongside  of  these  are  cicatricial  marks  of  healing. 
More  rarely  the  tongue,  fauces,  and  even  the  intestines  (large  and  small), 
and  the  liver  are  invaded.  The  latter  organ  may  also  become  involved 
metastatically.  The  fungus  has  been  found  in  the  stools  first  by  Ransom, 
and  pericecal  abscess  has  been  found  due  to  it. 

The  lungs  are  also  favorite  seats  of  invasion  by  actinomycosis,  and  it 
was  in  these  organs  in  man  that  Israel  recognized  the  fungus  which  proved 
to  be  the  ray-fungus  also.  The  syniptouis  produced  are  those  of  bronchitis 
— fever,  cough,  and  more  or  less  fetid  ejcpectoration,  in  which  the  fungus  is 
occasionally  found.  In  the  lungs  the  posterior  and  lateral  parts  are  affected 
rather  than  the  apices.  They  may  be  invaded  simultaneously  with  the  jaws. 
The  course  of  lung  actinomycosis  is  chronic.,  and  resembles  that  of  pulmonary 
consumption,  the  average  duration  in  man  being  ten  months. 

Actinomycosis  may  occur  in  connection  with  the  skin  alone,  and  even  in 
the  brain  abscesses  may  occur  containing  the  mycelium.  Bollinger  has 
reported  a  case  of  the  primary  disease  in  the  brain  of  man,  while  Gamgee 
and  Delpine  and  O.  B.  Keller  have  found  it  in  the  brain  secondary  to  pleural 
invasion.  The  metastatic  abscesses  are  the  direct  result  of  the  transfer  of 
a  portion  of  the  fungus. 

Diagnosis. — Sarcoma  of  the  jaw  presents  a  macroscopic  picture  very 


200  INFECTIOUS  DISEASES. 

like  that  of  actinomycosis,  but  its  course  is  more  rapid  and  there  is  less  sup- 
puration, yet  these  signs  are  of  themselves  insufficient,  and  the  recognition 
of  the  fungus  may  be  necessary  to  a  diagnosis. 

More  frequent,  perhaps,  than  any  other  error  is  that  which  mistakes 
the  disease  for  pyemia,  of  which,  indeed,  as  it  occurs  in  man,  it  is  a  chronic 
variety.  There  are  the  same  sort  of  metastases  in  the  lungs  and  elsewhere ; 
in  man  with  pus  formation,  in  animals  with  or  without  slight  suppuration. 

Treatment.— The  treatment  is  surgical,  consisting  in  thorough  extirpa- 
tion, the  opening  of  the  abscesses  and  removal  of  the  dead  bone,  followed  by 
thorough  drainage.  lodid  of  potassium  in  doses  of  40  to  60  grains  (3.66  to 
4  gm.)  was  recommended  by  Thomassen  in  1885,  and  cures  are  reported 
from  its  use.     Da  Costa  also  reports  success  with  this  drug.* 

FOOT  AXD  MOUTH  DISEASE. 
Syxoxym. — Aphthcc  cpizooticcB. 

Definition. —  An  acute  infectious  disease  of  lower  animals,  especially 
of  cattle,  sheep,  swine,  more  rarely  the  goat  and  horse,  and  still  more  rarely 
of  fowls,  dogs,  and  cats.  The  disease  in  cattle  spreads  rapidly  and  entails 
often  serious  loss.  It  is  characterized  by  fever  and  the  presence  of  vesicles 
and  ulcers  in  the  mucous  membrane  of  the  mouth,  in  the  furrows  and  clefts 
about  the  feet,  and  on  the  teats  of  animals.  It  is  communicable  to  man, 
especially  during  epidemics. 

History  and  Etiology. — The  early  confusion  of  foot  and  mouth  disease 
with  anthrax  and  actinomycosis  makes  it  difficult  to  date  its  first  recognition. 
Hertwig,  however,  established  its  contagiousness  as  early  as  1834  by  experi- 
ments upon  himself  and  two  other  men.  The  experiments  consisted  in  the 
drinking  of  infected  milk.  Local  and  constitutional  symptoms  of  the  disease 
resulted. 

The  microbe  responsible  for  foot  and  mouth  disease  has  not  been  settled 
upon,  though  a  streptococcus  has  been  isolated  from  the  fluid  of  the  vesicle 
by  Klein,  and  a  micrococcus  from  milk  by  Cnyrim  and  Libberitz ;  the  specific 
power  of  neither  has  as  yet  been  determined.  The  contagion  bearer  is  espe- 
cially the  contents  of  the  vesicle  alluded  to.  but  milk,  blood,  and  urine  and 
feces  are  also  media.  It  is  communicated  to  man  through  the  ingestion  of 
unboiled  milk,  butter,  and  cheese,  or  through  contact  with  the  fluid  of  the 
vesicles  on  the  teats  by  milkers.  It  is  said  to  be  communicable  even  by  the 
saliva  from  the  affected  animal. 

A  certain  relation  is  believed  to  exist  between  the  aphthous  sore  mouth 
of  children  and  the  foot  and  mouth  disease,  chiefly  because  it  has  been 
observed  that  aphthae  are  apt  to  prevail  in  children  at  the  same  time  with  the 
foot  and  mouth  disease  in  cattle. 

Morbid  Anatomy. — As  recovery  invariably  takes  place,  no  lesions 
other  than  those  to  be  noted  under  symptoms  have  as  yet  been  observed. 

Symptoms. — The  disease  has  a  period  of  incubation  of  from  three  to 
five  days.  At  this  time  there  is  a  febrile  movement  with  malaise  and  loss  rf 
appetite.  On  the  mucous  membrane  of  the  lips  and  tongue,  and  sometimes 
on  the  hard  palate  and  pharynx,  come  vesicles  containing  a  yellowish  serum. 
There  is  a  sensation  of  heat  and  bitrnin^c;  throughout  the  mouth,  and  the 
swelling  may  be  so  great  as  to  make  speech  difficult  and  swallowing  painful. 

*  "Proceedings  of  the  Association  of  American  Physicians,"  igoo. 


MILK  SICKNESS.  201 

There  is  copious  salivation.  Almost  simultaneously  appear  vesicles  between 
the  fingers  and  toes  and  around  the  nails.  Vesicles  have  also  been  noted  on 
the  nipples  of  women.  Indeed,  they  have  been  found  scattered  all  over  the 
body,  so  that  the  case  resembles  smallpox.  The  hands,  especially,  may  be 
extensively  involved.     Gastro-intestinal  symptoms  are  sometimes  present. 

Prognosis. — The  prognosis  is  favorable  in  man,  recovery  being  the 
rule.  Very  young  children  may  perish.  The  suckling  young  of  animals 
perish  in  large  numbers,  because  of  the  infected  milk  on  which  they  subsist. 

Treatment. — The  disease  can  be  easily  avoided  by  simple  prophylactic 
m^easures  by  those  in  contact  with  animals,  of  which  the  use  of  boiled  milk  is 
the  most  important.     Cleanliness  of  man  and  beast  conduce  to  the  same  end. 

Curative  measures  of  a  simple  kind  generally  suffice.  Mouth-washes 
of  a  saturated  solution  of  chlorate  of  potassium  should  be  frequently  used. 
Powdered  borax  and  alum  may  be  directly  applied.  The  separate  ulcers  or 
vesicles  should  be  touched  with  the  solid  silver  nitrate.  The  skin  lesions 
should  be  washed  in  corrosive  sublimate  solution  and  dressed  in  sublimate 
cotton  or  salicylated  cotton.  The  fever  should  be  combated  with  suitable 
antifebrile  measures. 

MILK  SICKNESS. 
Synonyms. — Trembles;  Puking  Fever;  Slows. 

Definition. —  An  infectious  disease  prevailing  in  the  western  and  south- 
western parts  of  the  United  States,  characterized  especially  by  trembling, 
vomiting,  constipation,  and  a  peculiar  fetor  of  the  breath. 

Etiology. —  A  like  disease  prevails  among  the  cattle  of  the  infested  dis- 
tricts, and  it  is  supposed  to  be  communicated  to  man  through  the  milk  and 
its  products — viz.,  cheese  and  butter,  and  also  flesh  when  used  as  food.  It  is 
more  common  in  summer  and  autumn  and  in  dry  seasons.  Nothing  more 
definite  is  known  as  to  its  cause. 

Morbid  Anatomy. — Our  knowledge  of  the  morbid  anatomy  of  milk 
fever  is  chiefly  by  inference  from  that  obtained  by  necropsies  on  cattle, 
those  on  man  being  few  and  imperfect.  The  lesions  noted  by  Grof  under 
these  circumstances  are  as  follows :  Cerebral  sinuses,  meningeal  vessels  of 
the  brain  and  cord  distended  with  blood ;  pia  mater  opaque  and  overlaid  with 
purulent  exudate ;  brain  soft ;  stomach  and  intestines  contracted  and  mucous 
membrane  injected ;  lungs,  liver,  kidneys,  and  spleen  engorged  with  blood, 
the  liver  and  spleen  soft,  the  latter  enlarged  in  some  cases  to  twice  the  normal 
size,  the  blood  fluid. 

Symptoms. — There  is  usually  a  prodrome  of  two  or  three  days,  mani- 
fested by  simple  uneasiness  and  discomfort,  after  which  the  disease  is  usually 
ushered  in  suddenly  by  severe  epigastric  pain,  constipation,  nausea,  and 
vomiting.  Hence  the  term  "  puking "  sickness.  There  is  also  moderate 
fever  and  disproportionate  thirst.  The  pulse  at  first  is  full;  later,  small  and 
rapid.  There  is  marked  tremor  or  muscular  twitching  on  attempt  at  motion. 
The  constipation  is  characteristic.  The  tongue  is  swollen  and  the  breath  is 
peculiarly  foul.  This  is  said  to  be  diagnostic.  A  typhoid  state  may  super- 
vene, preceded  by  restlessness,  irritability,  coma,  and  even  convulsions. 

Prognosis. — The  duration  of  the  disease  is  from  two  to  ten  days  or 
longer.  The  short  cases  are  the  fatal  ones.  When  recovery  takes  place,  con- 
valescence may  be  protracted  three  to  four  weeks. 

Treatment. — The   treatment    is    symptomatic,    and    consists    chiefly   in 


202  INFECTIOUS  DISEASES. 

combating  by  alcohol,  aromatic  spirits  of  ammonia,  and  food  the  tendency  to 
weakness.     Happily,  the  disease  appears  to  be  dying  out  as  land  is  improved. 
Prophylaxis  may  be  secured  by  fencing  off  cattle  affected  and  carefully 
guarding  against  the  use  of  infected  food  and  milk. 


SYPHILIS. 

Synonyms. — Lues  venerea;  The  Pox. 

Definition. — Syphilis  is  a  specific  constitutional  disease  of  human  beings, 
due  to  inoculation  by  a  special  virus  or  to  hereditary  transmission  character- 
ized by  a  tendency  to  a  localized  deposit  of  various  inflammatory  new  forma- 
tions. Under  the  former  condition  it  is  known  as  acquired  sypliilis ;  under 
the  latter,  as  hereditary  sypJiilis.    It  is  apparently  confined  to  the  human  race. 

Historical. — Svphilis  was  first  described  as  a  separate  form  of  venereal  disease  in 
1494,  when  it  prevailed  as  an  epidemic  among  the  troops  of  Charles  VIII  before 
Naples.  Thence  it  spread  over  Italy  into  France,  Germany  and  the  rest  of  Europe. 
As  this  was  immediately  after  the  discovery  of  America  it  has  been  alleged  that  the 
disease  was  introduced  into  Europe  from  America,  and  it  has  also  been  claimed  that 
it  was  introduced  from  Africa.  In  fact,  we  have  very  little  definite  knowledge  on  the 
subject,  but  there  seems  good  reason  to  believe  that  the  disease  is  much  older  than 
the  dates  given. 

Etiology. — In  common  with  all  infectious  diseases,  syphilis  is  ascribed 
to  the  operation  of  a  bacillus,  and  two  or  three  have  been  selected  as  respon- 
sible and  then  abandoned.  The  latest  is  that  described  by  Lustgarten  in 
1884.  It  resembles  the  tubercle  bacillus  and  leprosy  bacillus,  is  slightly 
clubbed  at  the  ends,  and  from  three  to  four  microns  in  length.  Mat-terstock, 
Travel,  and  Alvarez  claim  that  it  is  not  differentiable  from  a  similar  bacillus 
found  in  preputial  and  vulvar  smegma.  It  is  said,  however,  to  be  distin- 
guishable from  the  smegna  bacillus  by  the  carbofuchsin  test.  Cultures  of  the 
bacillus  of  syphilis  have  not  as  yet  been  successful,  and  it  must  be  admitted 
that  there  is  still  much  doubt  on  the  subject. 

Syphilis  is  one  of  the  most  highly  contagious  diseases.  In  the  first  place, 
the  blood  of  the  syphilitic  is  inoculable  and  capable  of  producing  the  disease. 
Further,  the  secretions  of  all  primary  and  secondary  lesions  of  the  skin  and 
mucous  membranes  are  similarly  potent.  The  products  of  the  third  or  gum- 
matous stage  are  not  so  regarded,  although  opinions  are  not  unanimous  on 
this  point.  A  raw  or  abraded  surface  is  a  necessary  condition  of  inoculation. 
The  physiological  secretions,  such  as  the  tears,  milk,  nasal  and  bronchial 
mucus,  do  not  communicate  the  disease  when  inoculated,  although  they  may 
become  virulent  by  contamination  with  the  poisonous  secretions.  Exceptions 
to  this  law  are  the  spermatozoid  of  man  and  the  ovule  of  woman,  each  of 
which,  if  derived  from  a  syphilitic  source,  is  capable  of  infecting  the  other. 

The  acquired  disease  has  three  stages — a  primary,  secondary,  and 
.tertiary.  The  primary  is  characterized  by  a  primary  sore  associated  with 
glandular  enlargement  in  the  neighborhood  of  the  seat  of  inoculation.  The 
secondary  stage  furnishes  lesions  of  the  skin  and  mucous  membranes^  among 
which  sore  throat  is  especially  conspicuous.  It  is  sometimes  accompanied  by 
fever.  The  tertiary  is  characterized  by  affections  of  deep-seated  structures, 
the  osseous  and  nervous  systems,  the  liver,  spleen,  kidney,  and  testicle ;  also 
the  subcutaneous  and  submucous  tissues. 

The  initial  sore  makes  its  appearance  within  six  weeks  after  exposure, 
usually  in  two  or  three  weeks.  The  phenomena  of  the  second  stage  usually 
show  themselves  within  three  months  or  from  six  to  twelve  weeks.     The 


SYPHILIS.  203 

third  stage  is  more  difficult  to  define  by  temporal  limits.  It  is  by  years 
rather  than  by  months,  and  is  characterized,  as  stated,  by  the  involvement  of 
the  deeper-seated  organs.  Hereditary  syphilis,  when  not  present  at  birth, 
makes  its  appearance  within  the  first  three  months ;  after  six  months  the  child 
may  be  regarded  as  safe. 

In  the  vast  majority  of  cases,  acquired  syphilis  comes  from  sexual  inter- 
course, but  it  may  be  the  result  of  contact  in  many  ways,  as  by  the  lips,  teeth, 
infected  hands,  and  other  parts  of  the  body.  Drinking-cups,  utensils,  and 
other  articles  used  by  the  infected  in  common  with  others,  sometimes  convey 
the  irrfection.  Physicians  are  not  infrequently  infected  in  midwifery  prac- 
tice, the  initial  lesion  making  its  appearance  around  the  nail  or  in  the  web 
between  the  first  and  second  fingers.  Wet-nurses  acquire  the  disease  from 
syphilitic  nurslings,  the  chancre  occurring  in  a  fissure  or  abrasion  of  the 
nipple.    Vaccination  has  in  rare  instances  been  a  means  of  infection. 

Heredity  syphilis  may  be  transmitted  through  the  father  or  the  mother. 
In  the  former  instance  it  is  called  sperm  inheritance ;  in  the  latter,  germ 
inheritance.  Syphilis  may  be  communicated  by  the  father  while  the  subject 
of  the  active  disease,  or  after  all  signs  of  it  have  disappeared.  On  the  other 
hand,  a  syphilitic  father  may  beget  healthy  children.  The  question  has  some- 
times to  be  decided  by  a  physician  as  to  whether  a  syphilitic,  apparently  recov- 
ered, may  marry  with  safety  to  offspring.  It  will  be  seen  from  the  above  that 
an  absolute  answer  dare  not  be  given ;  but  this  much  may  be  said,  that  the 
longer  the  interval  since  the  primary  attack  the  less  likely  is  the  offspring  to 
be  tainted,  and  it  is  generally  acknowledged  that  systematic  and  continuous 
treatment  may  eliminate  the  disease  altogether.  An  interval  of  not  less  than 
three  years  should  be  insisted  upon  between  the  disappearance  of  the  last 
symptom  and  the  patient's  marriage.  It  is  to  be  remembered  also  that  each 
successive  child  of  syphilitic  parents  shows  less  signs  of  the  disease,  imtil 
finally  healthy  offspring  results. 

A  syphilitic  mother  may,  of  course,  bear  syphilitic  children  from  germ 
infection,  producing  thus  true  hereditary  syphilis ;  but  a  child  may  also  be 
infected  at  the  moment  of  its  birth,  when  the  syphilis  is  congenital  but  not 
inherited.  On  the  other  hand,  a  woman  may  bear  a  syphilitic  child,  and, 
though  herself  without  signs  of  the  disease,  will  not,  according  to  Colles's 
law,  be  infected  by  her  child  should  she  suckle  it  while  it  has  syphilitic  ulcers 
of  the  lips  and  tongue.  Yet  a  healthy  nurse  who  suckles  this  same  child,  or 
merely  handles  and  dresses  it,  may  be  infected.  Such  a  woman  is  supposed 
to  have  received  protective  inoculation  without  evident  signs  of  the  disease ; 
and  we  may  have  here  an  example  of  protection  through  a  natural  antitoxin 
absorbed  from  the  syphilitic  fetus  by  its  non-syphilitic  mother. 

A  woman  may  be  infected  after  conception,  when  the  child  may  be  born 
non-syphilitic  or  syphilitic  by  placental  transmission. 

Of  course,  when  both  father  and  mother  are  infected,  the  chances  of 
the  offspring  being  infected  are  doubled. 

Morbid  Anatomy. — I.  Of  Acquired  Syphilis. — At  least  five  sets  of 
lesions  may  be  traced  to  acquired  syphilis.  The  first  is  the  initial  lesion,  the 
chancre  or  primary  sore  at  the  point  of  inoculation  and  usually  two  or  three 
weeks  afterward.  This  constitutes  primary  syphilis.  Beginning  as  a 
wounded  or  abraded  spot,  a  vesicle  or  papule  develops,  which  subsequently 
softens  in  the  center  and  forms  an  ulcer  with  a  hard,  grisly  base  and  edge, 
constituting  the  hard  or  indurated  chancre.  It  is  found  to  consist  in  a  dense 
infiltration    of   small    cells,    some    of   which    develop    into   large    formative 


204  INFECTIOUS  DISEASES. 

(epithelioid;  cells  and  others  even  into  giant  cells,  but  no  further  differentia- 
tion takes  place;  for  the  most  part  the  infiltration  breaks  down  and  is 
absorbed,  a  few  of  the  cells  going  to  form  the  cicatrix.  In  the  broken-down 
tissue  is  found  the  Lustgarten  bacillus.  The  chancre  is  found  usually  in 
males  on  some  part  of  the  penis,  especially  on  the  prepuce,  and  in  females  on 
the  labia  or  vaginal  part  of  the  cervix.  It  may  be  so  small  as  to  escape  notice, 
especially  when  within  the  urethra.  The  sore  lasts  from  three  or  four  weeks 
to  as  many  months.  Its  peculiar  induration  is  easily  recognized  by  taking  it 
up  and  pinching  it  between  the  fingers,  though  it  is  often  not  characteristic 
on  the  flat  mucous  membranes  of  the  genitalia  of  women. 

Along  with  the  chancre  there  is  a  second  lesion,  an  adenitis  of  the 
adjacent  lymph  glands,  which  may  suppurate,  forming  a  bubo,  or  there  may 
be  a  hyperplasia  of  connective  tissue,  terminating  in  persistent  induration  of 
the  gland.  It  usually  appears  simultaneously  with  the  induration  or  soon 
after  it  is  established.  Buboes  may  be  long  stationary  and  are  then  said  to 
be  indolent.  They  may  be  multiple.  They  belong  to  the  symptoms  of  pri- 
mary syphilis. 

The  third  lesion  is  the  mucous  patch,  soft  papule  or  condyloma  latum, 
which  is  one  of  the  events  of  the  secondary  stage  of  syphilis.  It  has  its  seat 
on  mucous  membrane  or  on  soft,  moist  skin,  as  in  the  perineum,  groins, 
between  the  toes,  at  the  junction  between  the  skin  and  mucous  membrane  at 
the  angle  of  the  mouth,  and  about  the  anus.  It  consists  of  an  inflammatory 
infiltration  of  the  epidermis  and  corium  with  small  cells.  A  more  highly 
differentiated  infiltration  of  the  papillae  of  the  mucous  membrane  is  the 
acuminate  condyloma,  or  venereal  wart,  especially  common  about  the  vulva 
and  anus. 

The  fourth  lesion  is  the  cutaneous  affection,  or  syphilid,  of  which  there 
is  a  roseolar  or  macular,  a  papular,  a  pustular,  a  squamous,  and  a  tubercular 
variety.  All  are  characterized  by  a  copper-colored  hue,  especially  permanent 
after  the  other  features  have  subsided,  and  a  tendency  to  symmetrical  distribu- 
tion. The  macular  or  roseolar  syphilid  affects  more  particularly  the 
abdomen,  the  chest,  and  the  front  of  the  arms,  while  the  face  is  exempt. 
This  syphilid  persists  a  week  or  two.  The  papular  eruption  is  in  groups  on 
the  face  and  trunk.  The  pustular  eruption  often  closely  resembles  that  of 
smallpox.  The  squamous  syphilid  resembles  other  squamse,  but  it  is  espe- 
cially distinguished  by  its  coppery  hue.  It  involves  preferably  the  backs  of 
the  arms  and  the  front  of  the  thighs — the  extensor  surfaces — and  is  moreover 
rare.  The  skin  syphilids  are^  symmetrical  in  the  early  stages,  but  in  the 
latest  stages  become  irregular  and  unilateral  in  their  distribution. 

The  fifth  or  remaining  set  of  lesions  constitutes  the  tertiary  manifesta- 
tion, and  involves  the  deeper  tissues,  such  as  the  subcutaneous  tissues,  the 
osseous  and  the  nervous  systems,  the  liver,  lungs,  and  kidney.  They  include 
especially  the  tubercular  and  gummatous  syphilids  and  fibroid  induration. 
The  first  occur  in  single  nodules  or  may  coalesce  to  form  a  solid  tubercular 
patch  :  also  form  serpiginous  patches  or  segments  of  circles.  They  are  con- 
fined to  certain  regions  as  a  rule,  face,  back,  and  more  rarely  extremities,  and 
are  usually  unilateral.  The  most  general  .of  these  is  the  fihroid  induration, 
consisting  in  a  development  of  fibroid  tissue  like  that  of  chronic  inflammation. 
The  new  tissue  thus  formed  arises  around  the  blood-vessels,  and  consists,  at 
first,  of  a  small-celled  infiltration,  which  later  is  converted  into  fibroid  tissue. 
It  is  found  also  in  the  periosteum,  the  sheaths  of  the  nerve  trunks,  the  cap- 
sules, and  interstitial  tissue  of  organs  and  muscles.     It  occupies,  for  the  most 


SYPHILIS.  205 

part,  small  areas  surrounded  by  normal,  unaffected  structures.  When  in  the 
capsules  of  organs  it  sends  prolongations  into  their  interior,  which  partition 
oft'  the  organ  and  by  their  subsequent  contraction  give  rise  to  irregular  thick- 
ening and  cicatricial  puckering. 

A  differentiation  of  this  libroid  change,  a  most  characteristic  lesion  of 
syphilis,  is  the  gumma,  a  yellowish-white  fibrous  nodule,  closely  continuous 
by  its  outer  layer  with  the  connective  tissue  of  the  organ  in  which  it  is 
imbedded.  It  varies  in  size  from  that  of  a  pin  point  to  three  to  five  centi- 
meters (I  to  2  inches)  in  diameter.  Histologically,  it  is  with  tolerable  ease 
separated  into  three  parts — a  central  or  oldest  part  in  a  state  of  atrophic 
cheesy  degeneration,  an  intermediate  layer  of  imperfect  fibrous  tissue,  and  an 
external  layer  of  vascular  granulation-tissue  rich  in  cells.  It  is  frequently 
associated  with  the  fibroid  change  above  described.  In  the  degenerative 
changes  to  which  the  gumma  is  subject  it  may  produce  extreme  destruction 
of  the  organ  in  which  it  is  imbedded. 

The  seats  of  the  gummy  tumor  are  the  skin,  subcutaneous  and  sub- 
mucous tissue,  muscles,  fascise,  bone,  where  it  forms  the  syphilituc  node,  the 
connective  tissue  of  organs,  especially  the  liver,  brain,  testicle,  and  kidney, 
less  commonly  the  lungs.  When  in  submucous  tissues,  it  may  give  rise  to 
deep-seated  ulceration  and  suppurative  processes,  leading  to  destruction,  not 
only  of  soft  tissues,  but  also  of  bone.  Especially  frequent  and  repulsive  in  its 
result  is  the  destruction  of  the  nasal  bones  with  perforation  of  the  palate. 
The  bacillus  of  Lustgarten  is  said  to  be  found  in  the  gummy  tumor. 

Another  variety  of  deep-seated  syphilids,  syphilitic  riipia,  consists  pri- 
marily of  large  pustules,  which  dry  and  crust  over  with  laminated  scabs, 
while  beneath  is  a  deep  ulcer.  This  may  subsequently  heal,  leaving  a  scar. 
Large  pustular  lesions  and  tubercular  syphiloderms  occur  especially  in  the 
neighborhood  of  the  sacrum. 

Another  tertiary  lesion  of  syphilis,  although  probably  not  peculiar  to  it, 
is  syphilitic  arteritis,  which  consists  in  a  cellular  thickening  of  the  vessel-walls, 
beginning  in  the  intima  and  intruding  thence  on  the  lumen  of  the  vessels. 
The  outer  coat  is  abnormally  vascular  and  infiltrated  with  small  cells  that  also 
invade  the  muscular  coat.  These  are  the  phenomena  of  obliterative  endar- 
teritis, which  have  thus  far  been  studied  only  in  the  vessels  of  the  brain  by 
Greenfield  and  Huebner. 

Symptoms. — The  symptoms  of  acquired  syphilis  are  so  largely  the 
morbid  states  described  under  the  head  of  morbid  anatomy  that  most  of 
them  need  only  be  enumerated  in  connection  with  the  date  of  their  appear- 
ance. The  chancre  or  primary  sore  and  the  bubo,  which  together  constitute 
primary  syphilis,  have  been  sufficiently  described. 

The  secondary  symptoms  manifest  themselves  usually  from  the  sixth 
to  the  twelfth  week,  but  may  be  as  late  as  three  months.  Sore  throat  is  one 
of  the  first  of  these  symptoms,  and  is  commonly  associated  with  fever,  which 
rarely  exceeds  101°  F.  (38.3°  C).  It  may  be  remittent  and  even  strikingly 
intermittent,  and  in  rare  instances  rises  much  higher  than  101°  F.  (38.3°  C), 
reaching  104°  F.  (40°  C),  and  even  10.=;°  F.  Uo.5°  C).  The  sore  throat 
alluded  to  is  associated  with  hyperemia  of  the  fauces,  often  with  intractable, 
gray-based  ulcers,  and  less  frequently,  with  mucous  patches  and  syphilitic 
warts.  The  inflammation  may  extend  from  the  throat  into  the  Eustachian 
tube  and  middle  ear,  producing  impaired  hearing.  The  larynx  is  especially 
liable  to  become  the  seat  of  ulceration,  which  may  heal  and  produce  marked 
deformity. 


2o6  INFECTIOUS  DISEASES. 

Then  there  are  the  syphilids  named.  Along  with  these,  a  very  common 
symptom  is  the  falling  out  of  the  hair,  and  especially  from  the  eyebrows,  giv- 
ing rise  to  a  striking  change  in  the  facial  expression.  An  inflammatory  con- 
dition at  the  root  of  the  nails,  syphilitic  onychia,  causes  them  to  become 
brittle  and  distorted.  Other  secondary  symptoms  not  mentioned  are  iritis, 
and  more  rarely  choroiditis  and  retinitis.  The  former  presents  itself  in  from 
three  to  six  months  after  the  primary  chancre,  and  is  one  of  the  most  painful 
and  trying  of  symptoms,  requiring  prompt  and  energetic  treatment.  Involve- 
ment of  the  ear  ossicles  is  rare  but  possible,  producing  deafness. 

Joint  affections  are  sometimes  associated  with  tertiary  syphilis.  These 
mav,  of  course,  result  from  the  invasion  of  the  joint  ends  of  the  bones  by  the 
gummatous  syphilitic  disease,  to  which  they  are  subject,  but  there  may  also  be 
direct  involvement  of  the  serous  tissues  themselves  by  inflammatory  and  gum- 
matous processes  that  give  rise  to  pain  and  interfere  with  motion.  The  bone 
affections  of  syphilis  are  characterized  by  nocturnal  pains,  said  to  be  due  to 
pressure  from  distended  veins. 

The  involvement  of  internal  glandular  organs  occurs  later,  ten  or  more 
vears  after  the  primary  lesion,  though  precocious  tertiary  lesions  of  this  kind 
have  been  reported  much  earlier.  Amyloid  disease  is  a  very  common  tertiary 
affection,  involving  liver  and  spleen  and  producing  some  of  the  most  striking 
enlargements  of  the  former.  But  cirrhosis  and  cicatricial  markings  are  also 
common.  Syphilitic  lesions  of  the  liver  are  of  such  a  degree  and  importance 
as  to  demand  separate  consideration  under  the  diseases  of  that  organ. 

A  sareocele  involving  the  whole  testicle  is  among  the  tertiary  aft'ections 
often  mistaken  for  tuberculosis,  from  which  it  may  be  distinguished  by  the 
fact  that  the  latter  is  accompanied  by  tuberculosis  elsewhere,  and  involves  the 
proper  structure  of  the  testicle  instead  of  the  whole  organ.  Sclerosis  of  the 
spinal  cord  is  frequently  associated  wath  syphilitic  history,  and  it  is  often 
ascribed  to  it.  A  special  condition  is  an  involvement  of  the  nervous  system 
of  such  importance  as  to  require  a  separate  section.  Gummy  tumors  of  the 
brain  occur,  producing  pressure  symptoms ;  a  similar  association  is  true  of 
arteriosclerosis  as  well  as  the  arteritis  obliterans  alluded  to. 

Sooner  or  later  the  syphilitic  becomes  anemic  and  an  examination  of  the 
blood  recognizes  a  reduction  in  the  number  of  red  corpuscles,  in  the  hemo- 
globin and  an  increase  in  the  white  cells. 

II.  Of  Hereditary  Syphilis. — Except  the  primary  chancre  all  the  symp- 
toms described  as  occurring  in  acquired  syphilis  may  be  present  in  the  con- 
genital form.  It  may  be  said^  in  a  word,  that  visceral  alterations  are  more 
prominent,  especially  those  involving  abdominal  organs.  It  is  necessar}^ 
therefore,  to  mention  here  only  those  that  may  be  regarded  as  additional. 

Among  the  most  important  of  these  is  repeated  abortion.  It  is  very 
common  to  have  four  or  five  and  even  more  abortions,  while  each  successive 
one  usually  takes  place  longer  after  conception  until  finally  a  living  child  is 
born.  Such  aborted  products  are  shriveled,  the  skin  exfoliates,  and  there  is 
often  reason  to  believe  they  have  been  some  time  dead.  Syphilitic  children 
born  at  term  have  evidently  been  arrested  in  development,  are  shriveled  and 
wizen-faced,  and  may  suffer  from  cutaneous  syphilids.  The  so-called  pem- 
phigus neonatorum,  \vith  blebs  occurring  about  the  wrists,  hands,  ankles,  and 
feet,  is  characteristic.  There  is  also  apt  to  be  enlarged  liver  and  spleen. 
Or  a  child  may  be  born  apparently  healthy  and  take  on  these  symptoms  after 
three  or  four  weeks.  Lesions  of  hereditary  syphilis  are  reported  as  begin- 
ning even  later  than  this,  up  to  the  sixth  month.     This  is,  however,  unusual. 


SYPHILIS. 


207 


Rhinitis,  or  nasal  catarrh  with  sniMes,  is  one  of  the  earliest,  to  be  followed 
by  cutaneous  lesions,  particularly  about  the  nates.  Fissures  about  the  lips 
and  ulcerations  on  the  muco-cutaneous  surface  are  present,  from  which  the 
discharges  are  inoculable. 

Disease  of  the  epiphyseal  cartilages  of  long  bones  and  of  the  cartilages 
of  the  ribs  is  a  very  common  symptom  of  hereditary  syphilis.  The  zone 
of  the  cartilage  adjacent  to  the  bone  exhibits  proliferated  cartilage  cells  and 
prolongations  over  the  end  into  the  diaphysis  instead  of  being  sharply  sepa- 
rated. There  is  tendency  to  hemorrhage.  A  syphilitic  cry,  high  pitched 
and  harsh,  is  described.  To  these  may  be  added  any  of  the  symptoms  already 
mentioned  under  acquired  syphilis. 

A  later  symptom  is  "  notched  teeth,"  first  described  by  Jonathan  Hutchin- 
son as  characteristic  and  distinctive  of  hereditary  syphilis.  The  teeth  affected 
are  the  permanent  central  incisors  of  the  upper  and  lower  jaws.  The  appear- 
ances are  not  uniform,  and  are  better  appreciated  by  examining  the  accom- 
panying drawings  than  from  descriptions.  Other  late  symptoms  are  kera- 
titis, iritis,  impaired  hearing  from  ear  affections,  periostitis,  and  splenic  and 
"hepatic  enlargement. 

If  it  survive  the  earlier  lesions  or  escape  them,  the  syphilitic  child 
remains  undeveloped  and  stunted  in  its  growth,  and  in  consequence  of  arrest 
of  development  a  singular  reversal  of  the  appearance  of  premature  age, 


Fig.  18. — The  lower  incisors  of 
a  girl,  aged  fifteen,  the 
subject  of  inherited  syph- 
ilis. The  teeth  are  very 
short,  rounded,  and  peg- 
like, with  wide  interspaces. 
This  set  shows  the  most 
tj'pical  condition  ever  ex- 
hibited by  the  lower  set— 
{after  Hiitchinso7i). 


Fig  19. — The  two  upper  and  four  lower  incisors  (per- 
manent) of  a  girl,  the  subject  of  inherited  sj'philis, 
all  recently  cut.  The  upper  teeth  are  narrow  from 
side  to  side,  at  their  edges,  and  show  a  thin 
middle  lobe,  bounded  above  by  a  crescentic  line. 
The  lower  teeth  are  rounded  and  show  foliated 
extremities.  All  the  teeth  are  small  and  spaces 
occur  between  the  adjacent  ones.  In  the  upper 
ones  the  crescentic  thin  mid-lobe,  and  in  the 
lower  ones  the  foliated  extremities  will,  before 
long,  break  away — {after  Htctc/iinson). 


described  as  characteristic  of  the  syphilitic  child  at  birth,  takes  place.  The 
new-born  syphilitic  child  looks  prematurely  old.  A  popular  novelist  has  aptly 
described  the  appearance  of  the  syphilitic  child  in  the  terse  phrase,  "  a  little 
old  man  with  a  cold  in  its  head."  The  syphilitic  who  outlives  his  childhood 
remains,  however,  younger  looking  than  he  actually  is,  insomuch  that  a  young 
man  of  twenty  may  appear  as  though  he  were  but  twelve,  a  condition  to 
which  Fournier  applies  the  name  infantilism.  In  such  the  forehead  is  promi- 
nent, the  frontal  bosses  are  marked,  the  bridge  of  the  nose  is  depressed,  its 
tip  turned  up.     The  head  may  be  asymmetrical. 

Diagnosis. — The  recognition  of  general  syphilis  is  not  difficult.  The 
symptoms  described  are  of  themselves  distinctive,  and  if  there  be  added  the 
history  of  exposure  or  heredity  they  are  unmistakable.  When  there  is  doubt 
the  administration  of  specific  remedies  will  soon  clear  it  up.     In  consequence 


2o8  INFECTIOUS  DISEASES. 

of  the  fever  and  frequently  associated  splenic  enlargement  with  roseola,  the 
second  stage  of  syphilis  has  been  confounded  with  typhoid  fever.  The  pus- 
tular syphilid  has  sometimes  caused  its  subject  to  be  taken  to  a  smallpox  hos- 
pital, where,  however,  time  soon  dissolves  all  doubt. 

The  so-called  "Justus  test"  is  based  upon  the  following  proposition: 
Mercury  destroys  the  hemoglobin  of  the  blood.  In  the  non-syphilitic  subject, 
the  organism  rapidly  replaces  the  lost  pigment.  In  the  syphilitic  patient, 
however,  the  percentage  being  reduced  by  the  disease,  the  organism  cannot 
at  once  restore  the  still  further  reduction  caused  by  the  use  of  mercury.  Con- 
sequently the  first  examination  after  an  inunction  or  injection  of  mercury 
will  show  a  distinct  fall  of  from  lo  to  20  per  cent.  This  reduction  is  in  turn 
followed  as  treatment  is  continued  by  a  steady  rise  to  the  normal,  where  it 
remains  as  long  as  treatment  is  maintained. 

Prognosis. — The  prognosis  of  acquired  syphilis  depends  wholly  on  the 
treatment.  With  early  treatment  properly  conducted  it  is  favorable ;  without 
treatment  or  with  defective  treatment  the  most  serious  consequences  result, 
while  the  physical  inconvenience  and  suffering  scarcely  exceed  the  mental 
misery  which  the  knowledge  of  the  presence  of  so  loathsome  a  disease  entails. 
In  congenital  syphilis  treatment  is  less  satisfactory  for  the  severer  mani- 
festations, and  it  is  perhaps  fortunate  that  so  many  perish  in  infancy  or  early 
childhood.  Even  those  most  fortunate  remain  delicate  and  vulnerable  to  dis- 
ease through  life,  and  too  often  fall  victims  to  causes  which  but  slightly 
affect  the  healthy  man  and  woman. 

Treatment. — Prophylaxis. — Against  sexual  syphilis  the  only  prophy- 
lactic measure  to  be  relied  upon  is  sexual  purity.  The  duty  of  the  physician 
is  plain  in  respect  to  this,  and  the  medical  man  who  advises  illicit  sexual  inter- 
course for  any  reason  degrades  his  calling.  Medical  men  should  be  exceed- 
ingly cautious  in  their  necessary  professional  contact  with  all  suspected  of 
having  syphilis  and  protect  themselves  against  accidental  infection.  It  is 
to  be  remembered  that  the  secretions  of  all  primary  and  secondary  lesions, 
as  well  as  the  blood  of  syphilitics,  may  transmit  the  disease. 

Treatment  of  the  Primary  Sore. — With  the  present  view  that  the  hard 
chancre,  which  makes  its  appearance  after  a  period  of  incubation  of  a  least 
two  weeks,  is  simply  the  local  expression  of  a  general  disease,  nothing  is 
gained  by  "  burning  it  out."  The  indication  is  simply  to  heal  the  ulcer  as 
thoroughly  and  as  soon  as  possible.  Fortunately,  there  is  little  difficulty  in 
accomplishing  this.  A  simple  dressing,  as  lint  wet  with  bichlorid  solution 
I  to  2000.  or  mercurial  ointment  smeared  on  adhesive  plaster,  with  an  un- 
covered edge  so  as  to  secure  adhesion,  will  accomplish  the  healing  in  a  short 
time.  Iodoform,  bismuth,  calomel  or  acetanilid  may  be  dusted  over  the  sore. 
The  Constitutional  Treatment — This  should  begin  at  once.  Mercury 
and  iodin  are  the  two  remedies,  and  if  properly  used  will  eradicate  the  second 
stage  and  hold  the  third  in  abeyance,  even  after  it  has  manifested  itself. 
Mercury  is  the  remedy  par  e.xxeUence  of  the  second  stage;  iodid  of  potas- 
sium, of  the  third.  The  best  method  of  administration  for  mercury  is  un- 
doubtedly by  inunction.  The  following  is  the  plan  to  be  pursued :  A  warm 
bath  is  taken,  if  possible,  each  day,  and  immediately  thereafter  one  dram 
(4  gm.)  of  mercurial  ointment  is  spread  between  the  hands  and  rubbed, 
one  day  on  the  inside  of  one  thigh,  the  next  on  the  inside  of  the 
other ;  again,  under  the  arm,  on  the  chest,  and  so  on  until  each  part  of 
the  body  covered  by  softer  skin  is  treated,  after  which  the  same  course 
can  be  repeated.     The  friction  is  to  be  kept  up  until  the  skin   is  thor- 


SYPHILIS.  209 

oughly  dry,  half  an  hour  being  usually  necessary.  The  part  rubbed 
should  be  washed  off  the  following  day.  Parts  covered  with  hair  are 
to  be  avoided,  because  mercurial  eczema,  characterized  by  pustules  start- 
ing from  the  hair  follicles,  is  more  apt  to  be  produced  in  these  localities. 
During  this  time  the  patient  should  not  smoke,  and  the  teeth  should  be 
frequently  and  carefully  cleansed  and  the  mouth  washed  with  solution  of 
chlorate  of  potash  with  a  view  of  averting  mercurial  sore  mouth.  Sooner 
or  later,  however,  sore  mouth  may  manifest  itself  by  a  fetid  odor,  swollen 
gums,  and  a  sensation  as  though  the  teeth  were  loose,  when  the  treatment 
should  be  suspended  for  a  week  or  ten  days.  The  daily  friction  should  be 
kept  up  for  thirty  days,  if  possible,  after  which,  if  no  symptoms  are  present,  it 
may  be  discontinued. 

The  inunctions  should  be  followed  up  by  the  use  of  protiodid  of  mercury, 
1-4  grain  (0.016  gm.)  three  times  a  day,  or  the  biniodid,  1-16  grain  (0.004 
gm.)  three  times  a  day.  The  former  is  usually  preferred  because  less  irritat- 
ing. This  last  addition  to  the  treatment  should  be  kept  up  indefinitely.  By 
such  means  as  these  tertiary  symptoms  can  be  averted  if  the  patient  is  but 
willing  to  continue  the  treatment.  The  great  difficulty  is  to  secure  this.  He 
tires  of  the  monotony  and  the  trouble  involved  in  a  faithful  adherence  to  the 
directions,  and  symptoms  sooner  or  later  return.  Should  secondary  symp- 
toms recur  a  course  of  immctions  may  be  repeated. 

In  lieu  of  the  inunction,  the  hydrargyrnni  cum  creta,  or  gray  powder, 
may  be  used.  It  is  the  favorite  of  Jonathan  Hutchinson,  who  gives  it  in 
form  of  a  pill,  i  grain  (0.066  gm.),  with  i  grain  (0.066  gm.)  of  Dover's 
powder,  from  four  to  six  times  a  day,  and  is  commended  by  my  colleague, 
Louis  A.  Duhring,  who  has  used  it  with  great  success. 

Again,  the  mercury  may  be  administered  by  fumigation.  For  this  the 
patient  sits  on  a  chair,  wrapped  in  blankets  to  the  chin,  as  in  a  tent.  Under 
the  chair  is  placed  a  spirit  lamp  and  over  this  a  tin  plate  on  which  calomel 
is  spread.  It  is  volatilized  by  the  heat  and  deposited  with  the  vapor  on 
the  patient's  skin.  The  exposure  should  last  twenty  minutes,  after  which 
the  patient  should  be  put  to  bed  wrapped  in  blankets,  without  washing  or 
drying. 

Most  recently,  mercury  has  been  administered  by  direct  injection  into 
the  muscles.  One-third  grain  (0.0216  gm.)  of  bichlorid  dissolved  in  20 
minims  (1.333  c.  c.)  of  water  is  injected  once  a  week,  or  from  i  to  2  grains 
(0.066  to  0.132  gm.)  of  calomel  in  20  minims  (1.333  c.  c.)  of  glycerin  and 
water.  The  injection  is  made  deep  into  the  muscles,  and  not  in  the  subcu- 
taneous tissue,  through  silver  cannulje.  The  points  selected  are  the  sides 
of  the  thorax  and  back,  where  abscesses  are  said  to  be  less  likely  to  occur. 
Great  care  should  be  taken  in  sterilizing  instruments.  The  nicest  attention 
to  these  points  is,  however,  still  followed  at  times  by  abscesses. 

In  the  treatment  of  the.  third  stage  the  iodids  are  especially  useful.  It 
is  here  that  massive  doses  of  iodid  of  potassium  are  indicated  and  often 
produce  such  magical  results.  The  most  convenient  mode  of  administration 
is  the  saturated  solution,  of  which  one  drop  contains  a  grain  (0.066  gm.). 
Starting  with  10  drops,  a  drop  may  be  added  each  day  to  the  dose  until  the 
symptoms  yield,  that  is,  until  the  gummy  tumors  melt  away.  Pressure 
symptoms  and  head  and  bone  pains  are  relieved.  The  iodid  is  well  admm- 
istered  in  milk.  The  indications  for  its  discontinuance  or  reduction  in  the 
dose  are  the  erythematous  rash,  coryza,  and  salivation  and  constriction  about 
the  throat  due  to  swelHng  of  the  salivary  glands. 
14 


2IO  INFECTIOUS  DISEASES. 


THE  GONORRHEAL  INFECTION. 

Recent  studies  go  to  show  that  the  gonorrheal  infection  is  scarcely 
less  harmful  and  widespread  in  its  effects  than  syphilis.  These  effects, 
formerly  limited  to  the  primary  infection,  the.  ophthalmia  and  gonorrheal 
arthritis  in  men  and  women,  have  been  found  to  be  responsible  for  the  vast 
majority  of  inflammatory  pelvic  troubles  in  women  that  make  life  a  martyr- 
dom and  child-bearing  an  impossibility.  The  explanation  of  this  appears 
to  lie  in  the  fact  that  a  urethral  discharge  continues  to  be  infectious  long 
after  it  has  lost  its  purulent  character,  and  the  only  test  of  recovery  from 
gonorrheal  infection  is  a  bacteriological  one.  At  least  such  is  the  inevitable 
conclusion  after  reading  the  able  and  exhaustive  paper  on  "  Gonorrhea ;  its 
Dangers  to  Society  "  by  Albert  Neisser,*  of  Breslau.  This  is  a  startUng 
statement,  but  should  be  proclaimed  from  the  housetops  if  it  will  have  any 
influence  in  preventing  infected  men  from  infecting  innocent  women  whom 
they  have  married  under  the  impression  that  they  are  free  from  disease. 

These  ills  which  have  been  referred  to  are  largely  surgical  and  do  not 
concern  us  as  physicians,  for  medical  treatment  is  generally  unavailing.  One 
is,  however,  classed  among  medical  ailments  and  will  be  here  considered. 
It  is — 

Gonorrheal   Arthritis. 

Definition. — Gonorrheal  arthritis  is  a  septic  arthritis  due  to  the  gono- 
coccus. 

Morbid  Anatomy  and  Pathology. — We  do  not  often  have  an  oppor- 
tunity to  study  the  morbid  changes  in  the  joints  in  this  affection,  since 
patients  never  die  of  this  disease  alone.  Reasonably,  however,  we  may  expect 
a  primary  hyperemia,  and  later  the  phenomena  peculiar  to  inflammation 
in  similar  structures — viz.,  exudation  into  the  joint  cavity,  including  the 
out-wandering  of  white  blood-corpuscles,  which  are,  however,  rarely  so 
numerous  as  to  constitute  pus.  The  periarthritic  tissues,  including  the 
sheaths  of  tendons,  are  invaded  by  the  exudate,  and  pus  has  been  found  in 
these  sheaths.  There  may  be  not  only  change  in  the  shape,  but  impairment 
also  in  the  motility  of  the  joints.  They  may  become  stiff  and  swollen  as  in 
chronic  rheumatism.  .^ 

Now  as  to  the  nature  of  this  disease.  Gonorrheal  rheumatism  is  an 
affection  in  which  symptoms  identical  with  those  of  rheumatism  are  more  or 
less  closely  associated  with  gonorrhea.  These  rheumatoid  symptoms  usually 
appear  from  six  to  ten  days  after  the  discharge  is  seen.  They  may  appear, 
however,  much  later — as  much  as  four  or  five  months  or  even  a  year  after 
the  discharge  sets  in,  or  during  a  chronic  gleet.  A  lately  married  woman 
may  acquire  it  from  a  husband  who  has  gleet,  indeed,  as  has  been  men- 
tioned, after  all  visible  objective  signs  of  gonorrhea  have  disappeared  from 
him,  though  a  bacterial  examination  may  discover  the  gonococcus.  There 
seems  to  be  no  relation  between  the  severity  of  the  symptoms  and  that  of 
the  original  disease.  The  discharge,  if  present,  generally  continues  with  the 
onset  of  the  joint  symptoms,  although  it  often  abates,  and  may  even  cease 
altogether  for  a  time.     It  may  even  recur  with  the  disappearance  of  the 

*  "Medical  News,"  January  13  and  20,  igoo. 


THE  GONORRHEAL  INFECTION.  211 

rheumatic  symptoms.  It  cannot  be  said  that  the  true  relation  between  these 
two  very  definite  conditions  is  exactly  known.  The  term  gonorrheal  rheu- 
matism is  very  generallt  recognized  in  all  languages,  and  some  English  and 
American  physicians  do  not  hesitate  to  speak  of  the  disease  as  a  species  of 
rheumatism.  This  is  certainly  erroneous.  It  is  doubtless  caused  by  the  gono- 
coccus,  which,  when  once  present,  seems  to  be  ineradicable,  though  it  may 
continue  latent  until  conditions  favorable  for  its  activity  arise.  Witness  its 
power  to  cause  ulcerative  endocarditis.  The  simple  non-purulent  synovitis 
and  arthritis  may  be  the  result  of  absorption  of  ptomains  furnished  by  the 
urethral  pus.  These  views  are  confirmed  by  modern  bacteriological  studies, 
which  have  found  gonococci  in  the  pus,  in  the  tendinous  sheaths,  and  more 
rarely  in  the  non-purulent  exudate. 

Although  the  gonorrheal  poison  is  quite  sufficient  to  produce  the 
arthritis  de  ipso,  it  frequently  happens  that  cold  co-operates  as  an  exciting 
or  predisposing  cause. 

Gerhardt  found  that  out  of  928  cases  of  arthritis  7.43  per  cent,  were 
gonorrheal,  while  Gricolle  found  that  out  of  4423  cases  of  gonorrhea  16  per 
cent  developed  arthritis. 

Symptoms. — A  study  of  these  admits  a  classification  as  made  by  the 
late  R.  P.  Howard,  of  Montreal,  into  seven  subdivisions : 

1.  The  purely  arthralgia  form,  i.  e.,  cases  characterized  by  pain,  but 
not  much  other  evidence  of  local  inflammation.  Fever  is  also  absent, 
although  the  condition  is  apt  to  be  polyarthritic,  wandering  from  joint  to 
joint. 

2.  Rheumatoid  gonorrheal  arthritis,  resembling  more  than  all  other 
forms  acute  inflammatory  rheumatism.  In  this  division  fever  is  added  to  the 
local  symptoms  of  rheumatism,  and  polyarthritic  involvement  is  also  common. 
The  fever,  however,  is  less  severe  than  would  be  expected  from  the  severity 
of  the  other  symptoms.  The  maximum  temperature  may  be  102°  F.  (39° 
C),  more  frequently  it  is  less  than  this. 

3.  Acute  gonorrheal  monarthritis,  in  which  one  joint  only  is  involved, 
with  severe  pain  and  swelling  and  moderate  fever.  It  is  the  knee-joint 
that  is  most  commonly  attacked  in  this  monarthritic  variety.  Next  in  order 
follow  the  ankle,  shoulder,  elbow,  and  wrist ;  any  one  of  these  is  liable  to 
be  the  seat  of  the  trouble.     Suppuration  is  rare. 

4.  Chronic  gonorrheal  arthritis,  without  or  with  effusion  (chronic 
hydro-arthrosis).  Suppuration,  though  rare,  does  take  place  and  pus  is 
found  in  the  joint  cavity.  In  these  cases,  too,  there  is  generally  slight 
elevation  of  temperature. 

5.  The  periarthritic  variety,  including  cases  in  which  the  periarthritic 
tissues  are  involved,  including  the  capsule,  ligaments,  tendons,  and  adjacent 
fibrous  structures.  The  periosteum  is  included  among  these,  but  the  joint 
cavity  itself  is  not  affected. 

6.  A  variety  which  invades  fibrous  tissue  not  connected  zvith  joints,  a.s 
the  plantar  fascia,  the  sclerotic  coat  of  the  eye  and  iris,  the  pericardium  and 
endocardium. 

7.  The  septicemic  form,  where,  in  addition  to  the  arthritis,  there  is  gen- 
eral sepsis  and  endocarditis.  In  this  •^event  there  are  the  usual  signs  of 
blood  invasion,  high  fever  with  or  without  chills,  and  sweats. 

Complications. — Isolated  and  even  multiple  cases  of  endocarditis 
associated  with  gonorrheal  rheumatism  have  been  reported  by  German  and 
French    physicians    during    the    past    thirty-eight    years.     Comparatively 


212  INFECTIOUS  DISEASES. 

recently  the  studies  of  Gluzinski  (1888)  and  R.  L.  MacDonnell  *  have 
settled  the  question  in  favor  of  a  causal  relation,  the  latter  having  found 
endocarditis  present  in  4  out  of  2"/  cases  of  gonorrheal  arthritis,  while 
Gluzinski  collected  31  cases.  They  may  reasonably  be  attributed  to  the 
action  of  the  micro-organisms  on  the  valves.  ]vlalignant  endocarditis  may 
be  thus  caused. 

Pericarditis  and  pleurisy  similarly  caused  may  complicate  the  disease, 
as  may  also  iritis  and  sclerotitis. 

Treatment. — This  is  not  always  satisfactory.  The  salicylates  are 
sometimes  distinctly  efficient,  especially  in  the  more  acute  forms.  lodid 
of  potassium  is  perhaps  the  drug  most  commonly  found  useful,  and  its  effect 
is  increased  when  combined  with  the  bichlorid  of  mercury.  It  must,  how- 
ever, be  associated  with  rest  and  local  treatment.  The  fomier  is  sometimes 
better  accomplished  by  the  use  of  splints,  the  latter  by  blisters  or  iodin. 
General  roborant  treatment  by  tonics  and  good  food  may  also  be  necessary. 
The  ammoniated  tincture  of  guaiac  may  also  be  used  as  in  chronic  rheu- 
matism. 

Dr.  James  C.  Wilson  t  has  reported  satisfactory  results  from  large 
doses  of  the  syrup  of  iodid  of  iron,  as  much  as  a  fluid  dram  (4  c.  c.) 
four  times  a  day,  beginning  with  smaller  doses. 


PNEUMONIA. 

CROUPOUS  PXEU^^IONIA. 

Synonyms. — Pneumonitis;  Lobar  Pnciinionia;  Fibrinous  Pneumonia; 

Genuine  Pncnuionia. 

Definition. — An  acute  infectious  inflammatory  disease  of  the  lungs, 
characterized  by  high  fever,  and  usually  terminating  by  crisis  in  from  five 
to  nine  days.  A  bacterium  especially  prone  to  occur  in  pairs  or  chains, 
known  as  the  diplococcus  pneiimonice,  diplococcus  lanceolatus.  or  micro- 
coccus pneunw)ii(e  crouposce  (Sternberg'),  is  found  in  75  per  cent,  of  all  cases 
of  lobar  pneumonia  and  is  commonly  regarded  as  its  cause. 

Varieties. — The  term  lobar  pneumonia  is  used  for  this  form  because  it 
generally  involves  at  least  a  single  lobe  or  the  greater  portion  of  one.  The 
term  pneumonia  of  the  apex  is  used  where  one  or  both  apices  of  the  lung  are 
involved.  A  rare  form  of  pneumonia  is  double  pneumonia  in  which  both 
lungs  are  involved,  though  not  necessarily  the  whole  of  each  lung.  A  massive 
pneumonia  is  an  inflammation  not  only  of  the  air-vesicles,  but  of  the  bronchi 
of  a  lobe  or  even  of  the  whole  lung.  A  creeping  or  migrator}-  pneumonia 
affects  successively  different  lobes  of  the  lung.  Epidemic  pneumonia 
involves  large  numbers  or  communities.  The  term  larval  pneumonia 
is  applied  to  a  form  of  the  disease  in  which  but  a  partial  development 
of  symptoms  occurs,  such  as  a  moderate  chill,  slight  fever,  and  imperfect 
local  signs.  It  occurs  more  particularly  in  connection  with  epidemics  or 
with  pneumonias  in  crowded  places,  as  ships,  camps,  and  garrisons. 

*  "Gonorrheal  Rheumatism."  "Am.  Jour,  of  the  Med.  Sci.,"  January,  1801. 

+  "  Iodid  of  Iron  in  the  Treatment  of  Certain  Forms  of  Infective  Arthritis,"  "  Jacobi  Festschrift,. 
1900,  p.  350. 


CROUPOUS  PNEUMONIA.  ■  213 

Historical. — Evidently  what  we  now  know  as  croupous  pneumonia  was  known  to 
the  earliest  medical  writers,  including  Hippocrates  (B.  C.  400-357),  who,  with  others, 
described  it  with  considerable  a.QC\irB.i:y  -az  pfri-pneurnonza,  ov  pleurttis.  Hippocrates 
said  of  it  that  it  was  a  "  disease  quickly  fatal  and  characterized  by  sputa  of  various 
colors."  Lesions  and  symptoms  corresponding  to  it  were  described  by  Thucydides 
in  his  description  of  "The  Plague  of  Athens,"  B.  C.  430.  Sydenham  (1670),  Valsalva 
(1666-1723),  Morgagni  (1761),  Boerhaave  (1668-1738),  all  gave  good  descriptions,  but 
failed  to  separate  it  from  pleurisy.  Laennec  (1819)  was  the  first  to  sharply  separate 
the  two  diseases,  and  made  the  classification  into  the  three  well-known  stages,  which 
hold  to-day  as  then — congestion,  hepatization,  and  resolution  or  suppuration.  Tne 
nature  of  the  exudate  was  first  accurately  described  from  the  macroscoijic  standpoint 
by  Rokitansky  in  1841.  Ziemssen  (1857-58)  furnished  valuable  data  on  the  geographi- 
cal  distribution  of  pneuomnia.  GrisoUe  (1864)  especially  collected  valuables  tatistics 
relating  to  climate,  development,  and  comparative  frequency  among  different  races. 

Etiology. — The  infectious  nature  of  pneumonia  was  first  advocated  by 
Jijrgensen  in  1872.  The  presence  of  a  special  organism  in  the  secretions  of 
hepatized  lung,  in  the  fibrinous  exudate  into  the  alveoli,  and  in  the  sputum 
was  demonstrated  by  Friedlander  in  1883,  and  again  by  Frankel  in  1886. 
The  organism  discovered  by  Friedlander  was  called  by  him  pneumococcus, 
while  Frankel  applied  to  his  the  term  diplococcus.  The  two  organisms  are 
not  identical. 

The  pneumococcus  of  Friedlander  is  a  short,  oval  bacillus,  always 
enclosed  in  a  capsule,  which  usually  contains  one  coccus  only,  rarely  two  or 
more.  It  is  non-motile  and  anaerobic — that  is,  grows  without  oxygen. 
When  treated  with  the  aqueous  staining  solutions  (as  carbol-fuchsin),  the 
bacillus  is  stained,  the  capsule  being  only  slightly  colored.  It  cannot  be 
stained  by  Gram's  method.  The  cocci  do  not  liquefy  gelatin,  and  stick- 
cultures  develop  into  a  nail-like  growth  with  a  thick  head.  The  cocci  flourish 
in  agar  and  on  the  potato.  They  are  found  in  5  1-2  per  cent,  of  cases  of 
pneumonia.* 

The  diplacocciis  of  Frankel,  to  which  the  name  Weichselbaum  has  also 
been  added,  is  the  true  pneumococcus.  It  occurs  in  pairs,  sometimes  in  rows 
or  beads.  It  is  also  pointed  at  one  end,  whence  the  term  bacillus  lanceolatus, 
"  lancet-shaped."  Like  the  pneumobacillus  of  Friedlander  it  is  encap- 
sulated when  in  the  body,  but  not  when  cultivated  out  of  the  body.  It 
differs  from  Friedlander's  bacillus  in  that  when  stained  by  the  carbol  fuchsin 
solution  the  coccus  is  intensely  red,  while  the  capsule  assumes  a  light  reddish 
tint.  Further,  it  can  also  be  stained  by  Gram's  method,  while  the  pneu- 
mococcus of  Friedlander  cannot.  It  thrives  on  agar  and  in  bouillon,  but 
not  on  gelatin.  It  is  probably  the  same  organism  as  that  found  by  Sternberg 
in  rabbits  inoculated  with  his  own  saliva  in  1880,  but  not  announced  until 
April,  1 88 1.  Pasteur  had  also  recognized  the  same  organism  in  the  saliva 
and  published  several  notes  on  the  same  subject,  January  to  March,  1881. 
The  coccus  occurs,  according  to  Netter,  in  20  per  cent,  of  all  persons. 
Frankel,  Talamon,  and  especially  Weichselbaum  showed  the  relations  of  this 
organism  to  pneumonia.  The  latter  found  it  in  92  per  cent,  of  cases  of  crou- 
pous pneumonia.  William  H.  Welch  found  it  in  every  one  of  ten  cases  of 
croupous  pneumonia  studied  at  the  Johns  Hopkins  Hospital  at  Baltimore. 
It  has  been  found  in  the  blood,  in  the  spleen  and  kidney,  in  endocardial  vege- 
tations, and  in  the  pus  of  cerebrospinal  meningitis  where  there  was  no  pneu- 
monia, as  well  as  in  the  saliva  of  healthy  persons  and  in  the  dust  on  the 
floors  of  houses.  Its  route  of  entrance  is  probably  the  respiratory  passages, 
since  it  has  been  found  in  the  nose,  larynx,  and  Eustachian  tube,  and  is  said 

*  The  opinion  at  present  appears  to  be  that'  the  bacillus  of  Friedlander  is  a  feeble  pathogenic 
organism,  a  harmless  saprophyte,  as  a  rule,  but  able,  at  time.s,  to  produce  inflammatory  effects. 


214  INFECTIOUS  DISEASES. 

to  persist  for  months  and  even  years  in  the  sahva  of  healthy  persons  who 
have  had  pneumonia.  On  the  other  hand,  it  is  a  very  perishable  organism, 
maintaining  its  virulence  outside  of  the  body  for  four  or  five  days  only. 

That  the  pneumococcus  of  Frankel  is  not  the  only  organism  capable  of 
producing  pneumonia  is,  however,  evident  from  the  experiments  of  Frankel 
himself,  of  Weichselbaum,  and  of  Pansini  and  Neumann.  It  may  be  accom- 
panied by  pus  organisms  and  others  which  ma>'  be  responsible  for  complica- 
tions and  modifications  of  the  ordinary  pneumonic  process.  Streptococcus- 
pneumonia  has  come  to  be  recognized  as  a  variety  of  pneumonia  having  a 
more  or  less  distinct  clinical  picture  that  will  be  again  referred  to. 

Nature  of  Pneumonia, — Thus  caused,  pneumonia  may  be  regarded 
from  two  standpoints.  First,  it  may  be  a  general  disease  with  a  local 
expression  in  the  lungs,  analogous  to  the  inflammation  of  Peyer's  patches  in 
typhoid  fever ;  or  it  may  be  a  local  disease,  which,  like  diphtheria,  infects 
the' general  economy  and  produces  the  constitutional  symptoms  character- 
istic of  it.  As  in  the  case  of  typhoid  fever,  there  were  facts  which  pointed 
to  the  infectious  nature  of  pneumonia  long  before  the  discovery  of  any 
organism  that  could  be  regarded  as  its  specific  cause.  The  occurrence  of 
pneumonia  in  epidemic  form  was  recognized  by  Laennec  and  Grisolle,  and 
since  their  day  innumerable  epidemics  have  been  described :  house  epidemics, 
including  those  in  which  a  number  of  individuals,  from  three  to  ten  or  more, 
have  been  attacked  under  the  same  roof,  and  general  epidemics,  invading 
institutions,  ships,  and  garrisons,  in  which  large  numbers  of  persons  are 
congregated.  Out  of  a  ship's  crew  of  815,  410  were  attacked  in  rapid 
succession,  and  out  of  720  attacked,  298  perished. 

While  the  state  of  knowledge  at  the  present  day  seems  to  demand  that 
we  consider  croupous  pneumonia  as  an  infectious  disease  due  to  the  action  of 
a  specific  organism,  we  cannot  ignore  the  operation  of  causes,  such  as  damp- 
ness and  cold,  which  until  recently  have  seemed  sufficient  to  account  for  a 
large  number  of  cases.  Thus  an  overworked  man  is  exposed  to  cold  for  a 
long  time,  and  becomes  thoroughly  chilled.  A  few  hours  later  he  is  seized 
with  a  rigor,  and  twenty-four  hours  afterward  the  physical  signs  of  a  pneu- 
monia have  developed.  The  lowered  vitality  consequent  on  the  exposure  in 
each  case  must  be  regarded  as  a  predisposing  cause,  preparing  the  system 
for  the  operation  of  the  ever-present  organism  as  the  exciting  cause.  The 
operation  of  cold  is  further  seen  in  the  influence  of  the  seasons,  pneumonia 
being  much  commoner  in  the  winter  months.  Other  predisposing  causes 
are :  a  previous  attack,  fatigue  of  mind  or  body,  and  debilitating  conditions 
of  all  kinds,  such  as  previous  or  present  illness,  especially  a  chronic  com- 
plaint, such  as  Bright's  disease.  A  patient  of  my  own  had  four  attacks  and 
succumbed  to  a  fifth.  Heredity  is  also  said  to  be  a  factor,  and  injuries  of 
the  chest  have  long  been  regarded  as  predisposing  causes. 

Morbid  Anatomy. — The  lung  in  croupous  pneumonia  exhibits  three 
distinct  stages : 

1.  Congestion  or  engorgement, 

2.  Red  hepatization. 

3.  Gray  hepatization. 

Pneumonia  seeks,  by  preference,  the  lower  lobes  of  the  lungs,  and  the 
right  lung  more  than  the  left.  Pneumonia  of  the  apex,  however,  not  infre- 
quently occurs,  more  often  in  children  than  in  adults. 

The  Stage  of  Congestion. — In  this  stage  the  lung  is  engorged  with 
blood,  yet  permeable  to  air.     The  capillaries  surrounding  the  air-vesicles  are 


CROUPOUS  PXEUMOXIA.  215 

turgid  and  intrude  upon  the  lumina  of  the  air-vesicles.  There  is  a  small 
amount  of  transudate,  in  which  ma}-  be  found  a  few  exfoliated  alveolar  cells 
and  red  blood-discs.  The  part  of  the  lung  invaded  is  redder  than  normal 
and  heavier,  but  not  nearly  so  heavy  as  in  the  next  stage.  On  section,  blood 
transudes  from  the  cut  vessels  and  bathes  the  surface. 

The  Stage  of  Red  Hepatization. — In  this  the  lung  is  dark  red  in  color, 
hard,  and  very  much  heavier  than  in  health — as  much  as  three  and  four  times 
the  normal  weight.  A  piece  dropped  in  water  rapidly  falls  to  the  bottom. 
The  lung  pits  on  pressure,  and  in  consequence  the  marks  of  the  ribs  are  often 
seen  on  it  after  removal.  On  section  the  aptness  of.  the  name  red  hepatiza- 
tion is  at  once  apparent.  The  surface  is  darker  in  color  than  in  the  first  stage, 
and  it  has  the  appearance  of  a  section  of  liver.  On  passing  the. finger  over  it, 
innumerable  little  hard  spots  like  grains  of  sand  are  felt.  These  are  air- 
vesicles  filled  with  the  croupous  exudate.  Corresponding  to  this,  a  granular 
appearance  is  recognized  by  the  eye.  the  distended  air-vesicles  appearing  as 
gHstening  points.  By  scraping,  little  plugs  of  fibrin  and  cellular  detritus 
mixed  with  serum  can  be  removed.  The  lung,  though  thus  hard,  is  never- 
theless friable,  and  may  be  broken  up  by  the  fingers. 

Histologically,  the  air-vesicles  are  found  to  contain  a  delicate  reticu- 
lum, the  meshes  of  which  are  tilled  with  red  blood-discs,  and  with  alveolar 
cells  in  different  stages  of  degeneration,  including  numerous  granular  fatty 
cells  or  compound  granular  cells.  The  vesicular  walls  are  found  infiltrated 
with  lymphoid  cells,  which  extend  even  into  the  interlobular  tissue  beyond 
them.  Plugs  of  fibrin  may  sometimes  be  traced  into  the  smaller  bronchi 
from  the  air- vesicles. 

The  diplococcus  of  Frankel  and  pneumococcus  of  Friedlander  may  be 
demonstrated  in  cover-glass  preparations  made  from  the  exudate.  They 
may  be  associated  with  the  streptococcus  and  staphylococcus. 

The  Stage  of  Gray  Hepatization. — This  is  also  well  named,  the  cut  lung 
exhibiting  a  grayish-white  coloration.  It  is  still  dense  and  heavy,  but  much 
moister  and  softer,  and  even  more  friable.  The  granulations  are,  however, 
less  distinct,  and  on  microscopic  examination  the  alveoli  are  found  filled 
with  white  blood-corpuscles,  while  the  red  corpuscles  and  fibrin  filaments 
have  disappeared.  Sometimes  all  three  stages  are  seen  alongside  of  one 
another. 

A  stage  beyond  gray  hepatization  is  sometimes  spoken  of  as  a  stage  of 
yellozv  hepatization.  In  this  stage  the  lung  has  assumed  a  more  yellowish 
appearance,  it  is  much  softer,  almost  liquid  in  consistence,  and  more  like  pus. 
On  minute  examination  the  air-vesicles  are  filled  with  pus-cells,  the  points  of 
greatest  softness  constituting  small  abscesses  as  large  as  a  pin's  head  and 
larger.  The  stage  of  gray  hepatization  is  the  stage  of  beginning  resolution, 
while  that  of  yellow  hepatization  represents  the  same  stage  in  which  the  pro- 
portion of  leukocytes  undergoing  fatty  degeneration  is  larger. 

If  recover}-  takes  place  the  contents  of  the  air-vesicles  liquefy,  the 
product  being  partly  expectorated,  but  probably  mostly  absorbed. 

The  pleura  adjacent  to  the  inflamed  lung  is  almost  always  inflamed,  the 
most  distinctive  sign  of  this  being  a  plastic  deposit.  There  may  also  be 
thickening  and  some  serous  efifusion.    , 

After  death  from  pneumonia,  the  heart  is  found  In  a  typical  pathological 
condition.  The  left  cavities  are  generally  found  empty  or  nearly  so,  while 
the  rieht  are  distended  with  firm  coagula.  which  often  extend  into  the 
branches  of  the  pulmonary  artery.     The  spleen  is  often  enlarged.     The  cells 


2i6  INFECTIOUS  DISEASES. 

lining  the  renal  tubes  are  often  found  in  a  state  of  cloudy  swelling;  rarely 
there  is  nephritis. 

Symptoms. —  Perhaps  no  other  disease  except  malarial  fever  is  so 
invariably  ushered  in  by  a  eliill  as  is  croupous  pneumonia,  and  often  a  chill 
of  great  severity.  It  may  come  on  at  night,  waking  the  patient  out  of  a  deep 
sleep.  It  may  or  may  not  be  preceded  by  a  day  or  two  of  prodromal  discom- 
fort, with  headache,  which  may  be  very  severe.  Almost  immediately  th.ere 
succeeds  a  high  fever,  in  which  the  temperature  rises  rapidly  to  from  103° 
to  105°  F.  (39.4°  to  40.5°  C).  A  significant  Hush  on  each  check  is  character- 
istic, occasionally  more  marked  on  the  affected  side.  The  pulse  is  full  and 
strong,  resisting  pressure,  rate  100  to  120.  There  is  thirst,  and  the  urine  is 
scanty  and  high  colored,  sometimes  albuminous.  Equally  promptly  ensues 
a  pain  in  the  side,  which  may  be  dull,  but  is  often  also  sharp  and  severe, 
caused  in  the  latter  instance  by  involvement  of  the  pleura.  The  respirations 
rise  rapidly  in  frequency,  and  there  is  cough,  at  first  dry  and  hard.  It  is 
often  restrained  on  account  of  the  pain  it  occasions.  Soon  there  is  a  small 
amount  of  mucous  expectoration  from  the  coincident  bronchitis,  but  usually 
in  twenty-four  to  forty-eight  hours  after  the  chill  the  sputum  exhibits  dis- 
tinctive characteristics.  It  is  tenacious,  light  red  in  hue, — "  rusty," — and  is 
ejected  from  the  mouth  with  difficulty.  At  other  times  it  is  much  thinner 
and  darker,  and  has  received  the  name  "  prune- juice  "  expectoration.  The 
amount  of  blood  and  the  degree  of  coloration  vary  greatly.  The  respira- 
tions are  exceedingly  rapid — 50,  60,  and  even  more  in  the  minute.  I  have 
known  them  to  be  82,  and  in  a  child  they  may  reach  100.  The  appearance 
of  a  patient  at  this  stage  is  very  striking.  The  face  is  flushed,  the  eye  is 
brilliant,  the  breath  is  rapid,  the  als  nasi  move  with  each,  breath,  while  a 
frequent  short  cough,  held  back  until  irresistible,  increases  at  times  the 
already  anxious  expression  of  the  patient. 

This  state  of  affairs  continues  unchanged  for  from  five  to  nine  days, 
when,  if  recovery  takes  place,  a  sudden  drop  in  the  temperature  occurs, 
accompanied  often  by  free  perspiration,  while  a  state  of  comparative  comfort 
succeeds  to  one  of  great  distress,  to  be  further  followed  oftentimes  by  a  long 
and  refreshing  sleep.  This  is  known  as  the  crisis.  It  may  be  preceded  by  a 
fall  of  temperature  a  day  or  two  earlier,  w^hich  is  again  followed  by  a  rise, 
whence  such  fall  is  called  the  pseudo-crisis.  The  accompanying  temperature 
chart  (Fig.  20),  from  a  case  seen  in  consultation  with  Alfred  Stengel,  illus- 
trates the  actual  crisis.  The  fall  in  crisis  is  sometimes  as  much  as  7"  F. 
(12.6°  C.)  in  twenty-four  hours,  and  the  minimum  is  quite  often  slightly 
subnormal,  whence  it  rises  rapidly  to  the  normal. 

From  this  point  onward  convalescence  is  rapid,  and  in  four  or  five  days 
more  the  patient  is  seemingly  well,  the  temperature  and  pulse-rate  normal, 
the  breathing  natural.  A  muscular  weakness  and  vulnerability,  however, 
remain,  which  demand  care  for  a  time  longer. 

The  duration  of  the  stages  may  be  roughly  stated  as  twenty-four  hours 
for  the  first,  five  to  eight  days  for  the  second,  and  a  few  days  to  several 
weeks  for  the  third. 

Physical  Signs. — The  physical  signs  of  a  typical  pneumonia  are  very 
distinctive. 

The  first,  or  stage  of  congestion,  in  which  the  air-vesicles  are  still  open, 
is  of  short  duration,  terminating  within  the  first  twenty-four  hours,  and  may 
therefore  be  overlooked.  Inspection  shows  the  face  flushed,  increased  fre- 
quency of  respiration,  with  restricted  movement  upon  the  affected  side  and 


CROUPOUS  PNEUMONIA. 


217 


increased  extent  of  motion  on  the  sound  side.  The  patient  Hes  by  prefer- 
ence on  the  affected  side  because  of  the  greater  comfort  it  gives  him.  This 
posture  not  only  diminishes  the  pain  by  hindering  the  motion  of  the  affected 
side,  but  also  lessens  the  dyspnea  by  permitting  unrestrained  expansion  of 
the  side  that  is  doing  the  work. 

Palpation  at  first  may  even  find  vocal  fremitus  diminished  on  account 
of  the  relaxation  of  the  air-vesicles,  but  it  becomes  decidedly  increased  as  the 
latter  fill  up.  The  skin  is  hot  and  the  pulse  is  frequent,  full,  and  strong,  as 
a  rule.  Percussion  obtains  but  slight,  if  any,  impairment  of  resonance.  In 
fact,  tympany,  or  the  vesiculo-tympany  of  Flint, — Skoda's  resonance, — may 
be  present  in  this  stage  as  a  result  of  the  relaxation  of  the  partially  filled  air- 
vesicles,  giving  resonance  by  immediate  relaxation.  In  the  Letter  part  of 
the  first  stage  there  is,  however,  impairment  of  resonance. 

Auscultation  in  the  very  earliest  stage  may  find  the  vesicular  murmur 
feeble,  but  very  soon  is  heard  the  distinctive  physical  sign  of  pneumonia,  the 
crepitant  rale  at  the  end  of  inspiration.  If  there  be  coincident  pleurisy, — 
pleuropneumonia, — the  closely  simulating  friction  sound  may  be  added. 
Under  such  circumstances  it  may  be  difficult  to  distinguish  these  two  physi- 
cal signs.  Over  the  normal  part  of  the  lung  there  is  exaggerated  vesicular 
breathing. 


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WEIGHT. 

Fig.  20.  — Showing  Cri&is  in  Pneumonia. 

But  all  these  physical  signs,  even  if  carefully  sought  for,  may  be  want- 
ing if  the  pneumonia  be  central  and  deep-seated,  as  is  not  infrequently  the 
case.  They  appear  as  the  surface  is  approached,  or  they  may  not  be  recog- 
nized at  all  if  the  disease  remains  central. 

The  second  stage,  or  stage  of  red  hepatization  or  solidification,  lasting 
four  or  five  days,  furnishes  unmistakable  signs.     All  the  signs  pneumonia 


218  INFECTIOUS  DISEASES. 

reveals  to  inspection  in  the  first  stage  are  intensified  in  the  second,  and  the 
breathing  is  markedly  abdominal.  To  palpation,  vocal  fremitus  is  now 
intense,  the  skin  is  hot  and  dry,  and  the  pulse  continues  frequent.  Mensu- 
ration almost  always  and  even  inspection  may  recognize  an  enlargement  of 
the  involved  side,  the  former  to  the  extent  of  0.5  to  2.5  cm. 

Percussion  gives  absolute  flatness  over  the  solidified  area,  with  high 
pitch  and  short  duration,  except  in  those  very  rare  instances  where  the 
extreme  consolidation  throws  the  column  of  air  in  the  trachea  and  bronchi 
into  vibration,  producing  tympany.  This  explanation  is  perhaps  the  only 
one  when  tympany  occurs  in  the  upper  lobe.  In  a  lower  lobe,  tympany  may 
result  in  the  same  way,  from  the  proximity  of  an  air-distended  stomach. 
Over  the  adjacent  normal  areas,  also,  resonance  is  exaggerated,  not  so  much, 
perhaps,  in  consequence  of  supplemental  function,  as  from  relaxation  of  the 
adjacent  air-vesicles — Skoda's  resonance  by  mediate  relaxation.  Even 
cracked-pot  sound  may  be  produced  by  percussion  over  the  solidified  lung 
as  a  result  of  the  sudden  expulsion  of  air  from  a  large  bronchus  leading  to 
the  solidified  area. 

•  Auscultation  discerns  high-pitched  bronchial  breathing  over  the  solidi- 
fied lung.  Indeed,  these  are  the  circumstances  that  give  the  typical  bron- 
chial or  tubal  br,eathing.  The  air-vesicles  are  obliterated,  and  the  resulting 
excellent  conducting  medium  brings  the  tracheo-bronchial  blowing  to  the 
ear.  In  very  rare  instances,  when  the  larger  bronchi  are  filled  with  exudate, 
there  may  be  no  bronchial  breathing.  The  ausculted  voice  gives  us  typical 
bronchophony  and  occasionally  even  pectoriloquy,  as  well  as  whispering 
bronchophony  and  pectoriloquy.  The  heart-sounds  are  also  heard  with  great 
distinctness  over  the  consolidated  lung,  owing  to  the  improved  conduction, 
while  the  sounds  of  a  concurrent  bronchitis  are  similarly  intensified.  A  lin- 
gering crepitant  rale  may  also  be  heard. 

The  tJiird  stage,  or  stage  of  gray  hepatization  or  resolution,  occupies 
six  to  ten  days.  It  repeats  largely,  to  inspection,  palpation,  and  ausculta- 
tion, the  phenomena  of  the  first.  Resonance  continues  impaired  for  some 
time.  The  normal  manner  of  breathing  gradually  returns,  the  temperature 
of  the  skin  is  notably  less,  the  crepitant  rale  returns,  technically  known  as 
the  "  crepitans  redux,"  and  is  finally  replaced  by  the  normal  vesicular 
breathing  sound,  by  which  time  the  dullness  has  disappeared. 

Croupous  pneumonia  may  rarely  terminate  in  abscess  or  gangrene; 
in  either  event  the  signs  of  the  second  stage  continue  and  the  temperature  does 
not  fall — in  a  word,  the  crisis  does  not  occur.  The  signs  of  a  cavity,  which 
might  naturally  be  expected,  are  rarely  present,  and  it  is  rather  by  the  general 
symptoms,  viz.,  the  failure  to  recover,  the  continued  high  temperature,  the 
expectoration  of  pus,  and,  in  the  case  of  gangrene,  the  intensely  disagreeable 
odor,  that  we  are  informed  of  the  issue.  These  issues  probably  represent  on 
a  large  scale  what  takes  place  in  every  instance  in  minute  areas  in  the  third 
stage  of  all  pneumonias  which  terminate  favorably.  The  occasional  termi- 
nation in  tubercular  phthisis  exhibits  a  similar  arrest  of  the  resolving  process 
in  the  second  stage,  and  the  phenomena  of  catarrhal  or  fibroid  phthisis 
supervene. 

The  obscuring  efifect  of  a  thickened  pleura  upon  all  these  signs  is  to  be 
remembered,  and  too  much  stress  cannot  be  laid  upon  the  fact  that  we  may 
have  a  central  deep-seated  pneumonia  that  may  give  no  physical  signs ;  also 
that  in  old  persons  the  physical  signs  of  a  pneumonia  are  very  apt  to  be 
delayed  from  one  to  three  days. 


CROUPOUS  PNEUMONIA. 


219 


Careful  differential  percussion  and  palpation  may  recognize  a  moderate 
enlargement  of  the  spleen. 

The  heart  should  be  carefully  watched  in  pneumonia.  The  sounds,  at 
first  loud  and  clear,  become  less  so  as  the  disease  progresses  and  the  lungs 
become  engorged.  The  pulmonic  second  sound  is  particularly  sharp  as  long 
as  the  heart  is  strong,  and  its  failure  is  an  unfavorable  sign,  as  it  means  that 
the  right  ventricle  is  failing  in  power  and  may  be  yielding  to  distention. 

Modifications  in  Symptoms  and  Special  Symptoms. — The  foregoing 
is  the  course  of  a  typical  case  of  pneumonia,  perhaps  of  three-fourths  of  all 
cases,  and  the  symptoms  mentioned  suffice  for  a  diagnosis.  All  of  them  are, 
however,  subject  to  modifications. 

Thus,  the  chill  may  be  absent  or  imperfectly  developed,  in  which  case 
all  the  symptoms  arise  more  gradually.  The  temperature,  especially  in  old 
persons  and  drunkards,  may  not  be  nearly  so  high ;  in  children  it  may  be 
higher.  The  same  is  true  of  the  respirations,  which  may  be  increased  to 
100  to  the  minute  in  children.  Pain  is  especially  absent  in  old  persons, 
cough  and  expectoration  also,  so  that  a  careful  physical  examination  of  the 
lungs  should  be  made  in  all  ailments  in  the  old  and  in  drunkards  also,  as  it 
not  infrequently  happens  that  pneumonia  is  overlooked  in  them.  The  pulse  is 
often  feeble  and  rapid  instead  of  full  and  strong.  Nay,  more,  even  the 
physical  signs  may  he  absent  in  the  old,  and  they  are  especially  apt  to  be 
delayed  in  their  development.  It  is  unsafe  to  say  of  an  old  person  at  the 
first  visit,  after  a  negative  physical  examination,  that  he  has  not  pneumonia, 
for  the  physical  signs  may  not  make  their  appearance  until  the  second  or 
third  day  and  even  later.  It  would  seem,  too,  that  central  pneumonia  is  more 
common  in  the  old  than  in  the  young,  while  even  an  afebrile  pneumonia  is 
a  possibility  in  the  old.  Even  in  younger  persons  the  appearance  of  physical 
signs  is  sometimes  delayed  three  or  four  days. 

The  expectoration  varies  a  good  deal  when  present,  especially  as  to  the 
quantity  of  blood.  Sometimes  it  is  bright  red  and  quite  liquid,  almost  like 
a  hemorrhage.  More  frequently  it  is  viscid  and  glutinous,  simply  stained 
with  blood.  The  term  "  prune- juice  expectoration  "  has  long  been  associ- 
ated with  pneumonia,  and  sometimes,  when  it  is  thin  and  dark-hued,  the  com- 
parison is  an  apt  one.  Under  the  microscope  the  sputum  is  found  to  con- 
tain blood-discs,  leukocytes,  and  alveolar  epithelium  in  various  stages 
of  degeneration,  including  numerous  compound  granule-cells,  also  ciliated 
epithelium.  Fibrinous  bronchial  coagula,  sometimes  large  enough  to  be 
seen  by  the  naked  eye,  are  also  met  with  in  the  expectoration,  and,  after 
suitable  staining,  diplococci.  Should  gangrene  supervene,  the  expectora- 
tion becomes  very  fetid. 

The  urine  is  especially  characterized  by  a  reduced  amount  of  chlorids, 
which  are  often  absent  until  the  crisis  is  passed,  when  they  reappear.  It  is 
supposed  that  during  this  period  they  are  transferred  to  the  exudate  in  the 
lungs.  A  trace  of  albumin  is  often  present  and  it  presents  the  other  features 
of  febrile  urine. 

There  is  sometimes  marked  jaundice.  It  may  even  be  the  first  symp- 
tom. It  may  be  a  catarrhal  or  a  hematogenous  jaundice.  The  cases 
attended  by  it  are  rather  more  serious.,  Various  explanations  have  been  sug- 
gested. According  to  one,  it  is  due  to  a  catarrh  of  the  bile-ducts ;  according 
to  another,  it  is  due  to  a  reabsorption  of  the  hemoglobin  derived  from  dis- 
integration of  the  red  blood-disc  of  the  exudate  in  the  air-vesicles;  and 
according  to  still  another,  it  is  due  to  a  congestion  of  the  liver.     All  these 


220  INFECTIOUS  DISEASES. 

views  are  speculative.  Recently  G.  Mante  *  ascribes  it  to  a  hemolytic 
action  of  the  diplococcus  lanccolatus.  His  conclusions  are  based  upon 
experiments  going  to  prove  that  such  hemolytic  action  takes  place. 

The  blood  exhibits  usually  a  leukocytosis,  the  number  of  corpuscles 
being  increased  from  6000  per  cubic  millimeter  to  19,000,  or  more.  As 
many  as  68,000  have  been  found.  The  increase  is  almost  alv^ays  in  the  poly- 
morphonuclear cells.  The  proportion  of  fibrin  is  also  increased  from  4  to 
10  parts  in  1000.  This  increase  of  fibrin  shows  itself  also  on  the  micro- 
scopic slide  in  the  shape  of  filaments  of  fibrin.  According  to  Hayem,  the 
blood-plaques  are  increased. 

Herpes  is  very  common  on  the  lip — present,  it  is  said,  in  from  12  to  40 
per  cent,  of  all  cases.     It  may  occur  elsewhere,  as  on  the  nose  and  genitals. 

Phlegmasia  alba  dolens,  or  milk-leg,  is  a  rare  sequel.  J.  M.  Da  Costa  f 
collected  nine  cases,  of  which  three  were  his  own.  The  complication 
occurs  late  and  has  been  more  frequent  in  the  left  leg. 

When  typhoid  fever  coexists  with  croupous  pneumonia  the  tongue  is 
coated,  and  becomes  dry  and  leathery.  Constipation  is  usual,  but  occasion- 
ally there  is  diarrhea,  especially  in  epidemics.  Except  in  typhoid  cases 
delirium  is  not  common,  but  may  be  very  active  in  the  young.  In  old  per- 
sons it  may  be  low  and  muttering.  In  drunkards,  in  whom  the  disease  is 
common  and  very  grave,  especially  after  a  debauch,  the  delirium  may  be 
taken  for  mania  a  potu,  or  the  two  may  coexist.  Such  a  patient  may  rise 
from  his  bed  and  wander  out  into  the  city  or  to  another  hospital  that  he  pre- 
fers, having  just  intelligence  and  strength  enough  to  accomplish  this  pur- 
pose, and  will  die  after  its  attainment. 

Streptococcus  pneumonia  has  been  mentioned,  with  the  statement  that 
it  presents  some  clinical  features  different  from  those  of  the  ordinary  croup- 
ous pneumonia,  at  least  at  times  recognizable.  I  must  say,  however,  that 
I  am  not  myself  confident  of  being  able  to  recognize  such  pneumonia  by 
these  symptoms,  since  many  of  them  are  the  same  as  those  heretofore 
regarded  as  peculiar  to  bronchopneumonia  as  ordinarily  caused.  In  the 
first  place,  it  is  held  that  the  serious  form  of  pneumonia,  which  often  com- 
plicates influenza,  is  thought  to  be  a  streptococcus  pneumonia.  Such  pneu- 
monias, like  bronchopneumonia,  commonly  begin  obscurely,  are  atypical, 
while  the  local  signs  are  slow  to  develop.  The  rusty  expectoration  is 
delayed ;  in  like  manner  the  crisis,  Avhich  may  be  substituted  by  lysis ;  or 
death  supervenes  instead  of  crisis.  The  physical  signs  also  rather  resemble 
those  of  bronchopneumonia,  \yhile  it  is  said  :|:  that  the  disease  is  more  fre- 
quently found  in  the  upper  lobe,  not  at  its  apex,  but  in  its  lower  part 
between  the  inferior  angle  of  the  scapula  and  the  axilla.  It  may  also  be 
irregularly  migratory.  The  sputum  may  be  mucopurulent  at  the  outset, 
and  is  always  less  conspicuously  red  or  rusty.  Like  bronchopneumonia,  it 
is  also  insidious  in  its  onset,  the  fever  is  irregular,  and  there  is  often  chilli- 
ness or  actual  rigor  with  sweats ;  in  a  word,  septic  symptoms  are  prominent. 

Termination. — When  the  pneumonia  terminates  favorably,  promptly 
after  the  crisis  is  passed,  it  is  said  to  terminate  by : 

I.  Resolution,  by  which  is  meant  that  the  inflammatory  product  lique- 
fies, is  absorbed  or  expectorated,  and  the  lung  resumes  its  natural  state  and 
normal  physical  features.     The  time  at  which  these  events  are  thoroughly 

*  "Centralblatt  fiir  Bakteriologie,"  etc.,  December  lo,  i8q6,  p.  849. 
+  "Philadelphia  Med.  Jour.,"  vol.  ii.,  1808,  p.  510. 

t  G.  Baumearten,  "Variations  in  the  Clinical  Course  of  Croupous  Pneumonia,"  "International 
Clinics,"  vol.  ii.     Sixth  Series,  i8q6. 


CROUPOUS  PNEUMONIA.  221 

established  varies  greatly,  and  if  there  happens  to  have  been  associated 
pleurisy,  with  resulting  thickened  membrane,  impairment  of  resonance  may 
last  a  long  while.  On  the  other  hand,  it  may  terminate  spontaneously  even 
earlier  than  the  periods  named  for  the  crisis.  In  such  event  the  pneumonia 
is  said  to  abort.  This  promptly  favorable  termination  does  not  always  take 
place.  Resolution  may  be  unduly  delayed  and  yet  ultimately  take  place. 
Such  cases  naturally  occasion  anxiety,  for  resolution  may  not  take  place  at 
all,  in  which  event  one  of  five  unfavorable  terminations  may  occur.  These 
are:  ^ 

(a)   Death  from  cardiac  failure. 

(&)  Abscess. 

(c)  Gangrene  of  the  lung. 

{d)  Interstitial  or  fibroid  pneumonia. 

{e)  Tubercular  phthisis. 

2.  Abscess  of  the  lung  is  a  termination  of  pneumonia  in  about  4  per 
cent,  of  fatal  cases.  Flint,  Sr.,  found  it  in  4  out  of  133  cases  recorded. 
When  this  occurs,  the  interstitial  tissue  of  the  lungs  becomes  infiltrated  with 
pus  cells,  small  foci  of  leukocytes  aggregate  to  form  larger,  until  a  large 
abscess  results,  which  may  occupy  a  whole  lobe  or  even  a  whole  lung.  In 
such  cases  the  fever  continues  high,  there  is  expectoration  of  pus  containing 
elastic  tissue  of  the  lung,  and  the  physical  signs  of  a  cavity  may  rarely  be 
present.  It  is  not  impossible,  however,  for  such  a  process  to  be  arrested  by 
a  reactive  inflammation,  by  which  a  tough  protective  layer  of  embryonic 
tissue  is  formed  about  the  abscess. 

3.  Gangrene  of  the  lung  occurs  in  about  3  per  cent,  of  fatal  cases.  It 
is  especially  prone  to  occur  where  the  pulmonary  vessels  become  so 
engorged  that  the  circulation  is  arrested,  and  where,  as  a  consequence,  the 
hemorrhagic  element  is  conspicuous.  Bronchiectatic  cavities  in  an  inflamed 
lobe  that  are  swarming  with  putrefactive  bacteria  are  an  important  predis- 
posing cause.  It  is  recognized  by  the  sickening  fetor,  which  pervades  a 
whole  ward,  and  which,  once  met,  is  never  forgotten.  The  expectoration  is 
thin  and  similarly  fetid,  and  contains  large  quantities  of  elastic  tissue  from 
the  lung.  The  lung  is  converted  into  a  gray-green,  fetid  pulp,  in  which 
cavities  with  ragged  walls  arise,  from  disintegration  and  expectoration  of 
lung  tissue.  Gangrenous  portions  may  be  surrounded  by  a  zone  of  true 
inflammation,  contrasting  by  its  red  color  with  the  gray  of  the  gangrene. 
Such  sloughs  have  been  successfully  excavated  by  surgical  treatment. 

4.  In  fibroid  induration  or  cirrhosis,  which  is  occasionally  met  with, 
there  is  also  invasion  of  interstitial  lung  tissue,  but  instead  of  being  infil- 
trated by  such  an  excess  of  leukocytes  as  to  produce  pus,  only  as  many  wan- 
der out  as  can  undergo  organization  and  conversion  into  permanent  tissue. 
Sometimes  this  results  from  the  lung  failing  to  expand  after  resolution  and 
absorption  of  the  exudate,  the  walls  of  the  unexpanded  alveoli  collapsing 
and  uniting.  In  other  cases  there  is  partial  absorption  of  the  exudate, 
repeated  infiltration  takes  place  into  the  alveolar  septa,  and  organization 
takes  place  in  both.  The  fibrinous  plugs  may  also  be  transformed  into  con- 
nective tissue.  Three  successive  stages  may  be  present.  In  the  first  the 
cirrhotic  patches  are  gray,  grayish-Ved,  or  grayish-yellow,  and  a  small 
amount  of  turbid  exudate  can  be  here  and  there  squeezed  out  of  them.  In 
the  second  stage,  where  the  formation  of  the  fibrous  tissue  in  the  alveoli  or 
their  walls  has  set  in.  the  lung  is  dense,  firm,  airless,  and  fleshy,  whence  the 
term  carniUcation.     In  the  third  stage  the  fibroid  transformation  is  com- 


222  INFECTIOUS  DISEASES. 

plete;  the  tissue  is  tough  and  slate-gray  in  color.  Such  induration  is  gen- 
erally in  bands  and  patches  that  merge  gradually  into  the  normal  vesicular 
structure. 

5.  Tubercular  phthisis  is  another  termination  of  pneumonia.  It  results 
from  infection  by  implantation  of  the  tubercle  bacillus.  Pneumonia  of  the 
apex  terminates  thus  most  frequently. 

Complications. — The  most  frequent  complication  is  pleurisy.  It  is 
probably  always  present  to  a  certain  extent,  except  in  the  central  forms.  It 
manifests  itself  in  the  first  stage  more  by  the  characteristic  severe  cutting' 
pain  than  by  physical  signs,  as  the  friction  sound  characteristic  of  that  stage 
is  commonly  obscured  by  the  physical  signs  of  the  pneumonia.  Should  the 
stage  of  effusion  be  reached,  the  physical  signs  of  the  pneumonia  subside. 
In  severe  cases  a  pleurisy  may  surround  the  entire  lung  and  bind  it  to  the 
chest-wall.  A  pneumonia  on  one  side  and  a  pleurisy  on  the  other  is  a  pos- 
sibility. That  very  interesting  pathological  state  known  as  pleurogenic 
pneumonia  is  sometimes  seen  in  the  human  being  as  a  form  of  tubercular 
pleurisv.  In  it  the  lung  becomes  partitioned  oft"  by  an  interstitial  frame- 
work starting  from  the  pleura.  It  has  its  typical  anatomical  product  in  the 
pleuropneumonia  of  cattle.  The  extension  takes  place  chiefly  by  way  of  the 
lymphatics. 

Endocarditis  is  a  comparatively  frequent  complication.  William  Osier 
especially  called  attention  to  this  fact  in  his  Gulstonian  lectures  for  1885. 
He  ascertained  that  of  209  cases  of  malignant  endocarditis  54,  or  over  25 
per  cent.,  occurred '  as  complications  of  pneumonia.  It  is  more  prone  to 
attack  persons  with  old  valvular  disease,  and  to  involve  the  left  heart. 
There  is  good  reason  to  believe  that  the  specific  lancet-shaped  bacillus  is 
responsible  for  this  form  of  valvulitis  as  a  complication  of  pneumonia.  The 
endocarditis  constantly  escapes  detection,  since  physical  signs  are  sometimes 
absent,  at  others  deceptive,  but  it  may  be  suspected : 

1.  When  the  fever  is  protracted  and  irregular. 

2.  When  signs  of  a  septic  condition  arise,  such  as  irregular  temperature 
with  chills  and  sweats. 

3.  When  embolic  pneumonia  develops. 

4.  When  a  loud,  rough  murmur,  especially  a  diastolic  aortic  murmur, 
develops  in  the  course  of  the  disease. 

Meningitis  is  another  complication  to  w^hich  Osier  has  called  especial 
attention,  finding  it  in  8  per  cent,  of  fatal  cases.  It  usually  comes  on  at  the 
height  of  the  fever,  and  may  b».  confounded  with  delirium.  It  is  often  asso- 
ciated with  endocarditis,  and  it  may  he  accompanied  by  cerebral  embolism, 
producing  hemiplegia.     Neuritis  is  a-  possible  complication. 

Parotitis  occasionally  occurs,  commonly  in  association  with  endocarditis. 
In  children  middle-ear  disease  is  not  an  infrequent  complication. 

Diagnosis. — The  diagnosis  of  a  case  of  typical  pneumonia  is  easy.  The 
chill,  the  rapidly  developed  fever,  and  the  physical  signs  are,  as  a  rule,  easily 
recognized.  It  is  to  be  remembered,  however,  that  the  physical  signs  may  be 
delayed  or  not  appear  at  all  in  the  central  varieties. 

Pleurisy  is  the  disease  from  which  pneumonia  has  most  frequently  to 
be  distinguished.  The  resemblance  between  the  friction  sound  and  the  crepi- 
tant rale  is  often  very  close,  while  there  is  impaired  resonance  to  percussion 
in  both.  Most  valuable  in  diagnosis  is  vocal  tactile  fremitus,  which  is 
invariably  increased  in  pneumonia  and  as  invariably  diminished  in  pleurisy 
of  any  variety.     In  the  not  very  rare  instances  of  pleurisy  with  effusion 


CROUPOUS  PNEUMONIA. 


223 


attended  by  bronchial  breathing  the  same  sign  is  pathognomonic,  tactile 
fremitus  being  diminished,  whereas  it  is  increased  in  pneumonia.  Com- 
monly, too,  in  this  stage  of  pleurisy  we  have  a  change  in  the  line  of  dullness 
as  the  patient  changes  position,  though  this  is  not  invariable.  The  exploring 
needle,  if  needed,  may  also  help  settle  that  question. 

Frequent  examination  of  the  lungs  should  be  made  in  alcoholism,  in 
chronic  valvular  disease  of  the  heart,  in  diabetes,  and  in  Bright's  disease, 
since  all  these  affections  are  prone  to  become  complicated  with  insidious 
forms  of  pneumonia. 

Typhoid  fever  and  pneumonia  are  sometimes  confounded.  The  former 
is  apt  to  become  associated  with  hypostatic  congestion  of  the  lungs,  and 
pneumonia  with  a  typhoid  state.  The  hypostasis,  however,  occurs  late  in 
typhoid  fever ;  the  dullness  in  pneumonia  sets  in  early.  A  more  excusable 
error  is  made  in  the  case  of  acute  tub erculo pneumonic  phthisis,  which  may 
begin  with  a  chill,  while  the  resemblance  is  otherwise  very  close,  especially 
in  physical  signs.  Microscopic  examination  of  the  sputum  should  recognize 
the  bacilli  of  either  disease.  This  should  always  be  made  where  an  apparent 
pneumonia  is  prolonged  beyond  two  weeks  without  a  crisis.  In  pneumonic 
phthisis  the  appearance  of  bacilli  is  generally  late. 

Prognosis. — Pneumonia  is  a  treacherous  and  uncertain  disease  at  any 
age.  Young,  robust  men  of  twenty-five,  taken  mildly  ill  with  every  reason- 
able expectation  of  recovery,  sometimes  die  suddenly  and  unexpectedly. 
On  the  other  hand,  while  in  the  old  and  intemperate  it  is  especially  danger- 
ous, old  men  and  women  over  seventy  often  recover  completely.  The  intem- 
perate are  less  fortunate,  yet  even  among  them  some  surprising  recoveriesi 
are  observed.  The  mortality  ranges  from  20  to  40  per  cent.,  or  about 
one  in  four  or  five  die.  It  is  the  most  fatal  of  the  acute  infections  of  adults 
in  temperate  climates.  Children  recover  often,  even  when  desperately  ill. 
The  disease  seems  to  be  more  fatal  in  cities  than  in  the  country,  and  is  cer- 
tainly so  during  epidemics,  or  in  ships  or  other  crowded  places. 

The  seriousness  of  an  attack  varies  more  or  less  with  the  extent  of  lung 
involved,  pneumonia  of  a  whole  lung  being  more  dangerous  than  that  of  a 
part,  double  pneumonia  more  than  that  affecting  one  lung,  while  massive 
pneumonias  are  always  fatal.  Meningitis  is  invariably  fatal,  but  its  presence 
must  not  be  inferred  from  every  violent  delirium.  Endocarditis  is  almost 
as  fatal.  Death  is  usually  by  heart  failure,  the  right  ventricle  becoming 
stretched  by  the  accumulated  blood,  and  the  valves  and  columnse  carneas 
embarrassed  by  fibrinous  coagula.  which  may  extend  from  auricle  to  ven- 
tricle and  even  into  the  branches  of  the  pulmonary  artery. 

The  conclusion  h  apparently  unjustified  by  a  study  of  statistics,*  but 
it  does  seem  to  me  that  pneumonia  is  a  more  fatal  disease  now  than  when  I 
began  practice  thirty-five  years  ago. 

Treatment. — A  fundamental  principle  which  experience  has  established 
is  that  no  single  plan  of  treatment  dare  be  recommended  for  pneumonia,  but 
that  each  case  is  a  law  unto  itself.  This  is  more  or  less  true  of  all  diseases, 
but  it  is  especially  so  of  pneumonia.  Undoubtedly  cases  occur  that  are  best 
treated  by  general  blood-letting,  while  many  more  do  not  require  it,  and  a 
few  may  be  harmed  by  it.  Pneumonia  may  be  a  general  disease  and  not  a 
local  one,  and  the  lung  involvement  may  be  secondary :  at  the  same  time  the 
patient  often  dies  from  the  direct  effect  of  such  local  involvement.     It  is  the 

*  For  an  excellent  analytical  examination  of  the  statistics  of  pneumonia  the  reader  is  referred  to 
a  paper  in  the  "  Medical  News,"  July  27,  1889,  by  Drs.  Townsend  and  Coolidge,  Jr.,  based  on  a  study 
of  the  cases  treated  in  the  Massachusetts  General  Hospital. 


224  INFECTIOUS  DISEASES. 

obstruction  to  the  movement  of  the  blood  through  the  hmgs  which  strains 
and  wears  out  the  right  heart.  The  blood-letting,  if  it  is  done  early,  lessens 
this  congestion,  and  thus  relieves  the  right  heart.  More  frequently  per- 
haps at  the  present  day  the  patient  dies  of  the  efifect  of  the  toxin  on  the  heart 
and  nervous  system. 

What  are  the  indications  for  blood-letting?  There  are  two  periods  in 
a  pneumonia  where  blood-letting  may  be  of  advantage :  First,  in  the  first 
stage  and  early  part  of  the  second  stage,  and,  second,  where  there  is  engorge- 
ment of  the  right  heart.  The  indications  in  the  first  period  include  ( i ) 
great  dyspnea;  (2)  full,  bounding  pulse;  and  (3)  sharp,  pleuritic  pain. 
The  relief  to  all  of  these  symptoms  is  often  magical.  The  amount  of  blood 
taken  at  such  time  should  not  be  less  than  16  ounces  (480  c.  c),  but  not  the 
quantity  of  blood  so  much  as  the  relief  to  the  symptoms  should  be  the  sign 
to  stop  the  bleeding.  The  same  results  may  be  accomplished  by  wet-cups, 
provided  a  sufficient  amount  of  blood  be  taken,  and  cupping  has  the  appear- 
ance of  being  less  formidable,  although  it  is  actually  more  painful  and  dis- 
turbing to  the  patient.  After  the  removal  of  the  cups  a  poultice  or  warm 
cotton  jacket  is  comforting.  If  doubt  is  entertained  as  to  the  propriety  of 
either  of  these  two  methods  of  bleeding,  the  affected  lung  should  be  covered 
with  dry-cups,  and  after  the  removal  of  these  the  hot  poultice  or  hot  jacket 
applied.  Even  by  this  method  the  relief  to  the  pain  and  dyspnea  is  often 
very  great,  but  it  is  more  likely  to  be  temporary.  Dry-cupping  may,  how- 
ever, be  repeated  daily,  if  it  affords  relief.  While  there  are  cases  in  which 
the  adynamia  is  so  great  as  to  make  blood-letting  in  any  form  of  doubtful 
propriety,  there  can  be  no  possible  objection  to  the  dry-cups.  Bleeding, 
besides  relieving  the  symptoms  referred  to,  hastens  the  crisis  and  shortens 
the  disease. 

The  indications  in  the  second  period  are  rapid  breathing  with  cyanosis 
and  laboring  pulse.  At  this  stage  the  removal  of  10  to  16  ounces  of  blood 
is  often  of  signal  service,  and  I  believe  I  have  seen  life  saved  by  such  a  blood- 
letting. 

These  measures  may  also  relieve  the  cough,  but  usually  something  addi- 
tional is  required.  Until  expectoration  sets  in.  opium  is  pre-eminently  the 
remedy,  and  no  preparation  is  so  good  as  morphin  in  doses  of  from  1-16  to 
1-12  grain  (0.004  to  0.005  S^'^-)  for  adults  every  two  hours  in  1-2  ounce 
(15  c.  c.)  of  the  solution  of  citrate  of  potassium  flavored  with  lemon  or  other 
syrup.  Doz'cr's  pozvdcr  in  full  doses  sometimes  acts  favorably.  It  is  best 
given  in  pill  form.  Expectorants  are  rarely  needed  at  the  outset,  but 
auiuwuium  cJiIorid  in  doses  of  5  to  10  grains  (0.32  to  0.65  gm.)  in  brown 
mixture,  also  combined  with  morphin  if  necessary,  will  meet  the  indications. 
If  a  still  more  stimulating  expectorant  is  required,  the  carbonate  of 
amuionimn  may  be  used  in  doses  of  5  to  10  grains  (0.32  to  0.65  gm.)  fre- 
quently repeated.  It  is  an  important  fact,  often  overlooked  in  prescribing 
diffusible  stimulants,  that  to  get  a  desired  effect  they  should  be  frequently 
repeated,  and  it  is  better  to  give  small  doses  often  than  large  doses  at  longer 
intervals. 

Pneumonia  calls  very  soon,  sometimes  from  the  very  outset,  for  alco- 
holic stimulants,  which  act  not  only  on  the  heart,  but  also  as  antipyretics. 
Half  an  ounce  or  even  an  ounce  ("15  to  30  c.  c.)  hourly,  in  cases  of  extreme 
adynamia,  may  be  necessary.  The  index  of  sufficiency  or  the  reverse  is  the 
state  of  the  pulse  and  heart.  Whisky  or  brandy,  as  selected,  should  be  givenJ 
in  milk,  which  is  the  most  suitable  nourishment.     From  4  to  8  ounces  (12a 


CROUPOUS  PNEUMONIA.  225 

to  140  c.  c.)  of  milk  every  two  hours,  containing  the  proper  dose  of  stimu- 
lant, may  be  given. 

Strychnin  is  an  invaluable  heart  tonic  in  pneumonia,  and  may  be  given 
in  doses  of  1-30  grain  (0.002  gm.)  or  more,  every  four  to  six  hours,  com- 
bined with  8  to  20  grains  (0.52  to  1.30  gm.)  of  qiiinin  in  the  twenty-four 
hours,  as  may  be  required. 

Digitalis  is  a  remedy  much  used  in  pneumonia,  and  it  is  a  useful  drug, 
but  it  is  not  always  judiciously  ordered.  To  whip  up  a  flagging  heart  to 
increased  effort  to  drive  blood  through  a  lung  almost  as  solid  as  a  stone  is 
like  whipping  up  a  jaded  horse  to  an  effort  beyond  his  strength,  and  is 
about  as  ineft'ectual.  On  the  other  hand,  such  a  stimulus  may  tide  over  an 
obstacle  which  is  not  insurmountable,  but  which  might  remain  in  the  way 
unless  removed.  On  the  whole,  I  prefer  to  give  digitalis  in  moderately  full 
doses,  5  to  10  minims  (0.3  to  0.6  c.  c. ),  as  an  adjuvant  to  alcohol  rather  than 
in  very  large  doses.  Occasionally  in  sudden  adynamia  very  large  doses,  say 
I  dram  (3.7  c.  c),  hypodermically,  may  turn  the  tide  toward  recovery. 
Aromatic  spirit  of  ammonia  is  an  important  adjuvant  in  straits  like  these, 
and  may  be  substituted  with  advantage  for  the  carbonate. 

Inhalation  of  oxygen  is  of  undoubted  advantage  in  relieving  the 
dyspnea  and  thus  comforting  the  patient.  Whether  it  is  curative  is  much 
more  doubtful. 

High  temperature  may  be  reduced  by  sponging,  though  the  tempera- 
ture itself  in  pneumonia  cannot  be  regarded  as  dangerous  per  se. 

Should  ive  ever  blister  in  pneumonia f  A  blister  in  pneumonia  some- 
times does  much  good.  It  is  especially  useful  in  delayed  resolution,  late  in 
the  disease,  where  the  crisis  has  been  imperfect  and  convalescence  does  not 
set  in.  It  may  even  take  the  place  of  a  local  or  general  blood-letting,  espe- 
cially when  these  have  been  deferred  too  long  or  are  impossible  from  any 
cause.  When  a  blister  is  applied,  let  it  be  an  effective  one.  A  large  blister 
is  no  more  painful  than  a  small  one,  and  neither  is  it  so  painful  as  is  com- 
Tnonly  supposed.  In  mild  cases  turpentine  stupes  may  be  sufficient  to 
relieve  pain. 

I  am  well  aware  that  pneumonia  is  regarded  as  a  self-limiting  disease, 
reaching  its  crisis  in  from  five  to  nine  days,  and  that  many  think  the  only 
indication  is  to  sustain  the  patient  until  the  crisis  is  reached.  In  many  cases 
this  is  true,  but  I  believe  that  the  fury  of  the  disease  may  be  diminished  by 
treatment,  and  that  a  prompt  bleeding  at  a  suitable  time  will  not  only  lessen 
the  suffering,  and  so  spare  the  strength  of  the  patient,  but  may  also  hasten 
the  crisis.  Another  stage  at  which  a  blood-letting  is  sometimes  serviceable 
is  where  the  right  heart,  from  its  ineffectual  efforts  to  propel  the  blood 
through  the  lung,  becomes  distended.  Such  a  stage  is  indicated  by  intense 
cyanosis  and  gasping  orthopnea. 

The  use  of  veratrum  viride  is  warmly  recommended  by  some  instead 
of  bleeding  in  the  earliest  stages  of  the  disease.  It  diminishes  the  force  of 
the  heart,  furnishes  a  diverticulum  for  the  excess  of  blood,  and,  as  my  col- 
league, Horatio  C.  Wood,  says,  "  The  patient  is  bled  into  his  own  circula- 
tion."    I  have  never  felt  comfortable  in  relying  upon  it. 

The  treatment  of  pneumonia  by  "ice-cold  applications  has  lately  been 
gaining  favor.  Its  most  ardent  supporters  in  this  country  are  Simon 
Earuch.  of  New  York  City,  and  Thomas  J.  Mays,  of  Philadelphia.  My 
experience  has  not  been  large,  but  it  has  been  such  as  to  encourage  me  to 
•continue  it.     Further  experience  since  the  first  edition  of  this  book  appeared 

15 


226 


IXFECTIOUS  DISEASES. 


confirms  mv  favorable  impression.  I  prefer  the  method,  recommended  by 
Baruch,  of  enveloping  the  chest  in  a  suitably  fitted  linen  or  muslin  jacket 
(the  ordinarv  cotton  jacket  answers  well),  wet  in  cold  water  at  60°  F. 
( 15.5'  C.)  and  covered  by  a  flannel  bandage  an  inch  wide  and  longer;  direct- 
ing that  the  jacket  be  removed  and  substituted  by  the  dry  cotton  jacket 
whenever  the  temperature  falls  to  100°  F.   (37.7°  C),  and  renewed  if  the 


MARK 

SE5P.       OR 
TEMP. 


^^  20  ^/ Q^e^od^/^ce,. 


^(J.c^f,^EimimimiiL C^a^it,  (?fc "yjQafc,     April 


Fig.  21.— Showing  Drop  in  Temperature  in  a  Case  of  Pneumonia  Succeeding  the 

Application  of  the  Cold,  Wet  Jacket. 

The  figures  opposite  resp.  in  upper  left  portion  indicate  the  breathing  rate,  which  was- 

too  rapid  on  admission  to  be  indicated  in  the  usual  way  by  the  chart. 

temperature  rises.  In  this  way  all  danger  is  averted.  Baruch  recommends 
a  preliminary  dose  of  15  to  20  grains  ( i  to  1.33  gm. )  of  calomel.  Appended 
is  the  temperature  chart  of  a  case  admitted  to  the  University  Hospital  under 
my  care,  breathing  at  the  rate  of  58  a  minute,  and  of  whose  recovery  I  had 
no  expectation,  but  which  passed  to  rapid  convalescence  after  the  applicatiorL 
of  the  cold,  wet  jacket. 


CROUPOUS  PNEUMONIA.  227 

Dr.  Mays  prefers  to  surround  the  affected  area  with  ice  contained  in 
bags  that  are  wrapped  in  towels ;  but  they  are  difficult  to  keep  in  place,  espe- 
cially when  more  than  one  bag  is  required,  which  is  the  case  if  more  than  a 
limited  area  is  involved.  He  says,  also,  that  if  the  temperature  falls  to  the 
normal,  or  near  it,  with  a  tendency  to  remain  there,  the  ice  is  to  be  gradu- 
ally removed.  The  fever  is,  of  course,  a  mere  index  of  the  severity  of  the 
disease,  and  it  is  not  for  the  direct  effect  on  it  that  the  ice  is  applied,  but  to 
arrest  the  process.  The  effect  of  the  ice  is  almost  immediately  to  cause  the 
tempierature  to  fall.  Such  fall  must  not  be  mistaken  for  the  crisis.  If 
induced  by  the  ice,  it  rises  soon  after  its  removal. 

Hypodermoclysis  of  normal  hot  saline  solution  was  used  in  desperate 
cases  of  pneumonia  in  the  Philadelphia  Hospital  by  Dr.  Frederick  P.  Henry 
as  early  as  the  spring  of  1889.  Dr.  Henry's  first  publication  upon  the 
subject,  however,  was  made  in  January,  1900.*  A  few  months  earlier 
than  this.  Dr.  Clement  A.  Penrose  j  published  a  paper  on  "  Infusion  of  Salt 
Solution,"  etc.,  in  pneumonia.  The  injection  is  made  in  the  usual  way, 
under  the  skin,  at  any  stage  in  bad  cases  of  pneumonia,  from  one-half 
pint  to  a  pint  (236  to  473  c.  c. )  of  a  .6  of  one  per  cent,  solution  being 
injected  daily.  Dr.  Penrose  added  that  the  treatment  is  more  efficient 
when  given  in  connection  with  oxygen  inhalations  associated  with  blood- 
letting if  there  is  distention  of  the  right  heart  as  evidenced  by  cyanosis, 
flagging  pulse,  and  sharp  accentuation  of  the  second  pulmonic  sound. 
The  effect  is  that  of  a  respiratory  stimulant,  reducing  the  pulse  and 
breathing  rate,  as  well  as  of  a  diluent  for  the  toxins  in  the  blood.  Dr.  Pen- 
rose also  describes  a  method  of  inhaling  oxygen  which  appears  to  be  very 
satisfactory.  In  place  of  the  usual  delivery  nozzle,  a  glass  funnel  is  substi- 
tuted, held  about  two  inches  from  the  face  by  a  framework  resting  on  the 
bed  or  an  adjoining  table.  In  this  way  oxygen  is  supplied  to  both  mouth 
and  nostrils  without  interfering  with  the  breathing.  These  measures  cer- 
tainly merit  a  trial  in  desperate  cases,  the  more  especially  as  they  are  at 
least  harmless,  and  add  in  no  way  to  the  discomfort  of  the  patient,  while  the 
results  claimed  by  both  Dr.  Henry  and  Dr.  Penrose  are  most  encouraging. 

Serum  Treatment, — Pneumonia  was  one  of  the  first  diseases  the  treat- 
ment of  which  by  serum  engaged  attention.  The  subject  was  studied  by  the 
brothers  G.  and  F.  Klemperer,  who  utilized  for  prophylactic  and  curative 
purposes  the  antitoxin  derived  from  the  blood  of  immunized  animals. 
Immunity  is  obtained  by  subcutaneous  or  intravenous  injection  of  filtered 
bouillon  cultures  of  the  pneumococcus,  cultures  sterilized  by  heat  or  anti- 
septics. Such  immunity  is  limited  to  six  months,  but  the  young  born 
within  this  period  are  also  immune,  while  the  serum  of  the  blood  of 
such  animals  has  the  power  to  immunize  other  susceptible  animals. 
Nay,  more,  these  fluids,  when  introduced  into  the  blood  of  animals 
already  infected,  were  found  capable  of  curing  them.  Thus,  in  such  ani- 
mals with  a  body  temperature  of  from  104°  to  106°  F.  (40°  to  41°  C.) 
the  fever  fell  to  normal  in  twenty-four  hours  after  the  injection  of  the 
serum.  It  is  held  by  these  experimenters  that  the  pneumococcus  pro- 
duces a  poisonous  albumin  or  pneumotoxin,  which  when  introduced  into  the 
circulation  of  an  animal  causes  a  rise  of  temperature,  and  later  an  antipneu- 
motoxin,  which  has  the  power  of  neutralizing  the  poisonous  albumin  formed 

_*"  Treatment   of  Pneumonia   by   Hypodermoclysis,"    "International   Clinics,"   vol.' iv.,   Ninth 
Series.  looo. 

t  "Johns  Hopkins  Hospital  Bulletin,"  Julj',  iSgg. 


228  IXFECTIOUS  DISEASES. 

by  the  bacteria.  During  the  pneumonia  the  pneumotoxin  produced  by  the 
bacteria  in  the  kuigs  is  constantly  being  absorbed  into  the  circulation.  In 
natural  recover}-  this  continues  until  enough  antidotal  substance  is  gener- 
ated in  the  circulation  to  exert  its  effect  when  the  crisis  occurs.  Thei 
bacteria  are  not  destroyed,  nor  is  their  ability  to  produce  poisonous  products, 
but  these  latter  are  neutralized  by  the  antitoxin,  the  presence  of  which  has 
been  demonstrated  in  the  serum  of  the  blood  of  pneumonia  patients  after 
the  crisis.  Klemperer  first  injected  this  serum  into  infected  animals,  with 
the  effect  of  curing  them.  Finally,  he  injected  into  persons  ill  with  pneu- 
monia the  blood  serum  from  others  convalescent  from  pneumonia,  with  a 
view  to  hastening  the  crisis.  In  six  cases  there  was  a  decided  reduction 
in  temperature  in  from  six  to  twelve  hours  after  injection  of  from  65  to  95 
minims  (4  to  6  c.  c.)  of  the  serum.  The  pulse  and  respirations  also  fell. 
The  serum  has  no  effect  when  injected  into  healthy  individuals. 

Pneumonia  antitoxin  has  continued  to  be  used,  from  time  to  time,  since 
its  introduction  by  the  Klemperers,  but  it  has  not  established  a  reputation  as 
a  remedv  superior  to  other  methods  of  treatment  in  common  use.  It  is  made. 
by  the  Mulford  Company,  in  Philadelphia,  whose  dose  is  20  c.  c,  or  three 
dessertspoonfuls,  beneath  the  skin,  repeated  in  from  four  to  six  hours  while 
the  temperature  exceeds  103'  F.  (38.3^  C),  after  which  it  should  be 
given  twice  a  day  for  several  days.  If  the  temperature  is  below  103°  F. 
and  there  is  severe  constitutional  disturbance,  the  injection  should  be  con- 
tinued more  frequently  until  there  is  marked  improvement. 

This  serum  is  produced  by  a  method  used  by  Pane,  Washburn,  de 
Renzi,  Lambert,  and  McFarland  by  immunizing  animals  to  increasing  doses 
of  live  virulent  cultures.  ]\IcFarland  has  secured  in  the  horse  a  tolerance 
to  100  c.  c.  of  a  very  virulent  culture.  From  such  an  antipneumococcus 
serum  is  obtained.  I  have  used  this  serum  in  some  19  unselected  cases,  but 
am  unable  as  vet  to  draw  any  conclusion  horn  my  observations. 


BROXCHOPXEU^IONIA. 

Synonyms. — Catarrhal  Pneumonia;  Capillary  Bronchitis;  SuifO'Cative 
Catarrh;  Lobular  Pneumonia;  Aspiration  Pneumonia;  Deglutition 
Pneumonia. 

Definition. — Bronchopneumonia  is  an  inflammation  of  lobular  or 
patchy  areas  of  lung  tissue  caused  by  microbic  or  other  irritants  that  find  their 
way  to  it  through  a  bronchus. 

Etiology. — The  effects  of  recent  studies  go  to  show  that  the  broncho- 
pneumonias of  children  are  the  result  of  the  same  causes  as  the  lobar  pneu- 
monias of  adults,  producing  however  in  the  latter  lobar  consolidation  and  in 
the  former  lobular  or  patchy  consolidation.*  Usually  bronchopneumonia 
succeeds  a  bronchitis  of  the  terminal  bronchus  leading  to  the  part.  Some 
would  consider  bronchopneumonia  and  capillary  bronchitis  one  and  the  same 
thing,  but  the  latter  term  is  best  restricted  to  what  it  actually  indicates — 
inflammation  of  the  smallest  bronchioles.  It  often  precedes,  and  is  often  asso- 
ciated with,  bronchopneumonia.  Parts  of  a  lobule,  a  whole  lobule,  or  scattered 

*  See  Samuel  West,  "  Clinical  Lecture  on  Bronchopneumonia,"  to  show  that  pneumococcal  pneu- 
monia in  a  child  takes  the  lobular  and  not  the  lobar  form.  Reprinted  for  the  author  from  the 
"British  Med.  Jour.,"  May  28,  i8q8. 


BRONCHOPNE  UMONIA. 


229 


groups  of  lobules  are  thus  affected,  and  may  unite  to  form  larger  areas. 
Thus,  while  a  bronchopneumonia  is  primarily  lobular,  we  may  have  even  a 
lobar  bronchopneumonia  if  all  the  lobules  of  a  lobe  are  simultaneously 
affected.  Aspiration  pneumonia  is  a  bronchopneumonia  caused  by  the  irri- 
tation of  inhaled  or  indrawn  particles,  including  bacteria,  among  which 
must  be  included  also  streptococci  and  staphylococci,  as  well  as  pneumococci 
and  tubercle  bacilli.  Tubercular  bronchopneumonia  is  one  variety  of  this. 
Syphilitic  bronchopneumonia  is  a  rare,  but  possible,  affection. 

The  recognition  of  bronchopneumonia  as  a  separate  disease  is  usually 
credited  to  Barthez  and  Rilliet. 

Simple  bronchopneumonia  is  pre-eminently  a  disease  of  the  very  young 
and  the  old.  In  the  young  it  occurs  as  an  idiopathic  affection,  though  it  is 
also  a  frequent  complication  of  the  infectious  fevers,  measles,  whooping- 
cough,  scarlet  fever,  diphtheria,  and  smallpox.  In  adults,  especially  the  old, 
it  occurs  during  influenza,  erysipelas,  typhoid  fever,  and  all  debilitating 
affections,  including  Bright's  disease  and  organic  disease  of  the  heart.  The 
inhalation  variety  especially  occurs  in  comatose  states,  however  induced. 
William  Pepper  laid  especial  stress  on  vesicular  emphysema  as  a  predispos- 
ing cause.  In  both  young  and  old  it  may  succeed  a  simple  bronchitis 
from  cold,  but  it  is  as  a  coniplication  of  the  infectious  diseases  named 
that  it  becomes  during  the  first  five  3'ears  of  life  a  very  common,  serious, 
and  fatal  disease,  causing,  it  is  said,  more  deaths  among  children  than 
any  other  disease  except  infantile  diarrhea.  Diarrhea  itself  and  rickets  are 
also  to  be  included  as  predisposing  causes.  All  influences  depressing  to  life, 
such  as  overwork,  fatigue,  the  air  of  badly  ventilated  and  crowded  houses, 
insufficient  food,  and  defects  of  hygiene  act  similarly.  Collapse  of  the  lung 
is  at  once  a  cause  and  a  consequence  of  bronchopneumonia. 

Another  cause  of  bronchopneumonia  more  common  in  adults  and  the 
aged  is  the  inhalation  of  fine  irritant  particles  or  the  aspiration  of  particles 
of  food.  In  comatose  states  from  any  cause  the  sensibility  of  the  larynx  is 
benumbed,  and  minute  particles  of  food  are  permitted  to  pass  beyond  the 
rima  glottidis  to  enter  the  larynx,  and  thence  the  smaller  bronchial  tubes, 
where  they  excite  inflammation.  Hence  the  term  aspiration  or  deglutition 
pneninonia.  Glossopharyngeal  palsy  is  often  associated  with  deglutition 
pneumonia,  which  may  follow  tracheotomy  and  cancer  of  the  larynx 
and  esophagus.  The  inflammation  thus  excited  is  sometimes  so  intense  as 
to  cause  suppuration  and  even  gangrene.  Stone-cutting,  steel-grinding,  and 
coal-mining  become  causes  through  the  irritating  particles  inhaled  in  these 
occupations.  Francis  Delafield,  in  the  section  on  bronchopneumonia,  in  his 
"  Studies  in  Pathological  Anatomy,"  says  the  extension  is  not  from  the 
bronchus  to  the  air-vesicles  that  are  connected  with  it,  but  to  those  that  sur- 
round it.  Thus  he  says,  "  It  is  as  if  a  red-hot  needle  were  thrust  through 
the  lung,  making  a  track  of  charred  tissue  around  it."  He  refers  more  par- 
ticularly to  the  bronchopneumonia  that  succeeds  bronchitis. 

Morbid  Anatomy. — The  morbid  anatomy  of  simple  bronchopneumonia 
is  quite  definite,  yet  somewhat  complex  and  difficult  of  description.  The 
lungs  may  be  superficially  unaltered  or  they  ma}^  be  large  and  heavy.  On 
the  exterior,  especially  at  the  base,  may  be  seen  a  mottled  appearance,  due  to 
an  alteration  of  dark-blue  or  bluish-black  depressed  areas  with  project- 
ing portions  more  natural  in  hue.  The  depressed  areas  represent  col- 
lapsed lung,  and  can,  for  the  most  part,  be  reinflated.  In  places  they  are 
continuous,   forming  large  patches.     Where  there  is  much  of  this  dift'use 


230  INFECTIOUS  DISEASES. 

pneumonia,  corresponding  patches  of  fibrin  may  be  seen  on  the  puhnonary 
pleura. 

On  section  the  surface  of  the  king  is  dark  red  in  color  and  from  it  pro- 
ject reddish-gray  spots,  representing  areas  of  bronchopneumonia.  These 
may  be  separated  by  tracts  of  uninflamed  and  collapsed  tissue,  or  may  unite 
to  form  more  extensive  inflamed  areas.  A  section  made  transverse  to  the 
lobule  will  be  found  penetrated  by  a  central  bronchiole  filled  with  muco-pus, 
while  if  the  section  is  parallel  with  the  length"  of  the  bronchiole,  the  central 
alveolar  passage  with  its  alveoli  may  be  readily  recognized,  being  rendered 
distinct  by  the  same  muco-purulent  contents.  Around  the  bronchus,  to  the 
extent  of  from  i-8  to  1-5  inch  (3  to  5  mm.)  or  more,  is  an  area  of  grayish- 
red  consolidation  elevated  above  the  surface,  usually  slightly  granular  to 
the  touch,  but  still  lacking  the  hard,  shot-like  feel  of  croupous  pneumonia. 
On  pressure,  a  mixture  of  pus  and  desquamated  cells  may  be  squeezed  out, 
which,  at  a  later  stage,  becomes  almost  pure  pus,  appearing  as  white  points 
in  the  non-depressed  tissue.  Surrounding  the  imperfectly  hepatized  areas 
and  at  a  lower  level  is  a  smooth,  dark,  airless  tissue,  representing  collapsed 
lung,  which  may  be  the  seat  of  beginning  inflammation.  At  a  later  stage, 
if  the  patient  survives,  especially  in  adults,  the  inflammatory  areas  may 
assume  a  darker  hue,  even  that  of  gray  hepatization.  Still  later,  in  the  per- 
sistent forms,  the  areas  may  contain  foci  resembling  miliary  tubercles,  from 
which  they  may  be  always  distinguished  by  the  fact  that  the  white  droplets 
can  be  squeezed  out,  while  tubercle  remains  firm.  These  areas  may  be  con- 
verted into  cirrhotic  patches.  During  the  progress  of  a  bronchopneumonia 
the  air-cells  in  the  adjacent  lobules  are  found  dilated,  and  the  edges  of  the 
lung  and  upper  portions  have  also  become  emphysematous.  The  bronchioles 
themselves  are  also  dilated  in  places.  The  uninflamed  areas  are  generally 
congested. 

The  contents  of  the  bronchioles  and  air-vesicles  are  pus-cells  and 
swollen  exfoliated  epithelium.  The  walls  of  the  bronchiole  and  of  the  air- 
vesicles  are  thickened  and  infiltrated  with  leukocytes.  Rarely  do  they  con- 
tain blood  or  the  fibrin-network  characteristic  of  lobar  pneumonia.  Occa- 
sionally, minute  extravasations  of  blood  may  be  found. 

The  phenomena  in  the  aspiration  form  of  bronchopneumonia  are  more 
intense  in  every  respect  than  in  the  other  forms,  the  infiltration  of  the  air- 
vesicles  with  leukocytes  leading  sometimes  to  suppuration  or  even  to 
gangrene. 

Symptoms. — The  initial  symptoms  vary  with  the  precursory  disease. 
In  a  child — and  here  the  disease  has  its  greatest  practical  interest — there 
may  have  been  measles  or  whooping-cough  or  diphtheria,  in  which  con- 
valescence may  or  may  not  have  set  in.  To  incipient  or  aggravated  cotigh 
decided  fez'er  is  added,  a  temperature  of  102°  F.  (38.9°  C.)  and  higher  being 
attained;  the  cough  becomes  more  severe  and  painful,  the  breathing  becomes 
rapid,  and  an  easily  visible,  distressing  dyspnea  supervenes.  The  embar- 
rassed breathing  grows  worse,  the  fever  is  higher,  the  lips  and  face  become 
cyanosed,  the  short,  incessant  cough  is  inefifectual  in  the  raising  of  expecto- 
ration, and  the  little  sufiferer  is  a  picture  of  pitiable  distress.  For  such  a 
state  of  afifairs  the  term  suffocative  catarrh  given  by  the  older  authorities  is 
well  chosen.  Happily,  as  the  disease  advances  and  the  blood  becomes 
charged  with  carbon  dioxid,  sensibility  wanes,  the  suffering  abates,  and  the 
cough  grows  less ;  but  the  frequent  breathing,  often  60  to  80,  the  lividity  of 
the  face,  and  the  frequent  pulse  show  that  the  fury  of  the  disease  is  not  spent, 


BRONCHOPNE  UMONIA.  23 1 

but  will  probably  terminate  only  in  the  death  of  the  little  sufferer,  which  is 
-directly  due  to  exhaustion  of  the  muscle  of  the  right  ventricle.  At  times, 
Jiowever,  and  even  when  least  expected,  a  favorable  turn  takes  place  and  a 
surprisingly  rapid  convalescence  sets  in. 

In  adults,  as  in  children,  the  symptoms  vary  with  the  mode  of  origin. 
In  the  idiopathic  form,  which  is  recurrent  in  some  old  persons,  there  are 
fever,  a  burning  spot  in  the  cheek,  and  shortness  of  breath,  but  a  cough 
less  troublesome  than  would  be  expected.  The  physical  signs  rather  than 
the  symptoms  determine  the  diagnosis.  There  are  fine  moist  rales,  with 
harsh  breathing  rather  than  bronchial  breathing,  and  relatively  clear 
percussion. 

The  symptoms  in  a  case  of  deglutition  pneumonia  are  very  similar. 
In  the  inhalation  pneumonia  of  miners,  stone-cutters,  and  steel-grinders 
the  symptoms  are  slower  in  their  development  and  resemble  more  those  of 
tubercular  phthisis. 

Physical  Signs. — These  are  by  no  means  as  distinctive  as  those  of 
croupous  pneumonia.  Though  I  think  it  best  to  separate  capillary  bron- 
chitis from  bronchopneumonia,  the  association  is  so  close  that,  given  the 
fine  subcrepitant  rales  of  the  former,  unaccompanied  by  impairment  of  reso- 
nance, we  may  infer  that  bronchopneumonia  is  at  hand.  Further  signs, 
liowever,  of  actual  involvement  of  the  lung-substance  are  moderate  impair- 
ment of  resonance  and  liarsh  breathing,  rather  than  true  bronchial  breath- 
ing, though  more  rarely  the  latter  may  be  present,  especially  when  the  bases 
of  the  lung  are  involved.  Inspection  may  recognize  retraction  of  the  car- 
tilages and  lower  sternum  during  inspiration,  indicating  defective  expan- 
sion of  the  lung. 

Diagnosis. — The  diagnosis  of  bronchopneumonia  is  usually  easy. 
High  fever,  cough,  mucous  expectoration,  fine  rales,  and  slight  impairment 
•of  resonance,  following  one  of  the  infectious  diseases  in  a  child  under  five 
years,  and  developing  gradually,  admit  of  but  one  interpretation.  When 
a  number  of  small  foci  unite  to  form  a  large  area  corresponding  to  the  whole 
or  a  portion  of  a  lobe,  the  physical  signs  are  more  like  those  of  a  lobar 
pneumonia,  and  the  absence  of  expectoration  in  children  increases  the  diffi- 
culty of  diagnosis.  Lobar  pneumonia  develops  more  suddenly  and  resolves 
more  rapidly. 

The  similarity  in  the  morbid  anatomy  of  persistent  bronchopneumonia 
and  tuberculosis  has  been  referred  to,  and  the  clinical  resemblance  is  even 
greater,  so  that  it  may  be  impossible  to  say  of  a  given  condition  in  a  child 
which  it  is.  The  presence  of  signs  at  the  apices  is  to  be  sought  for,  and,  if 
found,  tuberculosis  may  be  suspected ;  but  the  correct  diagnosis  is  sometimes 
made  only  on  the  autopsy  table. 

Prognosis. — The  prognosis  varies  with  the  etiology,  but  broncho- 
pneumonia is  always  a  serious  disease.  From  30  to  50  per  cent,  of  all  chil- 
dren perish  from  it. 

In  fatal  cases  in  children  death  may  '^ccur  in  twenty-four  hours.  When 
recoverv  takes  place,  the  disease  lasts  from  five  to  ten  days,  and  as  many 
more  are  required  for  complete  restoration  to  health.  More  rarely  a  chronic 
interstitial  pnemnonia,  what  Delafielql  calls  a  persistent  bronchopneumonia, 
develops,  which  may  last  for  months  or  years  and  finally  give  rise  to  miliary 
tuberculosis. 

Yet,  as  mentioned  under  symptomatology,  some  remarkable  recoveries 
take  place.     In  adults  it  is  about  as  serious  as  croupous  pneumonia.     The 


232  IXFECTIOUS  DISEASES. 

deglutition  variety  is  almost  always  fatal,  and  is  the  usual  cause  of  death 
in  glossopharyngeal  palsy.  Some  cases  pass  into  tubercular  consumption, 
even  in  children. 

Treatment. — The  indifiference  of  parents  and  the  carelessness  of  nurses 
are  responsible  for  many  cases  of  bronchopneumonia  occurring  during  con- 
valescence from  measles,  diphtheria,  and  whooping-cough  which,  with 
proper  care,  might  have  been  averted.  Among  the  causes  thus  responsible 
are  exposure  of  children  with  uncovered  heads  at  open  doors  and  windows, 
insufficient  clothing  during  sleep,  overheated  rooms,  and  drafty  corridors. 

Restorative  measures  are  indicated  in  this  disease  from  the  outset. 
Nauseating  expectorants  are  rarely  demanded  and  often  do  harm  by  lower- 
ing the  vitality  of  the  young  patient.  Blood-letting,  undoubtedly  useful  in 
some  cases  of  croupous  pneumonia,  is  not  called  for  in  catarrhal.  Opiates 
to  quiet  the  cough  and  relieve  the  pain  are  the  strongest  indications  in  the 
earlier  stages  of  the  disease  and  sometimes  throughout  it.  They  should  be 
associated  with  diaphoretics  and  febrifuges,  among  which  the  solution  of 
acetate  of  ammonium,  the  solution  of  citrate  of  potash,  and  sweet  spirit  of 
niter  are  the  best.  The  tincture  of  aconite  in  small,  but  often  repeated,  doses 
is  extremely  valuable  if  the  temperature  is  high  and  the  pulse  full  and  rapid. 

When  secretions  become  free  and  a  stimulating  expectorant  is  required, 
there  is  none  better  than  the  aromatic  spirit  of  ammonium,  which  fulfills 
every  indication  and  spares  the  stomach  more  than  the  chlorid  or  carbonate 
of  ammonium.  If  the  accumulation  of  mucus  become  troublesome,  it  may 
be  dislodged  by  a  mineral  emetic,  such  as  alum,  of  w^hich  the  dose  for  a  child 
is  a  heaping  teaspoonful ;  or  sulphate  of  zinc,  in  doses  of  lo  to  30  grains 
(0.65  to  2  gm. )  ;  or  the  syrup  of  ipecac,  more  likely  to  be  at  hand,  may  be 
used.  At  this  stage,  alcohol,  in  the  shape  of  whisky  or  brandy,  becomes 
an  important  adjuvant.  It  should  be  added  to  the  nourishment,  of  which 
the  best  form  is  milk,  although  nourishing  broths  are  also  indicated.  As 
digestion  is  likely  to  be  feeble,  the  milk  is  better  peptonized.  Quinin,  and 
especially  strychnin  as  a  respiratory  stimulant,  are  useful  tonics. 

In  the  way  of  local  treatment  counterirritation  by  mustard  and  tur- 
pentine is  especially  useful.  The  former  should  be  used  in  the  shape  of  a 
weak  plaster,  one  part  of  mustard  to  five  or  six  parts  of  flour  or  flaxseed  meal. 
If  white  of  egg  and  glycerin  be  used  to  mix  it  instead  of  water,  the  plaster 
is  less  painful  and  may  be  kept  on  continuously.  One  of  the  best  modes 
of  applying  turpentine  is  by  the  St.  John  Long  liniment,  which  may  be 
made  by  mixing  thoroughly  a  teacupful  of  vinegar,  a  wineglass  of  turpentine, 
and  one  egg.  This  may  either Idc  rubbed  thoroughly  on  the  chest  or  it  may 
be  applied  on  flannel.  It  may  be  that  the  turpentine  is  absorbed  and  acts 
as  an  expectorant.     Blisters  are  not  to  be  recommended. 

The  poultice  is  a  measure  of  treatment  for  catarrhal  pneumonia  which 
is  variously  valued.  It  is  undoubtedly  useful  in  children  if  properly  employed, 
but  great  care  should  be  taken  that  it  does  not  become  cold.  It  should  be 
lightly  made  and  changed  often:  and  when  changed,  it  should  be  done 
rapidly,  a  fresh,  hot  pouhice  being  at  hand  to  replace  the  one  removed. 
When  poultices  are  not  used,  the  cotton  jacket  should  be  substituted,  as  it 
insures  a  uniform  temperature  of  the  body.  This  should  be  further  fav- 
ored by  maintaining  a  uniform  room-temperature  of  70°  F.  (24.5°  C.)  and 
averting  drafts  by  screens. 

If  the  temperature  be  ven-  high,  it  may  be  reduced  by  sponging,  or, 
better,  by  the  wet-pack  at  a  temperature  of  75°  F.    (25°  C.).     The  child 


CHRONIC  INTERSTITIAL  PNEUMONIA. 


233 


does  not,  however,  die  of  the  effects  of  high  temperature,  but  rather,  finally, 
of  a  failing  right  heart.  The  bath  is,  nevertheless,  very  calming  to  the 
nervous  system,  and  should  be  used  for  this  reason. 

The  same  measures  may  be  used  with  appropriate  modifications  in  the 
catarrhal  pneumonia  of  adults,  and  also  in  the  variety  known  as  deglutition 
pneumonia.     As  this   last   form   of  pneumonia   is,   however,   generally  the 
beginning  of  the  end  in  some  other  serious  condition,  treatment  avails  but 
little. 


CHRONIC    INTERSTITIAL   PNEUMONIA. 

Synonym. — Cirrhosis  of  the  Lung. 

Definition. — A  chronic  inflammatory  disease  consisting  in  a  gradual 
invasion  of  a  lung  by  fibroid  tissue,  with  a  corresponding  reduction  in  the 
vesicular  structure  of  the  lung.  According  as  it  involves  limited  or  more 
extensive  areas  it  is  local  or  diffuse. 

Etiology. —  Interstitial  pneumonia  is  mainly  a  secondary  affection. 
There  are  few  chronic  affections  of  the  lung  which  do  not  cause  a  certain 
amount  of  fibroid  overgrowth.  Especially  is  this  true  of  tubercular  con- 
sumption and  bronchopneumonia.  A  form  of  the  latter  is  the  so-called. 
pneumoconiosis,  a  fibroid  induration  succeeding  a  bronchopneumonia  due 
to  the  irritating  effects  of  minute  particles  arising  in  the  occupations  of  coal- 
mining, stone-cutting,  steel-grinding,  and  iron-working  in  general.  To  the 
form  associated  with  tuberculosis  the  term  fibroid  phthisis  is  applied,  and  it 
has  received  separate  consideration.  The  seat  of  a  healed  tuberculosis  is 
also  occupied  by  fibroid  tissue,  which  may  be  regarded  as  an  example  of 
interstitial  pneumonia.  Less  frequently  it  succeeds  croupous  pneumonia  as 
fibroid  induration,  which  has  been  considered  on  page  221  and  constitutes 
an  important  product  in  pleurogenic  pneumonia  mentioned  on  page  222. 
Even  abscesses  of  the  lung  may  excite  it,  while  the  various  forms  of  morbid 
growths,  as  sarcoma,  carcinoma,  chondroma  and  hydatid  cysts,  are  causes  of. 
it,  and  are  surrounded  by  fibroid  growths.  Especially  does  the  fibroid 
change  occur  in  a  lung  that  has  been  long  in  a  state  of  compression,  as  by 
a  pleuritic  effusion.  Since  the  majority  of  cases  of  chronic  interstitial  pneu- 
monia are  directly  or  indirectly  the  result  of  microbic  agents,  it  has  appeared 
to  me  best  to  retain  its  consideration  in  this  section,  even  though  some  cases, 
may  be  due  to  other  causes. 

Morbid  Anatomy. —  Pathological  Histology. — In  bronchopneumonia 
the  fibrosis  usually  starts  from  the  outer  sheath  of  the  bronchi,  invading 
the  alveolar  walls  and  converting  the  entire  lobule  into  grayish  fibroid  tissue, 
.in  which  no  lung  structure  is  distinguishable.  This  form  is  frequently 
associated  with  dilated  bronchus,  of  which  the  fibrosis  is  probably  the  direct 
cause,  its  contraction  drawing  the  walls  apart.  The  line  of  demarction 
between  interstitial  pneumonia  on  the  one  hand  and  tuberculosis  on  the  other 
is  often  not  very  sharp.  , 

In  interstitial  pneumonia  after  croupous  pneumonia  a  gradual  organiza- 
tion takes  place  of  the  fibrinous  plugs  in  the  air-vesicles :  the  alveolar  walls 
themselves  become  thickened  by  a  new  formation,  at  first  cellular  and  sub- 
sequently fibrillated.     Death  usually  occurs  in  these  cases  in  one  to  three 


234  IXFECTIOUS  DISEASES. 

months  after  the  onset  of  the  disease.     The  whole  of  the  part  primarily 
invaded  may  become  thus  altered. 

Macrosco[>ic  Morbid  Anatonuy. — The  chest-walls  of  the  side  affected 
are  often  depressed,  and  on  opening  the  thorax,  the  lung,  or  as  much  of  it  as 
is  involved,  is  found  retracted ;  it  may  be  drawn  back  into  the  spinal  gutter. 
If  on  the  left  side,  the  heart  may  be  retracted  with  it.  Commonly  the  two 
pleurae  are  found  united,  but  not  always.  On  section  the  lung  is  hard  and 
tough.  It  is  gray,  fibrous,  and  the  alveolar  structure  has,  to  a  varying 
extent,  disappeared.  The  bronchi  and  the  blood-vessels,  however,  remain, 
the  former  being  often  dilated,  to  produce  the  so-called  bronchiectatic  cavity, 
of  which  there  may  be  a  number.  The  pulmonary  artery  may  be  atherom- 
atous. In  the  phthisical  variety  there  may  also  be  a  cavity  at  the  apex, 
and  a  recognition  of  this  before  death  will  be  an  aid  to  diagnosis.  Other- 
wise a  careful  study  is  often  necessary  to  distinguish  the  two  varieties,  unless 
the  tubercle  bacillus  has  been  found. 

The  uninvolved  lung  is  usually  enlarged  and  emphysematous  in  pro- 
portion to  the  degree  of  contraction  of  the  afitected  lung.  The  right  ven- 
tricle, which  has  increased  work  imposed  upon  it  in  forcing  the  blood 
through  the  contracted  lung,  becomes  hypertrophied  and  may  become  ulti- 
mately dilated. 

Symptoms. — The  principal  symptom  is  cough,  which  starts  with  the 
condition  causing  the  fibrosis  and  continues  to  the  end.  It  varies  greatly 
in  its  severity,  being  sometimes  trifling,  at  others  very  troublesome.  The 
expectoration  is  as  variable  as  the  cough ;  more  copious  as  the  cough  is  more 
troublesome.  Persons  thus  affected  have  the  appearance  of  delicate  health, 
and  are  commonly  regarded  as  phthisical,  although  they  have  often  con- 
siderable strength  and  can  pursue  some  occupation.  In  non-tubercular  inter- 
stitial pneumonia  there  is  less  fever  than  is  present  as  a  rule  in  phthisis,  but 
the  recognition  of  the  tubercle  bacillus  is  the  crucial  test,  for  otherwise  the 
symptoms  are  very  similar.  In  both  conditions  there  is  paroxysmal  cough, 
with  copious  expectoration  of  muco-purulent  matter.  The  resemblance  is 
still  more  close  if  there  is  bronchiectasis,  when  the  usual  emptying  of  the 
cavity  by  cough  takes  place,  commonly  in  the  morning,  sometimes  twice  a 
■day,  and  even  oftener.  The  expectorated  matter  of  the  bronchiectatic  cavi- 
ties may  be  fetid  from  decomposition.  There  is  usually  less  dyspnea  than  in 
true  phthisk.  and  except  where  the  disease  is  the  sequel  of  true  pneumonia, 
the  fatal  termination  is  longer  deferred  than  in  tuberculosis — it  may  be  for 
years. 

Physical  Signs. — The  chest  is  more  or  less  retracted,  its  circumference 
diminished.  Its  movements  are  restricted  and  its  topography  altered. 
When  the  left  lung  is  extensively  aft'ected.  a  pulsation  is  often  seen  in  the 
second,  third,  and  fourth  interspace,  very  similar  to  what  is  sometimes  seen 
in  the  right  of  the  sternum,  when  a  pleuritic  eft'usion  on  the  left  side  pushes 
the  heart  over  to  the  right.  It  is  probably  the  result  of  rhythmic  retrac- 
tion and  relaxation  of  the  interspaces  corresponding  to  the  cardiac  action  due 
to  adhesion.  In  high  degrees  of  the  disease  the  shoulder  is  drawn  down  and 
the  spinal  column  laterally  curved,  just  as  in  recovery  after  empyemic 
pleurisy.  The  unaffected  side  is  more  prominent  than  in  health.  The  tactile 
fremitus  may  be  diminished  or  increased  according  as  the  pleural  membrane 
is  thickened  or  not.  The  same  is  true  of  vocal  resonance.  Percussion  gen- 
erally elicits  impairment  of  resonance  over  the  affected  lung,  though  there 
may  be  high-pitched  tympany  and  even  amphoric  resonance  over  a  dilated 


EMBOLIC  PNEUMONIA.  235 

bronchus.  The  king  on  the  sound  side  furnishes  hyperresonance.  To  aus- 
cultation the  breathing  sounds  may  be  feeble,  but  there  may  be  broncho- 
vesicular  or  bronchial  and  even  amphoric  breathing  of  the  most  intense  kind. 

There  is  usually  sharp  accentuation  of  the  second  pulmonic  sound 
because  of  the  forcible  effort  of  the  right  ventricle  to  push  the  blood  through 
the  contracted  lung;  and  when  the  right  ventricle  begins  to  yield,  cardiac 
murmurs  may  develop  at  the  tricuspid  valve. 

Diagnosis. — Chronic  interstitial  pneumonia  is  mainly  to  be  distin- 
guished from  fibroid  phthisis,  which  is  often  impossible  without  an  examina-' 
tion  ni  the  sputum  for  bacilli.  The  history  and  duration  of  the  case  may 
be  of  assistance. 

Prognosis. — Recovery  is  impossible,  yet  cases  last  many  years — ten, 
fifteen,  and  even  longer. 

Treatment. — As  intimated,  treatment  for  the  fibrosis  is  unavailing, 
though  lung  gymnastics  should  be  practiced  with  a  view  to  developing  lung 
expansion.  Intercurrent  bronchitis  may  be  helped  by  the  usual  remedies 
for  that  disease.  Antispasmodics,  belladonna,  and  hyoscyamus  are  often 
useful  adjuvants  to  the  cough  medicines.  Patients  are  generally  better  in 
summer  and  in  a  warm  climate,  where  they  should  dwell,  if  possible.  They 
should  be  fed  with  an  abundance  of  rich,  nutritious  food,  and  surrounded  by 
the  most  favorable  hygienic  conditions. 


EMBOLIC   PNEUMONIA. 

Definition. — An  embolic  pneumonia  is  a  pneumonia  caused  by  an 
■embolus,  or,  more  rarely,  by  a  thrombus  formed  in  the  pulmonary  artery. 
Embolic  pneumonia  is  either  non-septic  or  septic. 

Embolic  Non-septic  Pneumonia. 

Synonym. — Hemorrhagic  Infarct  of  the  Lung. 

Etiology. — The  non-septic  hemorrhagic  infarct  of  the  lung  is  the  result 
of  embolism,  more  rarely  of  thrombosis,  of  the  pulmonary  artery.  The 
emboli  come  from  the  right  side  of  the  heart,  where  they  either  originate 
as  fragments  of  thrombi  or  have  entered  from  the  systemic  veins.  Emboli 
usually  lodge  at  the  bifurcation  of  the  branches  of  the  pulmonary  artery. 
The  usual  transudation  of  blood  takes  place  in  a  cone-shaped  area.  Not 
every  embolus  is  followed  by  an  infarct.  An  embolus  may  be  so  large  as  to 
cause  death  before  an  infarct  can  be  formed.  Nor  is  every  hemorrhagic 
infarct  followed  by  a  pneumonia.  The  ultimate  consequences  of  non- 
infectious emboli  depend  on  their  size.  A  large  embolus  and  a  corresponding 
infarct  with  free  extravasation  of  blood  are  liable  to  be  followed  by  gangrene 
of  the  lung,  which  may  excite  intense  reactive  inflammation  in  its  neighbor- 
hood, and  the  aspirated  blood  may  cause  pneumonia.  When  the  lodged 
particle  is  small,  the  hemorrhagic  infarct  is  small,  and  the  transudate  is  a 
diapedesis  rather  than  a  hemorrhage. ,  From  this,  true  embolic  pneumonia 
results  only  when  there  is  no  collateral  circulation — that  is,  when  it  is  supplied 
by  an  end-artery.*  

*  All  the  large  branches  of  the  pulmonary  artery  are  end  arteries,  and  many  of  the  smaller 
branches  also. 


236  IXFECTIOiS  DISEASES. 

Morbid  Anatomy. — The  infarct  thus  caused  is  conical  in  shape  with 
its  base  toward  the  pleura,  and  varies  in  size  from  that  of  a  cherry-stone  to 
that  of  a  hen's  egg.  The  pleura  over  the  infarct  at  first  projects  above  the 
surrounding  surface,  and  is  at  first  smooth,  but  later  is  roughened  by  a  film 
of  Ivmph.  The  infarct  when  recent  is  dark  reddish-brown  in  color,  and  on 
section  rises  also  above  the  surrounding  surface. 

This  transudation  is  the  preliminary  of  a  peculiar  reactive  inflamma- 
tion— the  embolic  pneumonia  under  consideration.  Succeeding  a  slight 
preliminary  contraction  there  takes  place  an  immigration  of  leukocytes  from 
the  contiguous  vessels  which  accelerates  the  reabsorption  of  the  blood.  To 
the  disintegration  and  absorption  of  the  red  blood-discs  succeed  a  more 
rapid  paling  and  contraction,  until  no  color' remains,  or  there  may  be  a  hard- 
ening of  the  pulmonary  tissue,  with  a  cicatricial-like  contraction,  into  which 
the  pleural  membrane  is  drawn,  producing  fibroid  thickening  with  radiated 
prolongations.  Such  hardening  is  partly  due  to  a  condensation  of  the  lung 
and  partly  to  an  organization  of  the  cells  in  the  infiltrated  alveoli  and  alve- 
olar walls.  Such  remnant  is  slate-gray  from  the  residue  of  hematin  derived 
from  the  extravasated  blood,  or  it  may  be  dark  red,  owing  to  hematoidin 
crystals  throughout  it.  If  the  infarct  is  large,  a  part  may  break  down  into 
reddish  inodorous  pulp,  which  may  be  absorbed,  or  a  part  may  make  its 
way  into  a  bronchus  and  may  be  expectorated.  In  the  event  of  so  large  an 
infarct  the  residue  of  cicatricial  tissue  is  larger.  Caseation  and  calcifica- 
tion of  the  remains  are  possible  results. 

The  embolus  itself  is  in  like  manner  removed,  a  few  filaments  or  slight 
wrinkles  in  the  walls  of  the  vessel  being  the  sole  residue. 

Symptoms. — There  may  be  no  symptoms,  or  these  may  be  confined 
to  a  transient  pleiiritk  pain  in  the  pleura  covering  the  embolus.  With  the 
increase  in  size  of  the  infarct  such  pain  increases,  and  mav  be  associated 
with  some  sJwrtiicss  of  breath,  due  to  destruction  of  the  aerating  surface. 
To  this  may  be  added  expectoration  of  blood  if  the  eft'used  blood  gets  into 
the  bronchus.  If  the  infarcted  area  be  sufficiently  large,  there  may  be 
dullness  on  percussion,  increased  vocal  fremitus  and  resonance,  crepitant 
and  subcrepitant  rales,  bronchial  breathing,  and  bronchophony.  Further 
characteristics  are  the  absence  of  fever  and  suddenness  of  onset  and  the 
presence  of  intravascular  disease.  It  has  been  mentioned  that  the  embolus 
may  be  so  large,  and  cut  oiT  so  large  a  supply  of  blood  to  the  lung,  that  death 
will  take  place  before  an  infarct  can  form. 

Diagnosis. — Embolic  non-septic  pneumonia  is  often  overlooked.  The 
foregoing  symptoms,  suddenly  occurring  in  conection  with  states  leading 
to  thromboses  in  the  veins  or  the  right  heart,  may  be  suspected  to  be  due  to 
non-septic  embolic  pneumonia.  Infarcts  that  form  in  the  lung  from  non- 
infectious emboli  arising  in  the  left  heart  or  arterial  system  must  be  so  small 
as  to  escape  detection,  since  the  emboli  themselves  must  be  so  small  as  to 
pass  through  capillaries  into  the  veins,  thence  into  the  right  heart,  and 
thence  to  the  lung. 

Prognosis. — The  prognosis  of  non-septic  embolic  pneumonia  is  favor- 
able unless  the  embolus  is  so  large  as  to  stop  up  a  large  vessel,  producing 
a  correspondingly  large  infarct.  An  embolus  plugging  one  of  the  largest 
branches  of  the  pulmonary  artery  is  fatal  before  an  infarct  can  form. 

Treatment. — Nothing  can  be  done  actively  to  relieve  an  embolic  pneu- 
monia of  this  kind.     A  patient  in  whom  it  is  suspected  must,  of  course,  be 


EMBOLIC  PNE  UMONIA. 


237 


kept  absolutely  at  rest.  Counterirritation  may  be  applied  to  the  chest-wall 
over  the  area  involved.  Anodynes  should  be  used  to  a  degree  required  to 
relieve  pain. 


Embolic  Septic  Pneumonia. 
Synonym. — Metastatic  Abscess. 

Etiology. — The  cause  of  septic  pneumonia  or  metastatic  abscess  of 
the  lung  is  a  septic  embolus.  Such  a  septic  embolus  may  originate  in  a 
thrombus  at  a  seat  of  putrid  inflammation  or  suppuration,  such  as  the  wound 
of  an  operation  or  a  compound  fracture,  or  in  the  uterus  after  childbirth. 
The  veins  of  such  a  focus  are  filled  with  thrombi,  which  extend  into  the 
larger  branches,  where  they  soften  and  break  up  into  fragments,  some  of 
which  may  pass  into  the  right  heart,  thence  into  the  pulmonary  artery  and 
its  branches,  until  one  is  reached  small  enough  to  resist  its  further  transit. 
Such  an  embolus,  which  is  probably  swarming  with  bacteria,  is  an  intense 
irritant,  and  inflammation  sets  in  that  invariably  terminates  in  abscess,  as 
contrasted  with  the  simple  indurative  irritation  caused  by  a  non-septic 
embolus.  Thus  caused,  septic  pneumonia  is  one  of  the  anatomical  features 
of  pyemia. 

Morbid  Anatomy. — Should  it  be  our  fortune  to  see  this  form  of  pneu- 
monia in  its  first  stage,  the  same  dark-red  color  as  that  seen  in  the  hemor- 
rhagic infarct  of  non-septic  pneumonia  may  be  noted,  except  that  the  blood 
extravasation  is  more  copious.  Such  extravasation  is  a  further  irritant,  and 
soon  an  intense  inflammation  sets  in,  which  may  also  be  divided  into  two 
stages.  In  the  first  stage  the  alveolar  spaces  and  the  connective  tissue  of  the 
alveolar  and  infundibular  w^alls  are  infiltrated  with  pus-cells.  The  latter 
furnish  a  white-gray  ground,  on  which  may  be  seen,  with  the  naked  eye, 
•delicate  red  lines  and  circles,  which  represent  infundibula  whose  vessels  are 
still  pervious  to  blood.  In  the  next  stage  abscess-formation  rapidly  suc- 
-ceeds,  when  the  hepatized  area  melts  into  a  creamy  pus,  in  which  float  a  few 
fragments  of  elastic  tissue  representing  broken-down  alveolar  walls  and 
blood-vessels.  The  abscesses  thus  produced  may  be  multiple,  but  are  mostly 
of  small  size.  If  the  abscess  is  subpleural,  there  will  be  suppurative  pleuritis 
with  empyema,  and  possibly  perforation  of  the  lung. 

In  case  a  very  large  vessel  is  obstructed  and  a  corresponding  part  of 
lung  cut  off,  say  a  fifth  of  a  lobe,  the  area  thus  deprived  of  pulmonary- 
arterial  blood  is  rapidly  filled  from  the  veins,  and  a  condition  analogous  to 
a  hemorrhagic  infarct  occurs,  to  the  border  of  which  the  inflammation  is 
confined,  where  finally  the  necrotic  mass  is  dissected  loose. 

Symptoms. — The  symptoms  are  those  of  pyemia  (see  p.  181),  of  which 
the  lung  abscesses  form  a  part  A  chill  succeeding  a  surgical  operation  of 
occurring:  during  the  lying-in  state,  followed  by  siveatiug  and  high  fever, 
are  significant  symptoms.     Successions  of  these  are  even  more  conclusive. 

Treatment. — Treatment  should  be  supporting  and  stimulating. 
Ouinin  should  be  administered  in  largfe  doses,  and  whisky  as  in  a  low  fever. 
The  physician  should  watch  for  an  opportunity  for  surgical  interference, 
although  such  opportunity  rarely  occurs. 


238  INFECTIOUS  DISEASES. 

TUBERCULOSIS. 
I.  General  Etiology  and  Invasion.     Morbid  Anatomy. 

Definition. — Tuberculosis  is  a  general  or  local  infectious  inflammatory 
disease,  the  result  of  the  implantation  and  proliferation  of  the  tubercle 
bacillus.  The  action  of  the  tubercle  bacillus  is  peculiar  in  that  it  stimulates 
the  cells  of  the  body  wherever  it  may  lodge  and  grow,  to  the  formation  of 
little  masses  of  new  tissue  which  are  called  miliary  tubercles.  A  miliary 
tubercle  may,  therefore,  be  defined  as  a  nodule  of  new  formation  around  an 
irritated  point,  the  focus  of  which  is  the  tubercle  bacillus. 

The  tubercle  bacillus  is  a  short  rod-bacterium  three  to  four  microns  in 
length,  equal  to  about  1-3  the  diameter  of  a  red  blood-disc,  and  1-6  to  1-5 
as  broad  as  it  is  long.  When  successfully  stained  and  viewed  with  high 
power  it  presents  at  times  a  beaded  appearance  once  ascribed  to  the  pres- 
ence of  spores,  but  now,  I  believe,  regarded  as  the  result  of  unequal  stain- 
ing. It  can  be  studied  satisfactorily  only  when  stained  by  one  of  the  anilin 
dyes.* 

Etiology. — Although  the  evidence  in  favor  of  the  bacterial  origin  of 
tuberculosis  may  be  regarded  as  conclusive,  the  readiness  with  which  the 
bacillus  lodges  and  grows  varies  greatly;  indeed,  the  number  of  instances 
in  which  it  fails  to  take  root  doubtless  vastly  exceeds  that  in  which  it  does. 
Hence,  the  contagiousness  of  tuberculosis  is  slight  and,  although  there 
appears  to  be  no  difficulty  in  transmitting  the  disease  from  one  domestic 

*  Of  the  various  methods  of  staining  tubercle  bacilli  that  by  the  carbol  fuchsin  solution  of  Ziehl- 
Neelsen,  with  or  without  Gabbet's  counter-stain  of  methyl  blue,  continues  to  be,  on  the  whole,  the 
most  satisfactory.  By  this  method  the  bacillus  takes  a  bright-red  color  from  the  fuchsin,  the  mor- 
dant being  carbolic  acid. 

The  carbol  fuchsin  solution  is  made  as  follows  : 

Powdered  fuchsin i  part 

Alcohol 10  parts 

•i  per  cent,  solution  carbolic  acid loo  parts 

Mix  and  filter. 

The  older  the  solution  the  better. 
A  rapid  and  a  slow  method  are  practiced  with  this  staining  fluid,  the  former  being  more  commonly- 
used  for  diagnostic  purposes. 

1.  The  Rapid  Method  ivith  Carbol  Fuchsin,  with  or  without  Counter-staift,  by  Methylene  Blue.— 
A  very  small  caseated  clump  of  the  sputum  (care  being  taken  that  a  bit  of  food  is  not  taken  by  mis- 
take) is  selected  with  forceps  or  a  platinum  loop  and  laid  on  a  clean  cover-glass.  Another  cover- 
glass  is  superimposed  and  the  two  are  rubbed  together  until  the  specimen  is  thoroughly  smeared 
over  both.  Thev  are  then  separated,  two  specimens  being  thus  obtained.  When  dry,  one  of  them  is 
passed,  sputum  side  up.  three  times  over  the  flame  of  a  spirit  lamp  or  Bunsen  burner,  by  which  the 
albumin  is  coagulated  and  the  specimen  is  fixed.  The  cover-glass  is  then  completely  covered  with 
the  staining  fluid  and  held  over  the  flame  until  the  solution  begins  to  vaporize,  care  being  taken  to 
keep  all  parts  of  the  glass  thoroughly  covered.  At  the  end  of  one  minute  it  is  washed  in  water.  It 
is  then  decolorized  in  acidulated  alcohol,  8  to  lo  gtt.  of  HClor  sgtt.  of  HNOjtoa  watch  crystal  of  alco- 
hol, and  examined.  For  this  a  1-12  oil  imjnersion  lens  and  Abbe's  condenser  are  best  suited,  but  after 
a  little  experience  an  ordinary  dry  system  of  350  diameters"  amplification,  or  higher,  will  easily  reveal 
the  bacilli,  which  are  stained  a  handsome  red. 

The  preparation  is  more  brilliant  and  its  study  rather  less  trying  to  the  eyes  if  counter-stained 
by  a  Gabbet's  acid  blue,  composed  of — 

Methylene  blue 2  parts 

25  per  cent,  solution  sulphuric  acid 100  jjarts 

After  being  washed  in  water  the  specimen  is  immersed  for  one-half  to  two  minutes  in  the  acid 
blue,  washed  off  in  water,  dried  between  folds  of  filter  paper,  and  examined  in  water. 

2.  Slower  Method  ivith  Carbol  Fuchsin  and  Counter-stain  by  Gabbefs  Acid  Blue.— This  slower 
method  is  always  more  satisfactory,  if  time  permits,  and  should  alone  be  used  for  permanent  prep- 
arations. .    . 

The  steps  are  the  same  until  the  staining  stage  is  reached,  when  the  cover-glasses  containmg  the 
specimen  are  placed  in  the  carbol  fuchsin  solution,  say  at  five  or  six  o'olock  in  the  evening,  and 
allowed  to  remain  until  next  morning.  They  are  then  washed  in  water,  counter-stained  by  Gabbet's 
acid  blue  solution,  washed  in  water,  dried  between  folds  of  filter-paper,  and  studied  in  water  ;  or,  if 
it  is  desired  to  movnt  the  specimen  permanently,  it  is  passed  through  alcohol,  xylol,  or  oil  of  cloves 
into  Canada  balsam.  Specimens  stained  in  anilin  colors  should  not  be  mounted  in  glycerin,  as 
this  gradually  withdraws  the  stain. 

When  bacilli  are  very  few,  in  viscid  sputum,  the  centrifugator  may  be  used,  or  Biedert's  method 
pursued.  Fifteen  c.  c.  of  the  sputum  are  mixed  with  75  to  100  c.  c.  ("about  two  teaspoonfuls)  of  water.  ^ 
to  8  gtt.,  according  to  the  density  of  the  fluid,  of  liquo'r  potassse  are  added,  and  the  whole  boiled.  If 
still  very  viscid,  add  gradually,  while  boiling,  4  to  6  teaspoonfuls  more  of  water,  until  a  thin  fluid 
results.  The  mixture  is  allowed  to  stand  in  a  conical  glass  for  two  days,  when  the  supernatant  fluid 
is  removed  and  the  sediment  is  examined  as  before.  It  is  to  be  remembered  that  bacilli  treated  with 
alkalies  .stain  slowly,  and  longer  immersion  in  the  staining  fluid  may  be  necessary  on  this  account. 


TUBERCULOSIS. 


239 


animal  to  another,  it  is  with  extreme  rarity  that  a  case  of  tuberculosis  in  a 
human  being  can  be  traced  to  another.  In  an  experience  of  thirty-five  years, 
including  large  general  hospital  service,  I  can  recall  but  a  single  instance 
of  probable  communication  of  the  disease,  and  this  was  from  a  husband  to 
the  wife  who  was  his  faithful  nurse  for  years.  It  would  seem,  however, 
that  the  contagium  is  more  active  than  such  experience  would  lead  one  to 
suppose.  Thus,  Cornet  studied  the  records  of  certain  institutions  whose 
inmates  are  devoted  to  nursing,  and  discovered  the  fact  that  a  large  pro- 
portion of  these  (62.8  per  cent,  in  twenty-five  years)  died  of  phthisis;  also 
that  of  100  nurses  63  died  of  this  disease.  It  is  to  be  remembered,  however, 
that  the  life  of  the  Sisters  in  convents  is  unw-holesome  from  too  close  con- 
finement. On  the  other  hand,  the  statistics  of  the  Brompton  Hospital  for 
Consumptives  in  London  is  decidedly  against  any  conclusion  that  contact 
with  patients  peculiarly  endangers  the  lives  of  doctors,  nurses,  or  attend- 
ants. This,  too,  though  they  cover  a  period  when  no  precautions  were 
taken  to  destroy  the  bacillus. 

Flick's  studies  also  point  to  a  greater  activity  of  the  contagium  than 
is  usually  admitted.  He  examined  all  of  the  houses  in  a  ward  in  Phila- 
delphia where  there  had  been  deaths  from  consumption,  and  found  that 
33  per  cent,  of  such  houses  had  more  than  one  case,  that  25  per  cent,  of 
these  houses  had  been  infected  prior  to  1888,  and  that  more  than  33  per 
cent,  of  the  deaths  which  occurred  since  1888  took  place  in  them.  These 
observations  accord  with  the  results  of  Cornet's  experiments,  which  demon- 
strated that  the  scraping  from  the  walls  of  phthisical  wards  inoculated  into 
the  lower  animals  produced  tuberculosis. 

A  truly  remarkable  experience  of  Reich  is  related  by  Eichhorst.*  In 
the  town  of  Neuenburg,  containing  1300  inhabitants,  the  midwifery  cases 
were  about  equally  divided  between  two  midwives.  One  of  these  contracted 
consumption.  She  was  in  the  habit  of  blowing  from  her  mouth  into  the  air 
passages  of  the  new-born  children,  with  a  view  to  clear  away  the  mucus. 
Within  two  years  ten  of  the  children  delivered  by  this  woman  died  of  tuber- 
cular meningitis,  while  of  the  children  delivered  by  the  healthy  midwife  none 
showed  any  sign  of  tuberculosis. 

The  conditions  which  favor  the  growth  and  multiplication  of  bacilli 
have  been  carefully  studied,  but  have  been  only  partially  determined.  One 
of  the  best  recognized  of  these. 

Heredity,  is  much  more  influential  when  both  parents  have  the  disease 
than  when  one  is  affected.  It  seems  to  be  true  that  the  child  resembling  a 
tuberculous  parent  is  more  liable  to  the  disease  than  one  who  resembles  the 
healthy  parent. 

A  second  favoring  condition  is  scrofiihsis.  or  the  "  delicate  constitution." 
The  peculiar  enlargement  of  the  lymphatic  glands,  formerly  known  as 
scrofula,  is  now^  regarded  as  true  tuberculosis  of  those  glands.  There 
remains,  however,  a  condition  called  scrofulosis,  characterized  by  paleness,, 
softness,  and  translucency  of  the  skin  of  its  subject,  in  whom  inflammations 
run  a  slow  course,  and  tend  to  resolve  slowly  and  to  terminate  in  cheesy 
products.  To  this  some,  and  notably  Rindfleisch,  would  still  apply  the 
name  scrofulosis  or  the  tuberculous  di,athesis.  In  these  the  tubercle  bacillus 
finds  a  favorable  soil.  On  the  other  hand,  there  is  a  tradition  that  persons 
affected  with  tuberculosis  of  the  lymphatic  glands  are  less  prone  to  tuber- 
culosis of  the  lungs  than  others. 

*  "  Patliologie  und  Therapie,"  vol.  i.  p.  559. 


240  IXFECTIOUS  DISEASES. 

Defective  and  insufficient  food,  especially  when  associated  with  imperfect 
ventilation,  privation,  grief,  and  overwork,  are  also  conditions  which  favor 
the  growth  of  the  bacillus. 

Frequentlx  recurring  bronchial  catarrh  by  lowering  the  vitality  of  the 
mucous  membrane  engenders  a  soil  favorable  to  the  growth  and  multipli- 
cation of  the  tubercle  bacillus.  Any  of  the  causes  that  produce  such 
catarrh  may  be  included  among  predisposing  factors.  Particles  of  dust  in- 
haled in  the  pursuit  of  various  trades  and  avocations,  as  in  coal-mining, 
5tone-cutting,  and  steel-grinding,  are  well  known  to  have  this  effect. 
^leasles,  whooping-cough,  and  typhoid  fever  with  bronchial  complications 
are  sometimes  followed  by  it. 

Damp  localities  favor  the  development  of  tuberculosis,  and  the  very 
interesting  observations  of  H.  P.  Bowditch,  made  a  number  of  years  ago, 
show  that  in  houses  thus  situated  case  after  case  occurs,  and  whole  families 
have  been  swept  away.  It  is  more  than  likely  these  results  are  dependent 
on  a  vulnerability  engendered  by  the  "  colds  "  and  catarrhs  which  such 
localities  induce. 

No  race  is  exempt,  but  the  colored  race  is  especially  predisposed,  as  is 
also  the  American  Indian  when  brought  under  the  influence  of  civilization. 
Tuberculosis  appears  to  be  spreading  among  the  Indians,  even  in  districts 
■  in  the  Rocky  ]\Iountains  where  the  disease  is  rare  among  the  whites.  It 
has  been  said  that  tuberculosis  aft'ects  in  the  shape  of  the  mild  or  severe 
form  of  pulmonary  tuberculosis  one-half  of  the  whole  human  race,  that  it 
causes  the  death  of  one-seventh  of  all  persons  w^ho  pass  away,  killing  one- 
third  of  those  who  perish  between  the  ages  of  fifteen  and  forty-five.  The 
Irish  race  in  this  country  is  also  susceptible  and  many  die  of  it.  On  the 
other  hand,  the  Russian-Polish  Jews  are  remarkably  exempt,  and  next  to 
them  are  the  native  American  whites.  I  am  indebted  to  W.  A.  King,  Chief 
Statistician  of  the  United  States  Census  Bureau,  for  the  following  advance 
figures  as  to  the  nationality  of  victims  of  this  disease : 

Six  3-ears  Calendar 

1884-1891  year    iqoo. 

Total 3q8.8  259.6 

White, 385.1  250.6 

Colored, 774-2  654.1 

White  persons  having  mothers  born  in: 

United  States, 205.1  151. 8 

Ireland, 645.7  526.1 

Germany,      .........  328.8  214.2 

Russia  and  Poland,      .         .  -     .         .         .         .         .  g8.2  88.5 

Over  6000  die  annually  from  tuberculosis  in  Pennsylvania  alone ;  while 
in  the  United  Kingdom  of  Great  Britain  and  Ireland  60.000  die  annually 
from  tuberculosis,  and  it  is  probable  that  at  least  three  times  this  number 
are  suft"ering  from  one  form  or  another  of  the  disease. 

Climates  characterized  especially  by  frequent  rapid  changes  of  tem- 
perature favor  the  development  of  tuberculosis.  Such  are  the  temperate 
zones.  Tuberculosis  is  less  common  in  the  frigid  and  torrid  zones,  but 
these  climates  are  not  exempt. 

Age  is  doubtless  a  predisposing  cause,  the  susceptible  period  for  pul- 
monary tuberculosis  being  between  twenty  and  thirty-five;  for  meningeal 
tiiberculosis,  between  two  and  seven;  while  the  lymphatic  glands,  includ- 
ing the  mesenteric  and  bronchial,  are  prone  to  involvement  in  the  first  ten 
vears  of  life.     The  mesenteric  glands  are  more  commonlv  infected  during; 


TUBERCULOSIS.  241 

the  first  five  years  of  life,  including  the  nursing  period  and  that  during  which 
the  child  is  nourished  on  milk. 

The  shape  of  the  chest  has  long  been  regarded  as  influencing  the  de- 
velopment of  tuberculosis,  and  a  form  of  body  peculiar  to  phthisical  sub- 
jects was  described  by  Hippocrates  (B.  C.  460-357)  ;  Galen  (A.  D.  130- 
200)  described  the  same  type  of  chest.  At  the  present  day  two  varieties 
of  chests  are  described  as  phthisical,  the  alar  and  the  Hat.  The  former  is 
narrow,  shallow,  and  long,  the  angles  of  the  scapulae  projecting  like  wings 
behind,  the  proper  ratio  between  the  antero-posterior  and  transverse  diame- 
ters-being, however,  preserved.  The  ribs  droop  or  are  unduly  oblique.  The 
throat  is  prominent,  the  neck  long,  and  the  head  bent  forward.  In  the  flat 
chest  the  antero-posterior  diameter  is  disproportionately  short,  owing  to  the 
absence  of  convexity  in  the  cartilages,  which  are  sometimes  even  depressed, 
carrying  with  them  the  sternum  and  producing  a  form  of  chest  which,  on 
■section,  is  kidney-shaped.  In  this  form  there  is  not  the  increased  obliquity 
•of  the  ribs  characteristic  of  the  alar  chest. 

Traumatism  is  also  an  agency  of  acknowledged  importance  in  favoring 
the  lodgment  of  the  tubercle  bacillus.  This  is  more  particularly  seen  in  the 
development  of  tuberculosis  of  the  joints  succeeding  injury.  It  is  true, 
also,  that  contusion  of  the  chest,  without  apparent  laceration  of  the  lungs  or 
fracture  of  a  rib,  has  been  followed  by  tuberculosis. 

Mode  of  Invasion  and  Spread. — The  bacillus  of  tuberculosis  is 
probably  omnipresent  in  the  atmosphere,  being  derived  from  the  drying  and 
pulverization  of  expectorated  sputum.  The  entrance  into  the  body  in  the 
-vast  majority  of  instances  is  by  the  respiratory  tract.  Hence  the  great  fre- 
quency of  tuberculosis  in  the  lungs  and  bronchial  glands,  which  are  the  first 
tissues  open  to  its  approach.  It  is  possible,  however,  for  it  to  enter  by  the 
skin,  causing  lupus  or  skin  tuberculosis.  It  enters  more  readily  by  open 
wounds.  Through  the  alimentary  canal  we  have  an  undoubted  route  of  in- 
fection. This  happens  most  frequently  in  children  from  the  use  of  the  milk 
of  tuberculous  cows  * ;  in  adults,  from  the  swallowing  of  sputum.  It  is  not 
necessary  that  the  cow  should  have  tuberculosis  of  the  udder  to  render  her 
milk  tuberculous.  This  has  been  conclusively  shown  by  Bollinger  and  con- 
firmed by  Hirschberger  and  Harold  Ernst.  The  boiling  of  milk  destroys 
its  infective  qualities.  Tuberculous  meat  is  less  frequently  the  cause  of 
tuberculous  infection  by  the  intestine  because  it  is  almost  invariably  cooked 
iDefore  eating,  and  also  because  striated  muscular  tissue  is  an  infrequent  seat 
■of  tuberculous  lesions. 

The  tubercle  bacillus  having  once  invaded  an  organ  produces  localized 
tuberculosis,  which  may  or  may  not  become  generalized  in  a  manner  to  be 
presently  described.  More  rarely,  tuberculosis  may  become  general  from 
the  onset  without  any  local  initial  lesion  being  discoverable.  This  consti- 
tutes one  of  the  varieties  of  acute  tuberculosis.  Once  established,  tubercu- 
losis spreads  by  contiguity  and  through  the  lymphatic  system  and  blood. 
In  the  former  the  tubercle  grows  by  the  addition  of  miliary  tubercles  at  its 
periphery.  Through  the  lymphatic  system  tuberculosis  spreads  to  the 
lymphatic  glands,  and  thence  to  the  adjacent  serous  membranes.  The  bar- 
rier of  the  lymphatic  glands  once  passed,  the  blood  becomes  the  medium 
of  a  general  infection.     In  the  vast  majority  of  cases  generalization  takes 

*  At  the  meeting  of  the  Association  of  American  Physicians.  Washington,  May,  1806,  Theobald 
"Smith,  in  a  noteworthy  paper  on  "Two  Varieties  of  Tubercle  Bacilli  from  Mammals,"  said  he 
thought  infection  of  the  human  subiect  through  the  milk  of  cattle  decidedly  questionable,  and  that 
the  subject  should  be  reinvestigated. 

16 


242  IXFECTIOUS  DISEASES. 

place  from  a  focus  of  tubercle  somewhere  in  the  system,  as  the  lungs,  or  a 
tubercular  lymphatic  gland,  from  which  the  bacilli  start  their  migration. 

The  favorite  seats  of  tuberculosis  are  the  lymphatic  glands,  lungs,  liver, 
kidney,  spleen,  intestinal  canal,  urogenital  mucous  membranes,  the  brain 
(especially  its  membranes  and  blood-vessels),  the  bones  and  joints.  In 
fact,  no  tissue  or  organ  is  exempt,  the  salivary  glands  and  pancreas  being 
least  frequently  invaded. 

Anatomy  and  Histology  of  Tubercle. — The  miliary  tubercle  is  the 
beginning  of  all  tubercular  deposits.  It  is  itself  a  compound  body  com- 
posed of  smaller  submiliary  tubercles,  of  which  from  lo  to  50  unite  to  form 
a  miliarv  tubercle.  It  is  about  the  size  of  a  millet  seed,  hence  the  name 
miliarv.  By  actual  measurement  it  ranges  from  i  to  5  millimeters  (1-25  to 
1-5  inch)  in  diameter.  In  its  young  state  it  is  a  translucent  gray  granula- 
tion, especially  characterized  by  its  want  of  vascularity.  The  typical  submili- 
ary tubercle  is  about  0.4  millimeter  (1-60  inch)  in  diameter,  and  contains  a 
giant  cell  in  its  center,  surrounded  by  a  close  infiltration  of  lymphoid  cells 
or  a  higher  tissue  of  the  lymphadenoid  connective-tissue  type,  in  the  meshes 
of  which  are  lodged  loose  lymph  corpuscles  or  larger  epithelioid  cells.  The 
giant  cell  may  be  wanting,  and  the  whole  tubercle  may  be  a  mass  of  lymphoid 
cells,  among  which  the  tubercle-bacilli  are  scattered,  or  the  bacilli  may  be 
found  in  the  giant  cells,  in  the  epithelioid  cells,  or  even  in  the  lymph  cells. 
When  isolated  the  miliary  tubercle  is  found  surrounded  by  a  dense  con- 
nective-tissue network,  welding  it  firmly  to  the  other  tissues  in  which  it 
is  imbedded.  The  miliary  tubercle  is  further  characterized  by  its  want  of 
vascularity.  In  thin  sections  of  an  injected  preparation  it  will  be  found  that 
the  blood-vessels  go  up  to  the  tubercle  and  there  terminate  abruptly.  Ta 
this  lack  of  vascularity  the  tubercle  owes  its  tendency  to  cheesy  degeneration, 
in  the  course  of  which  it  assumes  an  opaque  white  color.  When  this  hap- 
pens, the  center  exhibits  under  the  microscope  a  granular,  ground-glass 
appearance,  while  macroscopically  tubercle  in  mass  assumes  a  yellow  color. 

In  certain  situations,  especially  in  the  lungs,  the  miliary  tubercle  forms 
larger  foci,  which  gradually  increase  in  size  and  constitute  tubercular  infil- 
tration, the  yellow  or  crude  tubercle  of  Laennec  (1819?)  and  Louis  as 
contrasted  with  the  miliary  or  gray  tubercle.  According  to  these  and  other 
observers  during  the  first  thirty  or  forty  years  of  the  present  century,  gray 
and  yellow  tubercles  were  simply  differing  forms  of  tubercle.  Later,  how- 
ever, the  influence  of  Mrchow,  Buhl,  and  Niemeyer  (1857-70)  caused  it  to 
be  quite  generally  accepted  that  the  only  tubercle  was  the  gray  granulation 
or  miliary  tubercle,  while  yello\v  or  crude  tubercle  was  nothing  but  cheesy 
inflammatory  matter.  The  subjects  of  this  were  still  regarded  as  having 
phthisis,  but  not  tuberculosis,  whence  the  celebrated  declaration  of  Niemeyer 
(1866),  "The  greatest  danger  to  most  phthisical  patients  is  the  develop- 
ment of  the  tubercle."  * 

Even  before  the  discovery  of  the  bacillus  by  Koch,  in  1882 — a  discovery 
that  resulted  in  the  re-establishment  of  the  unity  of  phthisis — the  view 
began  to  gain  ground,  especially  through  the  teachings  of  Buhl  and  Rind- 
fle.isch,  that  cheesy  matter  may  be  metamorphosed  true  tubercle,  or  it  may 
have  been  primarily  scrofulous  inflammatory  deposit,  either  of  which  might 
produce  tubercle  by  an  auto-inoculation.  In  the  meantime,  in  1865, 
Villemin  announced  the  inoculability  of  tubercle.  The  discovery  of  the 
bacillus    by  Koch,  in    1882,  completed    the    overthrow   of    the  duality  of 

*  Niemeyer's  "Lectures  on  Phthisis,"  New  Sydenham  Society's  Translation,  1870,  p.  11. 


TUBERCULOSIS.  243 

phthisis,    the    final    result    of    which    was    the    proposition,    now    generally 
admitted,  that  all  phthisis  is  tubercular. 

The  histogenesis  of  tubercle  is  in  no  way  peculiar.  We  have  only  to 
remember  that  the  bacillus  is  an  irritant.  The  same  response  occurs  to  it 
as  to  other  irritants.  The  wandering  leukocytes  flow  from  the  adjacent 
vessels  and  form  the  lymphoid  cells  that  constitute  the  bulk  of  the  tubercle. 
The  stabile  cells  of  the  connective  tissue,  the  endothelial  and  perithelial 
cells  of  the  blood-  and  lymph-vessels,  the  epithelium  of  the  serous  mem- 
branes, proliferate  and  enlarge,  forming  the  epithelioid  cells,  and,  in  some 
instances,  the  giant  cells,  in  both  of  which  bacilli  may  be  imbedded.  The 
bacilli  seem,  however,  to  vary  inversely  with  the  giant  cells.  Thus,  in  lupus, 
joint  and  lymphatic  gland  tuberculosis,  giant  cells  are  numerous  and  bacilli 
scanty,  while  in  lung  tuberculosis  bacilli  are  numerous  and  giant-cells 
scanty. 

The  reticulum  of  connective  tissue,  usually  more  or  less  present  at  the 
periphery  of  the  miliary  nodule,  is  formed  just  as  is  connective  tissue  in 
ordinary  non-specific  inflammation,  by  the  fibrillation  of  the  protoplasm  of 
cells  and  the  rarefaction  of  the  resulting  matrix. 

The  origin  of  giant  cells  has  been  much  discussed,  but  it  seems  likely 
that  any  one  of  the  connective-tissue  cells  named  is  capable  of  developing 
into  a  giant  cell.  It  may  also  perhaps  arise  from  the  fusion  of  individual 
cells.  It  contains  from  4  to  20  nuclei,  commonly  arranged  in  the  periphery 
of  the  cell. 

Another  form  in  which  the  tubercle  presents  itself  is  the  solitary 
tubercle,  which  is  not  made  up  of  united  miliary  nodules,  but  consists  of  a 
single  large,  cheesy  mass  varying  in  size  from  that  of  a  pea  to  that  of  a 
human  fist.  It  is  almost  invariably  secondary  to  primary  tuberculosis  some- 
where else,  commonly  in  the  lungs.  It  is  made  up  chiefly  of  round  cells, 
in  which  are  found  also  tubercle  ba.cilli.  In  the  peripheral  layers  a  tissue 
of  more  fibrous  structure  prevails,  which  in  certain  tubercles  becomes  so 
abundant  as  to  give  rise  to  the  term  "  fibrous  tubercle."  In  addition  to 
caseation  the  solitary  tubercle  is  subject  to  puriform  liquefaction,  forming 
the  so-called  tuberculous  abscess,  and  also  to  calcification.  The  two  proc- 
esses last  named  may  be  associated  in  a  single  solitary  tubercle.  Some- 
times it  is  encysted.  An  especially  favorite  seat  for  solitary  tubercle  is  the 
brain  in  children,  especially  the  cerebellum  at  the  border  between  the  white 
and  gray  substance.  The  nodules  are  sometimes  multiple.  It  is  found  also 
in  the  spinal  cord,  the  spleen,  the  liver,  and  the  heart. 

Degeneration  of  Tubercle. — Tubercle  is  subject  to  changes,  of  which 
the  most  frequent  and  characteristic  is  caseation.  It  is  a  regressive  change, 
whereby  the  primarily  transparent  tubercular  tissue  is  converted  into  an 
opaque  yellowish  substance  of  various  degrees  of  consistency,  resembling 
certain  varieties  of  cheese,  whence  the  name.  The  process  is  a  form  of 
coagulation  necrosis,  beginning  in  the  center  of  the  tubercle.  The  cells 
lose  their  outline,  their  nuclei  are  no  longer  demonstrable  by  ordinary  stain- 
ing methods,  and  a  confused  granular  mass  results.  Bacilli  are,  however, 
present.  At  times,  on  section,  a  quasi  fibrillation  appears  in  the  caseated 
tubercle  that  is  not  to  be  mistaken  for  a  true  fibrous  matrix.  It  may  be  the 
result  of  compression.  Caseation  is  nol  limited  to  tubercle.  Cellular  inflam- 
matory products  and  even  cancer-cell  masses  may  undergo  the  cheesy  change. 

Most  frequently  caseation  is  followed  by  softening.  The  precise  condi- 
tions necessary  for  this  are  not  known,  though  commonly,  as   soon  as  a 


244  INFECTIOUS  DISEASES. 

caseated  mass  reaches  a  certain  size,  it  breaks  down  into  a  pyoid  product 
which  is  not  histologically  pus,  but  consists  of  a  number  of  fat  drops,  gran- 
ular debris,  and  shriveled,  formless  cells.  In  the  broken-down  material  the 
tubercle  bacilli  are  exceedingly  numerous,  much  more  so  than  in  the  dry 
caseated  tubercle.  From  this  circumstance  it  is  held  by  some  that  the 
caseation  and  subsequent  softening  are  the  effect  of  the  bacilli,  the  action 
of  which  is  compared  to  that  of  bacteria  of  decomposition.  It  seems  much 
more  reasonable  to  ascribe  these  degenerative  changes  to  defective  nourish- 
ment of  the  new  formation.  This  view  is  sustained  by  the  fact  that  softening 
does  not  take  place  until  the  tubercular  mass  acquires  a  certain  size,  com- 
monly a  half  to  one  centimeter  (0.2  to  0.4  inchj  in  diameter.  The  more 
rapid  the  formation  the  earlier  does  softening  set  in. 

iMore  rarely  caseated  tubercle  becomes  infiltrated  with  lime  sahs  and 
undergoes  cdikareous  change,  by  which  a  sort  of  healing  is  accomplished. 
The  calcareous  infiltration  of  tubercle  is  more  especially  prone  to  occur  in 
lymphatic  glands,  but  also  happens  rarely  in  the  lungs. 

Finally,  a  tubercle — and  especially  the  miliary  tubercle — may  undergo 
a  Hhroid  change,  or  sclerosis.  Under  these  circumstances  the  new  formation 
is  converted  into  fibroid  tissue.  A  certain  more  limited  degree  of  cheesy 
metamorphosis  takes  place  at  the  same  time,  but  the  product  is  a  firm,  tough 
nodule.  This  fibroid  change  is  more  prone  to  occur  in  tuberculosis  of  the 
peritoneum. 

Secondary  Inflammatory  Processes. — So  much  for  the  change  in 
tubercle  itself.  It  is,  however,  capable  of  exciting  retroactive  inilammation 
in  its  own  neighborhood.  Thus,  in  the  lungs  a  catarrhal  pneumonia  invol- 
ing  adjacent  acini  is  often  produced.  In  other  instances  an  overgrowth 
of  interstitial  tissue  ensues.  Sometimes  it  is  excessive  and  results  in  the 
so-called  fibroid  phthisis.  ]More  frequently  this  form  of  consumption  is  the 
result  of  a  coincident  irritation  by  another  cause,  such  as  the  irritant  parti- 
cles encountered  in  such  occupations  as  steel-grinding,  stone-cutting,  and 
mining.  Associated  with  tubercular  processes,  especially  in  the  lungs,  is 
constantly  found  true  suppuration,  the  result  of  mixed  infection — whence 
the  admixture  of  pus  in  the  expectoration  of  pulmonary  consumption.  It  is 
held  by  some,  and  apparently  by  Koch  himself,  that  the  tubercle  bacillus  is 
also  capable  of  exciting  suppuration  in  the  absence  of  other  pus-producing 
organisms. 

II.  Acute  Tuberculosis. 
Synoxyms. — Diffuse  General  Tuberculosis ;  Acute  Miliary  Tuberculosis. 

Definition. — The  simultaneous  comparatively  sudden  development  of 
miliary  tubercles  in  different  parts  of  the  body  as  the  result  of  an  irruption 
of  bacilH  into  the  blood  or  lymph  channels.  It  is  the  most  emphatic  expres- 
sion of  the  infectious  nature  of  tuberculosis.  The  infection  is  in  almost  ever}' 
instance  an  auto-inoculation,  of  which  the  source  is  a  nodule  of  softening 
tubercle  in  some  part  of  the  body. 

In  300  cases  of  miliary  tuberculosis  examined  by  Buhl  such  a  source 
was  found  in  all  but  ten,  while  Simmonds  in  100  cases  found  the  caseating 
focus  in  everv  instance.  The  most  common  seat  of  such  a  nodule  is  the 
lungs,  next  a  tubercular  lymphatic  gland,  especially  a  tracheo-bronchial 
gland.  After  this  there  is  less  constancy,  but  tubercular  joints,  a  tubercular 
pleurisv,  tubercular  peritonitis,  and  even  a  skin  tuberculosis  may  be  held 


TUBERCULOSIS. 


245 


responsible.  Such  a  nodule  may  break  directly  into  a  vein,  furnishing  an 
instance  of  true  embolic  infection. 

Acute  tuberculosis  occurs  most  frequently  in  young  persons  between 
twelve  and  twenty  years  of  age,  but  adults  are  not  exempt.  Any  tissue  or 
organ  may  be  involved,  but  very  seldom  do  we  find  all  the  organs  of  the 
body  affected,  though  it  is  quite  common  to  find  lesions  in  more  than  two, 
as,  for  example,  the  lungs,  the  pleura,  the  membranes  of  the  brain,  and  the 
peritoneum.     The  first  three  are  favorite  locations. 

Clinical  Varieties. — Three  principal  clinical  forms  of  acute  tubercu- 
losis are  recognized,  one  presenting  signs  of  acute  general  infection  without 
special  localization,  another  exhibiting,  in  addition,  easily  recognizable  pul- 
monary symptoms,  and  the  third,  cerebral  and  spinal  symptoms. 

I,    GENERAL  OR  TYPHOID  FORM   OF  ACUTE   MILIARY  TUBERCULOSIS. 

Morbid  Anatomy. — This  is  the  anatomy  of  tuberculosis  in  the  dififer- 
ent  organs  and  tissues  of  the  body,  and  so  far  as  not  already  described  will 
be  given  when  treating  of  the  disease  in  these  organs. 

Symptoms. — The  general  or  typhoid  form  of  acute  tuberculosis  has 
long  been  recognized  as  resembling  in  a  startlingly  close  manner  the  symp- 
toms of  typhoid  fever,  and  many  mistakes  have  been  made  in  diagnosis 
because  of  this  resemblance.  Since  the  use  of  the  clinical  thermometer  in 
diagnosis,  however,  such  mistakes  have  been  less  frequent. 

As  in  typhoid  fever,  a  prodrome  of  several  days,  and  even  weeks,  of 
ill-defined  sickness  often  precedes  the  taking  to  bed.  Fever,  with  its  height- 
ened temperature  and  frequent  pulse,  is  present,  as  are  also  the  dry  tongue, 
hebetude,  and  delirium  of  typhoid.  Yet  fever  is  not  always  present,  and 
afebrile  cases  are  reported  by  Reinhold  and  Eichhorst.  If  differences  are 
sought  in  the  fever  of  the  two  diseases,  it  will  be  found  that  the  pulse  and 
respiration  may  be  unduly  frequent  as  compared  with  typhoid  fever,  but 
above  all,  the  temperature  will  be  found  to  differ  in  its  course  from  that  of 
typhoid  fever.  There  is  an  absence  of  the  characteristic  "  tidal  wave  "  rise 
of  temperature  of  typhoid.  There  is  an  evening  rise  and  a  morning  fall ;  and 
an  occasional  inversion,  with  lower  evening  and  higher  morning  tempera- 
ture, takes  place,  which  is  held  to  be  characteristic.  The  range  is  between 
101°  and  103°  F.  (38.3°  and  39.4°  C),  but  may  reach  104°  or  105°  F. 
(40°  or  40.5°  C).    The  countenance  is  apt  to  be  more  dusky  than  in  typhoid. 

Excessive  sweating  is  a  symptom  more  characteristic  of  acute  tuber- 
culosis than  of  typhoid  fever,  and  may  result  in  sudamina,  which  also  char- 
acterize the  latter  disease.  Herpes  is,  however,  often  present,  while  it  is 
almost  a  negatively  pathognomonic  sign  of  typhoid.  These  two  symptoms 
— /.  e.,  sweating  and  herpes,  together  with  the  intermitting  fever — con- 
stitute a  resemblance  to  malarial  fever.  Waller  and  Eichhorst  have  found 
rose-colored  spots  on  the  abdomen  and  breast,  but  they  are  certainly  infre- 
quent, and  they  do  not  occur  in  crops  as  in  typhoid  fever.  Enlargement  of 
the  spleen  is  often  present  and  even  hemorrhage  from  the  hoivels  has  been 
noted.  Small  alhnminuria  is  a  frequent  symptom,  not  due,  as  might  be 
expected,  to  a  tubercular  involvement  of  the  kidney,  but  to  the  fever  process. 

Repeated  examinations  of  the  lisings  fail  to  discover  physical  signs 
indicating  disease  of  these  organs,  and  thus  the  conclusion  that  there  is  no 
lung  involvement  is  apparently  confirmed.  Later,  however,  pulmonary  S3^mp- 
toms  may  set  in,  also  meningeal  symptoms,  the  duration  of  which  may  lead 
to  a  suspicion  that  the  disease  is  not  typhoid  fever. 


246  INFECTIOUS  DISEASES. 

In  view  of  the  general  possibilities  of  acute  miliary  tuberculosis,  there 
may  be  pleural  or  pericardial  friction  and  other  symptoms  of  pericarditis  and 
pleurisy,  as  well  as  those  of  peritonitis  and  meningitis. 

Tuberculosis  of  the  choroid  coat  of  the  eye  has  been  frequently  met  in 
acute  miliary  tuberculosis,  more  particularly  in  cases  where  there  has  been 
the  widest  dissemination. 

Notwithstanding  the  difficulties  that  attend  the  investigation,  the 
instances  in  which  tubercle  bacilli  have  been  found  in  the  blood  have 
been  so  numerous  that  in  doubtful  cases  it  should  be  examined.  Rutimeyer 
suggests  that  the  blood  be  taken  for  this  purpose  from  the  spleen  by 
means  of  a  hypodermic  syringe,  since  it  has  been  shown  that  the  blood 
of  this  organ  may  be  especially  rich  in  bacilli.  On  the  other  hand,  bacilli 
are  rarelv  found  in  the  sputum  in  acute  general  tuberculosis,  even  if  there 
be  involvement  of  the  lungs,  because  in  this  form  of  tuberculosis  the  tubercles 
are  situated  not  in  the  open  air-passages  so  much  as  in  the  interstitial  tissue 
of  the  lung  and  in  the  blood-vessel  walls. 

Diagnosis. — As  stated,  acute  miliary  tuberculosis  resembles  especially 
typhoid  fever,  but  a  carefully  kept  temperature  chart  will  soon  exhibit  a  dif- 
ference in  the  two  diseases  from  this  point  of  view.  If  bacilli  are  found  in 
the  blood  and  tubercles  on  the  choroid  the  question  is  settled  at  once.  The 
duration  of  the  disease,  though  short,  is  usually  longer  than  that  of  typhoid 
fever,  and  before  the  clinical  thermometer  gave  us  its  valuable  information 
the  first  suggestion  that  something  else  than  typhoid  fever  was  present  came 
about  from  noting  an  absence  of  the  usual  defervescence.  The  Widal  reac- 
tion in  typhoid  fever  and  its  absence  in  tuberculosis  are  valuable  aids  in  the 
diagnosis. 

It  is  well  known  that  typhoid  fever  is  characterized  by  a  negative  leuko- 
cytosis, that  is,  a  diminution  rather  than  an  increase  of  leukocytes  in  the 
blood.  Precise  systematic  studies  of  the  blood  in  the  typhoid  form  of  acute 
miliary  tuberculosis  are  wanting,  but  from  such  observations  as  have  been 
made,  it  appears  reasonable  that  in  true,  uncomplicated  miliary  tuberculosis, 
there  is  also  wanting  an  increase  in  the  colorless  corpuscles  of  the  blood  over 
the  normal.  So  soon,  however,  as  there  becomes  associated  with  the  tubercu- 
losis any  catarrhal  or  suppurative  condition  of  the  parts  involved,  a  leuko- 
cytosis presents  itself.  It  cannot,  however,  be  said  that  leukocytosis  is  char- 
acteristic of  true,  miliary  tuberculosis  as  contrasted  wdth  a  diminished  num- 
ber of  leukocytes  characteristic  of  typhoid  fever. 

The  resemblance  to  intermittent  fever  has  been  noted.  Here,  too,  a 
close  study  of  the  temperature  will  soon  show  the  difference,  while  a  search 
for  the  hematozoon  of  malaria  should  be  made.  The  failure  of  quinin  to 
cure  will  settle  the  question  against  a  malarial  cause  for  the  fever. 

Prognosis. — The  course  is  invariably  toward  an  unfavorable  issue. 
Scarely  ever  less  than  four  weeks  in  duration,  it  is  often  eight  and  even 
longer,  although  cases  are  reported  to  have  terminated  at  the  end  of  two 
weeks  and  even  twelve  days.  Such  must,  however,  be  extremely  rare.  The 
relative  shortness  of  duration,  nevertheless,  constitutes  it  one  of  the  forms 
of  galloping  consumption.  Acute  miliary  tuberculosis  always  terminates 
fatally  sooner  or  later,  although  delusive  improvements  often  raise  hopes  that 
are  not  realized. 

Treatment. — Treatment  for  acute  tuberculosis  can  only  be  symptomatic. 
To  our  present  knowledge  a  cure  has  never  been  accomplished.  Antipyretics 
may  be  used  in  moderate  doses ;  three  to  five  grains  of  antipyrin,  antifebrin, 


TUBERCULOSIS. 


247 


or  phenacetin,  the  last  probably  the  best,  frequently  repeated,  abate  the  fever. 
Anodynes  to  quiet  cough  are  also  necessary.  Supporting  food  and  stimu- 
lants are  indicated. 

2.    PULMONARY    FORM    OF    ACUTE   TUBERCULOSIS. 

(a)  Miliary     Tuberculosis    Succeeding     on    Chronic    Bronchitis,     Chronic 
Tuberculosis,  Whooping-Cough,  Measles,  etc. 

'  Symptoms. — This  form  succeeds  in  adults  on  chronic  tuberculosis  of  the 
lung,  on  prolonged  bronchitis,  on  whooping-cough  or  on  measles  in  children. 
An  irruption  of  miliary  tuberculosis  the  result  of  infection  takes  place 
throughout  the  lung  with  or  without  bronchopneumonia.  The  tubercles  may 
be  scattered  throughout  the  lung,  distributed  by  the  blood,  and  may  be  found 
in  the  walls  of  the  vessels,  or  radially  arranged  around  the  primary  focus.  It 
is  this  event  which  gave  rise  to  Xiemeyer's  dictum,  "  The  greatest  danger  to 
most  phthisical  patients  is  the  development  of  the  tubercle."  To  the  pre- 
vious cough  and  physical  signs  are  added  higher  fever,  increased 
cough,  and  extreme  dyspnea  associated  with  marked  cyanosis.  The  last 
symptom  is  very  striking.  The  physical  signs  may  not  be  altered ;  there  may 
be  sonorous  and  sibilant' rales  or  there  may  be  signs  indicating  deeper  involve- 
ment of  the  lung,  including  small  areas  of  impaired  resonance,  crepitant  rales, 
and  bronchial  or  bronchovesicular  breathing  (bronchopneumonic  foci).  On 
this  account  there  may  be  rusty  expectoration,  rarely  hemoptysis.  The  dull 
areas  may  alternate  with  areas  of  hyperresonance — hyperresonance  due  to  re- 
laxation (the  Skodaic  type) — or  it  may  be  due  to  localized  emphysema.  On 
the  front  of  the  chest,  especially  in  some  cases  of  miliary  tuberculosis  of  the 
lungs,  there  may  be  unusual  resonance.  As  the  disease  progresses  moist  rales 
become  general  all  over  the  chest.  Again  there  may  be  friction  crepitation 
due  to  tubercular  pleurisy. 

Diagnosis. — The  diagnosis  is  made  by  recalling  the  symptoms  detailed. 
Choroidal  tubercle  should  be  looked  for.  Especially  important  are  the  dis- 
proportionate dyspnea  and  cyanosis  associated  with  the  signs  of  diffuse 
bronchitis.     Leukocytosis  is  here  present. 

Prognosis  and  Treatment. — The  disease  is  often  rapidly  fatal  and  treat- 
ment is  of  little  avail  toward  cure.  It  must  consist  in  efforts  to  make  the 
patient  comfortable,  but  as  the  diagnosis  can  perhaps  never  be  made  with 
absolute  certainty  the  treatment  to  be  detailed  later  for  the  cure  of  chronic 
tuberculosis  should  be  carried  out. 

{b)   Pneumonic  Phthisis — Bronchopneumonic  Phthisis. 

This  more  unusual  form  of  tubercular  phthisis  constitutes  one  variety 
of  "galloping  consumption,"  or  phthisis  Horida.  In  it  the  tubercular  infil- 
tration is  by  a  rapid  peripheral  invasion  inciting  to  active  inflammation. 
This  is  manifested  as  a  bronchopneumonia,  by  which  the  air-vesicles  and 
bronchioles  are  variously  blocked  with  cheesy  matter.  The  result  is  the  dis- 
semination through  extensive  areas  qf  lung  tissue  of  opaque,  white  foci  one- 
fifth  to  one-half  inch  (5  to  12  mm.)  in  diameter.  These  areas  are  usually 
separated  by  others  of  a  more  or  less  congested  but  still  crepitating  tissue, 
contrasting  strongly  with  the  white  of  the  tubercular  bronchopneumonic  foci. 
These  tend  to  soften  with  var>"ing  rapidity,  resulting  sometimes  in  numerous 


248  INFECTIOUS  DISEASES. 

little  abscess  cavities  throughout  the  lung.  At  other  times  the  broncho- 
pneumonic  foci  are  more  widely  separated  or  may  be  limited  to  the  apices, 
in  more  rare  instances  the  condition  may  succeed  on  croupous  pneumonia, 
forming  continuous  areas  which  may  also  extend  throughout  a  lobe  or  entire 
lung.  The  process  is  truly  pneumonic ;  the  results  resemble,  indeed,  more  a 
lung  in  the  second  stage  of  croupous  pneumonia.  As  in  it,  too,  the  lung  is 
heavy  and  airless,  sinking  rapidly  in  water.  There  is,  however,  a  greater 
tendency  to  disintegration  than  in  croupous  pneumonia,  and  cavities  form 
rapidly  in  the  apices  and  elsewhere. 

There  may  also  be  enlargement  of  the  bronchial  glands  in  either  of  these 
forms,  but  more  particularly  in  the  first — the  rapid  peripheral  extension. 

Symptoms. — The  broncho  pneumonic  form  of  consumption  occurs  most 
frequently  in  children  as  a  sequel  to  measles  or  whooping-cough.  In  such 
seemingly  ordinary  cases  of  bronchitis,  with  fever,  obstinate  cough,  and 
shortness  of  breath,  physical  examination  will  reveal  submucous  and  sub- 
crepitant  rales  throughout  the  chest  with  or  without  limited  areas  of  con- 
solidation. Tubercle  bacilli  and  elastic  tissue  appear  in  the  sputum.  The 
fever  continues  and  may  become  hectic,  with  sweats.  The  child  emaciates 
rapidly,  and  death  ensues  in  from  three  to  eight  weeks.  Other  cases  originate 
more  suddenly  and  with  less  apparent  cause  as  cases  of  simple  bronchial 
catarrh,  which  assume  the  graver  picture  described.  Such  children  may 
inherit  a  predisposition  to  phthisis. 

In  adults  the  attack  begins  as  an  ordinary  cold  in  a  person  with  a  pre- 
disposition to  tuberculosis,  though  apparently  healthy  or  run  down  with  over- 
work. The  cough  is  harassing,  and  soon  becomes  loose,  expectoration  muco- 
purulent. There  are  high  fever  and  rapid  ivasting,  and  hemorrhage  may  set^ 
in  to  the  surprise  of  everyone  concerned.  Then  there  may  be  a  lull  in  the 
storm,  but  for  a  short  time  only.  The  symptoms,  and  especially  the  burning 
fever,  wear  out  the  patient.  Bacilli  and  elastic  tissue  will  now  be  found  in  the 
sputum  and  the  diagnosis  is  settled.  The  patient  may  perish  in  three  weeks. 
On  the  other  hand,  a  reactive  effort  toward  improvement  may  take  place  and 
after  a  time  be  followed  again  by  decline  and  perhaps  again  by  improvement, 
with  the  effect  of  prolonging  the  disease,  but  not  of  altering  the  termination. 
The  physical  signs  are  the  same  as  in  children,  submucous  and  subcrepitant 
rales  throughout  the  chest  with  or  without  limited  areas  of  consolidation. 

The  pure  pneumonic  form  succeeding  what  seemed  to  be  croupous  pneu- 
monia is  more  an  affection  of  adults.  More  rare,  still,  than  the  bronchopneu- 
monic  form,  it  may  be  also  rapid  in  its  course.  It  begins  with  a  chill  fol- 
lowed by  fever,  often  after  exposure  to  cold,  with  pain  in  the  side,  cough, 
dyspnea,  mucous  and  rusty  sputum,  impairment  of  resonance,  bronchial 
breathing,  increased  vocal  fremitus — in  fact,  all  the  symptoms  of  a  pneumonia 
of  the  whole  or  a  part  of  a  lung,  which  may  be  an  upper  or  lower  lobe.  If 
the  lower  lobe,  it  is  probably  regarded  as  a  pneumonia  until  the  absence  of 
the  signs  of  resolution  call  attention  to  the  fact  that  something  unusual  "is 
going  on.  Later,  softening  and  the  signs  of  a  cavity  may  present  themselves 
at  the  apex,  and  bacilli  and  elastic  tissue  be  found  in  the  sputum.  The  case 
may  last  for  three  weeks  or  three  months,  or  even  pass  over  into  a  chronic 
phthisis. 

Diagnosis. — In  the  bronchopneumonic  form  it  is  difficult  to  make  the 
diagnosis  early  from  simple  bronchitis  and  bronchopneumonia.  The  tempera- 
ture in  phthisis  is  probably  more  irregular  and  higher.  Where  the  disease 
lasts  more  than  three  weeks,  the  sputum  should  be  examined  carefully  for 


TUBERCULOSIS.  249 

bacilli.  The  diagnosis  in  the  pneumonic  form  can  never  be  made  in 
the  beginning,  because  the  symptoms  of  the  first  and  second  stages  of  this 
form  are  identical  with  those  of  the  first  and  second  stages  of  true  pneumonia, 
and  it  is  only  when  the  type  of  the  latter  disease  is  departed  from  that  phthisis 
can  be  suspected.  The  fever  in  true  pneumonia  should  abate  by  the  ninth 
day  or  twelfth  day  at  latest,  and  if  it  continue  after  that  time  pneumonic 
phthisis  should  be  suspected  and  the  expectoration  should  be  examined  for 
bacilli. 

Prognosis. — The  prognosis  is  very  unfavorable  in  this  form  of  con- 
sumption, death  being  inevitable  in  from  a  few  weeks  to  a  few  months. 
Rarely,  patients  live  a  year  or  longer. 

Treatment. — Treatment  of  the  acute  stage  is  symptomatic.  After  the 
acute  stage  it  is  that  of  chronic  phthisis. 

3.    MENINGEAL  FORM  OF  ACUTE  MILIARY  TUBERCULOSIS.      TUBERCULOUS 

MENINGITIS. 

Synonyms. — Tuhercnloiis    Leptomeningitis ;    Basilar    Meningitis;     Acute 
HydrocepJmlns;  Water  on  the  Brain. 

Definition. — An  acute  inflammation  of  the  pia  mater  due  to  an  irrup- 
tion of  miliary  tubercles  on  this  membrane  and  on  the  blood-vessels  proceed- 
ing from  it,  extending  also  at  times  to  the  corresponding  membrane  of  the 
spinal  cord. 

HistoricaL — We  are  indebted  to  Dr.  Robert  Whytt  for  the  first  accurate  informa- 
tion of  this  disease  in  his  "  Observation  on  Dropsy  of  the  Brain,"  Edinburgh,  1768. 
In  1827  Guersant  applied  the  term  grafiular  mennigztzs  to  this  form  of  inflammation 
of  the  meninges,  and  in  1830  Pavoine  showed  the  nature  of  the  associated  granules- 
and  called  attention  to  their  concurrence  with  tubercles  in  other  parts  of  the  body. 
In  February,  1834,  W.  W.  Gerhard,  of  Philadelphia,  published  in  the  "  American 
Journal  of  the  Medical  Sciences"  a  paper  on  "Cerebral  Affections  of  Children," 
based  on  a  study  of  the  disease  made  in  the  Children's  Hospital  in  Paris.  These 
studies  included  autopsies  as  well  as  clinical  reports,  and  ^.he  descriptions  of  the 
lesions  found  in  the  former  are  so  accurate  that  they  can  scarcely  be  improved  upon. 
To  Gerhard  more  than  anyone  else  are  we  indebted  for  a  proper  location  and  classifi- 
cation of  the  disease. 

Etiology. —  I  have  said  that  the  disease  consists  in  essentially  an  irrup- 
tion of  miliary  tubercles  on  the  pia  mater,  with  the  resulting  inflammatory 
product.  To  this  end  there  must  be  somewhere  in  the  body  a  tubercular  focus 
whence  the  bacilli  start.  Tuberculous  bones  and  joints  may  furnish  such  a 
focus,  but  it  is  most  frequently  located  in  the  bronchial  or  mesenteric  glands. 
Such  focus  cannot  always  be  found,  even  when  present.  The  bare  possibility 
of  a  primary  tubercvflar  meningitis  may,  how^ever,  be  admitted,  in  which  event 
the  cribriform  plate  of  the  ethmoid  is  the  most  likely  route  of  bacilli  inhaled 
from  the  external  atmosphere  through  the  nose  to  the  brain.  The  disease 
is  most  common  in  children  between  the  second  and  fifth  years,  though  it  is 
not  very  rare  in  adults  Ions:  the  subjects  of  tuberculosis. 

Morbid  Anatomy. — The  pia  mater  at  the  base  of  the  brain  is  the  most 
frequent  seat,  whence  the  common  term  basilar  meningitis.  Particularly  are 
the  neighborhood  of  the  optic  chiasm,  the  Sylvian  fissure,  the  interpeduncular 
space  and  pons  varolii  involved.  In  addition  to  the  miliary  tubercles  are 
seen  turbidity  of  the  membrane  increasing  to  opacity,  the  whole  smeared  over 
with  fibrin  and  ous.  The  medulla  oblongata  and  base  of  the  cerebellum  may 
be  covered.  More  rarely  the  inflammation  may  extend  to  the  lateral  and 
convex  surfaces  of  the  brain.  Especially  do  we  find-tbe  adventifia-sheaths  of 
the  blood-vessels  invaded  bv  the  tubercles,  which  are  seen  in  bead-like  rows 


2  50  INFECTIOUS  DISEASES. 

when  the  vessels  are  withdrawn  from  the  substances  of  the  brain.  These 
vessels  are  better  examined  when  spread  on  a  dark  background,  with  a  low 
magnifying  power.  Sections  of  blood-vessels  should  be  made  also,  because 
there  may  be  tubercular  infiltration  of  the  intima,  causing  narrowing  and 
obliteration  of  the  vessel.  The  cerebral  convolutions  are  softened  to  a  slight 
depth  by  the  invasion,  the  blood-vessels  dragging  a  portion  of  the  brain- 
substance  when  drawn  out.     Thus  there  is  really  a  meningo-encephalitis. 

The  lateral  ventricles  contain  a  varying  quantity  of  limpid  or  turbid 
fluid,  a  dram  to  several  ounces,  the  ependyma  is  softened  and  swollen ;  the 
septum  lucidum  and  fornix  are  disrupted.  The  convolutions  may  be  flat- 
tened because  of  the  pressure  exerted  between  the  dilated  ventricles  and  un- 
yielding cranium.  More  rarely  there  is  a  chronic  process  like  that  described, 
but  slower  in  its  course.  As  already  mentioned,  the  pia  mater  of  the  cord 
may  be  involved,  resulting  in  the  same  turbid  picture. 

Symptoms. — The  symptoms  of  tubercular  meningitis  are  varied  and 
irregular  in  their  course.  At  times,  the  beginning,  at  least  to  the  superficial 
observer,  is  sudden.  At  others,  there  are  many  weeks  of  ill-health  with  ill- 
defined  symptoms  that  go  to  make  the  child  unhappy,  restless,  and  an  evident 
sufferer.  In  the  course  of  such  weeks  the  child's  appetite  is  poor,  its  tongue 
coated,  its  bowels  are  constipated  or  the  reverse,  and  it  loses  weight.  The 
sudden  events  alluded  to  are  a  coiiriilsion,  obstinate  vomiting,  or  headache. 
Such  a  child  may  have  been  convalescent  from  measles,  whooping-cough, 
bronchitis,  or  other  ills  of  childhood. 

An  attempt  has  been  made  with  more  or  less  success  to  divide  the  symp- 
toms of  the  disease  into  stages,  of  which  the  first  may  be  called  irritative ; 
the  second,  that  of  subsiding  irritation;  the  third,  paralysis.  The  symptoms 
most  constant  in  the  irritative  stage  are  headache,  fever,  and  vomiting,  of 
Vv-hich  the  latter  may  be  first.  As  has  been  stated,  convulsions  may  usher  in 
the  attack,  and  these  convulsions  may  intermit  and  be  separated  by  periods  of 
some  length.  Sometimes  an  accident,  as  a  fall,  may  be  an  exciting  cause, 
and  the  first  vomiting  may  be  excited  by  a  meal  of  food  unsuited  to  the  child's 
age.  The  three  symptoms  mentioned  as  more  constant  grow  in  severity, 
especially  the  headache,  which  becomes  more  or  less  incessant  and  intense,  so 
that  the  child  is  never  free  from  it.  Yet  there  may  be  a  lull  in  the  pain  as  the 
result  of  treatment  or  other  cause,  followed  by  an  acute  exacerbation,  which 
probably  causes  the  peculiar  short  cry  known  as  the  "  hydrocephalic  cry." 
In  other  cases  there  is  constant  screaming,  which  points  to  the  degree  of  suf- 
fering. The  child  rarely  sleeps  more  than  a  few  minutes  at  a  time,  tmless 
under  the  influence  of  powerful  anodynes.  There  is  always  fever  in  this 
stage,  though  it  may  not  be  very  high,  103°  F.  (39.4°  C.)  being  commonly 
the  maximum.  There  is  more  or  less  dehrium.  The  piilse  is  rapid,  even 
rapid  disproportionately  to  the  temperature,  while  the  breathing  rate  is  little 
altered,  furnishing  a  symptom  of  some  diagnostic  value.  Evidences  of  nerv- 
ous irritation  may  occur  early,  more  commonly  late  in  this  stage.  The  con- 
vulsion has  been  alluded  to.  The  pupils  may  be  contracted  or  irregular,  there 
may  be  strabismus,  or  twitching  of  the  muscles  of  the  face  from  involvement 
of  the  facial  nerve. 

In  the  second  stage  delirium  yields  to  coma,  though  convulsions  may 
continue.  There  may  be  localized  rigidity  of  the  muscles  of  one  limb  or  of 
half  the  body.  The  head  may  be  retracted.  Headache  is  not  complained  of, 
though  the  child  still  may  occasionally  cry  out.  The  pupils  are  dilated  or 
irregular  and  squint  is  more  marked  from  oculo-motor  or  third-nerve  paraly- 


TUBERCULOSIS.  251 

sis ;  the  bowels  are  constipated ;  the  abdomen  is  retracted — scaphoid.  The 
temperature  tends  to  be  lower,  but  is  variable.  There  is  often  a  patchy  red- 
ness of  the  skin  and  tache  cerebrale  may  be  brought  out  by  drawing  the 
finger-nail  across  the  skin. 

In  the  third  period,  or  stage  of  paralysis,  the  stupor  increases  and  may  be 
profound.  Convulsions,  however,  still  occur.  They  may  be  localized  in  a 
group  of  muscles  or  those  of  one  limb,  or  the  convulsion  may  be  unilateral. 
On  the  other  hand,  there  may  be  absolute  paralysis  of  the  oculo-motor  nerves, 
and  even  hemiplegia.  As  a  result  of  the  former  the  pupils  are  dilated,  the 
eyelids  partially  closed,  and  the  eye  turned  upward.  Hemiplegia  is  more  apt 
to  occur  when  the  fissure  of  Sylvius  is  invaded,  when,  too,  there  may  be 
aphasia.  Optic  neuritis  is  sometimes  present  in  this  stage,  usually  occurring 
late,  due  to  invasion  of  the  optic  nerve  within  the  skull.  The  facial  nerve 
may  be  involved  in  basilar  cases,  producing  slight  facial  paralysis  ;  so  may  the 
fifth,  producing  anesthesia,  and  atrophic  changes  in  the  cornea  if  the  Gas- 
serian  ganglion  be  involved.  Hyperesthesia  of  the  special  senses  may  also  be 
present,  though  this  is  rather  a  symptom  of  the  first  stage.  Toward  the  end 
a  typhoid  state  may  supervene,  characterized  by  dry  tongue,  muttering 
delirium,  and  involuntary  discharge  of  urine  and  feces.  The  temperature  at 
this  stage  may  be  subnormal,  falling  as  low  as  93°  F.  (33.9°  C).  On  the 
other  hand,  the  temperature  sometimes  rises  just  before  death  to  106°  F. 
(41.1°  C.)  or  more.  The  entire  duration  of  the  disease  is  from  two  to  three 
weeks.     The  blood  examination  fails  to  find  a  characteristic  leukocytosis. 

Diagnosis. — In  the  diagnosis  we  have  first  to  recognize  the  presence  of 
a  meningitis,  and,  second,  to  separate  the  tubercular  meningitis  from  menin- 
gitis due  to  other  causes.  The  former  is  commonly  easy,  yet  mistakes  are  often 
made  because  so  many  of  the  head  symptoms  are  simulated  by  head  symp- 
toms in  dyscrasic  conditions,  of  which  cholera  infantum  is  a  type,  while 
retraction  of  the  head  may  result  from  rheumatism  of  the  muscles  of  the  back 
of  the  neck ;  but  optic  neuritis  and  paralytic  symptoms  are  confined  to  menin- 
gitis. The  presence  of  tuberculosis  elsewhere  strengthens  other  signs.  The 
other  forms  of  meningitis  that  may  give  similar  symptoms  are  meningitis  due 
to  internal  ear  disease,  traumatic  meningitis  due  to  blows  and  injuries,  and 
syphilitic  meningitis.  In  meningitis  due  to  ear  disease  the  history  of  the 
case  should  prevent  a  mistake.  Traumatic  meningitis,  especially  with  abscess, 
might  simulate  the  symptoms  described,  but  here,  too,  the  history  of  the  acci- 
dent would  be  helpful,  but  in  absence  of  a  knowledge  of  the  cause  there  might 
be  confusion.  Syphilitic  meningitis  is  usually  chronic,  rarely  acute,  although 
it  affects  the  base  of  the  brain ;  also,  the  lesion  is  more  apt  to  be  limited  in 
area  and  confined  to  one  side.  Basal  headache  and  signs  pointing  to  localiza- 
tion are  present.  Often  the  history  does  not  help  us  because  the  patient 
denies  the  existence  of  the  specific  cause.  Syphilitic  disease  involves  the  con- 
vexity more  frequently  than  does  tubercular,  causing  the  symptoms  of  cortical 
lesions,  including  focal  convulsions.  The  diagnosis  is  most  conclusively 
established  if  tubercles  be  detected  in  the  choroid. 

Prognosis. — The  prognosis  of  tuberculous  meningitis  well  established  is 
invariably  fatal.  On  the  other  hand,  the  chances  of  error  in  diagnosis  are  so 
many  that  it  is  not  wise  to  be  too  confident.  It  has  happened  to  me  more 
than  once  to  have  had  cases  in  children  recover  where  I  had  thought  the  dis- 
ease present,  but  where  the  ultimate  result  proved  the  diagnosis  erroneous. 

Treatment. — Curative  treatment  is,  therefore,  futile,  but  for  the  same 
reason  should  be  persevered  in.    The  cases  whose  recovery  has  surprised  me 


252  INFECTIOi'S  DISEASES. 

have  invariably  been  those  in  which  I  used  cod-hver  oil  inunctions.  These 
should,  therefore,  be  persisted  in.  In  addition  to  this  all  other  supporting 
measures  possible  should  be  used  with  such  treatment  of  symptoms  as  will 
secure  the  least  suffering  to  the  little  patient. 

III.  Chronic   Tuberculosis, 

I.    PULMONARY    TUBERCULOSIS. 

Synonyms. — Phthisis  pulmonalis;  Pulmonary  Consumption;  Consumptiovir 

of  the  Lungs. 

The  Greek  ttvmcpdiffi^is  an  admirable  word,  meaning  literally  wasting, 
which  is  almost,  if  not  quite,  the  most  characteristic  s}-mptom  of  the  disease 
known  technically  as  phthisis  pulmonalis. 

Definition. —  Pulmonary  tuberculosis  is  an  infectious  disease  due  to  the 
lodgment  and  proliferation  of  the  tubercle  bacillus  in  the  lung  substance. 

Etiology. — The  dependence  of  tubercular  consumption  on  the  tubercle 
bacillus  and  its  various  favoring  elements  has  been  fully  considered  under 
the  head  of  General  Tuberculosis,  page  238.  There  are  two  possible  routes 
of  invasion  of  the  lungs,  one  by  the  air-passages, — inhalation  tuberculosis, — 
the  other  by  the  blood.  The  former  is  by  far  the  most  common  for  ordinary 
forms  of  consumption,  while  the  latter  produces  usually  miliary  tuberculosis. 

Morbid  Anatomy. — Inhalation  Tuberculosis. — The  bacillus,  notwith- 
standing its  probable  detention  at  various  points  in  its  journey,  rarely  obtains 
a  fruitful  soil  until  it  reaches  the  ultimate  ramifications  of  a  bronchus  or  its 
termination  in  the  alveolar  passages,  infundibula.  and  air-vesicles.  It  is  in  the 
septa  forming  these  that  it  locates  itself  by  preference,  multiplies,  and  excites 
secondary  inflammatory  processes,  the  sum  of  which  constitutes  the  tuber- 
cular nodule. 

A  correct  understanding  of  what  is  to  follow  may  be  facilitated  by  a 
review  of  the  drawing  on  p.  253,  showing  a  single  lung  lobule  1.5  cm.  long 
and  I  cm.  broad,  magnified  ten  times.  The  principal  bronchus  is  seen  enter- 
ing the  lobule  and  dividing  into  seven  smaller  bronchioles,  and  each  of  these 
into  two  still  smaller  ones.  These  smaller  bronchioles  open  directly  into  a 
group  of  from  three  to  five  branching  alveolar  passages,  with  their  infun- 
dibula beset  with  air-vesicles.  These  form  the  equivalent  of  an  acinus  in  a 
racemose  gland,  and  may  be  teamed  lung  acini,  a  more  constant  unit  of  lung 
structure,  as  Rindfleisch  truly  says,  than  the  lobule,  at  least  as  far  as  size  is 
concerned,  since  as  few  as  two  of  these  may  unite  to  form  a  lobule,  or  as  many 
as  20  to  30.  The  figure  in  the  text  is  made  up  of  14.  In  pathological  proc- 
esses other  than  tuberculosis,  the  lobule  is  the  more  important  element,  since 
each  is  determined  by  the  distribution  of  the  blood-vessels  and  interstitial 
connective  tissue.  Emboli,  infarcts,  and  abscesses  therefore  light  upon  the 
border  of  the  lobules,  while  the  miliary  tubercle  is  found  between  the  bron- 
chioles and  within  the  alveolar  septa,  where  the  bacillus  secures  lodgment 
and  the  tubercle  its  growth.  This  favorite  position  may  be  seen  by  making 
a  section  across  one  of  the  smaller  bronchioles  after  it  passes  into  the  acinus, 
when  we  will  meet  the  circular  edge  of  a  bronchiole  and  an  entire  system  of 
partitions  between  three  and  five  alveolar  passages. 

Under  the  irritating  influence  of  the  bacillus,  these  septa  undergo  cellu- 
lar infiltration,  which  results  in  their  thickening  and  encroachment  upon  the 


TUBERCULOSIS.  253 

liimina  of  the  air-passages.  By  this  process  is  produced  a  Httle  granulation 
that  corresponds  at  first  in  size  to  an  acinus,  and  enlarged  by  the  implication 
of  other  acini  until  a  lobule  is  finally  involved,  producing  an  irregularly 
rounded  or  oval  body  assuming  somewhat  the  shape  of  a  lobule,  ranging  in 
diameter  from  one  millimeter  to  six  millimeters  (1-25  to  1-4  inch) — the 
tubercle  granulum.  On  section  such  a  granule  is  found  perforated  by  one  or 
more  minute  openings  or  slits  corresponding  to  the  air-passages,  one  for  each 
of  the  roundish  subdivisions  which  make  up  the  nodule.  In  vertical  section 
the  appearance  is  more  definite,  having  a  central  stem  with  branches.  The 
area  is  whitish-yellow  in  color,  surrounded  by  a  ring  of  hyperemic  tissue. 
The  microscope  shows  the  periphery  of  the  bronchiole  or  air-passage  infil- 
trated with  concentric  layers,  of  which  the  external  is  made  up  of  small 


Fig.  22. — Lobule  of  Lung,  Showing  Acini  and 
Alveolar  Passages — {after  Rindfleisch). 

lymphoid,  the  middle  of  large  epithelioid  cells,  and  within  this  again  a  third 
zone  in  which  no  cells  are  differentiable,  these  having  lost  their  contour  and 
become  fused  into  a  homogeneous  mass — in  a  word,  having  become  caseous. 
The  lumen  of  the  tube  itself  is  plugged  with  cheesy  matter.  The  blood- 
vessels stop  short  at  the  edge  of  the  tubercle,  as  it  is  thoroughly  avascular. 

By  suitable  staining  methods,  tubercle  bacilli  may  be  demonstrated 
among  the  cells  of  the  tubercle  granule  in  moderate  numbers  at  its  periphery, 
but  not  in  the  cheesy  center,  where  they  do  not  seem  to  thrive  until  softening 
takes  place,  when  they  are  found  in  great  numbers. 

Thus  begin  most  cases  of  pulmonary  phthisis  as  a  localized  tuberculosis 
of  the  smallest  air-passages  at  the  apex  of  one  of  the  lungs.  The  apices  are 
attacked  first,  because  here  the  unfoldmg  of  the  lungs,  in  the  act  of  breath- 
ing, is  more  limited,  the  blood  moves  less  freely  and  tends  rather  to  stagnate 
— ^conditions  which  favor  the  retention  of  secretion,  favor  the  lodgment,  and 
encourage  the  srrowth  of  the  bacillus. 


254  INFECTIOUS  DISEASES. 

On  the  other  hand,  the  view  so  long  entertained  that  the  left  apex  is 
more  frequently  affected  than  the  right  seems  to  be  erroneous  in  the  light  of 
modern  studies.  Thus,  William  Osier  out  of  413  cases  found  the  right  apex 
involved  in  172;  the  left,  in  130;  both,  in  iii.  Pension  examinations  furnish 
an  opportunitv  for  obtaining  information  on  this  subject,  and  my  friend, 
Theodore  G.  Davis,  of  Bridgeton,  X.  J.,  took  occasion,  as  examiner  in  a  pen- 
sion board,  to  note  the  cases  of  tubercular  phthisis  which  passed  before  his 
board,  with  the  following  results :  Out  of  897  males,  whose  ages  ranged  from 
forty-five  to  seventy-one  years,  94,  or  about  10  1-2  per  cent.,  had  pulmonary 
tuberculosis,  more  or  less  pronounced.  Of  these,  39  were  markedly  worse  on 
the  right  side  and  29  on  the  left ;  both  sides  were  affected  in  26 — ^proportions 
very  like  those  of  Osier. 

From  this  usual  starting  point  the  disease  spreads  with  varying  rapidity 
to  other  parts  of  the  lung.  Two  principal  varieties,  however,  result,  based 
upon  the  rapidity  of  the  spread  of  the  disease.  The  first  includes  the  ordinary 
chronic  form  of  consumption,  or  chronic  ulcerative  phthisis,  and  an  allied 
slow  form  characterized  by  a  special  involvement  of  the  connective  tissue, 
known  as  fibroid  piuhisis;  the  second  is  pneumonic  phthisis,  one  of  the  forms 
of  galloping  consumption,  which  has  already  been  considered. 

(a)  Chronic  Ulcerative  Phthisis. 

Syxoxym. — Sloiu  Consumption. 

Morbid  Anatomy. — This  most  usual  form  of  consumption,  beginning 
with  the  tubercle  granulum  and  associated  with  more  or  less  catarrh  of  the 
apex,  extends  thence  slowly  downward.  The  deposit  in  the  beginning  is  not 
actually  in  the  very  apex,  but  a  little  below  it,  and  usually  the  first  point  at 
which  physical  signs  are  found  is  on  the  middle  of  the  clavicle  or  just  below 
it.  Sometimes,  however,  the  extension  is  rather  backward,  so  that  the  physi- 
cal signs  are  first  manifested  in  the  supra-spinous  fossa,  whence  the  impor- 
tance of  always  insisting  on  the  posterior  examination. 

From  this  initial  focus,  usually  toward  the  anterior  face  of  the  lung, 
the  disease  extends  more  or  less  throughout  the  lobe,  or  it  may  pass  to 
another  lobe.  If  the  disease  be  on  the  right  side,  from  the  upper  it  may  extend 
to  the  middle  lobe  and  thence  into  the  lower  lobe  about  an  inch  blow  its  apex, 
corresponding  also  to  a  point  on  the  surface  opposite  the  fifth  dorsal  spine. 
On  the  left  side,  the  extension  is  directly  from  the  upper  to  the  lower  lobe. 
From  its  previous  focus  the  tubercular  infiltrate  travels  centripetally  along 
the  bronchi  from  smaller  to  larger  as  a  tuberculous  peribronchitis.  As  E. 
Rindfleisch  aptly  expresses  it :  "  The  white  berries  acquire  a  stalk  of  the  same 
nature  and  color.  The  stalks  unite  with  each  other  and  thus  form  a  radiat- 
ing or  rudely  stellate  focus  of  larger  extent."  These  stalks  are  bronchioles 
the  walls  of  which  are  infiltrated  with  tubercle.  Larger  and  larger  branches 
become  implicated  with  the  intermediate  parenchyma,  but  usually  it  does  not 
extend  beyond  the  cartilage-ringed  bronchi  of  the  second  order,  forming 
tubercular  masses  of  corresponding  size. 

The  infiltration  is  not  limited  to  peribronchial  tissue.  It  extends  also 
inward  toward  the  lumen  of  the  tube,  invading  the  submucous  tissue,  where 
it  may  be  seen  as  whitish  or  cloudy  patches  on  slitting  up  the  bronchi  and 
washing  off  the  adherent  muco-pus.  Thus  uncovered,  the  mucous  membrane 
is  found  also  red  and  inflamed,  contrasting  strongly  with  the  whitish  patches 


TUBERCULOSIS.  ■  255 

referred  to.  As  we  penetrate  deeper,  these  enlarge  and  intrude  upon  the 
lumen  of  the  tube,  while  the  hyperemic  areas  grow  smaller.  Such  intrusion 
becomes  finally  complete  occupation,  associated,  sooner  or  later,  with  an  ex- 
coriation or  rupture  of  the  mucous  membrane.  This  is  the  beginning  of 
ulceration,  which  assumes  an  important  place  in  facilitating  subsequent  de- 
structive process,  and  is  the  foundation  of  the  term  adopted  for  this  form  of 
phthisis,  chronic  ulcerative  phthisis. 

The  pathological  processes  referred  to,  and  the  destructive  effects  of 
which  they  are  the  cause,  give  to  the  lung  in  a  state  of  chronic  phthisis  a 
varied- picture  that  is  not  always  found  in  a  single  case,  nor,  indeed,  would 
the  lesions  of  two  or  more  cases  always  cover  this  picture.  They  include  the 
following : 

1.  The  caseous  tubercular  masses^  formerly  called  crude  tubercle.  They 
embrace  single  or  compound  peribronchial  foci  perforated  by  the  central 
bronchiole,  itself  plugged  with  cheesy  matter.  Thus-  constituted  they  form 
grayish-yellow  masses  from  a  couple  of  millimeters  to  four  or  five  centimeters 
(1-12  to  2  inches)  in  diameter.  They  have  the  composition  already 
described.  Though  usually  massed  toward  the  apices  of  the  lung,  they  may 
also  be  disseminated  through  the  remainder  of  the  organ,  and  around  them 
there  may  also  be  found  scattered  true  miliary  tubercles. 

2.  The  second  anatomical  feature  of  the  phthisical  lung  is  the  cavity. 
As  soon  as  a  tuberculous  area  reaches  a  certain  size,  the  tendency  to  break 
down  is  increased,  though  such  tendency  does  not  depend  altogether  on 
extent.  The  bronchial  wall,  weakened  by  the  tubercular  infiltration  and  the 
ulceration  referred  to,  is  the  initial  invitation.  The  wall  yields  to  the  pressure 
which  it  formerly  easily  resisted — the  inspiratory  and  expiratory  strain  inci- 
dent to  coughing, — the  bronchus  dilates,  the  gap  of  the  ulcer  widens,  and  the 
texture  of  the  bronchus  gradually  yields.  The  free  access  of  air  to  the 
already  necrotic  caseous  matter  causes  it  to  soften,  break  down,  and  a  cavity 
results.  Small  foci  unite  with  others  and  thus  larger  cavities  form,  occu- 
pying the  greater  part  of  a  lobe,  or  even  a  whole  lung  in  very  rare 
instances. 

Large  cavities  have  usually  smooth  walls  and  are  lined  by  the  so-called 
pyogenic  membrane,  into  which,  however,  often  protrude  blood-vessels  of 
large  size,  as  thick  as  a  crow-quill,  and  exhibiting  also  at  times  aneurysmal 
dilatations.  Rarely  such  vessels  pass  directly  across  a  cavity,  and  when 
eroded  they  may  give  rise  to  fatal  hemorrhage  toward  the  end  of  a  case  of 
chronic  phthisis.  On  the  other  hand,  these  vessels  may  also  become  thor- 
oughly occluded  by  an  obliterating  endarteritis.  The  surface  of  these  smooth- 
walled  cavities  is  constantly  producing  pus,  while  muco-pus  is  being  added  by 
communicating  bronchi.  Such  cavities  may  be  more  or  less  completely 
emptied  by  expectoration.  They  are  also  surrounded  by  a  consolidated  lung 
tissue,  which  gives  a  dull  percussion  note  and  thus  often  prevents  the  tym- 
pany natural  to  a  cavity.  Small  cavities  have  rough  and  ragged  walls,  from 
which  there  is  constant  breaking  down,  adding  elastic  tissue,  pus,  granular 
debris,  and  bacilli  to  the  matter  expectorated.  There  may  be  a  number  of 
these  small  cavities,  and  if  under  the  pleura  one  may  rupture  into  the  pleural 
sac,  producing  pneumo-thorax. 

Other  cavities  form  by  the  softening  of  the  center  of  a  caseous  area. 
Others  still  may  be  purely  bronchiectatic,  being  limited  by  bronchial  walls. 
It  is  more  particularly  the  bronchi  of  medium  size  that  are  thus  involved, 
weakened  also  bv  tubercular  infiltration.   The  form  of  dilatation  mav  be  cylin- 


256  INFECTIOUS  DISEASES. 

drical  or  globular.     The  small  tubes  especially  may  be  the  seat  of  cylindrical 
dilatation. 

3.  Pleurisy  is  constantly  associated  with  tubercular  phthisis.  It  is  found 
in  four  forms : 

{a)  As  an  adhesive  pleurisy  in  the  immediate  neighborhood  of  tubercular 
infiltration,  causing  a  collateral  hyperemia  and  intlammation  of  the  pleura. 

( b )  There  may  be  perforation  from  a  cavity  into  the  pleura,  exciting  a 
purulent  pleurisy  and  a  pyopneumothorax. 

(c)  A  pleurisy  may  be  lighted  up  by  cold  in  a  favorable  focus  of  col- 
lateral hyperemia. 

(d)  Finally,  the  pleura  may  be  the  seat  of  a  tubercular  pleurisy,  result- 
ing in  a  thickened  membrane,  which  may  be  limited  or  may  encase  the  whole 
lung  and  cement  the  lobes  in  a  continuous  inseparable  mass. 

4.  Pulmonary  concretions  are  also  found  in  the  phthisical  lung,  usually 
about  half  as  large  as  a  pea,  smooth  or  lobulated.  They  represent  calcareous 
infiltration  of  alveoli  *  of  the  lung,  filled  with  tubercular  bronchopneumonic 
products.  They  are  a  medium  of  one  form  of  healing  of  tuberculosis. 
Those  retained  in  the  lung  are  commonly  surrounded  by  a  ring  of  hyper- 
plastic connective  tissue.  At  times  they  are  expectorated,  being  released  by 
a  sequestrating  suppuration  into  an  adjacent  bronchus,  whence  they  are 
brought  up  by  coughing.  Sometimes  a  good  many  are  coughed  up.  They 
are  something  different  from  bronchial  calcuH,  which  are  always  smooth, 
spherical,  or  elliptical,  and  are  found  in  small  bronchic static  cavities. 

5.  Other  evidences  of  attempts  at  healing  seen  in  the  phthisical  lungs 
are  of  the  nature  of  reactive  inflammation.     They  may  occur : 

(a)  In  the  initial  stage  as  the  result  of  treatment  and  favorable  hygienic 
surroundings,  when  the  initial  granule  is  replaced  by  a  cicatricial-like  pucker- 
ing of  fibrous  tissue  or  a  hard  cartilaginous  mass  of  connective  tissue. 

(b)  There  may  be  a  sequestration  or  encapsulation  of  a  cheesy  nodule, 
which  may  or  may  not  undergo  calcareous  infiltration. 

(c)  Even  a  cavity  of  moderate  size  may  heal,  in  which  event,  the  cavity 
being  cleared  out,  its  walls  unite  by  adhesive  inflammation  and  thus  a  band  of 
cicatricial  tissue  takes  the  place  of  the  cavity.  Larger  cavities  may  be 
reduced  in  size  by  a  contraction  of  the  cicatricial  tissue  surrounding  them,  or 
several  small  cavities  may  be  thus  surrounded.  Quite  small  cavities  sur- 
rounded by  connective  tissue  and  communicating  with  a  bronchus  w^ere  called 
cicatrices  fistuleuses  by  Laennec. 

•  6.  The  neighborhood  of  a  tubercular  infiltration  is  often  the  seat  of  a 
pneumonia  which  may  be  siniply  reactive  or  due  to  the  irritative  effect  of  the 
bacillus — /.  e.,  a  tubercular  bronchopneumonia.  The  area  is  hyperemic,  hard, 
consolidated,  and  the  air-vesicles  filled  with  exfoliated  epithelium.  The  latter 
may  exhibit  various  stages  of  fatty  degeneration.  It  may  be  complete  w^hen 
an  appearance  indistinguishable  from  that  of  tubercular  infiltration  is  present. 
In  fact,  it  is  tubercular  infiltration  plus  catarrhal  pneumonia. 

7.  When  a  subject  dies  of  tubercular  phthisis,  other  organs  should  be 
searched  for  tubercles.  Tuberculosis  of  the  larynx  is  common  and  is  not 
infrequently  associated  with  destruction  of  the  cords  and  epiglottis.  The 
bronchial  glands  are  usually  involved,  swollen,  inflamed,  or  tubercular,  and 
when  tubercular  may  become  caseous  and  sometimes  calcareous.  Other 
glands  are  also  affected,  such  as  the  cervical,  mediastinal,  and  post-peritoneal. 

*  If  macerated  in  hydrochloric  acid  the  lime  salt.s  can  be  dissolved  out,  and  the  actual  elastic 
■tissue  framework  of  an  alveolus,  with  its  infundibula  and  attached  air-vessels,  be  left. 


TUBERCULOSIS.  257 

It  is  now  recognized  that  the  so-called  "  scrofula  "  of  the  neck  is  a  tubercu- 
losis of  lymphatic  glands.  After  the  bronchial  glands  the  organs  most 
affected  are  the  intestine ;  next,  the  spleen,  kidneys,  and  brain  in  nearly  equal 
proportion ;  then  the  liver  and  the  pericardium. 

8.  The  only  remaining  morbid  states  which  may  be  considered  as  having 
any  essential  relation  to  tubercular  consumption  are  the  amyloid  and  fatty 
irMtration.  The  former  is  found  affecting  the  kidneys,  liver,  spleen,  and 
mucous  membrane  of  the  intestines ;  the  latter,  especially,  the  liver  and 
kidney. 

Symptoms. — The  onset  of  tubercular  consumption  is  by  no  means 
uniform.  Xotwdthstanding  the  fact  that  its  insidious  nature  is  well  recog- 
nized, its  initial  stadium  is  often  overlooked.  The  victim  is  scarcely  appreci- 
ably ill.  Yet  he  may  lose  flesh  and  strength  continuously.  He  may  even 
say  that  he  has  no  cough,  while  close  questioning  will  ascertain  that  he  has 
had  a  slight  hacking  •cough  for  some  time,  worse  in  the  morning.  Soon  the 
symptoms  are  plainer,  there  is  evident  z^'astijig,  an  intermittent  fever,  a  bright 
eye,  and  the  cough  zuith  expectoration  is  a  conspicuous  symptom.  Yet  dur- 
ing all  this  the  patient  is  cheerful  and  denies  that  there  is  much  the  matter 
with  him. 

In  another  instance  an  individual  is  "  subject  to  cold  " ;  he  takes  cold 
repeatedly,  and  each  attack,  while  passing  away,  yields  more  stubbornly  than 
the  previous  one,  and  finally  one  comes  that  persists.  There  is  daily  fever 
which  abates  to  return  again,  emaciation  is  evident,  and  the  bright  eye  and 
burning  cheeks  and  night-szveats  again  attest  the  arrival  of  the  dread  disease. 

Another  case  may  begin  with  hoarseness,  due  probably  to  tubercular 
laryngitis,  not  infrequently  the  initial  symptom. 

Again,  after  a  stubborn  attack  of  bronchitis  in  a  person  previously 
healthy  a  hemorrhage  of  the  lungs  unexpectedly  makes  its  appearance,  or 
such  a  hemorrhage  may  set  in  without  previous  warning,  although,  again, 
careful  inquiry  may  find  that  cough  has  been  present  for  some  time.  The 
patient  has,  perhaps,  previously  been  overworked,  or  lived  under  unfavorable 
hygienic  surroundings,  or  may  possess  a  hereditary  tendency. 

In  still  another  instance  a  patient  may  consult  the  physician  without  sus- 
pecting that  he  is  very  ill,  and  the  signs  of  advanced  disease  of  the  apices  will 
be  found  present,  and  there  may  be  but  a  few  more  months  of  life  remaining 
to  the  unsuspecting  victim. 

A  certain  number  of  cases  of  consumption  begin  as  tubercular  pleurisy, 
which  invades  the  lung  by  contiguity  or  by  blood  infection.  One  of  the  most 
convincing  facts  in  favor  of  the  infectious  theory,  which  seemed  established 
prior  to  the  discovery  of  the  bacillus,  was  the  frequent  occurrence  of  pleurisy 
as  a  forerunner  of  phthisis.  It  was  held  that  the  caseous  product  of  the 
pleurisy  furnished  the  infectious  virus,  which,  entering  the  blood,  caused 
tubercle  formations  in  various  parts  of  the  body.  Thus,  one-third  of  the  90 
cases  of  pleurisy  followed  up  by  Bowditch  terminated  in  phthisis. 

Inveterate  dyspepsia  is  associated  with  many  cases  and  is  as  often  a  pre- 
disposing cause  as  a  symptom.  A  great  loss  of  appetite  and  indisposition  to 
take  food  are  often  symptomatic,  and  their  presence  does  much  to  diminish 
the  efficiency  of  remedies  and  nutrimen1;s  so  essential  to  successfully  combat 
the  disease. 

Physical  Signs. — Given  the  suspicion  of  the  existence  of  tubercular  con- 
sumption from  the  presence  of  the  above  symptoms,  whatever  others  may  be 
superadded,  or  whatever  modification  may  occur  in  them,  the  diagnosis  is 

17 


258  INFECTIOUS  DISEASES. 

completed  by  a  physical  examination.  The  physical  signs,  therefore,  will  be 
next  studied.  While  it  is  not  always  easy  to  separate  the  clinical  history  of 
a  case  of  consumption  into  three  sets  of  symptoms  corresponding  to  the  three 
separate  stages  in  the  morbid  anatomy,  the  physical  signs  corresponding  with 
these  stages  are  tolerably  definite.     They  are : 

1.  The  incipient  stage,  or  beginning  deposit. 

2.  Stage  of  complete  consolidation. 

3.  Stage  of  softening  and  cavity  formation. 

1.  Inspection,  in  the  incipient  stage,  is  as  often  negative  as  not.  A 
slightlv  diminished  expansion  in  the  infraclavicular  space,  as  compared  with 
the  opposite  side,  may  be  present,  and  more  rarely  a  slight  flattening  of  the 
same  region.  The  clavicle  becomes  correspondingly  conspicuous.  The  body 
may  continue  well  nourished  or  slightly  emaciated,  or  the  heart-beat  in  the 
normal  position  may  be  somewhat  accelerated,  while  the  respirations  are  likely 
to  be  more  frequent  than  in  health. 

Palpation  may  recognize  increased  vocal  fremitus  in  the  same  situation, 
although  not  always,  while  the  physiological  difference  in  favor  of  the  right 
side  is  to  be  remembered.  Percussion  in  this  stage  gives  slightly  higher  pitch 
and  impairment  of  resonance,  which  may  be  noted  above,  on,  or  below  the 
clavicle.  Dullness  may  sometimes  be  brought  out  by  directing  the  patient 
to  iiold  his  mouth  open  during  percussion  or  to  hold  his  breath  at  expiration. 

To  auscultation  above  or  below  the  clavicle,  we  have  the  first  evidence 
of  abnormality  in  a  prolongation  of  the  expiratory  murmur  and  harshness  in 
the  inspiratory  sound — in  a  word,  in  bronchovesicular  breathing.  Theoreti- 
cally, this  should  be  preceded  by  a  diminished  intensity  in  the  inspiratory 
sound,  owing  to  the  interference  of  the  newly-deposited  tubercles  with  the 
entrance  of  air  into  the  air-vesicles,  but  practically  such  diminished  intensity 
is  rarely  encountered,  and  even  if  present  is  not  of  distinctive  significance. 

Increased  vocal  resonance  is  a  constant  accompaniment  of  these  modi- 
fications in  the  normal  breathing-sounds,  but  it,  as  well  as  the  vocal  fremitus, 
may  be  masked  by  a  pleuritic  thickening,  and  the  physiological  dift"erence  so 
often  referred  to  must  be  remembered.  J.  M.  Da  Costa  also  calls  attention  to 
the  fact  that  in  a  certain  number  of  cases,  at  this  stage,  there  is  a  blowing 
sound  in  the  subclavian  or  pulmonary  artery,  and  that  a  murmur  is  some- 
times present  in  these  vessels  before  any  other  physical  sign  is  noted.  There 
are  frequently  concurrent  with  these  signs  those  of  a  bronchitis  more  or  less 
acute. 

2.  In  the  second  stage  the  changes  discoverable  by  inspection  are  more 
easily  recognized.  There  is  evident  loss  of  flesh,  depression  of  surface,  and 
impaired  range  of  respiratory  movement.  The  hectic  flush  is  intermittingly 
present.  Palpation  may  even  discover  an  increased  warmth  of  skin.  The 
increased  vocal  fremitus  is  now  plainly  recognized  unless  obscured  by  a 
thickened  pleural  membrane.  Dullness  on  percussion  is  positive  and  easily 
elicited. 

To  auscultation  there  is  increased  vocal  resonance.  The  bronchial 
factor  in  the  breathing  now  becomes  conspicuous,  showing  itself  by  the 
harshness  and  relative  shortening  of  the  inspiratory  element,  with  the 
decidedly  prolonged  and  blowing  expiration ;  also  a  gradual  diminution  of  the 
vesicular  factor,  until  the  latter  disappears  entirely,  when  we  have  the  typical 
bronchial  breathing  of  extended  areas  of  tubercular  infiltration.  This  sign 
will  now  be  found  in  the  supraspinous  fossa  posteriorly  as  well  as  anteriorly. 
The  conduction  of  the  normal  heart  sounds  to  the  area  of  infiltration,  if  at 


TUBERCULOSIS.  259 

either  apex,  is  a  very  frequent  and  significant  sign.  The  high  degree  of  vocal 
resonance  known  as  bronchophony  is  also  superadded  as  a  valuable  confirma- 
tion of  the  presence  of  complete  consolidation.  The  auscultation  signs  of  a 
concurrent  bronchitis  may  also  be  present  in  this  and  in  the  next  stage. 

3.  In  the  third  stage  the  information  furnished  by  inspection  is  still  more 
positive.  Emaciation  is  marked,  breathing  and  the  pulse  are  rapid,  and  the 
face  is  often  flushed.  There  is  flattening  over  the  affected  area,  and  the 
excursion  of  respiratory  movement  is  still  more  limited.  In  this  stage  the 
superficial  veins  over  the  involved  area  may  be  prominent,  partly  from 
emaciation  and  partly  from  obstructed  circulation.  There  may  be  visible 
pulsation  in  the  second,  third,  and  fourth  interspaces  to  the  left  of  the  sternum 
because  of  the  retraction  of  the  lung,  while  the  heart  may  even  be  drawn  up  if 
this  retraction  be  of  the  left  upper  lobe.  This  is  seen  more  particularly  in 
the  variety  known  as  fibroid  phthisis.  To  palpation  the  vocal  fremitus  is 
still  more  marked,  and  even  remains  distinct  over  cavities,  because  of  the 
consolidation  around  them,  unless  there  be  some  obstruction  to  the  entrance 
of  air  into  the  bronchus  leading  to  the  involved  area.  Rhonchal  fremitus 
may  be  added  if  adventitious  sounds  be  present.  The  skin  is  hot  and  dry, 
nnless  succeeding  one  of  the  sweats  that  characterize  this  stage,  when  it  may 
be  moist  and  clammy. 

Dullness  on  percussion  is  always  to  be  found  in  the  third  stage,  but  to 
it  is  often  added  some  one  of  the  varieties  of  tympanitic  note — viz.,  pure 
tympany,  the  "  cracked-pot "  sound,  or  amphoric  resonance,  due  to  cavities. 
These  require  sufficient  size  and  superficial  situation  on  the  part  of  the  cavity. 
On  the  other  hand,  resonance  may  even  be  normal  over  a  cavity  some  dis- 
tance from  the  surface,  especially  if  the  percussion  be  lightly  made,  while  the 
consolidated  tissue  which  almost  invariably  surrounds  a  cavity  often  permits 
only  a  dull  sound  to  be  elicited.  Wintrich's  change  of  note  should  be  sought 
— a  change  of  note  produced  during  percussion  over  a  cavity  on  opening  and 
closing  the  mouth,  the  pitch  being  higher  when  the  mouth  is  open. 

Auscultation  in  this  stage  may  continue  to  recognize  the  bronchial 
l)reathing  of  the  second,  but  to  it  are  superadded  first  small  bubbling  sounds 
or  subcrepitant  rales  indicating  liquefaction ;  later,  may  be  added  the  dis- 
tinctive signs  of  a  cavity.  These  signs  are  cavernous  breathing,  cavernous 
voice,  pectoriloquy,  either  whispering  or  loud  speaking,  amphoric  breathing, 
and  amphoric  voice.  To  these  are  often  added  the  large  bubbling  sounds 
known  as  gurgling,  caused  by  the  air  bubbling  through  fluid  in  a  cavity. 
Metallic  tinkling  may  be  added  to  these  phenomena,  caused  by  the  bursting 
■of  bubbles  in  a  cavity  with  amphoric  conditions. 

"  Cavernous  breathing,"  strictly  speaking,  is  any  modification  of  the 
normal  breathing  sounds  due  to  the  air  passing  in  and  out  of  a  cavity. 
When  high  pitched  it  becomes  tubal  or  amphoric.  The  amphoric  sound  is 
supposed  to  occur  in  cavities  with  firm  walls  that  best  secure  the  "  echo- 
ing," which  is  the  condition  of  amphoric  breathing  and  amphoric  percussion. 
Over  more  yielding  walls  the  breathing  is  lower  pitched,  and  to  this  the 
term  "  cavernous  "  is  especially  applied. 

Special  Symptoms. — The  cough  of  consumption  varies  greatly.  It  is 
at  first  very  slight,  and  may  continue  ,so  even  in  advanced  stages.  As  a 
rule,  however,  it  grows  in  severity  with  the  progress  of  the  disease.  It  is 
caused  by  the  irritation  of  intercurrent  bronchitis  or  bronchopneumonia  or 
the  accumulated  contents  of  cavities.  When  a  cavity  becomes  more  or  less 
ifilled  with  secretion  it  must  be  emptied,  and  a  spell  of  coughing  comes  on 


26o  INFECTIOUS  DISEASES. 

and  continues  until  the  cavity  is  cleared  out,  whence  the  paroxysmal  char- 
acter so  often  assumed  by  the  cough  when  this  stage  is  reached. 

The  expectoration  of  tuberculosis  varies  with  the  stage  of  the  disease. 
At  first  scanty,  and  in  no  way  characteristic,  it  grows  more  copious  and 
becomes  puriform  as  the  disease  progresses.  A  more  or  less  circular  shape 
is  finally  assumed,  which  is  somewhat  distinctive,  and  is  called  "  num- 
mular," from  its  resemblance  to  a  coin.  The  quantity  of  expectoration 
varies  greatly,  from  1-2  ounce  (15  c.  c.)  to  1-2  pint  (250  c.  c.)  in  the 
twenty-four  hours.  It  generally  has  a  sweetish,  unpleasant  odor,  but  is 
rarely  offensive.  It  is  sometimes  tinged  with  blood,  and  may  contain 
Charcot's  crystals  (p.  265). 

Minutely,  the  expectoration  is  made  up  chiefly  of  pus-corpuscles,  among 
which  may,  however,  be  found  epithelial  cells  from  the  mouth  and  lung 
alveoli,  elastic  tissue  from  the  air-vesicles,  more  rarely  from  the  bronchial 
tubes  or  blood-vessels,  oil  drops,  particles  of  food,  generally  innumerable 
tubercle  bacilli,  and  at  times  blood-discs.  The  elastic  tissue  is  most  easily 
demonstrated  by  boiling  the  sputum  in  a  test-tube  with  an  excess  of  solution 
of  potash  or  soda,  the  effect  of  which  is  to  thin  the  sputum  and  permit  the 
elastic  tissue  to  fall  to  the  bottom  of  the  tube;  whence  it  is  easily  carried 
by  the  pipette  to  the  glass  slide  and  recognized  under  the  microscope  by 
its  wreath-like  or  circular  shape,  if  derived  from  the  air-vesicles.  Care  must 
be  taken  to  eliminate  fibers  of  elastic  tissue  that  may  be  derived  from  food. 
To  this  end  the  mouth  should  be  carefully  rinsed  before  collecting  spu- 
tum for  examination,  and  it  is  further  to  be  remembered  that  particles  of  food 
containing  such  tissue  may  remain  in  the  mouth  for  two  or  three  days.  The 
elastic  tissue  from  the  bronchi  occurs  in  the  shape  of  elongated  or 
reticular  fibers.  That  from  blood-vessels  is  similar;  more  rarely  it  is 
fenestrated  membrane.  The  alveolar  epithelial  cells  are  round  and  oval, 
mononucleated,  highly  granular,  nearly  twice  the  diameter  of  a  pus-corpuscle. 

The  bacilli,  which  are  an  unfailing  sign  of  tuberculosis,  are  demon- 
strable only  by  special  staining  methods,  of  which  that  by  carbol  fuchsin, 
with  or  without  Gabbet's  counter-stain  of  methyl-blue  (see  p.  238),  is  recom- 
mended. 

One  of  the  most  unpleasant  consequences  of  the  cough  is  the  vomiting 
which  it  induces,  more  especially  in  the  last  stages  of  the  disease.  It  is  not 
unusual  to  throw  up  a  meal  immediately  after  it  is  taken  as  the  result  of  a 
paroxysm  of  coughing.  Such  vomiting  is  probably  a  reflex  act,  excited  by 
irritation  of  the  pharynx  in  coughing.  Fortunate  is  the  patient  who  can 
immediately  thereafter  take  another  meal,  since  this  meal  is  generally 
retained,  because  the  accumulated  muco-pus  which  caused  the  coughing 
spell  is  also  thrown  up  with  the  food  in  the  first  act  of  vomiting,  and  the 
cough  ceases  for  a  while. 

Pain  is  not  inherent  to  tuberculosis — that  is,  the  seat  of  a  tubercular 
infiltration  is  not  usually  a  seat  of  pain.  Pain  is,  however,  a  frequent  sec- 
ondary symptom.  It  is  most  severe  as  the  result  of  a  concurrent  pleurisy, 
when  it  is  usually  sharp  and  cutting  at  the  site  of  the  pleurisy.  Pain  also 
results  from  inveterate  cough.  Such  pain  is  usually  in  the  lower  part  of 
the  chest  and  is  mainly  caused,  I  believe,  by  the  motion  to  which  this  part  of 
the  thorax  and  the  diaphragm  are  subjected  in  the  act  of  coughing. 

Fever  is  a  symptom  of  all  stages  of  pulmonary  consumption.  At  the 
onset  there  may  be  fever  of  an  irritative  kind,  due  to  the  deposition  of 
the  tubercle  and  to  inflammation.     This  is  a  fever  of  a  continued  type  with 


TUBERCULOSIS. 


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262 


INFECTIOUS  DISEASES. 


slight  evening  increments,  often  overlooked,  until  it  becomes  associated  with 
hectic  fever,  which  is  a  septic  fever  occurring  during  softening  and  cavity 
formation.  Hectic  fever  is  one  of  the  most  interesting  symptoms  of  con- 
sumption, adding  often  a  picturesqueness  that  increases  the  sadness  of  the 
situation.  Coming  on  usually  toward  the  end  of  the  day,  the  maximum  point 
is  reached  at  no  fixed  hour,  but  generally  occurs  between  2  and  6  P.  M., 
though   it   may   be    as   late   as    10    P.    M.     The    minimum,    usually    noted 


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Fig.  24. — Temperature  Chart  of  a  Case  of  Tubercular  Consumption  without  Fever, 
long  under  treatment  at  the  Hospital  of  the  University  of  Pennsj^vania. 

between  2  A.  M.  and  6  A.  J\I.,  may  occur  as  late  as  12  noon.  Hence,  fre- 
quent observations  of  temperature  should  be  made  during  the  day  and  night, 
two  in  twenty-four  hours  being  inadequate.  Once  in  four  hours  is  not  infre- 
quently desirable,  and  where  careful  study  is  desired,  once  in  tv/o  hours  may 
be  necessary.  The  chart  (Fig.  23),  on  page  261,  shows  extreme  range  of 
temperature  in  hectic  fever. 

There  is,  however,  no  greater  mistake  than  to  suppose  that  every  case 
of  consumption  must  have  fever  throughout.  It  probably  always  has  fever 
in  the  beginning — the  fever  of  onset;  but  with  the  disease  once  established 
it  frequently  happens  that  there  is  no  fever  in  any  part  of  the  twenty-four 
hours.     Appended  is  a  chart  of  such  a  case  (Fig.  24). 

In  the  course  of  a  caae  of  consumption  it  constantly  happens  that 
periods  occur  of  various  duration,  from  one  to  seven  days,  in  which  the 
fever  is  higher  than  usual  with  moderate  remissions,  say  of  one  degree,  and 
attended  with  increased  localized  pain.  These  are  explained  by  the  occur- 
rence of  new  patches  of  bronchopneumonia,  which  may  be  either  simple  or 
tubercular. 

The  fever  of  hectic  is  generally  followed  by  siveating,  sometimes  lim- 
ited to  the  head  or  the  neck.  The  occurrence  of  sweats  in  the  night,  or 
rather  toward  morning,  has  given  rise  to  the  term  "  night-sweat."  They 
are  not,  however,  confined  to  the  night,  but  may  occur  at  any  time,  especially 
during  sleep. 

The  pulse  is  always  frequent  in  tubercular  consumption,  and  gradually 
grows  feebler  as  the  disease  progresses. 

Hemorrhage  from  the  lungs  is  a  symptom  everywhere  associated  with 
the  idea  of  consumption.     There  are  two  periods  in  which  it  occurs — one 


TUBERCULOSIS.  263 

early  and  one  late.  The  early  hemorrhages  are  usually  moderate  and  are  due 
to  the  rupture  of  blood-vessels  weakened  by  tubercular  infiltration.  They  are 
sometimes  the  very  first  announcement  of  the  presence  of  the  disease,  at 
others  they  are  a  means  of  relief  to  a  certain  feeling  of  oppression  in  the 
chest  which  precedes  them.  Their  greatest  danger  is  production  of  an  insuf- 
flation pneumonia  by  the  inspiration  of  small  particles  of  clot  that  act  as 
irritants.  When  the  hemorrhages  are  small  the  blood  is  often  admixed  with 
mucus,  constituting  the  true  hemoptysis.  In  such  cases  the  blood  probably 
comes  from  the  mucous  membrane  of  the  bronchial  tubes.  The  hemor- 
rhages' late  in  the  disease  are  commonly  large,  sometimes  enough  to  cause 
immediate  death.  The  amount  of  blood  lost  in  such  a  fatal  case  has  reached 
four  pounds  (1.8  kilos) .  Yet  enormous  hemorrhages  are  sometimes  survived. 
They  are  due  to  ulceration  into  a  large  blood-vessel,  often  one  of  those 
described  as  traversing  the  wall  of  a  cavity  or  bridging  it  from  side  to  side. 

Diarrhea  is  a  frequent  symptom  late  in  the  disease.  It  is  commonly 
due  to  tuberculosis  of  the  bowel  and  is  often  exceedingly  obstinate.  Not 
every  diarrhea,  however,  in  tuberculosis  is  tubercular. 

The  cluh-fingcr  was  noted  by  Hippocrates,  and  has  long  been  asso- 
ciated with  consumption — though  not  peculiar  to  it.  It  is  a  condition  found 
in  other  chronic  diseases,  as  emphysema,  chronic  bronchitis,  chronic  cardiac 
disease,  and  aneurysm.  The  end  of  the  finger  is  bulbous,  quite  like  a  club, 
and  the  nail  curves  over  the  end.     It  may  involve  some  of  the  fingers  only. 

Tuberculous  meningitis  may  be  added  toward  the  close  of  the  disease. 
In  it  there  is  extension  of  tuberculosis  to  the  membranes  of  the  brain,  pro- 
ducing symptoms  such  as  pain  in.  the  head,  delirium,  acute  mania,  vomiting, 
fever,  and  finally  convulsions  and  coma.  The  symptoms  vary  a  good  deal 
with  the  seat  of  the  involvement,  and  have  been  considered  in  detail  when 
treating  of  tubercular  meningitis.  If  the  inflammation  is  in  the  fissure  of 
Sylvius,  there  may  be  aphasia  and  even  hemiplegia ;  if  at  the  base,  retraction 
0:f  the  head  and  palsies  of  the  cranial  nerves  from  pressure,  also  optic 
neuritis ;  if  on  the  convexity,  delirium  is  more  decided,  and  there  may  be 
local  convulsions  with  hemiplegic  weakness.  Ventricular  efifusion — acute 
hydrocephalus — adds  little  to  the  specialization  of  symptoms.  There  may 
be  co-involvement  of  the  membranes  of  the  brain  and  spinal  cord,  pro- 
ducing symptoms  of  cerebrospinal  meningitis. 

The  relation  of  pulmonary  consumption  to  cardiac  disease  has  always 
been  an  interesting  one.  It  is  commonly  thought  that  affections  of  the 
heart  and  lungs  are  never  concurrent.  Occasionally  such  concurrence  is 
observed,  but  whether  such  relation  is  any  but  an  accidental  one  is  doubt- 
ful. Osier  reports  12  instances  of  endocarditis  in  216  autopsies  on  cases  of 
consumption.  The  rarity  of  lung  tuberculosis  succeeding  chronic  valvular 
heart  disease  must  still  be  admitted.  It  has  been  ascribed  to  hypertrophy  of 
the  unstriped  muscular  structure  about  the  smaller  bronchioles  and  their 
acinous  terminations,  which  keeps  the  alveoli  evacuated  of  such  secretions  as 
favor  the  development  of  phthisis. 

Chronic  nephritis  and  amyloid  kidney  are  frequent  complications  of 
chronic  phthisis.  From  these  causes  alhumimiria  may  result.  There  may 
be  simple  febrile  albuminuria.  Or  albi^minuria  may  be  due  to  pus,  if  there  is 
tuberculosis  of  the  bladder  or  kidney.  Tubercle  bacilli  should  be  sought  for 
in  purulent  urine. 

The  liver  is  often  enlarged  from  fatty  infiltration. 

Diagnosis. — The  diagnosis  of  chronic  tubercular  consumption  may  be 


264  INFECTIOUS  DISEASES. 

difficult  in  tiie  early  stages,  but  later,  when  the  physical  signs  have  devel- 
oped, it  is  easy.  Even  in  the  early  stages  the  finding  of  the  bacillus  removes 
all  doubt.  Occasionally,  however,  the  sputum  is  very  scanty  and  difficult 
to  get.  If  such  an  examination  is  not  possible,  or  furnishes  negative  results, 
some  days  may  elapse  before  a  positive  diagnosis  is  obtained.  For  the 
physical  signs  in  the  early  stages  cannot  always  be  relied  on,  while  there 
occur  cases  in  which,  even  months  after  bacilli  have  been  found  in  the  spu- 
tum, the  physical  signs  are  confusing  and  inconclusive.  Due  regard  must  be 
paid  to  the  fact  that  in  health  the  expiratory  sound  below  the  right  clavicle 
is  longer  and  rougher  than  in  a  corresponding  position  on  the  opposite 
side,  while  the  percussion  note  may  also  be  somewhat  higher  pitched.  The 
presence  of  fever  more  or  less  constant,  the  bright  eye,  and  crimson  flush 
in  the  cheek,  with  or  without  emaciation,  should  excite  suspicion  and  lead 
to  careful  physical  exploration  and  examination  of  the  sputum,  if  not  already 
made.  The  search  of  the  sputum  for  elastic  tissue  is  relatively  less  valu- 
able, because  bacilli  are  usually  found  much  earlier. 

In  doubtful  cases  the  tuberculin  test  may  be  made.  I  have  found  it 
very  reliable  in  a  number  of  cases,  and  believe  it  is  without  danger.  E.  L. 
Trudeau,  of  Saranac  Lake,  confirms  this  by  his  large  experience,  and  says 
further,  that  tuberculosis  of  so  moderate  an  extent  as  not  to  give  any  positive 
symptoms  probably  exists  in  30  per  cent,  of  individuals  who  have  no  reason 
to  suspect  its  presence.  One  milligram  of  pure  tuberculin  is  injected  hypo- 
dermically,  and  if  there  be  no  febrile  reaction  in  10  to  12  hours,  twice  this 
quantity  is  used  two  or  three  days  later,  and  gradually  increased  at  intervals 
until  five  milligrams  have  been  injected  at  a  dose.  If  there  be  no  rise  in 
temperature  within  ten  to  twelve  hours  the  patient  may  be  considered  free 
from  tuberculosis.  The  usual  rise  is  from  two  to  four  degrees  F.  Tuber- 
culin should  not  be  used  where  the  diagnosis  can  be  made  without  it.* 

I  cannot  refrain  from  adding  a  word  on  the  importance  of  securing  the 
physical  examination  under  favorable  conditions  early  in  the  study  of  a 
case.  Especially  is  this  true  of  cases  in  which  there  is  a  hereditary  tend- 
ency. It  goes  without  saying,  that  the  physical  signs  of  incipient  con- 
sumption may  easily  escape  detection  when  an  examination  is  made  with 
the  clothing  on,  while  they  would  be  easily  recognized  if  the  patient  were 
stripped  to  the  skin.  Too  frequently,  also,  an  examination  is  deferred 
because  of  a  fear  that  the  patient  will  be  needlessly  alarmed  thereby.  So- 
called  "  hemorrhages  from  the  throat  "  should  be  carefully  investigated,  as 
should  also  any  continued  hacking  cough.  Many  of  these  coughs  are  now 
known  to  be  due  to  tonsillar  trouble,  but  this  should  not  be  taken  for  granted, 
and  a  careful  examination  of  the  throat  should  be  associated  with  a  physical 
examination  of  the  chest.  A  habitually  frequent  pulse  and  rapid  breathing 
should  also  excite  suspicion.  We  should  not  omit  either  to  examine  the 
posterior  part  of  the  chest  in  the  supraspinous  fossae,  for  it  sometimes  hap- 
pens that  physical  signs  are  here  detected  before  they  are  recognizable  in 
front. 

*  Tuberculin  is  the  concentrated  glycerin  extract  of  tubercle  bacilli,  and  is  made  by  evaporating 
a  luxuriant  glycerin  bouillon  culture  of  the  bacillus  to  one-tenth  of  its  volume.  This  is  known  as 
crude  tuberculin,  and  while  used  as  such  for  bovine  inoculation  must  be  greatly  diluted  for  use  upon 
the  human  subject.  The  crude  extract  is  on  the  market,  being  prepared  in  Koch's  laboratory  in 
Berlin  and  by  dilTerent  commercial  firms  in  this  country.  Dr.  Ravenel,  of  the  Laboratory  of  the 
Live  Stock  Association  of  Pennsylvania,  prepares  from  the  crude  article  made  by  him  a  stock  solu- 
tion for  human  inoculation.  One  cubic  centimeter  of  this  solution  contains  o.i  gram  of  crude 
tuberculin  in  a  one  per  cent,  solution  of  carbolic  acid.  The  latter  is  added  in  order  to  preserve  the 
active  properties  of  the  tuberculin  and  to  keep  the  preparation  sterile.  At  the  time  of  using,  one 
part  of  the  stock  solution  is  diluted  in  twenty  parts  of  sterile  water,  and  then  one  cubic  centimeter 
(15  minims)  will  contain  0.005  gram  or  5  milligrams.  Further  dilution  necessary  to  obtain  the 
smallest  quantity  desired  may  be  made  at  the  time  of  using. 


TUBERCULOSIS.  265 

Prognosis. — The  prognosis  of  chronic  ulcerative  phthisis  varies  greatly 
w^ith  different  cases.  Its  duration  extends  over  periods  of  from  a  few  months 
to  years. 

A  more  important  practical  question  is  that  of  its  possible  curability 
and  our  power  to  defer  the  unfavorable  end.  That  occasional  cures  from 
consumption  take  place  cannot  be  denied ;  that  there  is  such  a  thing  even 
as  spontaneous  recovery  must  also  be  admitted.  That  such  recoveries  are 
infrequent  and  even  rare  does  not  alter  the  fact  that  they  do  occur.  That 
much  may  also  be  done  to  put  off  the  fatal  ending  of  this  very  sad  disease 
admits  of  even  less  dispute.  Sooner  or  later,  however,  it  is  usually  fatal. 
But  we  should  not  be  deterred  by  this  fact  from  using  our  best  endeavors, 
not  only  to  put  off  the  end,  but  also  to  seek  an  ultimate  cure. 

{h)  Fibroid  Phthisis. 

Definition. — This  term  is  applied  to  a  form  of  pulmonary  consumption 
in  which  the  lung,  in  addition  to  being  the  seat  of  tuberculosis,  is  permeated 
by  an  overgrowth  of  fibroid  tissue.  Its  course  is  much  slower,  and  while 
it  often  begins  as  an  inhalation  bronchitis  in  those  exposed  to  the  inhala- 
tion of  fine  particles  of  dust  from  various  sources,  it  may  also  begin  as  an 
ordinary  ulcerative  or  catarrhal  phthisis. 

Symptoms. — Its  symptoms,  on  the  whole,  are  less  aggravated  than  those 
of  ordinary  phthisis.  The  cough  is  less  severe,  less  exhausting,  though 
more  apt  to  be  paroxysmal,  and  the  patient  has  less  fever  and  emaciates 
less  rapidly.  He  is  often  able  to  pursue  some  occupation.  Bacilli  are  less 
numerous  and  are  found  with  greater  difficulty.  Expectoration  is  often, 
however,  as  copious,  usually  arising  from  cavities  or  dilated  bronchi,  and 
is  more  frequently  fetid.  It  may  contain  fat  crystals  and  Charcot's  acicular 
crystals.  There  may  also  be  hemorrhage.  With  the  addition  of  these  symp- 
toms, and  the  presence  of  bacilli  in  the  sputum,  the  clinical  history  is 
scarcely  different  from  that  of  simple  non-specific  cirrhosis  of  the  lung,  from 
which  it  is,  indeed,  often  separated  with  difficulty.  As  in  this  affection 
there  may  be  hypertrophy  of  the  right  ventricle,  induced  by  the  extra  effort' 
demanded  of  the  right  heart  to  move  the  blood  through  the  fibroid  lung. 
Fibroid  phthisis  is  especially  characterized  by  its  prolonged  course,  which 
may  extend  over  years. 

Physical  Signs. — The  degree  of  retraction  of  the  chest  wall  as  noticed 
by  inspection  is  greater  than  in  the  ulcerative  form,  more  easily  recognized, 
and  not  always  confined  to  the  vicinity  of  the  apices  of  the  lungs.  The  heart 
is  frequently  dislocated  and  its  apex  correspondingly  awry,  sometimes  to  an 
extreme  degree.  If  on  the  left  side,  owing  to  retraction  of  the  lung,  there 
may  sometimes  be  seen  a  distinct  cardiac  pulsation  in  the  second,  third,  and 
fourth  interspaces.  The  intercostal  spaces  are  often  narrowed  and  the  dia- 
phragm may  be  drawn  up.  Modifications  of  vocal  fremitus  as  revealed  to 
palpation  are  not  nearly  so  constant,  being  masked  by  the  retraction  and 
pleuritic  complications,  and  may  be  absent.  There  is  often  little  or  no  eleva- 
tion of  temperature. 

Percussion  is  more  constant  in  its  results,  there  being  marked  dullness 
and  a  wooden-like  resistance.  The  hypertrophy  of  the  right  ventricle  re- 
ferred to  may  extend  the  normal  cardiac  dullness  in  positive  degree  toward 
the  right  edge  of  the  sternum. 

Auscultation  most  frequently  notes  bronchial  breathing  and  exaggerated 


266  INFECTIOUS  DISEASES. 

voice  sound,  but  both  of  these  may  be  lessened  in  intensity  by  a  thickened 
pleural  membrane.  A  dilated  bronchus  is  frequently  present,  yielding  the 
signs  of  a  cavity,  which  may  be  found  in  the  middle  or  even  at  the  base 

of  the  lung. 

To  the  signs  of  the  fibroid  state  in  one  part  of  a  lung  are  frequently 
added  those  of  emphysema  in  the  remainder  or  in  the  other  lung. 

Prognosis. — This  is  perhaps  no  better,  so  far  as  cure  is  concerned, 
than  for  the  chronic  ulcerative  phthisis,  but,  as  has  already  been  stated,  the 
duration  of  the  disease  is  much  longer,  and  under  favorable  circumstances 
much  more  can  be  done  for  the  patient  by  the  same  treatment. 

Treatment  of  Chronic  Tubercular  Phthisis. — There  is  no  disease  of 
like  importance  in  which  treatment  must  for  various  reasons  differ  so  much  in 
different  cases.  This  is  owing  partly  to  the  fact  that  curative  measures  must 
be  adapted  more  or  less  to  the  circumstances  of  the  patient,  and  partly  to  the 
varving  peculiarities  of  the  patient  himself.  In  the  following  pages  I  will 
advise  first,  regardless  of  the  patient's  circumstances,  the  treatment  which 
experience  has  shown  to  be  most  efficient,  then  recommend  such  measures  as 
are  useful  or  necessary  under  any  circumstances. 

The  fundamental  principle  of  a  successful  treatment  of  a  case  of  tuber- 
cular consumption  is  early  diagnosis  and  corresponding  promptness  in  the 
application  of  remedial  measures,  supported  by  the  belief  that  consumption 
is  not  a  hopelessly  incurable  disease.^ 

1.  Climate  Treatment. — Immediately  after  its  recognition,  or  even,  if 
possible,  when  the  disease  is  threatened,  the  patient  with  tubercular  con- 
sumption should  be  sent  to  a  suitable  climate,  provided  always  that  other 
necessary  conditions  of  a  wholesome  and  happy  life  can  be  secured.  To 
discuss  at  length  the  relative  value  of  such  places  would  occupy  more  space 
than  is  justified  in  a  text-book,  but  the  following  may  be  laid  down  as  truths 
reached  by  those  who  have  specially  studied  the  subject:  f 

1.  Tuberculosis  is  relatively  rare  in  the  following  localities  in  the  order 
named,  viz. :  On  certain  sea-coasts,  such  as  that  of  southern  California,  in- 
cluding Santa  Barbara,  San  Diego,  Coronado  Beach,  and  somewhat  further 
inland,  Los  Angeles  and  Pasadena;  on  certain  islands  enjoying  a  nearly 
pure  ocean  climate,  such  as  the  Madeiras  and  Canaries ;  in  desert  places  of 
wide  extent,  such  as  are  found  in  the  interior  of  continents,  including  the 
Nile  Valley  and  Algiers ;  in  polar  regions ;  and,  finally,  it  is  rarest  at  high 
altitudes,  its  frequency  diminishing  with  increasing  altitude.  The  elevated 
plains  of  Colorado  and  New  Alexico  furnish  pre-eminently  the  best  condi- 
tions. 

2.  Animals  successfully  inoculated  with  the  bacilli  of  tuberculosis  de- 
velop the  disease  rapidly  when  confined,  while  those  kept  in  the  open  air 
may  escape  entirely. 

3.  Damp,  especially  cold  and  damp  soil,  favors  the  development  of  tuber- 
culosis, as  do  also  variations  in  dampness  when  conjoined  wath  changes  in 
temperature. 

4.  ]\Ioist  heat  has  no  influence  in  producing  the  disease,  but  cases  origi- 
nating in  tropical  countries  where  the  disease  is  prevalent  progress  rapidly. 

5.  Dryness  of  air  is  a  positive  advantage  to  the  consumptive,  while 
variability  in  a  comparatively  dry  air  has  no  prejudicial  influence.    Humidity 

*  For  evidence  of  the  correctne<;s  of  this  dictum  see  a  paper  by  S.  Edwin  Solly,  "Neglect  of  the 
Early  Dias^nosis  and  Treatment  of  Pulmonarv  Tuberculosis,"  "  Aled.  News,"  February  4,  i8q^. 

t'See  S.  E.  Solly's  article  "Climate,"  in  Hare's  "  System  of  Therapeutics,"  vol.  i.  p.  415,  Philadel- 
phia, 1801. 


TUBERCULOSIS.  267 

apart  from  other  factors  is  apparently  without  effect,  either  in  causing  the 
disease  or  curing  it;  for,  although  benefit  has  been  received  in  a  humid  or 
sea  climate,  Solly  considers  it  "  probable  that  it  is  mainly  due  to  greater 
purity  of  the  air  or  the  elimination  of  unsanitary  conditions  and  hurtful  occu- 
pations, as  when  an  overworked  citizen  takes  a  sea  voyage,  or  a  Bostonian  is 
sent  into  such  a  climate  as  the  Isles  of  Shoals,  or  a  Philadelphian  to  Atlantic 
City."  Whatever  the  cause,  the  beneficial  influence  of  a  sea  voyage  to  the 
consumptive  is  undoubted. 

Where  low  climates  are  characterized  b}-  infrequency  of  phthisis  it  is  by 
reason  of  dryness  and  uniformity  of  temperature,  as  is  the  case  in  lower 
Egypt  and  the  Valley  of  the  Nile  in  Central  and  Upper  Egypt,  and  in  the 
interior  of  Algiers  as  contrasted  with  the  coast  belt  of  that  country,  with 
Java,  with  the  Gulf  States  of  America,  Mexico,  Guiana,  and  some  of  the 
West  India  Islands. 

That  elevation  is  unfavorable  to  the  development  of  consumption  and 
favorable  to  its  cure  is  abundantly  attested,  but  there  is  some  difference  in 
opinion  as  to  the  degree  of  altitude  at  which  these  qualities  are  manifested, 
some  placing  it  as  low  as  1500  feet,  the  majority  at  2500  feet.  The  latter  is 
probably  the  more  correct,  though  there  is  reason  to  believe  that  different 
individuals  as  well  as  different  stages  of  the  disease  may  be  differently 
influenced  in  this  respect.  For  the  most  part  dryness  goes  with  altitude, 
so  that  the  two  conditions  are  commonly  associated.  How  altitude  operates 
independently  of  dryness  is  not  easy  of  explanation,  although  it  is  probable 
that  diminished  atmospheric  pressure  is  the  potent  factor.  The  method  of 
its  action  is  perhaps  not  precisely  understood,  but  the  immediate  effect  is 
increased  breathing-rate  and  pulse-rate;  next,  an  increase  in  the  depth  of 
each  respiration,  followed  by  cardiac  expansion  and  by  hypertrophy ;  and 
later,  by  a  fall  in  the  rate  of  breathing  and  pulse  to  the  normal,  as  the  depth 
of  the  respirations  and  the  amount  of  blood  passing  through  the  heart  at 
each  contraction  are  increased. 

The  following  classification,  by  G.  A.  Evans,*  of  the  climates  resorted 
to  by  consumptives  may  be  found  useful  in  making  a  selection  of  climate 
for  a  particular  case: 

1.  Climate  Cool  and  Moderately  Moist,  general  elevation  2000  feet — 
Western  slope  of  the  Appalachian  chain,  Adirondacks,  Catskill,  Allegheny, 
and  Cumberland  Mountains. 

2.  Climate  Moderately  Warm  and  Moderately  IMoist. — Western  North 
Carolina,  Asheville,  elevation  2250  feet ;  Western  South  Carolina,  Aiken ; 
Georgia,  Marietta  and  Thomasville. 

3.  Climate  Warm  and  Moist. — Florida,  Southern  California,  coast  region. 

4.  Climate  Warm  and  Moderately  Dry,  elevation  about  2000  feet. — 
Southwestern  Texas,  Southern  California,  inland. 

5.  Climate  Cool  and  Moderately  Dry,  elevation  about  1000  feet. — yiin- 
nesota,  Nebraska,  Dakota. 

6.  Climate  Cool  and  Dry,  elevation  from  4000  to  7000  feet. — Montana, 
Wyoming,  Colorado,  Northern  New  Mexico,  and  Western  Kansas.  In  this 
group  are  to  be  placed  Davos  and  St.  Moritz,  in  Europe. 

7.  Climate  Warm  and  Dry,  elevation  3000  to  5000  feet. — Southern 
New  Mexico  and  Southern  Arizona. 

A  further  division  of  resorts  in  accordance  with  altitude  is  into  !ozv_, 

*  "Handbook  of  Phthisology,"  New  York,  1888. 


268  JXFECTIOL'S  DISEASES. 

mediiun,  and  elevated.  In  the  first  of  these  fall  naturally  Florida,  Georgia,, 
and  Southern  California ;  in  the  second,  places  with  an  elevation  of  from 
1500  to  2500  feet,  including  Asheville,  the  Adirondack  and  Catskill  Aloun- 
tains;  in  the  third,  altitude  of  5000  feet  and  above,  including  the  slopes  of 
the  Rocky  ^Mountains  from  Wyoming  down  to  Arizona  in  this  country  and 
Davos  and  St.  ]\Ioritz  in  Europe. 

As  to  the  permanence  of  the  curative  results  of  treatment  at  high  alti- 
tudes, it  is  a  common  impression  among  the  laity  that  persons  to  retain  the 
advantages  gained  in  such  climates  must  remain  there.  Of  this  Solly  says : 
"  I  am  firml}-  of  the  belief  that  persons  cured  in  elevated  countries  have  at 
least  as  good  a  chance  of  keeping  well  after  returning  home  as  those  cured 
at  sea  level,  and  owing  to  the  decided  increase  in  general  and  pulmonary 
vitality  imparted  by  the  climate,  probably  a  much  better  one." 

The  usefulness  of  sanitaria  for  consumptives  has  of  late  been  conclu- 
sively demonstrated.  Late  observations  would  seem  to  show  that  less  impor- 
tance attaches  to  location  of  these  sanitaria  than  has  heretofore  been  believed, 
although  it  is  reasonable  to  suppose,  that  sanitaria  at  high  altitudes  will  fur- 
nish the  most  satisfactory  results.  The  keynote  of  success  in  tJiese  is  the 
stringent  hygiene  and  open  air  life. 

II,  Hygiene  Treatment. — The  following  should  be  carried  out  as  far 
as  possible  in  every  case,  whether  the  patient  is  enabled  to  make  the  change 
of  climate  advised  or  compelled  by  the  force  of  circumstances  to  remain  at 
home:  Secure  a  habitation  wholesomely  located,  free  from  dampness,  avoid- 
ing low  ground.  The  apartments  occupied  should  be  those  accessible  to 
sunlight  for  as  many  hours  of  the  day  as  possible.  In  this  latitude  a  south 
and  west  exposure  obtains  this  condition.  Provide  the  best  possible  ventila- 
tion for  day  and  night.  Especially  at  night  should  sleeping  chambers  be 
thoroughly  ventilated,  as  during  the  day  the  patient  secures  the  efifects  of 
change  of  place,  while  at  night  he  is  compelled  to  remain  in  a  single  room. 
The  more  nearly  the  air  of  the  sleeping  chamber  approaches  that  of  out- 
doors the  more  likely  is  the  patient  to  improve.  \^entilation  should  be 
secured  without  subjecting  the  patient  to  drafts  of  air.  A  low  temperature  at 
night  may  be  rendered  less  harmful  than  drafts  of  warmer  air,  since  its 
effects  may  be  counteracted  by  extra  covering. 

In  addition  to  availing  himself  of  a  proper  location  and  ventilation,  the 
patient  should  spend  as  much  time  as  possible  out-of-doors,  and  except  dur- 
ing active  fever,  in  the  practice  of  moderate  exercise,  due  regard  being  had 
to  its  effect  on  the  heart  and  breathing.  No  sudden  or  forced  efforts  should 
be  made.  For  the  most  part  the  patient  should  be  kept  moving,  although,  if 
the  weather  is  suitable,  he  may  also  sit  for  a  time.  Sunlight  rather  than 
shade  should  surround  him  in  his  outdoor  life,  and  the  temptation  to  sit 
down  long  for  rest  in  cool,  shady  places  should  be  resisted. 

Daily  bathing  of  the  most  thorough  kind  should  be  insisted  upon,  it 
may  be  wath  cool  though  not  with  very  cold  water.  It  should  be  followed 
by  active  friction,  so  as  to  maintain  the  skin  functions  at  their  highest  point.. 
Cold  sea-bathing  is  not  to  be  recommended,  because  the  reactive  power  of 
consumptives  is  very  feeble,  and  a  chill  of  the  body  may  be  followed  by 
permanently  harmful  results. 

The  body  should  be  clothed  in  wool  next  the  skin  by  day  and  by  night, 
winter  and  summer.  At  night  nothing  is  better  or  more  convenient  than  a 
long  flannel  night-gown  extending  almost  to  the  feet. 

III.  Food  should  be  abundant  and  of  the  best  and  most  nutritious  kind. 


TUBERCULOSIS.  269 

Meats,  including  especially  fats,  poultry,  game,  oysters,  fish,  rich  animal 
broths  prepared  in  the  most  tempting  way  should  be  provided,  because  the 
quantity  taken  should  be  as  large  as  can  be  digested  and  assimilated.  Milk 
and  cream,  cheeses,  and  the  like  are  eminently  suitable.  Koumiss  or  zoolak 
may  be  substituted  for  milk. 

What  shall  we  say  of  alcohol?  It  is  in  the  majority  of  cases  an  efficient 
adjuvant  in  consumption,  if  properly  used.  That  it  is  at  times  abused  and 
that  the  alcoholic  habit  is  sometimes  acquired  does  not  alter  the  fact  that 
it  is  useful.  The  physician  should  watch  its  use  as  he  does  that  of  mor- 
phin.  A  moderate  amount  with  meals  in  the  shape  of  whisky  improves 
digestion  and  increases  appetite,  while  combined  with  milk  and  cod-liver 
oil  it  helps  the  assimilation  of  the  latter  and  contributes  to  fat  production — 
an  acknowledged  advantage  to  the  phthisical  patient.  He  should  be  limited 
to  a  couple  of  glasses  of  sherry  or  as  many  tablespoonfuls  of  whisky  at  dinner, 
while  a  half-ounce  morning  and  evening  with  a  glass  of  milk  will  be  as  use- 
ful as  a  larger  amount. 

The  whole  purpose  of  the  measures  recommended  under  this  heading 
is  the  production  by  improved  nutrition  of  a  soil  prejudicial  to  the  growth 
of  the  bacillus  of  tuberculosis.  The  effect  of  unhealthy  location,  dampness, 
bad  ventilation,  darkness,  deficiency  in  fresh  air  and  sunlight,  filth  of  body, 
chilling  influences,  colds,  improper  clothing,  and  insufficient  food  is  to  favor 
such  growth. 

The  treatment  of  consumption  by  suralimentation,  as  suggested  by 
Debove,  may  be  considered  at  this  point.  By  it  is  meant  surcharging  the 
stomach  with  food  through  the  stomach-tube.  While  it  is  true  of  the  victim 
of  consumption,  as  of  no  other  disease,  that  he  should  be  fed,  the  method 
does  not  seem  reasonable.  The  introduction  of  food  far  beyond  what  the 
appetite  calls  for  is  usually  attended  sooner  or  later  by  a  rebellion  of  the 
stomach.  At  the  same  time  some  happy  results  are  reported.  The  method, 
as  recommended,  is  to  wash  out  the  stomach  with  cold  water  and  then 
introduce  a  liter  ( i  quart)  of  milk,  an  egg,  and  100  gm.  (about  3  1-2  ounces) 
of  very  finely  powdered  meat.  This  is  done  three  times  a  day.  It  is  much 
more  rational  to  secure  a  natural  appetite  by  fresh  air  and  outdoor  life.  If, 
on  the  other  hand,  there  be  reason  to  believe  gastric  catarrh  is  present,  an 
occasional  washing  out  of  the  stomach  may  stimulate  the  appetite  whole- 
somely. Or  the  vegetable  bitters  may  be  used  for  this  purpose.  Of  these, 
the  tincture  of  nux  vomica  in  20-  to  30-minim  (1.3  to  2  c.  c.)  doses  before 
meals  in  cold  ws»ter  is  one  of  the  best.  The  compound  infusion  or  tincture 
of  gentian  in  two-dram  (8  c.  c.)  doses  is  also  excellent. 

IV.  Medicinal  Treatment. — As  to  medicines,  the  remedy  that  has 
undoubtedly  been  of  more  use  in  the  treatment  of  consumption  than  any 
other  is  really  a  food — cod-liver  oil.  When  cod-liver  oil  is  well  borne  it 
should  be  administered  to  every  such  case  of  consumption.  When  it  is  not 
well  borne,  that  is,  when  unpleasantly  eructated  or  causing  indigestion,  loss 
of  appetite,  or  diarrhea,  it  should  at  once  be  discontinued,  and  if  a  cautious 
attempt  to  return  to  it  is  met  with  a  similar  experience  no  further  trial  should 
be  made.  In  my  hands  the  best  method  of  administration  is  to  place  in  a 
wineglass  from  two  teaspoonfuls  to, a  tablespoon ful  of  whiskv  and  overlay  it 
with  the  same  amount  of  cod-liver  oil.  It  is  then  "  tossed  "  into  the  back 
part  of  the  throat,  and  after  a  little  experience  this  is  accomplished  with 
great  facility,  while  nothing  is  tasted  but  a  pleasant  rpsidue  of  whisky.  The 
maximum  dose  should  be  a  tablespoonful  twice  a  day.     The  best  time  is 


2^0  INFECTIOUS  DISEASES. 

immediately  after  breakfast  and  on  retiring  at  night,  although  experience 
may  determine  more  suitable  seasons. 

The  various  compound  preparations  and  emulsions,  consisting  of  cod- 
liver  oil,  other  tonic  substances,  gums,  and  flavors  to  cover  up  the  taste  do 
not  meet  with  much  favor  with  me.  At  best  they  are  but  half  oil,  they  are 
costly,  and  as  a  rule,  in  my  experience,  are  no  better  borne  than  the  pure  oil. 
Occasionally  they  are  better  tolerated,  and  under  such  circumstances  they 
should  be  administered.  It  should  be  remembered  that  the  chief  purpose  of 
the  whisky  is  not  so  much  to  cover  the  taste  of  the  oil  and  to  render  easy  its 
administration  as  to  favor  its  assimilation  and  efficiency. 

After  cod-liver  oil,  more  frequently  in  conjunction  with  it,  I  value 
creasote  or  its  derivative  creasotol.  Creasote  is  not  a  specific  for  consump- 
tion, but  it  relieves  the  catarrhal  symptoms  and  diminishes  the  cough  and 
expectoration.  There  are  various  modes  of  administering  it.  One  drop,  as 
dropped  from  an  ordinary  bottle — not  a  dropper— equals  very  nearly  1-2 
minim,  and  a  minim  weighs  almost  exactly  a  grain.  A  convenient  shape  is 
a  gelatin-coated  pill,  of  which  1-2  grain  (0.03  gm.)  pills  and  i  grain  (0.065 
gm.)  pills  are  made.  Beginning  with  i  grain  after  each  meal  and  increasing 
1-2  grain  a  day,  a  dose  of  6  to  7  grains  (0.39  to  0.45  gm.)  three  times  a  day 
is  very  easily  attained,  as  a  rule.  I  do  not  often  exceed  5  grains  (0.32  gm.) 
or  10  drops  three  times  a  day,  lest  the  stomach  be  upset.  One  should  seek, 
however,  to  reach  at  least  this  dose  and  keep  it  up  with  occasional  intermis- 
sions. Another  excellent  mode  of  administration  is  in  hot  water  immediately 
after  meals,  beginning  with  two  drops  or  a  minim  at  a  dose  and  increasing  up 
to  10  drops,  which  correspond  very  nearly  to  5  grains  (0.32  gm.).  It  may 
also  be  given  in  one  of  the  bitter  tinctures,  or  in  any  mixture  with  alcohol,  or 
in  emulsion,  or  with  sherry  wine.  Cod-liver  oil  and  creasote  ma}^  be  given 
conjointly — that  is,  the  creasote  may  be  incorporated  with  the  oil  before 
using. 

Still  better  than  creasote,  though  more  expensive,  is  creasotol  or  car- 
bonate of  creasote.  It  has  the  great  advantage  of  being  unirritating  and 
can  therefore  be  given  in  larger  doses.  I  begin  with  10  minims  (0.66  c.  c.) 
and  increase  to  30  minims  (2  c.  c.)  after  meals,  omitting  it  for  a  time  at  the 
end  of  every  six  weeks.  It  is  conveniently  given  in  capsules.  Among  those 
who  report  favorably  on  it  is  the  Berlin  clinician,  Leyden. 

Duotol  or  guiacol  carbonate  is  similar  in  its  effect  and  is  said  to  be  better 
borne  at  times  than  creasotol.  It  is  given  in  doses  of  0.2  to  0.5  gram  (3  to 
7  1-2  grains)  three  times  daily  in  capsules  or  wafers  or  dry  on  the  tongue, 
followed  by  a  mouthful  of  water." 

I  have  never  been  able  to  secure  happy  results  from  the  use  of  creasote 
by  inhalation.  It  may,  however,  be  employed  in  combination  with  chloro- 
form and  alcohol,  to  which  tincture  of  conium  is  sometimes  added  to  miti- 
gate the  irritating  qualities  of  the  vapor.  A  mixture  of  equal  parts  of  each 
may  be  made  and  a  few  drops  placed  on  the  sponge  of  a  Burney  Yeo's  inhaler, 
and  inhaled  as  long  at  a  time  as  possible ;  or  10  to  20  drops  (0.6  to  1.3  c.  c.) 
may  be  added  to  7  drams  (26.25  c.  c.)  of  water  and  i  dram  (4  c.  c.)  of 
glycerin,  and  used  in  one  of  the  numerous  excellent  forms  of  nebulizer  now 
in  use.  Or  it  may  be  placed  on  the  surface  of  steaming  water,  with  the  vapor 
of  which  it  may  be  carried  to  the  mouth  by  a  suitable  appliance.  A  little 
glass  tube,  open  at  both  ends  and  filled  with  small  pieces  of  pumice  on  which 
the  substance  to  be  inhaled  is  dropped,  also  serves  the  purpose  fairly  well. 

It  is  probable  that  the  inhalation  at  a  single  sitting  has  not  been  long 


TUBERCULOSIS,  271 

enough  continued.  The  following,  recommended  by  Clement  A.  Penrose,* 
has  impressed  me — creasote,  oil  of  turpentine,  each  four  drams  (16  c.  c.)  ; 
comp.  tr.  benzoin,  three  ounces  (90  c.  c.)  ;  one  dram  to  a  pint  of  hot  water. 
As  the  patient  becomes  accustomed  to  the  fumes,  more  of  the  creasote 
and  oil  of  turpentine  is  gradually  added  until  the  mixture  consists 
of  equal  parts  of  the  three  ingredients.  The  inhalations,  to  be  effective, 
should  be  systematic  and  of  from  ten  to  fifteen  minutes'  duration  each.  The 
above  inhalation  mixture  may  be  combined  with  steam  alone,  with  steam 
and  oxygen,  or  with  steam  at  home  and  with  steam  and  oxygen  at  the 
office. 

lodin  has  long  been  a  popular  remedy  employed  by  inhalation.  A  good 
way  is  to  dissolve  a  few  grains  in  an  ounce  of  ether  and  to  inhale  the  vapor 
with  the  mouth  or  nose  over  the  vial  for  a  few  minutes  at  a  time.  The  fol- 
lowing combination  may  be  used  in  the  little  pumice-loaded  tube  referred  to : 
Compound  tincture  of  iodin,  glycerole  of  carbolic  acid,  tincture  of  conium, 
each  a  dram  (4  c.  c.)  ;  spirit  of  chloroform,  enough  to  make  an  ounce  (30 
c.  c).  The  carbolic  acid  may  be  omitted,  if  desired,  and  other  changes  made. 
S.  Solis-Cohen  recommends  the  use  of  ethyl  iodid  placed  simply  in  an  ounce- 
vial,  over  which  the  patient  places  his  mouth  or  nose  and  inhales  for  five 
minutes  at  a  time.  Or  glass  capsules  containing  five  minims  of  the  drug 
may  be  crushed  in  a  cloth  and  then  inhaled.  He  regards  it  as  especially  use- 
ful in  ulcerative  laryngitis  and  as  assisting  in  the  disinfection  and  healing  of 
pulmonary  cavities. 

Iron  is  indicated  in  all  consumptive  cases,  and  it  is  generally  well  borne, 
but  it  should  be  given  in  much  smaller  doses  than  is  usual.  The  bane  of 
iron  is  its  constipating  effect,  and  this  counteracts  all  the  good  it  otherwise 
does,  and  in  my  experience  the  various  preparations  of  iron  do  not  differ 
materially  in  this  respect.  Such  effect  is  not  produced,  however,  if  a  proper 
dose  is  given,  and  if  it  constipates  in  the  dose  administered,  this  should  be 
reduced  until  no  such  effect  results.  When  this  is  attained  it  should  be  kept 
up  with  occasional  intermissions.  Five  or  six  drops  of  the  tincture  of  the 
chlorid  of  iron  thus  administered  and  kept  up  for  a  long  time  go  a  great  way 
toward  keeping  up  the  strength  and  counteracting  the  tendency  to  anemia 
so  characteristic  of  consumption.  Other  preparations  of  iron  are:  reduced 
iron,  carbonate  of  iron,  which  may  be  given  in  the  shape  of  Blaud's  pills,  and 
the  sulphate  of  iron.  The  vegetable  salts  of  iron,  the  citrates  and  malates, 
are  elegant  preparations,  and  the  same  principle  should  be  observed  in  their 
administration. 

Arsenic  is  often  useful  in  consumption  and  may  be  combined  with  iron 
or  alternated  with  it.  Many  consider  arsenic  more  beneficial  than  iron.  It 
is  not  desirable  to  give  very  large  doses,  and  five  minims  of  Fowler's  solu- 
tion are  a  sufficient  maximum  dose.  It  is  especially  useful  in  small  doses 
where  there  are  gastric  symptoms,  and  may  be  continued  in  moderate  doses 
for  a  long  time. 

Strychnin  is  a  drug  that  is  very  valuable  in  pulmonary  consumption, 
more  especially  as  a  heart  tonic.  It  should  also  be  continued  over  long 
periods  in  doses  of  1-30  to  1-20  grain  (0.0022  to  0.0032  gm.)  three  or  four 
times  a  day.  Ouinin  is  also  at  tim^es  very  useful,  especially  when  there  is 
fever. 

V.    Serum  Treatment  of  Tuberculosis.— The  late  J.  T.  Whittaker  * 


*  "  Johns  Hopkins  Hospital  Bulletin,"  November,  i8qo. 

t  "Theory  and  Practice  of  Medicine,"  New  York,  1893,  p.  158. 


272  LXFECTIOUS  DISEASES. 

correctly  said :  "  The  discovery  of  tuberculin  established  the  first  real  epoch 
in  the  treatment  of  tuberculosis,  as  it  constitutes  the  first  actual  address  to  its 
cause."  This  is  none  the  less  true  in  view  of  the  fact  that  the  first  essays 
with  it  appeared  to  be  absolute  failures.  There  is  reason  to  believe,  how- 
ever, that  the  continued  use  of  it  and  antitubercle  serum  by  certain  coura- 
geous therapeutists — Whittaker,  of  Cincinnati,  just  quoted,  Dennison,  of 
Colorado,  Trudeau,  of  the  Adirondack  region  in  Xew  York,  Karl  v.  Ruck, 
of  Asheville,  ]^Iaragliano,  and  E.  A.  de  Schweinitz — may  be  followed  by 
results  that  promise  more  than  the  earlier  trials  immediately  succeeding 
Koch's  announcement.  This  expectation  is  reasonable  in  view  of  the 
acknowledged  efficacy  of  the  serum  treatment  of  other  diseases,  notably 
diphtheria. 

Referring  to  the  refined  tuberculin  of  Koch,  the  "  modified  "  tuberculin 
prepared  by  Trudeau,  the  watery  extract  of  tubercle  bacilli  by  von  Ruck, 
or  the  antituberculin  serum  by  de  Schweinitz  in  Washington,  the  pros- 
pect of  benefit  to  be  derived  from  it  is  the  greater  the  earlier  its  use  in  the  dis- 
ease, the  more  localised  the  process,  and  the  less  general  the  infection.  It 
is  contra-indicated  in  cases  with  decided  fever,  also  when  there  is  hemor- 
rhage. 

The  dose  of  tuberculin  administered  should  be  short  of  that  sufficient 
to  produce  a  febrile  reaction.  The  primary  dose  should  be  0.2  mgm.  hypo- 
dermically  on  alternate  days,  increased  with  every  other  administration  o.i 
mgm.  until  a  2  mgm.  dose  is  attained,  when  it  may  be  increased  more  rapidly, 
say  0.5  mgm.  every  two  or  three  days.  After  a  15  mgm.  dose  is  attained  the 
increase  may  be  more  rapid  according  to  the  effect  produced  until  0.05  to  o.i 
gm.  dose  is  attained,  when  it  should  be  decreased  by  halving  the  dose  at  every 
injection  and  discontinue  altogether  at  o.oi  mgm.  The  injection  is  best 
given  in  the  back  between  the  shoulders.  The  general  guide  as  to  dose  is  the 
body  temperature,  which  should  be  taken  for  a  week  before  treatment  as  a 
basis  for  comparison.  A  slight  rise  (1-2°  to  1°  F. )  six  to  twelve  hours  after 
the  injection  is  the  signal  that  enough  has  been  given,  and  the  dose  should 
not  be  repeated  until  the  temperature  again  falls  to  the  standard  deter- 
mined, after  which  the  dose  last  given  is  repeated  until  it  produces  no 
fever. 

The  object  aimed  at  is  to  get  in  as  much  tuberculin  as  possible,  say  up 
to  O.I  gm.,  so  gradually  as  to  produce  only  a  little  local  and  as  little  gen- 
eral reaction  as  possible.  It  is  to  be  remembered  that  tuberculin  can  influ- 
ence favorably  only  the  tubercular  element  of  phthisis  and  is  powerless  and 
probably  injurious  where  any  extensive  and  generalized  complicating  strep- 
tococcus infection  has  taken  place.  On  this  account  the  previous  or  con- 
current use  of  antistreptococcus  serum  has  been  practiced  with  results  some- 
what encouraging.  The  injections  of  10  c.  c.  are  made  at  much  longer  inter- 
vals, say  a  week  or  ten  days. 

The  antitubercle  serum  of  de  Schweinitz  may  be  injected  in  doses  of 
I  c.  c.  on  alternate  days.  By  either  remedy  the  treatment  should  be  con- 
tinued for  six  months,  unless  the  disease  is  earlier  arrested,  or  unless  harm- 
ful results  appear  earlier.  Late  experience  seems  to  show  that  the  serum  is 
to  be  preferred  to  tuberculin.* 

VI.  Pneumotherapy. — Where  for  any  reason  the  advantages  of  high 
altitude  are  not  available,  some  benefit  may  be  derived  from  artificial  pneu- 


*  See  "  Some  Statistics  upon  Sero-Therapy  in  Tuberculosis."    Bj-  J.  Edward  Stubbert,  "  Medical 
News,"  March  n,  i8gq. 


TUBERCULOSIS.  273 

motherapy,  by  which  it  is  sought  to  modify  the  air  breathed,  more  especially 
as  to  density,  although  such  therapy  may  also  include  modifications  in  tem- 
perature, humidity,  and  chemical  composition.  The  simplest  application  as 
applied  to  density  is  the  producing  of  conditions  by  which  the  patient  may 
be  immersed  in  a  compressed  or  rarefied  air  which  he  likewise  breathes.  The 
more  usual  application  at  the  present  day  is,  however,  that  of  "  pneumatic 
differentiation,"  by  which  the  patient  inhales  air  different  in  density  from  that 
which  surrounds  him. 

In  the  dift"erential  method  the  object  is  also  to  facilitate  inspiration  or 
expiration,  or  both.  Inspiration  of  compressed  air  favors  inspiration,  as 
does  also  expiration  into  compressed  air.  Expiration,  on  the  other  hand,  is 
favored  by  inspiration  of  rarefied  air  and  expiration  into  rarefied  air.  These 
objects  are  accomplished  by  the  pneumatic  cabinet,  and  very  satisfactory 
results  are  claimed  by  some  observers.  The  treatment  is  truly  rational.  But 
whether  it  be  the  result  of  inherent  difficulties  in  the  use  of  the  apparatus  or 
failure  to  accomplish  what  was  expected,  the  use  of  it  does  not  seem  to  grow 
in  favor,  and  I  doubt  whether  as  many  cabinets  are  in  use  to-day  as  ten  years 
ago.  To  be  efficient  the  apparatus  should  be  used  two  or  three  times  a  day, 
with  intervals  of  rest  between,  and  unless  the  patient  have  it  at  his  own  home 
or  be  in  a  hospital  provided  with  one,  it  becomes  almost  impossible  to  avail 
himself  of  it. 

VII.  Treatment  of  Special  Symptoms. — Naturally,  the  first  of  these 
is  cough,  and  there  is  no  symptom  that  requires  more  judgment  in  its 
management.  A  slight  cough  is  often  best  let  alone,  because  it  is  an 
effort  to  remove  secretion,  the  retention  of  which  may  be  harmful.  If  a 
cough  becomes  harassing,  so  as  to  keep  the  patient  awake  or  otherwise  wear 
him  out,  it  should  be  controlled.  This  should  be  done,  if  possible,  by  coun- 
terirritation.  A  simple  capsicum  plaster,  or  painting  with  iodin,  or  iodin 
with  a  little  croton  oil  added,  or  a  mustard  plaster,  or  a  turpentine  stupe  may 
answer  the  purpose  when  the  cough  is  not  too  severe. 

As  to  cough  medicines,  creasote  and  creasotol  may  be  classed  among  the 
curative  measures  for  this  symptom,  as  they  diminish  secretion  and  thus 
relieve  cough.  Moderate  cough  is  often  easily  controlled  by  simple  syrupy 
remedies,  such  as  syrup  of  wild  cherry  and  syrup  of  tolu,  to  which  some  dilute 
hydrocyanic  acid  may  be  added,  two  to  four  minims  (0.12  to  0.24  c.  c.)  to  the 
dose.  If  these  measures  are  not  sufficient,  an  opiate  becomes  indispensable. 
It  does  not  matter  much  what  preparation  is  used.  A  teaspoonful  of  pare- 
goric in  the  beginning  is  often  sufficient,  acting  like  a  charm,  or  deodorized 
tincture  of  opium,  if  a  stronger  preparation  be  needed,  will  answer  better 
because  of  its  smaller  bulk.  For  this  reason,  too,  sooner  or  later,  the  alka- 
loids of  opium  are  indicated.  Codein  is  the  best  of  these  to  start  out  with 
in  doses  of  1-4  grain  (0.0165  gm.)  increased.  Heroin  is  the  most  recent 
and  is  much  commended.  It  is  given  in  doses  of  1-20  grain  (0.0033  gm.)  or 
more.  Morphin,  however,  becomes  ultimately  the  best  remedy  in  the 
majority  of  cases.  When  this  stage  is  reached  the  wiser  course  is  not  to  order 
it  at  stated  intervals,  but  at  such  times  as  the  cough  needs  especially  to  be 
controlled,  as  at  night  on  going  to  bed,  or  once  during  the  night.  In  the 
morning  the  patient  should  be  allowed  to  cough  for  a  time  to  get  up  the 
accumulated  secretion.  The  dose  essential  for  this  purpose  must  vary,  any- 
thing from  1-2 A  to  1-4  grain  (0.00275  to  0.0165  gm.).  Sometimes  it  may 
be  combined  with  advantage  with  a  syrupy  preparation,  which  facilitates 
expectoration,  and  to  this  may  be  added  a  few  drops  of  a  mineral  acid,  as  the 
18 


274  INFECTIOUS  DISEASES. 

aromatic  sulphuric.     A  cough  medicine  of  this  kind,  long  in  use  in  Phila- 
delphia, is  as  follows : 

^      Morphinaj  sulph gr.  ss-ij  (gm.  0.033-0.066) 

Potass,  cyanid grs.  iij     (gm.  0.2) 

Ac.  sulph.  aromat f  3  j-ij       (c  c.  4-8) 

Syr.  prun.  Virginian q.  s.  ad  1 1  iij       (c  c.  95) 

M.  et  Sig. — Teaspoonful  as  often  as  necessary  to  quiet  cough. 

In  the  morning  when  a  patient  has  to  contend  with  a  cavity  full  of  pus 
it  is  better  to  give  him  a  tablespoonful  of  whisky  or  a  milk  punch,  to  aid  in 
coughing  up  the  accumulated  matter,  than  to  give  a  sedative  cough  mixture. 

The  ammonium  preparations,  chlorid  and  carbonate,  are  rarely  useful 
in  the  cough  of  consumptives,  while  their  effect  is  to  derange  the  stomach 
and  destroy  the  appetite.  Sometimes,  however,  where  there  is  much  loose 
phlegm,  the  use  of  the  former  for  a  short  time  may  be  beneficial.  Under 
the  same  circumstances  terebene  is  one  of  the  best  medicines  given  in  doses 
of  5  to  10  minims  (0.3  to  0.6  c.  c).  It  taxes  the  stomach,  however,  some- 
what severely.  Terpin  hydrate  may  be  substituted  in  doses  of  3  to  6  grains 
(0.2  to  0.4  gm.). 

The  fever  of  consumptives  rarely  demands  special  measures.  Should  the 
temperature  exceed  103°  F.  (39.4°  C.)  there  is  no  more  satisfactory  or  harm- 
less measure  than  sponging,  allowing  to  remain  on  the  surface  a  thin  film  of 
water,  the  evaporation  of  which  produces  the  refrigerating  effect.  Or  3 
grains  of  antipyrin  or  acetanilid  or  5  of  phenacetin  (0.2  to  0.33  gm.)  may 
be  given,  the  effect  watched,  and  the  drug  repeated  two  or  three  times  if 
necessary.  The  high  fever  of  phthisis  rarely  lasts  long  and  of  itself  does 
little  or  no  harm.  It  is  merely  a  symptom  of  a  more  uncontrollable  septic 
process. 

Night-sweats  do  demand  special  measures.  By  far  the  most  reliable 
therapeutic  agent  is  atropin ;  i-ioo  to  1-60  grain  (0.00066  to  o.ooii  gm.)  at 
bedtime  usually  suffices.  It  may  be  combined  with  morphin,  if  the  latter  is 
necessary.  Sponging  at  bedtime  with  a  saturated  solution  of  alum  in  alcohol 
is  often  efficient  when  atropin  fails,  or  sponging  with  simple  hot  water  may 
answer. 

Agaricin  or  agaric  acid  in  doses  of  1-8  to  1-4  grain  (0.0082  to  0.0165 
gm.)  is  a  modern  remedy  for  night  sweats.  Camphoric  acid,  20  to  30  grains 
(1.32  to  2  gm.)  in  a  capsule  at  bedtime,  is  another  remedy  highly  recom- 
mended. So  are  muscarin,  5  minims  (0.3  c.  c.)  of  a  i  per  cent,  solution,  and 
picrotoxin,  1-60  grain  (o.ooii^  gm.).  An  old  remedy  is  the  aromatic  sul- 
phuric acid,  and  it  is  certainly  a  good  tonic,  which,  administered  in  doses  of 
10  to  20  drops  (0.6  to  1.3  c.  c.)  before  meals,  may  also  aid  in  checking  the 
sweats.  Or  the  following  lotion  may  be  used  :  Balsam  of  Peru,  i  part ;  formic 
acid,  5  parts ;  chloral  hydrate,  5  parts ;  trichloracetic  acid,  i  part ;  absolute 
alcohol,  100  parts. 

Hemorrhage  is  an  alarming  symptom  and  must  be  treated,  although  it 
is  probable  that  most  hemorrhages  stop  of  their  own  accord.  The  patient 
should  be  immediately  put  to  bed  at  rest,  with  the  shoulders  raised.  Ice, 
suitably  encased,  may  be  applied  to  the  chest,  or  cloths  wrung  out  in  cold 
water.  A  hypodermic  injection  of  1-4  grain  (0.016  gm.)  of  morphin  to  an 
adult  is  a  useful  measure  to  secure  quiet.  Indeed,  I  almost  always  begin 
treatment  with  it.  If  the  pulse  is  full  and  bounding,  3  drops  of  the  tincture 
of  aconite  may  be  given  hourly  until  some  effect  is  produced.  Gallic 
acid  may  be  given  in  doses  of  15  grains  (i  gm.)  every  half  hour  while  the 


TUBERCULOSIS.  275 

hemorrhage  lasts.  The  domestic  remedy,  common  salt,  is  probably  useful  by 
exciting  reflex  contraction.  A  teaspoonful  swallowed  is  the  dose.  When 
the  hemorrhage  persists  hypodermic  use  of  ergot  is  recommended.  The  best 
preparation  for  this  purpose  is  a  good  quality  of  the  fluid  extract,  of  which 
30  minims  or  a  dram  ( 2  to  4  c.  c. )  may  be  injected  at  one  time,  twice  in  the 
twenty-four  hours.  What  is  known  as  ergotin  is  probably  a  solid  extract, 
of  which  I  grain  (^0.065  gm.J  is  equivalent  to  5  minims  (0.3  c.  c.j  of  the 
fluid  extract. 

Gelatin  is  as  efficient  in  the  treatment  of  hemorrhage  of  the  lungs  as  in 
other  hemorhages.  A  very  promising  method  is  to  administer  hypoder- 
mically  loc  c.  c.  of  a  2  per  cent,  solution  at  a  temperature  of  110°  F.  (43°  C). 
The  gelatin  is  also  advised  by  the  stomach,  although  it  would  seem  that  the 
effect  of  digestion  would  tend  to  destroy  any  hemostatic  properties.  Good 
results  are,  notwithstanding,  claimed  for  it.  It  is  certainly  an  easier  and 
much  less  painful  mode  of  administration.  I  am  in  the  habit  of  ordering 
the  usual  homemade  gelatin  as  prepared  for  the  table,  in  wineglass  doses 
every  two  to  four  hours.  Suprarenal  extract  is  also  recommended  in  doses 
of  five  grains  to  the  powder  every  two  hours.  Strapping  is  very  highly 
recommended  by  William  Gilman  Thompson.  He  directs  that  pads  of 
cheese-cloth  be  placed  in  the  axillae  and  over  the  femoral  veins,  and  buckle- 
straps  drawn  over  them  tight  enough  to  prevent  venous  return,  but  not  to 
prevent  arterial  flow.  It  is  best  to  strap  but  three  extremities  at  one  time, 
loosening  one  strap  every  fifteen  minutes  and  re-applying  it  to  the  unstrapped 
limb.  The  compression  may  be  maintained  for  an  hour  or  two.  Care  should 
be  taken  not  to  loosen  all  the  straps  at  one  time. 

The  diarrhea  of  consumption  does  not  generally  become  troublesome 
until  tuberculosis  of  the  bowel  develops.  Slight  degrees  seem  often  to  relieve 
the  cough.  When  there  is  tuberculosis  of  the  bowel  it  is  exceedingly  diffi- 
cult to  control.  Sufficient  doses  of  bismuth  are  on  the  whole  the  best  remedy 
— sufficient,  because  at  first  the  smaller  quantities,  say  10  grains  (0.66  gm.) 
answer,  while  later  much  larger  doses  are  necessary.  Opium  is,  however, 
often  necessary,  and  sometimes  the  mineral  astringents,  as  the  acetate  of 
lead,  nitrate  of  silver,  and  oxid  of  zinc,  act  well  in  combination  with  it. 
Tannic  acid  is  also  efficient  in  combination  with  opium,  and  changes  must  be 
rung  on  these  various  remedies,  as  any  one  is  apt  to  lose  its  effect. 

VIII.  Prophylaxis  against  Tuberculosis. — Accepted  views  as  to  the 
nature  and  causation  of  tuberculosis  have  raised  the  question  of  prophylaxis 
into  one  of  paramount  importance.  Careful  analysis  of  accumulated  evi- 
dence in  favor  of  the  communication  of  tuberculosis  goes  to  show  that  sputum 
dried  and  disseminated  with  dust  in  the  atmosphere  is  by  far  the  most  impor- 
tant medium.  After  this  the  meat  and  milk  of  tuberculous  cattle,  though 
most  recent  studies,  already  referred  to-  on  page  241,  go  to  show  that  it  is 
doubtful  whether  tuberculosis  was  ever  caused  by  the  drinking  of  milk.  The 
perspiration  of  the  affected  subject  must  be  acknowledged  to  be  a  possible 
medium,  since  inoculation  of  animals  by  it  has  resulted  in  tuberculosis,  while 
the  sweat  collected  after  washing  and  the  use  of  proper  antiseptics  failed  to 
produce  the  result.  Kissing  and  the  use  of  wind  instruments  and  pipes  pre- 
viously used  by  tubercular  subjects  arp  possible  media.  It  is  claimed  of  meat 
and  milk  that  they  infect  through  the  alimentary  canal  and  the  form  of  tuber- 
culosis resulting  from  them  is  usually  glandular,  especially  of  the  adjacent 
mesenteric  glands.  In  like  manner  the  tuberculosis  traced  to  kissing  has 
been  in  the  silands  about  the  neck.     The  discharges  from  skin  tuberculosis 


2/6 


INFECTIOUS  DISEASES. 


or  lupus  are  also  vehicles  of  infection.  Mainly,  however,  we  have  to  guard 
against  sputum  as  an  agent  of  infection,  the  other  causes  being  comparatively 
easy  of  escape. 

The  first  and  most  important  measure  is,  therefore,  the  disinfection  of 
tl-i£  sputum.  To  this  end  a  spit-cup  should  always  be  used  when  possible, 
and  it  should  contain  a  germicide  that  will  destroy  the  bacillus.  The  best  of 
these  germicides  is  corrosive  sublimate,  dissolved  in  water  in  the  proportion 
of  I  to  1000  or  1-2  grain  to  the  ounce  (0.033  to  30  c.  c),  and  a  small  quantity 
of  this  solution  should  be  placed  in  the  spit-cup.  In  consequence  of  the  fact 
that  corrosive  sublimate  coagulates  albumin,  the  tartaric  or  citric  acid  subli- 
mate should  be  used.  Next  in  efficiency  is  carbolic  acid  in  proportion  of  i 
to  30  or  24  grains  (1.6  gm.)  to  an  ounce  (30  c.  c.)  of  water.  A  strong  solu- 
tion of  soda  or  potash  may  be  used.  As  already  stated,  sputum  becomes  prac- 
tically active  only  when  dried,  pulverized,  and  carried  into  the  air  as  dust. 
It  is  evident,  therefore,  that  even  water  in  the  cup  will  render  it  harmless  for 
the  time  being,  while,  if  scalding  water  be  substituted,  its  permanent  destruc- 
tion is  secured.  The  first-mentioned  methods  are  most  efficient  and  should 
be  practiced  when  possible.  Such  vessels  should  be  further  washed  with 
scalding  water  and  more  germicide  solution  added  at  least  once  a  day. 

Under  no  circumstances  should  the  patient  be  allowed  to  expectorate 
upon  the  floor,  in  cars  or  other  public  conveyances,  or  even,  if  possible  to 
prevent  it,  in  the  street.  In  order  to  meet  these  necessities  as  well  as  those 
of  other  situations  in  the  house  where  temporarily  the  use  of  sterilizing  cups 
is  impossible,  the  handkerchief  is  indispensable,  but  it  should  consist  either 
of  old  pieces  of  muslin  or  linen,  which  can  be  burned  after  use,  or  of  porous 
paper  to  be  similarly  disposed  of.  The  so-called  Japanese  handkerchiefs 
answer  the  purpose  admirably. 

Dettweiler's  pocket  spit-cup,  invented  for  use  in  the  street  or  elsewhere 
as  a  substitute  for  the  handkerchief,  is  an  admirable  invention.  It  is  made 
of  blue  glass,  is  flat,  and  holds  about  three  fluid  ounces,  or  90  c.  c.  There 
are  two  openings,  one  at  the  top  and  one  at  the  bottom,  both  provided  with 


Fig.  25. — Pasteboard  Spit-cup. 

metallic  screw-caps.  The  upper  and  larger  opening  receives  a  polished 
metal  funnel  extending  half  way  down  into  the  flask,  and  the  whole  is  closed 
tightly  with  a  spring  cover  or  cap.  The  funnel  acts  like  a  similar  appliance 
in  certain  ink  bottles  and  prevents  the  spilling  of  the  contents  of  the  flask, 
even  if  the  cap  be  left  open.  The  lower  opening  is  intended  to  facilitate 
the  thorough  cleansing  of  the  flask.  It  is  said  that  it  can  be  made  at  a  cost 
of  less  than  50  cents,  and  can  be  easily  kept  clean.  The  pasteboard  spit-cups, 
supported  in  a  rim  of  steel,  recommended  by  the  New  York  City  Health 
Department,  intended  to  be  burned  after  use,  are  correspondingly  inexpensive 
and  answer  the  purpose  very  well. 

To  the  same  end,  diminution  of  the  possibility  of  harboring  dried  bacilli, 


TUBERCULOSIS. 


277 


umvashable  curtains  and  superfluous  upholstering  should  be  banished  from 
the  rooms  occupied  by  tuberculous  patients.  There  should  either  be  no  car- 
pets, or  they  should  be  replaced  by  rugs  that  can  be  frequently  taken  up 
and  shaken.  The  sleeping-car,  with  restricted  air  space  per  caput,  its  costly 
upholstery  and  curtains,  used  year  after  year,  becomes  a  possible  source  of 
infection,  especially  in  routes  toward  health  resorts,  but  is  less  serious  than 
it  might  be  because  of  the  short  time  that  it  is  generally  occupied  by  the 
tuberculous  and  healthy  alike.  The  state-room  of  the  ocean  steamer  stands 
a  greater  chance  of  being  a  medium  of  infection  from  its  longer  occupation. 

When  it  is  remembered  how  easy  it  is  with  ordinary  intelligence  and 
simple  means  to  render  completely  innocuous  the  bacillus  of  tuberculosis,  I 
do  not  myself  believe  it  can  be  any  more  efficiently  accomplished  by  the 
assistance  of  Boards  of  Health,  and  I  see  nothing  to  be  gained  by  reporting 
tuberculosis  as  an  infectious  disease,  like  scarlet  fever  and  diphtheria.  I  do 
not  object  to  reporting  consumption  to  Boards  of  Health,  for  statistical  pur- 
poses, but  am  opposed  to  it  with  a  view  to  surveillance  by  such  Boards, 
because  I  believe  it  unnecessary,  that  nothing  is  gained  by  it,  and  that  need- 
less inconvenience,  to  say  the  least,  is  occasioned  to  victims  and  their 
families. 

The  second  source  of  infection,  the  milk  of  the  tuberculous  cow,  if  it 
he  a  source,  is  avoided  by  boiling  the  milk,  which  is  thus  rendered  thoroughly 
sterile.  There  are,  however,  objections  to  boiling  milk.  In  the  first  place, 
the  taste  of  boiled  milk  is  not  always  agreeable,  but  of  greater  importance  is 
the  fact  that  it  is  constipating,  especially  when  it  is  the  only  food,  as  in  the 
case  of  children.  It  is  desirable  for  this  reason,  therefore,  to  be  able  to  use 
milk  unboiled.  That  this  is  possible  without  harmful  results  was  shown  by 
some  interesting  experiments  of  Gebbard,  who  ascertained  that  the  virulence 
of  tuberculous  milk  is  destroyed  by  dilution  with  the  milk  of  other  cows. 
Thus,  milk  from  the  udder  of  tuberculous  cows  was  found  to  have  lost  its 
virulence  when  diluted  in  one  instance  40  times,  in  another  50,  and  in  a  third 
100  times.  On  the  other  hand,  the  dilution  of  sputum  100,000  times  was 
found  not  to  affect  its  virulence,  while  pure  cultures  do  not  lose  virulence 
when  diluted  400,000  times.  An  important  practical  conclusion  is  deduced 
from  these  experiments  of  Gebbard — viz.,  that  a  time-honored  practice  as  to 
"hand-fed  babies  of  using  only  the  milk  from  one  cow  is  more  dangerous 
than  the  mixed  milk  of  a  herd.  For  the  chances  of  infection  with  such  are 
much  greater.  Practically,  the  use  by  adults  of  raw  milk  mixed  with  other 
food  cannot  be  regarded  as  dangerous,  but  with  children  fed  exclusively  on 
milk  precautions  should  be  taken  to  render  it  sterile  by  cooking,  or  if  it  must 
be  used  uncooked  it  should  be  the  mixed  milk  of  a  number  of  cows.  The 
milk  of  a  cow  known  to  be  tuberculous  should  be  invariably  condemned  and 
the  animal  slaughtered.  The  products  of  milk — that  is,  butter  and  cheese — 
are,  of  course,  not  amenable  to  the  treatment  to  which  milk  can  be  subjected. 
Safety  from  infection  from  these  sources  can  only  be  secured  by  a  rigid  in- 
spection of  cows,  and  by  measures  to  prevent  the  development  of  tuberculosis 
in  these  animals. 

Infection  by  tuberculous  meat  is  still  rarer.  In  the  first  place,  the  flesh 
of  tuberculous  animals  may  not  itself  be  tuberculous,  and,  in  the  second 
place,  the  cooking  to  which  meat  is  subjected  must  kill  bacilli.  On  the 
other  hand,  that  the  communication  of  tuberculosis  by  tuberculous  meat 
when  carelessly  used  is  possible  is  shown  by  the  fact  that  tuberculosis  has 
been  produced  in  animals  by  the  introduction  of  the  juice  of  the  meat  of 


2/8  INFECTIOUS  DISEASES. 

other  tuberculous  animals  and  even  from  tuberculous  human  beings.  The 
use  of  raw  or  half-cooked  meat  should  therefore  be  prohibited. 

In  consequence  of  what  has  been  said  of  the  experimental  production 
of  tuberculosis  by  the  inoculation  of  sweat  as  well  as  the  increased  possi- 
bilities of  getting  into  the  mouth  portions  of  tuberculous  sputum,  no  one 
should  sleep  with  a  tuberculous  patient.  Dishes  and  utensils  used  by  such 
patients  should  not  be  used  by  others  unless  first  scrupulously  cleaned,  and 
this  is  best  accomplished  by  thorough  boiling.  The  patient  should  himself 
be  taught  to  prevent  his  hands,  face,  and  bedding  from  becoming  smeared 
with  sputum. 

Precautions  against  auto-infection  are  scarcely  less  important  than  those 
against  infection  of  others.  It  has  been  said  that  if  it  were  not  for  auto- 
infection  most  cases  of  tuberculosis,  except  those  within  the  cranium,  would 
get  well.  Be  this  as  it  may,  it  is  certain  that  new  foci  of  tuberculosis  are 
constantly  being  developed  in  the  same  patient,  which  aggravate  his  com- 
plaint and  hasten  his  death.  Such  a  focus  is  tuberculosis  of  the  intestine, 
which  probably  often  has  its  origin  in  swallowed  sputum.  Patients  should 
therefore  be  enjoined  against  the  practice  of  swallowing  sputum. 

The  close  dependence  of  tuberculosis  upon  predisposition,  hereditary 
or  acquired,  chiefly  the  former,  has  long  been  recognized.  As  to  whether 
this  or  infecti'on  is  the  more  important  factor  in  the  production  of  the  disease 
cannot  be  regarded  as  settled.  Thus,  one  authority,  \^olland,  in  1892,  de- 
clared that  the  greatest  amount  of  good  will  be  done  by  such  treatment  early 
in  life  as  will  correct  any  possible  constitutional  taint.  Behrend,  on  the 
other  hand,  claims  that  our  principal  efforts  are  to  be  directed  against  the 
dangers  of  infection.  Under  the  circumstances,  a  due  amount  of  attention 
paid  to  both  factors  cannot  be  amiss. 

It  goes  without  saying  that  a  tuberculous  mother  should  not  nurse  her 
infant,  but  what  should  the  child  or  adult  predisposed  to  consumption  do 
to  avert  the  evil?  The  residence  is  the  first  consideration.  If  possible,  the 
person  should  be  reared  in  a  country  of  high  altitude.  Such  a  course  is 
much  more  likely  to  prevent  tuberculosis  than  to  cure  it,  if  once  acquired. 
Above  all,  he  should  avoid  residence  in  houses  situated  in  low,  damp,  and 
shaded  localities.  Bowditch's  observations  many  years  ago,  already  alluded 
to,  showed  conclusively  that  consumption  is  favored  by  these  conditions. 
Further,  such  person  should  not  reside  in  a  house  where  many  cases  of  con- 
sumption have  preceded.  And  if  it  is  impossible  to  avoid  this  the  walls  and 
floors  should  be  thoroughly  ckaned  with  the  germicide  solutions  already 
mentioned.  The  rooms  of  the  house  should  be  large,  airy,  and  well  ven- 
tilated. The  predisposed  individual  should  sleep  at  night  with  windows  and 
even  doors  open,  due  precaution  being  taken  against  drafts. 

Outdoor  life  should  be  sought  under  all  circumstances,  avoiding,  how- 
ever, especially  damp,  cold  exposure.  Riding  and  driving  should  be  prac- 
ticed. Judicious  athletics,  such  as  develop  all  parts  of  the  body  in  good 
proportion  and  especially  such  as  secure  expansion  of  the  lungs,  should  be 
encouraged.  Frequent  inflation  of  the  lungs  should  be  practiced  several 
times  a  day.  Practice  with  dumb-bells  and  clubs  of  moderate  weight  is  pre- 
eminently calculated  to  empty  the  deeper  recesses  of  the  lungs  of  retained 
mucus,  and  to  cause  the  blood  to  move  more  rapidly  through  the  more  remote 
parts  where  the  circulation  is  naturally  sluggish. 

The  treatment  of  acute  or  pneumonic  phthisis  is  supporting  and  stimu- 
lant, symptomatic  and  palliative.     There  is  no  advantage  to  be  derived  by 


TUBERCULOSIS.  279 

taking  the  patient  away  from  home.  Food  and  stimulants  are  required  to 
combat  the  exhausting  effect  of  the  disease  and  its  fever.  The  fever  itself 
may  be  lowered  by  sponging  and  the  cautious  use  of  such  apyretics  as  phenac- 
etin,  acetanilid,  and  the  like,  because  in  this  form  of  the  disease  it  is  more 
apt  to  be  continuous  and  exhaustive  in  character.  The  cough  must  be  con- 
trolled by  opiates,  and  such  other  measures  must  be  taken  as  wdll  make  the 
patient  comfortable  and  mitigate  the  sadness  with  which  an  inevitable  fatal 
prospect  is  more  or  less  associated.  If  it  should  happen  that  the  disease 
assumes  an  unexpected  chronicity,  it  may  fall  into  a  class  of  cases  in  which 
the  treatment  laid  down  for  the  more  chronic  forms  of  consumption  is 
available. 

IV.  Tuberculosis  of  Lymphatic  Glands, 

Syxonyms. — Scrofula,  or  the  King's  Evil ;  Tuberculous  Lymphadenitis. 

Etiology. — Even  before  the  discovery  of  the  bacillus  of  tuberculosis  by 
Koch  in  1882,  it  was  generally  conceded  that  what  has  been  known  as 
scrofula,  or  the  King's  Evil,  was  a  true  tuberculosis  of  lymphatic  glands. 
The  minute  study  of  these  glands  showed  the  presence  of  miliary  tubercles, 
and  since  Koch's  announcement  the  bacillus  has  been  found  in  them.  The 
bacillus  may  be  regarded  as  the  immediate  cause  of  the  specific  inflammatory 
process. 

Tuberculous  lymphadenitis  is  most  common  in  children  and  young 
adults,  but  may  occur  at  any  age. 

Symptoms. — The  glands  most  frequently  affected  are  those  of  the  neck, 
which  appear  in  various  degrees  swollen  and  tender,  in  many  instances  sup- 
purating and  rupturing  when  not  opened  by  the  surgeon's  knife.  The  sub- 
maxillary glands  are  usually  the  first  involved,  but  those  in  the  posterior 
cervical  triangle  are  also  frequently  invaded  on  one  or  both  sides,  though 
commonly  on  one  side  more  than  the  other.  The  cervical  and  axillary  glands 
may  be  conjointly  involved,  forming  a  continuous  chain  behind  the  clavicle 
and  pectoral  muscles.  The  bacillus  usually  attacks  the  glands  nearest  its 
point  of  entrance,  and  presumably  the  cervical  glands  are  infected  by  bacilli, 
which  enter  by  the  way  of  the  nasal  or  naso-pharyngeal  passages.  The  vul- 
nerability of  these  mucous  membranes  to  the  bacilli  is,  of  course,  increased 
by  any  inflammatory  state  present.  As  a  rule,  there  is  little  or  no  'consti- 
tutional sympathy  in  such  a  degree  of  invasion.  There  may,  however,  be 
slight  fever. 

Alore  rarely  there  is  involvement  of  all  the  lymphatic  glands  of  the  body. 
Such  cases  are  sometimes  met  among  negroes.  In  them  are  swelling, 
pain,  and  tenderness  of  all  the  visible  glands,  including  the  cervical,  sub- 
maxillary, and  axillary  glands,  while  autopsy  discloses  the  involvement  of 
bronchial,  mesenteric,  and  retroperitoneal  glands.  In  such  cases  there  is 
more  or  less  continuous  fever,  but  death  is  usually  the  result  of  some  inter- 
current disease,  or  of  pressure  upon  the  respiratory  passages. 

In  addition  to  the  visible  pictures  described,  the  bronchial  glands  are 
often  involved  without  visible  enlargement,  the  condition  being  first  found 
at  autopsy,  when  it  may  or  may  not  be  associated  with  lung  tuberculosis. 
The  enlargements  may,  however,  reach  such  a  size  as  to  form  a  recogniz- 
able mediastinal  tumor,  which  may  or  may  not  produce  the  signs  of  pressure. 
The  bacilli  which  invade  these  glands  filter  through  the  respiratory  passages. 


28o  IXFECTIOUS  DISEASES. 

Tabes  Mcscnterica. — When  the  mesenteric  or  retroperitoneal  glands  are 
especially  involved  the  disease  is  called  tabes  mesenterica,  or  ahdom-inal 
scrofula.  These  cases  occur  among  children.  The  trunk  and  limbs  are  puny, 
wasted,  and  anemic,  while  their  little  bellies  are  prominent,  partly  because 
of  the  enlarged  glands  and  partly  from  tympany,  producing  a  striking  pic- 
ture. The  tympanitic  distention  often  predominates,  making  it  difficult  to 
feel  the  enlarged  glands.  In  these  cases,  too,  there  is  often  diarrhea,  with 
thin,  offensive  stools,  yet  the  bowels  are  not  generally  the  seat  of  tuber- 
culosis. There  may  be  tuberculosis  of  the  peritoneum,  which  may  also  give 
rise  to  an  uneven,  nodular,  tender,  and  painful  enlargement  easily  recognized 
by  palpation.  The  disease  prevails  among  poorly  fed  children  in  the  slums 
and  badly  drained  and  ill  ventilated  houses  of  the  poor.  There  are  fever, 
fretfulness,  and  a  general  aspect  of  abject  misery.  Death  generally  takes 
place  through  exhaustion;  or  some  acute  intercurrent  disease,  such  as  ente- 
ritis, carries  off  the  little  sufferers.  ]\Iore  rarely  adults  may  be  affected  with 
tabes  mesenterica,  either  as  a  primary  disease  or  as  secondary  to  pulmonary 
tuberculosis.  I  well  remember  a  case  associated  with  peritoneal  tuberculosis 
in  which  the  diagnosis  between  this  condition  and  carcinoma  was  difficult, 
the  autopsy  determining  the  question  in  favor  of  the  former. 

While  tuberculous  glands  of  the  neck,  and  even  of  the  axilla,  tend  to 
suppurate,  the  retroperitoneal  and  mesenteric  glands  more  frequently  caseate 
without  suppuration,  and  especially  characteristic  is  a  tendency  in  the  latter 
to  calcify,  furnishing  a  mode  of  healing  of  tuberculosis.  The  bronchial 
glands  are  also  less  prone  to  suppurate,  but  caseate  and,  at  times,  liquefy. 
The  easier  accessibility  of  the  external  glands  to  the  pyogenic  organisms 
may  explain  the  greater  frequency  of  suppuration  in  them. 

Diagnosis. — The  diagnosis  of  tuberculous  lymphadenitis  requires  its 
differentiation  from  lymphadenoma  (Hodgkin's  disease),  lymphatic  leu- 
kemia, and  simple  lymphoma.  The  aft'ected  glands  in  tubercular  lymph- 
adenitis are  usually  more  tender  than  those  in  Hodgkin's  disease ;  they  are 
more  closely  adherent  to  each  other  and  the  adjacent  tissues,  and  are,  there- 
fore, more  fixed  and  immovable  than  the  glands  in  Hodgkin's  disease. 
Again,  tuberculosis  rarely  invades  more  than  one  group  of  glands,  is  asso- 
ciated with  caseation  and  suppuration,  while  the  lymphadenoid  growths  do 
not  suppurate.  Xotwathstanding  this,  the  tubercular  process  is  slower. 
Tuberculosis  affects  the  young — those  of  either  sex  under  twenty — w^hile 
Hodgkin's  disease  occurs  at  any  age,  is  less  frequent  in  the  young,  and  is 
more  common  in  males. 

From  lymphatic  leukemia  tuberculosis  of  lymph-glands  is  easily  recog- 
nized by  the  absence  of  leukocytosis  characteristic  of  the  former.  Simple 
lymphoma  also  affects  a  single  group  of  glands,  and  is  doubtless  often  mis- 
taken for  scrofulosis  of  the  glands  about  the  neck.  The  glands  are.  how- 
ever, harder  and  less  tender,  less  painful  than  tubercular  glands,  and  there 
is  less  constitutional  involvement,  less  anemia. 

Sarcoma  involves  groups  of  glands,  and  spreads  rapidly,  invading  also 
adjacent  tissues,  while  carcinoma  is  always  secondary  to  primary  cancer 
somewhere  else. 

Prognosis. — The  prognosis  except  in  tabes  mesenterica  is  generally 
favorable  unless  systemic  infection  occur,  recovery  being  sometimes  spon- 
taneous. This  is  favored  by  suitable  conditions  to  be  mentioned  under  treat- 
ment. In  former  times  "  scrofula  "  was  regarded  as  a  protective  against 
consumption.     At  the  present  day  it  is  looked  upon  as  a  menace  because  of 


TUBERCULOSIS.  281 

the  danger  of  systemic  infection  through  it,  and  it  is  said  that  three-fourths 
of  the  cases  of  acute  tuberculosis  owe  their  existence  to  it.  Under  the  cir- 
cumstances we  must  regard  cases  of  recovery  from  tubercular  lymphadenitis 
in  childhood  as  instances  of  a  survival  of  the  fittest.  Certainly  our  present 
knowledge  demands  a  prompter  attempt  to  eradicate  the  local  condition 
than  was  formerly  practiced. 

Treatment. — The  general  management  of  a  case  of  tuberculosis  of  the 
lymphatic  glands  is  similar  to  that  of  a  case  of  tuberculosis  of  the  lungs. 
The  patient  should  be  surrounded  by  the  most  favorable  hygienic  conditions, 
have  T:he  best  of  food,  take  cod-liver  oil  and  the  iodid  of  iron.  The  local 
use  of  iodin  is  undoubtedly  efficient  at  times  in  dispersing"  these  glandular 
swellings,  probably  by  exciting  an  inflammatory  process  destructive  to  the 
bacillus,  which  in  a  general  way  is  similar  to  the  reactive  effect  of  tuber- 
culin. 

When  suppuration  has  set  in  it  is  best  to  open  an  exposed  abscess  with 
the  knife,  because  if  allowed  to  open  itself  there  is  apt  to  result  an  unhealthy 
sinuous  ulcer,  very  slow  to  heal,  and  when  healed  causing  marked  disfigura- 
tion by  unsightly  cicatrices.  The  access  of  air  permitted  by  the  opening 
seems  also  to  be  antagonistic  to  the  life  of  the  bacillus,  for  with  the  healing 
of  the  abscess  the  tubercular  process  stops  in  that  particular  gland.  Counter- 
irritation  by  any  means  seems  to  act  similarly,  although  iodin  appears  to 
be  the  most  efficient. 

V.  Tuberculosis  of  the  Serous  Membranes. 

General  tviberculosis  of  the  serous  membranes  is  a  rare  condition, 
and  is  recognized  chiefly  by  the  signs  of  tuberculosis  of  the  peritoneum  and, 
so  far  as  they  exist,  of  the  pleura,  these  being  the  two  serous  membranes  of 
greatest  extent  and  importance. 

Tuberculosis  of  the  Pleura. 

Tuberculosis  of  the  pleura  may  be  suspected  when,  along  with  the  phys- 
ical signs  of  tuberculosis  elsewhere,  there  appear  the  signs  and  symptoms 
of  a  dry  pleurisy.  (See  p.  542.)  This  is  rendered  still  more  likely  if  there 
be  added  the  signs  of  pyothorax  with  fever,  flatness  on  percussion,  and  the 
auscultatory  signs  of  such  effusion.  (See  Physical  Signs  of  Pleurisy  with 
Effusion.) 

Tuberculosis  of  the  pleura  manifests  itself — 

1.  As  an  acute  primary  inflammation  characterized  by  a  sero-fibrinous 
or  purulent  exudate.  The  onset  of  such  an  inflammation  may  be  like  that 
of  ordinary  acute  pleurisy  or  it  may  be  insidious  in  its  development,  like  that 
of  the  latent  form  of  pleurisy  to  be  described  under  diseases  of  the  pleura. 
It  may  immediately  precede  pulmonary  tuberculosis,  be  associated  with  it, 
or  succeed  it. 

2.  As  an  acute  pleurisy  the  result  of  extension  from  an  adjacent  tuber- 
culous lung,  and  as  such  it  may  be  ^circumscribed,  adhesive,  or  may  con- 
stitute an  extensive  sero-fibrinous  or  purulent  pleurisy. 

3.  A  chronic,  adhesive,  proliferative,  tuberculous  pleurisy  characterized 
by  great  thickening  and  adhesion  of  the  pleurae,  with  tuberculous  infiltration 
of  the  thickened  product. 


282  INFECTIOUS  DISEASES. 

The  symptoms  and  physical  signs  are  in  no  way  different  from  those  to 
be  described  in  connection  with  the  non-specific  forms  of  pleurisy. 

Treatment. — Some  time  often  elapses  before  an  absolute  diagnosis 
is  made,  after  which,  if  the  disease  is  at  all  extensive,  its  treatment  is  mainly 
surgical,  consisting  in  drainage  and  washing  out  of  the  pleural  sac.  In  some 
instances  its  complete  success  is  secured  only  by  excision  of  one  or  more 
ribs. 

In  addition  the  usual  restorative  and  hygienic  measures  employed  in 
tuberculosis  of  the  lungs  should  be  carried  out. 


Tuberculosis  of  the  Peritoneum. 
Synonyms. — Tubercular  Peritonitis;  Tabes  Mesenterica. 

Tuberculosis  invades  the  peritoneum  in  two  ways : 

1.  As  a  more  or  less  diffuse  deposit  of  miliary  tubercles  over  the  visceral 
and  reflected  layer,  unattended  by  active  inflammation. 

2.  As  a  tubercular  peritonitis  when  the  tubercular  deposit  is  associated 
with  an  inflammatory  proliferation  more  or  less  abundant.  In  a  simpler 
variety  of  the  lattef,  the  diffuse  adhesive,  the  peritoneal  cavity  is  obliterated, 
the  coils  of  intestine  being  matted  together  and  adherent  to  the  abdominal 
walls.  In  a  second  variety,  known  as  proliferative  peritonitis,  there  is 
marked  thickening  of  the  peritoneal  layer  with  less  tendency  to  adhesion  and 
obliteration  of  the  cavity.  The  omentum  is  sometimes  an  inch  in  thickness 
and  composed  of  tubercular  tissue  in  various  stages  of  degeneration.  The 
mesentery  is  similarly  infiltrated  and  shrunken,  drawing  the  intestines  to- 
gether into  a  ball-like  mass  or  tumor  as  large  as  a  child's  head.  The  coats 
of  the  bowel,  especially  the  large  gut,  also  show  localized  areas  of  similar 
morbid  changes.  Tubercular  peritonitis  is  sometimes  associated  with  cir- 
rhosis of  the  liver,  whose  capsule  and  that  of  the  spleen  may  be  infiltrated 
to  enormous  thickness.  There  is  often  in  this  form  considerable  effusion, 
which  may  be  serous  or  purulent,  at  times  bloody. 

Symptoms. — The  symptoms  include  those  of  chronic  peritonitis,  except 
that  the  abdomen  is  apt  to  be  harder  and  more  tender.  Indeed,  a  stiff  and 
rigid  abdomen  is  quite  characteristic  of  tubercular  peritonitis.  Later,  how- 
ever, is  added,  particularly  in  the  upper  part  of  the  abdomen,  the  tympany 
so  characteristic  of  peritonitis. 

In  connection  with  this  must  be  taken  the  history  of  the  patient,  his 
appearance,  the  condition  of  the  lungs  and  the  presence  of  tuberculosis  there 
and  elsewhere,  particularly  in  the  pleura  and  bowel,  whence  extension  to  the 
peritoneum  is  easy  by  the  lymphatic  vessels.  Four-fifths  of  all  cases  of 
tubercular  peritonitis  are  said  to  succeed  primary  tuberculosis  of  the  lungs. 
In  children  tubercular  peritonitis  is  frequent  as  a  part  of  a  general  miliary 
tuberculosis.  By  primary  tuberculosis  of  the  peritoneum  is  meant  simply  a 
tuberculosis  in  which  no  primary  focus  has  been  found  elsewhere. 

Diagnosis. — To  the  symptoms  above  described  may  be  added,  if 
needed  for  the  purposes  of  diagnosis,  the  information  to  be  derived  from  a 
test  injection  of  Koch's  tuberculin  and  an  examination  for  tubercle  bacillus 
of  the  fluid  obtained  by  tapping.  The  rise  of  temperature  succeeding  the 
injection  is  almost  infallible  evidence,  due  antiseptic  precautions  being  taken, 
of  the  presence  of  tuberculosis. 


TUBERCULOSIS.  283 

Treatment. — The  treatment  for  tubercular  peritonitis  is  the  general 
treatment  for  tuberculosis,  with  such  operative  interference  as  may  be  deemed 
appropriate  after  a  careful  study  of  each  case.  The  results  of  operation  thus 
far  have  been  quite  sufficiently  satisfactory  to  justify  its  repetition  in  suitable 
cases. 

VI.  Tuberculosis  of  the  Genito-Urinary  Organs. 

This  includes  tuberculosis  of  the  kidney  and  its  pelvis,  tuberculosis  of 
the  ureters  and  bladder,  and  tuberculosis  of  the  ovaries. 

Tuberculosis  of  the  Kidney. 

Morbid  Anatomy. — Tuberculosis  presents  itself  in  the  kidney  in  two 
forms : 

1.  In  the  shape  of  miliary  granulations,  which  are  a  part  of  a  general 
tuberculosis,  giving  rise  to  no  special  local  symptoms. 

2.  As  primary  foci  of  localized  tuberculosis,  which  in  time  may  fuse  to 
form  larger  areas  that  undergo  caseation  and  liquefaction,  transforming  the 
whole  kidney  at  times  into  a  sac  of  purulent  or  cheesy  matter.  Such  tuber- 
culosis may  start  in  the  prostate  gland,  bladder,  ureter,  or  pelvis  of  the 
kidney,  and  may  extend  also  into  the  testicle  and  epididymis  in  men,  and 
the  ovary  and  fallopian  tubes  in  women. 

Symptoms. — The  first  form  is  without  special  symptoms.  There  may 
be  none  at  all  or  they  may  simulate  closely  those  of  nephro-lithiasis.  Those 
of  the  second,  so  far  as  the  neighborhood  of  the  kidney  is  concerned,  are 
not  distinctive  or  constant.  There  ma}^  be  none  or  there  may  be  fullness, 
tenderness,  and  even  in  extreme  cases  fluctuation.  Frequently,  subjective 
symptoms  are  reflected  to  the  bladder,  and  they  include  frequent  micturi- 
tion, pain,  and  tenderness  in  the  region  of  the  bladder.  There  is  also  puru- 
lent urine,  but  commonly  this  differs  from  that  of  cystitis.  It  is  more  uni- 
formly acid  in  reaction,  and  contains  pus  less  admixed  with  mucus. 
Blood  is  much  more  frequent  than  in  simple  cystitis,  and  correspondingly 
albumin.  Tube  casts  are  very  rarely  found.  Cheesy  masses  are  sometimes 
present  in  the  urine  and  with  them  the  tubercle  bacillus,  which  is  the  only 
pathognomonic  sign.  It  should  always  be  sought.  The  method  for  its  rec- 
ognition is  the  same  as  for  the  tubercle  bacillus  in  sputum.  It  should  not  be 
confounded  with  the  bacillus  found  by  Malterstock,  Travel,  and  Alvarez  in 
the  preputial  and  vulvar  smegma.  Hence,  these  parts  should  be  carefully 
cleaned  preliminary  to  the  search.  A  negative  result  does  not,  however, 
exclude  tuberculosis.  In  such  event  Damsch  suggested  inoculation  with  the 
pus  from  the  urine  into  the  anterior  chamber  of  the  rabbit's  eye.  At  the  end 
of  three  weeks  tubercular  nodules  should  make  their  appearance  if  the  pus 
be  tubercular.  Sometimes,  also,  shreds  composed  of  white  fibrous  and 
elastic  tissue  representing  the  disintegrating  kidney  or  mucous  membrane 
are  found  in  the  urine,  but  are  not  diagnostic,  since  they  may  be  found  in 
other  varieties  of  destructive  disease  of  the  organ.  The  features  of  the  urine 
described  are  almost  characteristically  intermittent — that  is,  the  urine  is 
sometimes  almost  or  quite  clear  and  again  becomes  purulent. 

In  the  absence  of  such  conclusive  proof  as  bacilli  in  the  urine,  the  pres- 
ence of  tubercle  elsewhere,  as  in  the  lungs  or  nearer  parts,  as  the  testicles 
and  prostate  in  men  or  the  ovaries  and  fallopian  tubes  in  women,  affords 


284  INFECTIOUS  DISEASES. 

suggestive  evidence.  The  latter  may  be  investigated  through  the  vagina 
and  rectum,  while  catherization  of  the  ureters  may  also  be  practiced  in 
women  and  stenosis  of  the  ureter  due  to  tubercular  infiltration  of  the  pyelo- 
uretal  wall  thus  recognized.  Even  in  men  the  thickened  ureters  may  rarely 
be  felt  through  the  abdominal  wall.  In  other  cases  where  the  lungs  are 
not  primarily  tubercular  they  may  be  secondarily  invaded.  Hydronephrosis, 
it  is  said,  may  result  from  complete  obstruction  of  the  ureter  by  tubercular 
infiltration. 

Treatment. — Beyond  the  general  restorative  and  palliative  treatment 
useful  in  general  tuberculosis  there  is  no  medical  treatment  of  tubercular 
kidney.  As  soon  as  the  diagnosis  is  made  the  surgeon  should  be  called 
and  nephrotomy  done.  Life  is  almost  invariably  prolonged  by  it,  and  if 
the  operator  be  so  fortunate  as  to  find  only  a  few  isolated  nodules  on  sec- 
tion, they  may  be  scraped  away.  I  have  such  a  patient,  a  woman,  thus 
operated  upon  six  years  ago  by  Dr.  J.  \\'illiam  White,  who  remains  up 
to  the  present  time  quite  free  of  a  return  of  the  disease.  In  cases  in  which 
the  whole  organ  is  involved  a  persistent  renal  fistula  must  be  expected, 
if  the  kidney  be  not  removed.  Exploratory  operation  may  even  be  justified 
under  circumstances  that  must  be  determined  in  each  case. 

Tuberculosis  of  the  Pelvis  of  the  Kidney,  Ureters,  and  Bladder. 

It  is  not  always  easy  to  separate  tuberculosis  of  these  parts  of  the 
urinary  tract.  So  far  as  symptomatology  is  concerned,  outside  of  the  bac- 
teriological examination,  the  symptoms  of  tuberculosis  are  those  of  simple 
inflammation.  If  the  disease  is  advanced  there  is  tenderness,  but  this  is  the 
case  also  when  there  is  impacted  stone  or  pyelitis  from  other  causes.  The 
invasion  of  the  bladder  produces  symptoms  like  those  of  cystitis,  including 
frequent  micturition  and  purulent  urine  in  which  there  may  be  a  small 
amount  of  blood.  These  symptoms,  again,  are  not  peculiar  to  tuberculosis, 
and  the  examination  for  bacilli  again  becomes  necessary.  This  is  much 
easier  since  the  centrifugating  apparatus  has  come  into  use.  It  must 
be  remembered,  however,  that  the  presence  of  the  bacillus  in  the  urine 
tells  us  no  more  than  that  there  is  tuberculosis  of  this  tract.  AVe  are 
still  as  much  in  want  of  information  as  to  whether  it  comes  from  the 
pelvis  of  the  kidney,  the  ureter,  or  the  bladder.  Cystoscopic  examination 
may  help  us  to  locate  the  disease,  but  as  often  it  does  not  do  so.  In  women 
the  catheterization  of  the  ureter,  if  negative  in  one  or  the  other  ureter,  tells 
us  that  the  disease  is  probably  located  in  the  obstructed  ureter.  It  is  very 
important  to  remember  that  sometimes  tuberculosis,  and,  indeed,  any  form 
of  inflammation  of  the  pelvis  of  the  kidney,  produces  the  same  frequent  desire 
to  pass  water  as  the  same  condition  of  the  bladder,  and  that,  too,  when  the 
bladder  is  entirely  normal :  so  that  we  must  not  be  too  positive  from  the 
presence  of  this  symptom  that  the  bladder  is  the  seat  of  infection,  while,  if 
there  be  tenderness  in  the  kidney  region  and  in  the  course  of  the  ureter,  these 
latter  are  more  likely  to  be  the  seat  of  the  disease.  The  diagnosis  by  ex- 
clusion may  be  of  service.  Thus,  if  we  can  exclude  calculus  and  infection 
of  the  bladder  and  ureters  by  gonorrhea,  or  in  women  by  the  milder  in- 
fections which  sometimes  attend  child-birth,  the  probabilities  are  increased 
that  we  have  to  do  with  tuberculosis.  Suspected  cases  of  tuberculosis  of 
these  parts  are  rendered  more  probable  if  the  patient  is  a  subject  of  pul- 


TUBERCULOSIS.  285 

monary  tuberculosis.     Primary  tuberculosis  of  these  organs   is,  however, 
possible. 

Tuberculosis  of  the  Ovaries,  Fallopian  Tubes,  and  Uterus. 

A  good  deal  of  attention  has  been  paid  of  late  to  tuberculosis  of  the 
ovaries  by  Wolff,  Charles  B.  Penrose,  Kynoch,  and  others.  The  ovaries 
may  be  the  seat  of  miliary  tubercles  or  may  contain  large  cheesy  masses. 
Ovarian  tuberculosis  is  commonly  associated  with  tuberculosis  of  the  fallo- 
pian t-ubes.  The  symptoms  of  the  former  are  in  no  way  different  from  those 
of  ovaritis  from  other  causes.  Fallopian  salpingitis  produces  a  hard  and 
thick  infiltration  of  the  fallopian  tubes,  which  may  be  recognized  by  the 
usual  method  of  examination  for  disease  of  these  organs.  The  uterine  ends 
are  commonly  closed,  while  the  intervening  portion  may  be  dilated  and 
contain  mucus,  pus,  and  cheesy  material.  Tubal  tuberculosis  is  commonly 
double. 

Tuberculosis  also  invades  the  uterus,  infiltrating  it  by  miliary  tubercles, 
which  coalesce,  soften,  and  break  down,  producing  metritis  and  ulceration, 
discharges  from  which  may  contain  the  bacilli.  Uterine  tuberculosis  usually 
begins  in  the  region  of  the  orifices  of  the  fallopian  tubes,  and  is  really  an 
extension  of  the  disease  from  the  tubes.  It  may,  on  the  other  hand,  extend 
from  below,  from  a  tuberculosis  of  the  vagina.  The  symptoms  of  the  result- 
ing metritis  are  the  same  as  those  of  metritis  from  other  causes.  Tender- 
ness and  moderate  enlargement  may  be  named.  Other  symptoms,  such  as 
hectic  fever  and  sweats,  usually  occur  only  when  tuberculosis  of  these  organs 
is  a  part  of  general  tuberculosis.  The  disease  makes  its  appearance  more 
frequently  during  the  period  of  greatest  sexual  activity,  but  it  has  been 
found  in  young  children,  and  in  them  the  ovaries  and  uterus  have  been 
found  involved  without  participation  of  the  fallopian  tubes.  It  should  be 
mentioned  also  that  tuberculosis  may  extend  from  these  organs  to  the  peri- 
toneum as  well  as  from  the  peritoneum  to  them.  Wolff  *  especially  believes 
tuberculosis  of  the  ovaries  is  not  so  rare  as  commonly  supposed,  since  in  17 
women  who  died  of  tuberculosis  he  found  five  in  which  the  genitalia  were 
invaded,  and  in  three  tuberculosis  of  the  ovaries  on  both  sides  could  be  demon- 
strated. 

Tuberculosis  of  the  Testes,  Prostate  Gland,  and  Seminal  Vesicles. 

Tuberculosis  of  the  testes  and  prostate  is  not  infrequent.  It  presents 
itself  as  cheesy  infiltration,  which  more  frequently  does  not  liquefy.  More 
rarely,  the  vesiculae  seminales  are  invaded.  The  enlarged  vesiculse  semi- 
nales  may  be  felt  through  the  rectum.  The  symptoms  of  this  form  of 
prostatic  disease  are  in  no  way  different  from  those  of  other  diseases  of  the 
prostate  with  enlargement,  until  rupture  takes  place. 

Tuberculosis  of  the  testes  is  not  such  a  rare  affection.  It  is  commonly 
secondary  to  that  of  the  bladder  and  prostate,  whence  the  bacilli  travel  along 
the  vas  deferens  into  the  epididymis,  which  may  be  converted  into  a  cheesy 
mass  surrounding  the  testicle.  With  the  invasion  of  the  testicle  further 
enlargement  results  with  softening,  ulceration,  and  fistulous  burrowing.  The 
walls  of  these  fistulse  are  infiltrated  with  tubercles.  This  malady  is  char- 
acteristically painless. 


*  "  Centralblatt  fiir  Gynakologie,"  No.  46,  18 


286  INFECTIOUS  DISEASES. 

The  treatment  of  these  conditions  is  mainly  surgical,  although  the  gen- 
eral measures  usual  in  tuberculosis  elsewhere  are  also  suitable. 

VII.  Tuberculosis  of  the  Mammary  Glaxds. 

The  mammary  gland,  though  rarely  invaded  by  tuberculosis,  is  never- 
theless an  occasional  seat,  Warden  having  collected  58  authentic  cases  in 
literature,  nearly  90  per  cent,  of  whom  were  females.  Most  cases  developed 
in  the  third  decennium.  Others  have  found  the  disease  more  frequent  dur- 
ing the  child-bearing  period.  The  bacilli  causing  the  disease  are  probably 
carried  by  the  blood  from  adjacent  or  surrounding  organs.  The  special 
local  product  is  a  cheesy  nodule  in  the  gland,  which  softens,  breaks  down, 
and  breaks  through  to  the  surface,  often  through  the  skin,  with  resulting 
fistul^e.  Sharp,  lancinating  pains  radiating  into  the  arm  are  said  to  be  char- 
acteristic. The  tubercular  nodules  may  be  more  deep-seated  and  hard  or  soft 
in  consistency.  Adjacent  axillary  lymphatic  glands  may  be  invaded  by  the 
infiltration.  The  finding  of  the  bacillus  is,  of  course,  the  crucial  evidence, 
although  the  association  of  fistulse  and  ulcers  in  connection  with  tuberculosis 
elsewhere  suggests  this  disease. 

VIII.  Tuberculosis  of  the  Heart  and  Blood-Vessels. 

History. — As  far  back  as  1814,  D.  F.  L.  Kreysig,*  in  Berlin,  said  "  Tubercular 
tumors  of  the  heart  walls,  while  met  with  ver}' rarely,  are  ver}' probable."  In  1826 
Laennac  said  the  heart  muscle  is  subject  to  tuberculosis.  In  1832  Townsend,  of 
Dublin,  recorded  a  case  wherein  a  large  tuberculous  nodule  started  from  the  left  au- 
ricle and  compressed  the  pulmonarj-  vein.  Virchow  originally  announced  that 
tubercle  differed  from  gumma  in  that  it  was  not  capsulated,  but  later  Fuchs  has 
shown  that  true  tubercle  may  also  become  surrounded  with  a  capsule. f  It  is  prob- 
ably more  common  than  is  supposed. 

Tuberculosis  of  the  Heart. — Tuberculosis  of  the  heart  presents 
itself  in  the  shape  of  miliary  tubercles  scattered  throughout  the  substance 
of  the  heart,  more  frequently  in  the  membranes,  causing  tubercular  peri- 
carditis. The  latter  may  be  acute  or  chronic,  more  commonly  acute,  caused 
by  sudden  invasion.  Both  are  usually  a  part  of  a  general  tuberculosis. 
Very  rarely  is  the  acute  form  primary.  Tubercular  pericarditis  is  followed 
by  exudation  of  fibrin,  and  sometimes  of  blood  and  pus. 

Tubercular  pericarditis  is  found  sometimes  in  old  persons  in  whom  it 
promptly  causes  death.  In  cardiac  tuberculosis  it  is  supposed  that  the  bacilli 
arise  from  long  latent  foci  of  tuberculosis  of  the  bronchial  or  mediastinal 
lymphatic  glands.  The  latter,  on  the  other  hand,  may  be  secondarily  invaded 
from  the  cardiac  tuberculosis.  Such  pericarditis  is  also  commonly  adhesive, 
and  is  not  distinguishable  by  physical  signs  and  symptoms  from  the  other 
forms  of  pericarditis. 

Tuberculosis  also  occasionally  occurs  in  the  papillary  muscular  sub- 
stance of  the  heart. 

Tubercles  are  sometimes  found  on  the  valves  of  the  heart. 

Tuberculosis  of  Blood-Vessels. — Tuberculosis  may  also  invade  the 
blood-vessels  of  a  part  attacked,  and  in  tuberculosis  of  the  lungs  hemor- 
rhages are  commonly  due  to  such  invasion,  which  weakens  the  vessel  and 
ultimately  perforates  it. 

*  "  Tuberculosis  of  the  Heart  Muscle,"  "  Edinburgh  Medical  Journal,"  September  ii,  igoi. 
t  "  Krankheiten  des  Herzens,"  Berlin,  1816. 


LEPROSY.  287 

LEPROSY. 

Synonyms. — Elephantiasis  GrcEcorum. 

Definition. — Leprosy  is  an  infectious  disease,  due  to  the  bacillus  leprce, 
characterized  by  a  subcutaneous  and  submucous  nodular  infiltrate,  or  by 
similar  infiltration  of  nerve-trunks.  The  former  constitutes  tubercular  lep- 
rosy ;  the  latter,  anesthetic  leprosy. 

History. — The  disease  is  identified  with  the  early  history  of  Egypt  and  India,  and 
is  described  in  the  Books  of  Moses,  who  gave  many  rules  for  its  recognition,  the  isola- 
tion of  victims,  the  test  of  recovery,  and  rules  to  be  complied  with  before  the  con- 
valescent could  mingle  with  his  people.  It  prevailed  in  Europe  in  the  jNliddle  Ages, 
but  has  become  almost  extinct  there,  except  in  Norway  and  Sweden,  Hungarj-,  and 
Roumania.  In  Greece  and  Turkey,  Palestine,  Syria,  E'gypt,  India,  China,  Siam,  the 
Sandwich  Islands,  and  West  Indies  it  is  still  ende'mic. 


Etiology. — The  bacillus  of  leprosy  was  discovered  by  Hansen  in  i! 
and  subsequently  clearly  described  by  Neisser,  and  is  especially  character- 
ized by  its  close  resemblance  to  the  tubercle  bacillus.  The  bacilli  are  delicate 
rods  whose  length  equals  1-3  to  1-2  the  width  of  a  red  blood-disc.  They  are 
for  the  most  part  found  in  the  interior  of  cells,  rarely  outside  of  them.  Some 
of  these  cells  are  of  large  size  and  known  as  lepra  cells.  In  the  interior  of 
these  cells  the  bacilli  often  form  clumps.  They  are  exceedingly  numerous 
in  leprous  tissue.  They  stain  readily  in  anilin  colors,  but  not  in  vesuvin, 
differing  in  this  respect  from  tubercle  bacilli,  and  also  in  that  they  liquefy 
coagulated  blood  serum,  while  tubercle  bacilli  do  not.  In  the  fresh  condition 
the  lepra  bacilli  exhibit  active  movement. 

While  the  disease  is  contagious,  its  spread,  under  circumstances  the 
most  favorable,  is  exceedingly  slow,  the  most  intimate  contact,  as  that  be- 
tween parent  and  child,  being  often  unattended  by  inoculation.  Experi- 
mental inoculation  was,  however,  successfully  performed  on  a  Hawaiian 
convict  by  Arning,  as  well  as  in  rabbits  by  IMelcher  and  Artmann.  Accord- 
ing to  IMorrow,  in  the  majority  of  cases  the  disease  spreads  by  sexual  inter- 
course, but  cracks  and  fissures  in  the  skin  also  favor  the  lodgment  of  the 
bacillus.  In  certain  countries,  especially  the  tropical,  its  spread  is  more  rapid. 
Such  are  India,  where  there  are  said  to  be  250,000  lepers,  and  the  Sand- 
wich Islands,  where,  in  1889,  there  were  iioo  in  the  settlement  at  Molokai. 
In  the  West  Indies  there  are  also  many  cases,  and  some  remarkable  morbid 
specimens  from  Trinidad  were  exhibited  by  Dr.  Beaven  Rake  at  the  Pan- 
American  Medical  Congress,  held  in  Washington,  \J.  S.  A.,  in  September, 

1893- 

In  this  country  the  cases  are  for  the  most  part  isolated  ones  that  enter 

by  the  seaports  of  the  Pacific  and  Atlantic  coasts.  In  Tracadie,  on  the  Gulf 
of  St.  Lawrence,  there  is,  however,  a  leper  settlement,  the  disease  having 
been  brought  from  Norway  in  the  latter  part  of  the  eighteenth  century. 
The  number  of  cases  is  being  graduallv  reduced,  there  being  in  1896  but  18 
as  compared  to  40  a  few  years  ago.  This  is  apparently  the  result  of  segre- 
gation,  which  is  now  generally  practiced  where  possible. 

All  ages  and  sexes  are  liable  to  th;s  disease.  Animals  are  not  subject  toi 
it,  although  guinea  pigs  have  been  successfully  inoculated.  A  curious  im- 
pression has  arisen  that  the  disease  is  caused  by  eating  spoiled  fish  or  vege- 
tables. To  this  view  Jonathan  Hutchinson  has  given  the  weight  of  his 
opinion.     In  view,  however,  of  the  acknowledged  bacillary  origin  of  the 


288  INFECTIOUS  DISEASES. 

disease,  this  can  only  be  considered  as  a  predisposing  cause  that  lowers 
vitality  by  altering  nutrition. 

Morbid  Anatomy.— Tubercular  leprosy  is  characterized  by  its  nodular 
outgrowths  on  the  skin,  the  nodules  being  made  up  of  a  small-celled  infil- 
trate, maintaining  itself  for  a  considerable  time,  after  which  it  breaks  down 
and  ulcerates.  The  ulcers  may  heal,  producing  cicatrices.  The  mucous 
membrane  is  also  invaded,  particularly  that  of  the  eyelids,  the  conjunctiva, 
cornea,  and  larynx.  Lymphatic  glands,  cartilage,  liver,  lungs,  and  spleen 
are  also  at  times  affected.  The  lepra  nodes- are  vascular,  differing  in  this 
respect  from  tubercles. 

The  morbid  anatomy  of  the  anesthetic  variety  will  be  included  in  the 
anatomical  changes  of  the  skin  to  be  described  in  the  symptomatology  of  that 
type  of  the  disease. 

Symptoms. — Nothing  is  known  of  a  period  of  incubation.  The  outbreak 
of  the  disease  is  apt  to  be  preceded  by  an  intermittent  febrile  movement, 
which  has  been  mistaken  for  intermittent  fever  and  which  may  last  for  one 
or  two  years.  There  is  often  an  erythematous  redness  of  the  skin,  which 
in  places  becomes  pale  and  in  others  assumes  a  brownish  tinge.  From  this 
appearance  the  name  macular  leprosy  has  been  applied  to  certain  cases  which 
go  no  farther.  From  these  spots  the  pigment  may  also  disappear,  leaving 
perfectly  white  anesthetic  areas — lepra  alba. 

In  the  tubercular  form,  which  is  the  more  common,  an  infiltration  of 
the  skin  with  tubercular  nodules  takes  place.  These  remain  for  a  long  time 
intact,  without  degenerating,  but  sooner  or  later,  as  a  rule,  though  often 
only  after  many  years,  softening  and  ulceration  take  place.  Some  of  them, 
on  the  other  hand,  gradually  disappear  without  ulceration.  The  number  of 
nodules  varies  greatly.  Some  of  them  are  pediculated,  others  are  a  simple 
thickening  of  the  skin,  which  is  conspicuous  in  such  portions  as  the  eyelids, 
nose,  and  ears,  parts  of  which  may  disappear  by  ulceration.  Even  the 
cornea  and  conjunctiva  may  be  the  seat  of  nodules,  and  blindness  may  result. 

The  same  development  may  take  place  in  mucous  membranes  produc- 
ing obstruction  of  the  respiratory  passages,  including  the  nose  and  larynx. 
There  may  also  be  leprous  deposits  in  internal  organs,  including  the  liver, 
spleen,  lungs,  and  lymphatic  glands. 

In  the  nervous  or  anesthetic  form  the  peripheral  nerves  become  infil- 
trated wiih  the  leprous  growth  and  are  converted  into  thickened  cords  that 
may  even  be  felt  under  the  skin.  These  are  at  first  painful,  but  later 
become  anesthetic.  Trophic  phenomena  of  a  striking  character  result,  pro- 
ducing dryness,  smoothness,  and  tightness  of  the  skin  with  a  total  absence 
of  nodules.  Atrophy  and  wasting  ensue  from  the  same  cause,  and  toes, 
fingers,  and  even  larger  limbs  drop  off.  Great  vesicles  also  sometimes  form. 
Subsequently  are  added  signs  of  weakness  and  exhaustion  which  gradually 
increase  until  the  patient  succumbs. 

Diagnosis, — ^The  diagnosis  of  the  tubercular  form  is  not  difficult.  The 
anesthetic  variety  resembles  closely  certain  forms  of  scleroderma,  but  the 
trophic  changes  are  more  extensive.  The  resemblance  of  the  early  stage  to 
intermittent  fever  has  been  referred  to.  The  diagnosis  may  be  made  absolute 
by  the  detection  of  lepra  bacilli  in  portions  cut  out  for  the  purpose  of  study. 

The  anesthetic  or  nervous  form  of  leprosv  and  syringomyelia  bear  a  close 
clinical  resemblance.  The  characteristic  differences  are  thus  pointed  out  by 
Laehr  :*     Leprosy  is  an  infectious  disease  due  to  the  bacillus  leprce,  begin- 

*  "Deutsche  med.  Wochenschrift,"  January  17,  1897,  p.  45. 


RHEUMATIC  FEVER.  289 

ning  with  a  febrile  movement  and  primarily  seated  on  peripheral  nerves. 
Synngomyelia  is  a  non-febrile  or  slightly  febrile  developmental  disease,  with 
its  seat  in  the  upper  spinai  cord,  m  leprosy  the  circumscribed  anesthesia, 
muscular  atrophy,  and  vasomotor-trophic  disturbances  of  the  skin,  bones, 
and  joints  appear  upon  the  face,  trunk,  and  upper  extremities  and  simul- 
taneously or  earlier  in  the  lower.  In  syringomyelia  the  upper  extremities 
are  first  affected,  the  lower  very  late,  if  at  all,  the  face  escaping,  as  a  rule, 
completely.  Sweating  is  absent  in  leprosy,  but  characteristic  of  syringo- 
myelia. The  wasting  in  leprosy  involves  first  the  muscles  of  distal  parts  of 
the  extremities,  while  that  of  syringomyelia  begins  in  the  proximal  portions. 
The  anesthesia  in  leprosy  includes  pain  sense,  temperature  sense,  and  tactile 
sense,  while  tactile  sensibility  is  rarely  involved  in  syringomyelia.  In  leprosy 
the  anesthetic  areas  vary  in  form  and  extent,  and,  as  a  rule,  are 
scattered  over  the  entire  body.  In  syringomyelia  sensory  changes  show 
themselves  on  the  trunk  in  the  form  of  a  girdle.  The  sensory  disturbances 
correspond  to  the  portions  of  the  cord  involved,  while  the  anesthesia  of  lep- 
rosy depends  upon  local  cutaneous  disease  and  occasionally  upon  disease  of 
the  peripheral  nerves.  As  a  rule,  it  is  possible  to  detect  spindle-shaped 
thickenings  of  the  peripheral  nerves,  especially  of  the  ulnar  and  the  peroneal, 
before  the  manifestations  of  neuritis  are  apparent.  Altogether  the  symptoms 
of  syringomyelia  are  similar  to  those  of  anesthetic  leprosy,  but  in  the  latter 
disease  the  trophic  changes  are  more  marked,  the  phalanges  often  drop- 
ping off. 

Prognosis. — The  course  of  the  disease  is  almost  always  prolonged,  and 
the  patient  may  die  from  intercurrent  disease.  In  some  cases  death  results 
from  the  gradual  exhaustion  of  the  system,  which  is  more  rapid  in  the  ulcer- 
ative forms.  From  the  nervous  form  of  leprosy  recovery  does  sometimes 
take  place,  though  the  secondary  changes  resulting  remain  permanent. 

Treatment. — So  far  as  known,  treatment  is  unavailing.  Segregation 
should  be  practiced  whenever  possible,  for  such  a  course  is  invariably  accom- 
panied by  a  falling  off  in  the  number  of  cases,  and  the  continued  practice  of 
this  method  must  ultimately  result  in  the  disease  being  stamped  out. 

Among  the  remedies  that  have  been  recommended  are  mercury  and 
iodin  by  inunction.  Internally  are  advised  iodid  of  potassium,  creasote 
and  salicylic  acid,  chaulmoogra  oil,  and  gurjun  oil.  The  chaulmoogra  has 
most  reputation,  and  is  regarded  by  Danielson  after  forty  years'  experience 
with  it  as  distinctly  useful.  It  is  used  in  doses  of  two  drams  (8  gm.)  every 
two  hours,  and  gurjun  oil  in  doses  of  ten  minims  (0.66  gm.).  The  latter 
may  also  be  used  by  inunction. 


RHEUMATIC    FEVER. 

Synonyms. — Acute   RheumaHsm;   Acute   Articular   Rheumatism;   Inflam- 
matory Rheumatism. 

Definition. — An  acute  febrile,  jinfectious,  but  non-contagious  fever, 
characterized  by  arthritis,  usually  multiple. 

Etiology. — While  no  distinctive  bacterium  has  as  yet  been  isolated, 
Hermann  Sahli  found  in  diseased  joints  in  which  there  was  no  suppuration 
a  bacterium  closely  resembling  the  staphylococcus  citreus,  and  Leyden  a 

19 


290  INFECTIOUS  DISEASES. 

cliplococcus  differing  from  that  of  pneumonia.  Drs.  F,  J.  Poynton  and  F. 
A.  Paine  with  the  diplococcus  isolated  from  rheumatic  fever  have  obtained 
in  rabbits  results  which  go  to  show  that  the  organism  with  which  they 
experimented  is  able  to  produce  lesions  of  rheumatic  fever,  namely,  mitral 
valvulitis,  pericarditis,  and  polyarthritis.  The  diplococcus  experimented 
with  was  obtained  from  the  joints,  from  the  throat  in  a  case  of  rheumatic 
angina,  from  the  bladder,  and  after  death  from  the  morbid  product  of  rheu- 
matic pericarditis  and  endocarditis.  Again,  by  injecting  a  young  rabbit 
with  the  organisms  from  the  blood  and  cerebrospinal  fluid  of  the  infected 
rabbit  they  also  produced  polyarthritis  and  endocarditis  in  the  second  ani- 
mal. Some  of  the  animals  recovered  and  others  perished.  In  addition  to 
the  symptoms  mentioned,  there  were  wasting  and  involuntary  clonic  move- 
ments like  those  of  chorea  and  the  animal  was  also  very  nervous.  With  the 
chorea  there  was  valvulitis.*  In  another  instance  the  micrococcus  lanceo- 
latiis  was  found.  In  view  of  the  fact  that  several  organisms  have  been, 
found  associated  with  rheumatic  polyarthritis  it  may  be  true,  as  Flexner 
and  Barker  \  suggested,  that  acute  articular  rheumatism  has  no  etiological 
unity,  but  may  be  brought  about  by  the  entrance  into  the  blood  of  one  of 
several  different  pyogenic  organisms  under  circumstances  incompatible  with 
the  development  of  the  phenomena  of  a  general  septicemia,  but  which  may 
give  rise  to  an  inflammation  of  one  of  the  several  serous  membranes,  includ- 
ing the  synovial,  as  well  as  the  meninges,  pleura,  pericardium,  or  endo- 
cardium. 

A  predisposing  cause  seems,  however,  to  be  necessary  in  the  majority 
of  cases,  and  exposure  to  cold  is  the  most  common,  although  epidemics  of 
acute  rheumatism  occur  quite  independently  of  such  exposure.  While  sud- 
den changes  in  temperature,  also,  often  afford  the  needed  conditions,  the 
continued  action  of  moderate  degrees  of  cold,  especially  when  accompanied 
by  moisture,  is  almost  as  frequently  responsible.  If  to  these  be  added  a 
lowered  vitality  due  to  insufficient  food,  fatigue,  overwork,  or  all  these  com- 
bined, we  include  the  majority  of  predisposing  causes.  The  winter  and  spring, 
being  the  seasons  in  which  the  conditions  of  temperature  and  moisture  operate 
most  strongly,  are  those  in  which  the  disease  is  most  prevalent.  For  a  like 
reason  it  is  more  common  in  the  temperate  zones,  the  extreme  North  as  well 
as  the  extreme  South  being  for  the  most  part  exempt.  In  my  own  experi- 
ence, the  late  spring  finds  many  cases  due  to  the  cold  and  dampness  of  houses 
where  fires  have  been  prematurely  dispensed  with.  It  is  a  disease  especially 
of  young  adults,  being  rare  before  fifteen  and  after  fifty;  w4iile  the  exposing 
occupations,  including  those"  of  driver,  servant,  and  laborer,  favor  its 
development. 

It  may  be  still  in  place,  in  connection  with  the  newer  etiology,  to  men- 
tion two  of  the  older  theories  of  acute  rheumatism.  According  to  the  meta- 
bolic theory,  a  morbid  material  is  developed  in  the  economy  as  the  result  of 
defective  assimilation.  Prout  early  named  lactic  acid  as  the  peccant 
material,  and  more  recently  P.  W.  Latham  has  suggested  a  combination  of 
lactic  acid  with  other  substances.  The  nervous  theory  was  suggested  by 
the  late  John  K.  Mitchell  in  1831.  t  According  to  it.  the  nerve-centers  are 
affected  by  cold,  and  the  local  lesions  are  trophic  in  character,  or  defects  of 


*  Communication  to  the   Pathological  Society  of  London,  Tuesday,  October  i6,  1900  ;  published 
in  the   "  British  Med.  Jour.,"  October  20,  1901. 
t  "Am.  Jour.  Med.  Sci.."  1804. 
%  "Am.  Jour.  Med.  Sci.,"  viii.,  1831,  p.  53. 


RHEUMATIC  FEVER.  291 

metabolism  result  from  the  primary  nervous  lesion,  whence  arises  lactic 
acid,  which  accumulates  in  the  blood. 

Acute  rheumatism  is  a  disease  simulated  by  other  affections  not  infre- 
quently called  rheumatic.  Thus,  scarlet  fever  is  often  accompanied  by  a 
painful  swelling  of  the  joints  due  to  the  specific  cause  of  that  disease,  and 
called  rheumatic,  when  it  should  be  spoken  of  as  scarlatinal  synovitis.  The 
same  is  true  of  the  so-called  gonorrheal  rheumatism,  which  is  not  a  rheu- 
matism, but  a  gonorrheal  synovitis  due  to  the  gonococcus,  and  not  a  rheu- 
matism accurately  speaking. 

^Morbid  Anatomy.— There  is  little  to  be  added  to  what  will  be  de- 
scribed in  treating  of  symptoms,  and  to  w^hat  is  furnished  by  the  compli- 
cations, whose  morbid  anatomy  will  also  be  considered  in  connection  with 
the  diseases  that  constitute  them.  The  synovial  membrane  is  hyperemic  and 
swollen,  and  in  some  cases  the  fluid  in  the  joints  is  increased,  is  turbid,  and 
contains  flakes  of  lymph,  rarely  pus.  There  may  be  slight  erosion  of  the 
cartilages.     The  fibrin  of  the  blood  is  usually  increased. 

Symptoms. — While  rheumatic  fever  is  seldom  ushered  in  by  a  chill, 
there  is  more  frequently  a  short  prodrome  of  a  day  or  two,  during  which  the 
patient  feels  uncomfortable  or  has  an  unpleasant  aching  feeling  in  his  joints. 
More  often,  however,  the  painful  arthritis,  which  is  the  first  symptom  to 
attract  attention,  develops  rapidly,  coming  on  in  a  single  day  or  night,  or 
seemingly  in  a  much  shorter  time,  making  locomotion  at  once  difficult  or 
impossible. 

The  joint  aft'ection  has  some  peculiarities.  In  the  first  place,  the 
involvement  is  almost  always  multiple,  and  generally  includes  the  larger 
joints,  such  as  the  knee,  ankle,  elbow,  wrist,  shoulder,  and  hip,  although 
none  are  exempt,  and  the  phalangeal  and  metacarpo-phalangeal  articulations 
also  suffer.  The  toe-joints  escape  most  frequently.  It  rarely  happens  that 
a  single  joint  is  involved,  but  its  occasional  occurrence  must  be  admitted. 
More  rarely,  if  ever,  does  it  happen  that  all  are  affected,  although  even  the 
vertebral  articulations  must  sometimes  be  included.  The  joint-inflammation 
is  further  characterized  by  a  tendency  to  fly  from  one  joint  to  another.  Now 
it  will  be  the  elbow,  then  the  wrist ;  again,  the  knee,  and  then  the  ankle  or 
shoulder  or  hip,  either  on  the  same  side  or  the  other;  but  while  there  will 
be  a  reduction  in  the  degree  of  inflammation,  and  correspondingly  of  pain 
in  the  relieved  joints,  the  relief  will  not  be  total.  On  another  day,  again,  the 
pain  will  have  returned  to  the  joint  which  had  been  temporarily  relieved. 

While  the  joint-affection  always  includes  a  synovitis,  the  process  is  by 
no  means  confined  to  the  synovial  membrane.  The  adjacent  structures, 
including  the  capsular  and  lateral  ligaments,  and  the  tendons,  with  their 
sheaths,  coursing  over  the  joint,  and  even  muscles,  are  all  the  seat  of 
involvement,  contributing  to  the  swelling  and  to  the  pain  by  the  exudation 
pervading  them.  Comparing  two  hands,  one  of  which  is  involved  and  the 
other  not,  one  can  often  see  the  depressions  between  the  metacarpal  bones 
in  the  former  obliterated  by  swelling,  while  they  maintain  their  usual  dis- 
tinctness in  the  latter.  It  is  for  such  reasons  that  I  prefer  the  name  acute 
rheumatism  to  that  of  acute  articular  rheumatism,  which  would  limit  the 
process  to  the  joints.     Rheumatic  fev.er  is  probably  the  best  term. 

Finally,  mention  should  not  be  omitted  of  the  non-articular  rheumatic 
fever  to  which  Kohler  *  has  called  attention,  in  which  there  are  no  joint- 
symptoms.  ^^___ 

*  "  Zeitschrift  f.  klin.  Med."  Bd.  xix.  i8qi. 


292  INFECTIOUS  DISEASES. 

The  pain  is  almost  always  extremely  severe,  making  all  motion  an 
agony,  while  jarring  of  the  bed,  or  even  the  weight  of  bed  clothing,  may 
cause  the  patient  to  cry  out  with  pain.  To  diminish  the  tension,  which  aggra- 
vates the  pain,  the  patient  is  disposed  to  lie  with  all  the  limbs  semiflexed. 

From  the  beginning  there  is  fever,  but  being  seldom  high  at  this  stage, 
it  is  not  commonly  the  first  symptom  to  attract  attenion.  Later,  it  usually 
increases  proportionately  to  the  extent  of  joint  involvement,  but  only  in  the 
meningeal  form  is  it  extremely  high.  Nor  does  it  pursue  a  course  at  all 
distinctive.  In  one  case,  for  example,  the  temperature  remained  at  102°  F. 
(38.8°  C.)  and  a  fraction,  night  and  morning  and  throughout  the  day  for  a 
number  of  days.  ]\Iore  rarely  it  rises  to  104°  F.  (39.9°  C.)  Occasionally, 
however,  there  is  intense  hyperpyrexia,  w'hen  the  temperature  rises  rapidly 
from  104°  F.  to  110°  F.  (39.9°  C.  to  44.3^  C),  and  even  higher.  With  this 
are  associated  cerebral  symptoms  of  an  alarming  and  dangerous  kind,  intense 
headache,  and  delirium — symptoms  otherwise  rather  unusual  in  acute  rheu- 
matism. To  these  are  often  added  unconsciousness,  pulselessness,  and 
cyanosis,  rapidly  followed  by  death,  unless  the  temperature  is  promptly 
reduced.  The  sudden  onset  of  these  symptoms  adds  to  their  alarming  char- 
acter. This  combination  of  severe  symptoms  is  known  as  the  meningeal 
form,  or  rhcuniaiisui  of  the  brain. 

The  pulse  in  rheumatic  fever  is  rapid,  often  disproportionately  so  to  the 
fever,  probably  because  of  the  nervous  demoralization  caused  by  the  acute 
suffering. 

Next  to  the  fever  and  joint-inflammation,  the  most  distinctive  symptom 
of  acute  rheumatism  is  the  szi'eatiiig,  which  is  copious  and  usually  acid  in 
reaction,  sometimes  even  to  such  an  extent  as  to  impart  an  acid  odor  to  the 
air  of  the  room.  Sudamina  are  a  frequent  consequence  of  such  profuse 
sweating. 

Discolorations  of  the  skin,  varying  in  intensity  and  character,  make  their 
appearance  in  certain  cases.  There  may  be  a  simple  diffuse  erythema,  or  it 
may  be  papular  or  tuberculated  or  marginate.  There  may  be  true  urticaria, 
or  there  may  be  extravasations  of  blood,  purpuric  patches  of  such 
extent  and  depth  as  to  result  in  sloughing  of  the  tissues,  hemor- 
rhages from  the  mucous  membranes,  and  hematuria.  In  one  case 
under  my  observation  there  ensued  permanent  blindness  from  extravasa- 
tion into  the  retina.  These  cases  of  peliosis  rheuniatica  are  not  acknowl- 
edged by  all  to  be  truly  rheumatic,  the  joint-affection  being  declared  to  be 
of  a  different  nature,  analogous  to  that  of  scorbutus  and  hemophilia. 

The  urine  is  also  somewhat  characteristic.  It  is  scanty,  of  high  specific 
gravity,  very  acid  in  reaction,  and  deposits  a  copious  sediment  of  pink-hued 
mixed  urates. 

Very  interesting  and  characteristic  are  certain  subcutaneous  nodules, 
attached  to  tendons  and  fascia,  which  have  long  been  observed  as  occasional 
events  in  connection  with  acute  rheumatism,  and  have  been  especially 
studied  by  Barlow  and  Warner.  They  vary  in  size  from  a  shot  to  that  of  a 
pea,  and  may  be  numerous  or  but  few.  They  occur  on  the  fingers,  hands 
and  wrists,  elbows,  knees,  scapulae,  spines  of  the  vertebrae,  and  more  particu- 
larly after  the  acuteness  has  passed  away.  They  may  last  a  few  days  or  for 
months,  and  are  more  common  in  children  than  in  adults. 

Disposition  to  recurrence  must  be  mentioned  as  a  characteristic  feature 
of  acute  rheumatism.  Quite  rarely  does  a  person  who  has  had  one  attack 
escape  another,  and  it  is  these  successive  attacks  which,  augmenting  pre- 


RHEUMATIC  FEVER.  293 

vious  cardiac  lesions,  finally  cripple  the  heart  until  its  work  is  greatly  ham- 
pered. The  intervals  between  successive  attacks  are  various, — from  a  year 
to  four  or  five  years, — and  they  are  the  more  frequent  and  more  liable  to 
occur  the  younger  the  subject. 

Complications. — Very  interesting  in  connection  with  acute  rheumatism 
is  the  frequent  involvement  of  the  serous  membranes  other  than  those  of 
the  joints,  such  as  the  pleural  membranes  and  the  peritoneum.  The  involve- 
ment of  the  former  simulates  pleurisy  and  the  latter  peritonitis,  and  I  well 
remember  a  case  of  my  own,  a  girl  of  eight  years,  in  whom  for  days  I 
thought  I  was  dealing  with  peritonitis,  when  a  few  doses  of  salicylate  of 
sodium  relieved  my  anxiety  by  promptly  arresting  the  disease.  In  rheu- 
matism of  the  pleura  the  absence  of  physical  signs  aids  in  the  diagnosis. 
These  phenomena  are  easily  explained  with  the  modern  views  of  the  etiology 
of  rheumatic  fever,  since  we  have  only  to  suppose  the  infectious  material 
circulating  in  the  blood  to  lodge  upon  the  serous  membranes  instead  of  the 
joint  tissues. 

Of  the  same  class  is  a  much  more  common  complication,  cardiac  dis- 
ease, including  endocarditis  and  pericarditis,  the  former  being  by  far  the 
more  frequent,  and  confined  almost  exclusively  to  the  left  heart.  Again, 
the  mitral  leaflets  are  much  more  frequently  attacked  than  the  aortic.  While 
the  cardiac  involvement  bears  some  relation  to  the  severity  of  the  disease, 
the  mildest  cases  may  become  complicated  as  well  as  the  severest.  Hence, 
the  heart  should  be  daily  examined,  and  for  the  further  reason  that  the 
approach  of  the  disease  is  often  exceedingly  insidious.  On  the  other  hand, 
cardiac  oppression  and  palpitation  may  occur  without  actual  structural 
change,  and  even  a  functional  murmur  ma}^  be  present  in  acute  rheumatism, 
and  this,  too,  not  only  at  the  base,  but  also  at  the  apex  of  the  heart,  an 
unusual  site  for  such  a  murmur. 

The  proportion  of  cases  in  which  cardiac  complications  occur,  though 
difficult  to  estimate,  is  not  less  than  25  to  33  per  cent,  for  endocarditis,  with 
10  per  cent,  more  for  pericarditis,  making  in  all  35  to  43  per  cent.,  while 
some  estimate  even  a  larger  proportion.*  Young  subjects  are  more  vulner- 
able than  adults,  and  Fagge  mentions  an  interesting  difference  in  the  sexes 
after  adult  life,  which  is,  that  pericarditis  is  more  frequent  in  men  above 
twenty-five  than  in  women  of  the  same  age,  probably  because  at  this  age 
men  work  much  harder  than  women. 

The  variety  of  endocarditis  is  usually  the  verrucose,  or  warty,  ulcera- 
tion, laceration  or  perforation  of  the  valve  flaps  being  very  rare.  The  malig- 
nant form  of  endocarditis  does,  however,  occur.  While  the  endocardial 
murmurs  in  the  endocarditis  of  acute  rheumatism  are  commonly  soft,  the 
pericardial  murm_urs  are  often  loud,  rough,  and  rasping,  and  the  vibration 
resulting  from  the  friction  may  even  be  communicated  to  the  hand  laid  upon 
the  precordium.  Both  conditions  may  result  in  complete  recovery,  but  the 
former  more  commonly  is  the  beginning  of  a  chronic  valvular  defect. 

Acute  myocarditis  is  a  fatal,  but  fortunately  rare,  complication  of  rheu- 
matic fever,  occurring  alone  or  in  association  with  endocarditis  and  peri- 
carditis. It  is  commonly  first  discovered  at  the  autopsy,  though  severe 
epigastric  or  precordial  pain,  embarrassed  respiration,  and  cyanosis  may 
suggest  it.  It  probably  occurs  more  frequently  than  is  reported,  although 
the  facts  do  not  substantiate  it. 

*De  Lancey  Rochester  in  a  paper  published  in  the  "  Tour,  of  the  Am.  Tiled.  Assn.,"  December  15, 
1900,  says  60  per  cent,  for  endocarditis  and  10  per  cent,  for  pericarditis. 


294  INFECTIOUS  DISEASES. 

Other  complications  of  rheumatism  are  probably  also  the  direct  result 
of  the  poison.  They  include  the  inflammation  of  the  serous  membranes 
mentioned,  bronchitis,  and,  more  rarely,  pneumonia.  Convalescence  from 
the  latter  is  said  to  be  slow. 

The  sequelcs  directly  traceable  to  acute  rheumatism  are  also  few. 
Chorea,  acute  nephritis,  and  exophthalmic  goiter  are  among  those  so 
regarded.  The  nephritis  is,  perhaps,  better  considered  a  complication  result- 
ing from  the  same  cause,  just  as  are  the  endocarditis,  pleurisy,  and  peri- 
tonitis. Among  sequelae  should  be  included  the  more  unusual  one  of  chronic 
arthritic  changes  identical  with  those  of  chronic  articular  rheumatism  and 
even  rheumatoid  arthritis. 

Diagnosis. — The  diagnosis  of  acute  rheumatism -is  seldom  difficult,  the 
multiple  painful  involvement  of  the  joints,  the  fever,  and  sweating  seldom 
mean  anything  else;  but  pyemia  and  scarlatinal  and  gonorrheal  arthritis 
must  be  remembered  as  possible  events.  It  is  the  monarticular  variety  which 
demands  most  discrimination  in  its  determination.  Traumatic  synovitis, 
tuberculosis  or  white  swelling,  and  the  so-called  nervous  arthropathies  are 
to  be  eliminated. 

It  is  not  ahvays  easy  at  a  first  visit  to  distinguish  gout  from  acute  rheu- 
matism, but  the  most  serious  possible  error  in  diagnosis  is  to  mistake  a 
pyemic  arthritis  for  a  rheumatic  arthritis.  This  is  not  an  uncommon  mis- 
take where  there  is  no  evident  surgical  lesion  to  suggest  it.  Osteomyelitis  is 
said  to  be  the  most  common  cause  of  such  pyemias ;  but  other  bone-diseases, 
puerperal  sepsis,  and  gonorrhea  are  also  causes. 

Prognosis. — The  course  of  acute  rheumatism  is  characterized  by  many 
fluctuations  independent  of  treatment,  and  its  duration  is  various.  Sooner 
or  later  recovery  generally  takes  place,  although  it  may  be  with  a  crippled 
heart  and  a  susceptibility  to  return.  ^lore  rarely  the  attack  passes  over 
into  a  subacute  condition  which  makes  the  patient  a  sufferer  for  a  long  time, 
while  still  more  rarely  true  chronic  rheumatism  is  the  result.  It  used  to  be 
said  the  cure  for  inflammatory  rheumatism  is  "  six  weeks,"  and  though  this 
is  not  true  of  every  case,  many  are  prolonged  to  quite  this  length. 

Subacute  Rheuinatisin. 

This  term  is  applied  to  forms  in  which  all  the  symptoms  are  less  marked 
and  more  prolonged.  The  fever  is  not  so  high,  ranging  from  99°  to  101°  F. 
(37.2°  to  38.3''  C).  The  inflammation  of  joints  is  not  so  intense  and  the 
joints  involved  are  less  numerous.  It  exhibits  the  same  "  flying  "  tendency. 
It  may  also  be  associated  with  the  cardiac  complications,  especially  in  chil- 
dren.    It  may  pass  into  the  chronic  form. 

Treatment. — ^Whatever  may  be  the  drawbacks  to  a  successful  treat- 
ment of  acute  rheumatism, — and  they  are  many, — it  is  certain  that  most  of 
those  who  had  to  treat  this  disease  a  quarter  of  a  century  ago  now  attack  it 
with  much  more  confidence  than  they  did  in  that  day.  The  drug  which  is 
responsible  for  this  feeling  is  salicylic  acid,  and  very  few  physicians  think 
of  any  other  at  the  outset  of  a  typical  case.  The  introduction  of  salicylic 
acid  as  a  remedy  for  acute  rheumatism  is  commonly  ascribed  to  Buss,  of 
Basle,  some  time  prior  to  1876,  but  attention  was  first  prominently  drawn 
to  it  in  the  latter  year  by  Dr.  Strieker,  of  Traube's  clinic  in  Berlin. 

Salicylic  acid  and  salicylate  •  of  sodium  are  equally  efficient,  but  the 
former  has  been  largely  superseded  by  the  latter,  because  less  irritating  and 


RHEUMATIC  FEVER.  295 

easier  of  administration.  Still  better  borne  is  strontium  salicylate.  Which- 
ever is  used,  there  is  one  necessary  condition  of  its  efficiency,  and  that  is  its 
constitutional  impression.  The  aim  in  the  administration  is,  of  course,  to 
relieve  the  patient,  but  this  effect  is  seldom  obtained,  or,  if  obtained,  is  of 
fleeting  character,  until  the  peculiar  ringing  in  the  ears  is  secured.  To  do 
this  in  the  adult  i  1-2  to  2  drams  (5.8  to  y.y  gm.)  of  salicylic  acid  and  from 
2  to  3  drams  {y.y  to  11.6  gm.)  of  the  sodium  salicylate  in  the  first  twenty- 
four  hours  are  required.  If  the  salicylic  acid  is  given,  it  should  be  in  cap- 
sules.or  compressed  pills  containing  7  1-2  to  10  grains  (0.49  to  0.65  gm.) 
every  two  hours,  followed  by  a  little  water  or  milk.  The  salicylate  of  sodium 
may  be  given  in  doses  of  10  to  15  grains  (0.65  to  i  gm.)  in  solution  every 
two  hours,  or  every  hour  if  the  pain  be  severe,  until  relief  comes,  after  which 
it  should  be  kept  up  until  the  toxic  effect  is  produced,  when  the  dose  should 
be  diminished,  but  the  drug  continued ;  or  the  interval  may  also  be  prolonged. 
Others  would  give  the  salicylate  of  sodium,  i  to  i  1-2  drams  (5.8  to  y.y  gm.), 
in  a  single  dose,  but  in  my  experience  few  stomachs  will  submit  to  such 
quantities.  The  doses  laid  down  may  be  pushed  more  rapidly  if  the  suffer- 
ing is  extreme,  but  I  have  seldom  found  it  necessary.  Under  this  treatment 
the  pain  fades  away,  the  swelling  diminishes,  and  the  anxious  expression  of 
the  patient  is  changed  to  one  of  comfort  in  from  twenty-four  to  forty-eight 
hours.  Those  who  object  to  the  salicylate  treatment  do  so  on  the  ground 
that  the  relief  is  not  permanent,  and  it  must  be  admitted  that  relapses  do 
occur.  I  am  confident,  however,  that  this  is  often  due  to  the  fact  that  the 
remedy  is  discontinued  too  soon.  As  stated,  the  drug,  while  it  should  be 
cut  down  with  the  appearance  of  relief  and  toxic  effect,  must  be  continued 
for  some  time  after  relief  is  obtained. 

Salicin,  first  used  by  T.  J.  Maclagan,  appears  to  be  about  as  efflcient 
as  salicylic  acid,  given  in  20-grain  (1.33  gm.)  doses  every  two  hours,  in 
suspension  or  dissolved  in  warm  water.  It  is  much  less  irritating  than 
salicylic  acid,  but  has  not  superseded  it  on  this  account. 

We  should  not,  however,  rely  wholly  upon  the  treatment  by  salicylates. 
Warmth  is  commonly  a  useful  adjuvant,  and  to  this  end  the  joints  and  limbs 
should  be  kept  surrounded  by  warm  flannels  or  carded  wool  or  cotton.  The 
patient  should,  further,  sleep  between  blankets  and  in  a  flannel  gown  so 
made  that  it  may  be  easily  removed,  with  split  sleeves  and  split  skirt,  because 
of  the  extreme  sensitiveness  of  the  sufferer.  The  bed,  if  possible,  should 
be  narrow  because  of  greater  convenience  in  handling.  The  opposite  plan, 
treatment  by  cold,  is  also  recommended  by  some. 

Sometimes  the  salicylates  cannot  be  tolerated  by  the  stomach,  even  in 
the  smallest  doses  likely  to  be  useful.  They  may  then  be  given  by  injection 
as  follows :  The  rectum  is  washed  out  with  warm  water,  and  after  a  short 
rest,  20  to  40  grains  (1.3  to  2.6  gm.)  or  more  of  sodium  salicylate  in  solu- 
tion are  injected  well  up  into  the  bowel.  This  may  be  done  once  in  six  hours 
with  the  happiest  result,  as  I  can  attest  from  personal  experience.  If  larger 
doses  are  thus  given,  90  to  120  grains  (6  to  8  gm.)  being  recommended  by 
some,  it  is  well  to  guard  them  with  a  little  tincture  of  opium. 

But  the  salicylate  treatment  is  not  always  successful,  and  sometimes 
the  drug  is  not  well  borne  in  any  shap'e.  Then  the  oil  of  wintergreen,  which 
contains  90  per  cent,  of  salicjdate  of  methyl,  may  be  tried,  in  doses  of  10  to 
15  minims  (0.6  to  i  c.  c.)  ever\'  two  hours,  in  capsules  or  in  emulsion.  Or  it 
may  be  alternated  with  the  salicylate,  if  it  be  a  question  of  tolerance  of  the 
latter,  the  gaultheria  being  usually  better  borne  for  a  time  by  the  stomach.     I 


296  INFECTIOUS  DISEASES. 

say  for  a  time,  because,  however  pleasant  wintergreen  is  at  first,  its  continued 
use  is  apt  also  to  excite  disgust. 

Oil  of  gaultheria  is  also  used  locally,  at  times  with  excellent  results. 
It  mav  be  used  as  an  embrocation  in  the  proportion  of  one  part  of  oil  of  gaul- 
theria to  two  parts  of  olive  oi'.  More  usually  it  is  applied. to  the  affected  joint 
on  lint,  which  is  thoroughly  moistened  with  the  oil,  wrapped  about  the  joint, 
and  surrounded  by  gutta-percha,  oiled  silk,  or  other  impermeable  covering 
to  prevent  evaporation.  This  is  further  prevented  by  bandaging  the  whole 
limb.  That  the  salicylate  of  methyl  is  thus  absorbed  is  seen  from  the  fact 
that  salicyluric  acid  appears  in  the  urine  a  few  days  later,  while  the  usual 
evidence  of  the  physiological  action  of  salicylates — viz.,  headache  or  fullness 
of  the  head  with  ringing  in  the  ears — takes  place.  In  view  of  the  gastric 
disturbances  w-hich  the  salicylates  cause  in  some  persons,  this  mode  of  admin- 
istration should  not  be  overlooked. 

The  alkaline  treatment  of  acute  rheumatism,  most  relied  upon  before 
the  salicylic  treatment  came  into  vogue,  is  a  treatment  which  is  by  no  means 
worthless.  This,  originally  instituted  by  Sir  A.  Garrod,  received  an  addi- 
tional impulse  from  the  late  Dr.  H.  W.  Fuller,  who  insisted  upon  the  admin- 
istration of  such  doses  as  secured  and  maintained  an  alkaline  reaction  of  the 
urine.  This  is  accomplished  by  sufficient  doses  of  almost  any  of  the 
alkaline  salts,  as  potassium  citrate,  potassium  acetate,  sodium  carbonate ;  or 
liquor  potassce  may  be  used.  Twenty  grains  (1.33  gm.)  every  two  hours  of 
the  first  three  are  generally  sufficient,  or  20  minims  (1.3  c.  c.)  of  the  last. 
The  dose  may  then  be  reduced,  but  enough  should  be  given  to  maintain  the 
alkalinity  of  the  urine. 

Failing  for  any  cause  in  the  treatment  with  salicylic  acid,  the  alkaline 
treatment,  or  what  is  called  the  "  mixed  "  treatment,  may  be  employed.  By 
this  is  meant  the  combined  alternate  use  of  the  salicylates  and  alkalies. 
This  may  be  tried,  for  example,  where  sufficient  doses  of  the  salicylates  are 
not  well  borne  by  the  stomach,  when  they  may  be  supplemented  by  alkalies. 

While  using  the  alkaline  treatment  before  the  salicylates  came  into  use, 
it  was  quite  usual  to  combine  with  it  the  "  flying  "  blister,  one  of  small  size, 
— say  an  inch  square, — and  to  apply  it  now  to  one  joint  and  then  to  another. 
That  this  practice  is  efficient  in  relieving  pain  there  can  be  no  doubt,  while 
there  is  also  reason  to  believe  that  it  sometimes  cuts  short  the  inflammation 
in  the  joint  treated.  It  is  more  than  likely  that  this  treatment  has  been  too 
much  neglected  since  the  salicylates  have  become  popular.  In  the  subacute 
and  chronic  stages  of  the  disease  counterirritation  by  blisters  or  iodin  is  also 
of  service. 

For  the  relief  of  pain,  opium  or  its  derivatives  is  sometimes  necessary, 
but  less  frequently  than  before  the  introduction  of  salicylates.  Here,  again, 
the  hypodermic  injection  of  morphin,  1-4  grain  (0.016  gm.),  is  most  com- 
forting, but  the  Dover's  powder  in  lo-grain  (0.6  gm.)  doses  is  often  efficient. 
Phenacetin.  acetanilid,  and  exalgin  may  be  used  for  milder  degrees.  It  is 
soothing  to  have  the  joints  enveloped  in  cotton  or  wool. 

The  treatment  of  the  hyperpyrexia  of  acute  rheumatism  must  be  prompt 
and  energetic,  as  the  danger  to  life  is  imminent,  the  extraordinarily  high 
temperatures  thus  encountered  being  inevitably  fatal  in  a  few  hours.  There 
is  but  one  treatment.  It  is  the  application  of  cold.  The  bath  is  to  be  pre- 
ferred, although  in  its  absence  afifusions  of  ice-cold  water  and  rubbing  the 
head  and  body  with  ice  may  be  substituted.  As  soon  as  the  temperature 
begins  to  mount  rapidly  above  105°  F.  (40.5°  C.)  it  should  be  used,  and  if 


EPHEMERAL  FEVER. 


297 


delirum  or  unconsciousness  is  associated  with  such  temperature,  its  need  is 
even  more  imperative.  When  time  permits,  the  apphcation  of  cold  may  be 
more  gradual.  Thus  the  patient  may  be  put  in  the  bath  at  70°  F.  (21°  C.) 
and  the  temperature  further  reduced,  if  necessary,  by  the  addition  of  ice  or 
colder  water.  As  stated,  there  seems  now  to  be  no  doubt  about  the  pro- 
priety of  this  treatment.  Numerous  cases  of  recovery  have  been  reported, 
some  even  where  the  temperature  had  reached  107°,  108'',  and  even  109°  F. 
(41.6°,  42.2",  42.7°  C).  With  the  reduction  of  temperature,  the  cerebral 
symptoms  gradually  disappear. 

As  the  disease  becomes  more  subacute  or  chronic,  the  necessity  for 
more  active  local  associated  with  tonic  treatment  becomes  urgent.  It  would 
seem  that  at  such  stage  the  pathogenic  cause  has  exhausted  itself,  and  the 
disease  has  become  more  a  local  one,  maintained  by  the  dyscrasic  state  of  the 
blood,  itself  brought  about  by  the  prolonged  suffering.  Hence  roborant 
treatment  with  iron,  arsenic,  cod-liver  oil,  wine,  and  nourishing  food  becomes 
necessary.  Indeed,  the  patient  with  acute  rheumatism  should  be  well  fed 
throughout.  Counterirritation  by  iodin  or  by  blisters  should  be  kept  up 
with  appropriate  intermissions,  although  the  results  are  often  slow  in 
appearing.  Massage  is  especially  valuable,  and  often  surprisingly  soothing 
ultimately,  even  although  at  first  somewhat  painful,  while  by  it  the  mobility 
of  the  joints  may  be  gradually  restored.  There  results  sometimes  in  the 
muscles  in  the  neighborhood  of  the  joint,  and  especially  in  the  case  of  the 
shoulder,  a  paretic  state,  which  is  also  benefited  by  massage,  especially  when 
associated  with  electricity. 

Allusion  may  be  made  to  remedies  now  more  or  less  obsolete  which 
have  had  some  reputation  in  the  treatment  of  acute  rheumatism.  Ni- 
trate of  potassium  was  among  the  most  popular  of  the  older  remedies.  As 
much  as  2  drams  (8  gm.)  of  the  latter  were  given  by  Brocklesby  three  and 
four  times  a  day.  It  was  revived  by  Basham,  who  applied  it  locally  to  the 
inflamed  joints.  It  is  diuretic  and  diaphoretic.  Guiac  is  also  one  of  the 
older  remedies  still  used  in  chronic  rheumatism,  which  see.  The  bromid  of 
ammonium  had  the  indorsement  of  J.  M.  Da  Costa  in  the  quantity  of  i  to 
I  1-2  drams  (4  to  6  gm.)  in  twenty-four  hours. 

It  should  be  mentioned  also  that  no  less  eminent  authorities  than  Sir 
Alfred  Garrod  and  the  late  Austin  Flint,  Sr.,  thought  acute  rheumatism  was 
self-limiting,  and  that  it  terminated  about  as  quickly  without  medicines  as 
with  them. 

Diet  in  Rheumathc  Fever. — The  diet  of  the  patient  with  rheumatic  fever 
should  be  simple  and  easily  assimilable,  but  nourishing.  While  there  is  fever 
the  food  should  be  liquid,  but  the  rule  of  conduct  should  be :  feed  well — do 
not  starve. 

INFECTIOUS  DISEASES  OF  DOUBTFUL    NATURE. 

EPHEMERAL  FEVER— FEBRICULA. 

Synonyms. — Irritative   Fever;    Gastric   Fever;   Simple    Continued   Fever. 

Definition. — A  fever  of  short  duration,  depending  on  a  variety  of  irri- 
tative causes.     A  febrile  movement,  lasting  twenty-four  hours  and  disappear- 
ing, may  for  convenience  be  called  ephemeral  fever;  if  of  three  or  four  days 
duration,  febricula. 


298  INFECTIOUS  DISEASES. 

Etiology. — The  most  frequent  cause  of  this  form  of  fever  is  probably 
the  irritation  of  foods  difficult  of  digestion,  either  by  their  inherent  qualities 
or  by  reason  of  some  temporary  functional  derangement  of  the  stomach. 
In  a  word,  indigestion  is  perhaps  the  most  frequent  cause  of  such  a  fever. 
This  is  especially  the  case  with  children,  in  whom  the  condition  is  often 
spoken  of  as  gastric  fever. 

Another  cause  is  probably  exposure  to  cold  insufficient  to  produce  a 
bronchitis,  tonsillitis,  or  other  affection,  too  slight  to  be  recognizable  by  the 
usual  signs.  Undue  exposure  to  the  sun,  too,  may  produce  it,  or  even  fatigue. 
The  inhalation  of  noxious  gases  is  a  possible  cause,  though  somewhat  dis- 
credited by  recent  studies;'^  also,  the  absorption  from  the  stomach  and 
intestine  of  lower  toxic  albumoses  from  putrid  or  decomposing  foods — auto- 
intoxication by  ptomains. 

It  is  possible,  too,  that  the  germ  of  an  infectious  disease  or  its  toxic 
products  may  enter  the  economy  in  quantity  insufficient  to  develop  the 
specific  affection  which  is  its  usual  result.  Possibly  the  poison  of  rheu- 
matism or  malaria  may  operate  in  this  way. 

Symptoms. — The  symptoms  of  irritative  fever  are  those  usual  to  fever 
in  mild  degree,  /.  e.,  moderate  elevation  of  temperature,  rarely  above  103°  F. 
(39.4"  C),  frequent  pulse,  headcrche,  a  sense  of  lassitude  and  weariness,  loss 
of  appetite,  nausea,  and  restlessness;  in  children  perhaps  delirium.  The 
fever  is  apt  to  terminate  suddenly  by  crisis  on  the  second  or  third  day. 

Diagnosis. — The  diagnosis  resolves  itself  into  this :  where  a  careful 
search  fails  to  reveal  the  action  of  a  cause,  save  one  of  those  referred  to, 
and  no  symptoms  develop  characteristic  of  any  of  the  recognized  diseases, 
the  affection  is  irritative  fever. 

Prognosis. — Always  favorable. 

Treatment. — Rest  in  bed,  a  simple  aperient,  a  fever  mixture  consist- 
ing of  solution  of  citrate  of  potash,  sweet  spirit  of  niter,  solution  of  acetate 
of  ammonium  or  aconite  tincture,  will  suffice  to  break  up  the  fever  and 
insure  recovery. 

PROTRACTED  SBIPLE  CONTINUED  FEVER. 

Definition  and  Etiology. — It  seems  necessary  for  the  present  to  con- 
tinue this  term  for  a  feverish  process  of  a  longer  duration  than  ephemeral 
fever  or  febricula, — a  fever  that  is  not  typhoid,  not  influenza, — lasting  from 
two  weeks  to  three  months,  and  without  definite  lesions.  Knowing,  how- 
ever, what  we  do  know,  and  littiited  as  our  knowledge  still  is  of  infection,  it 
is  more  than  likely  that  some  day  a  specific  cause  will  be  found  for  each  of  a 
motley  group  of  such  fevers,  which  will  give  them  a  definite  name,  just  as 
cases  formerly  thus  grouped  are  now  relegated  to  typhoid  fever. 

Some  of  these  cases,  too,  may  belong  to  the  group  covered  by  the  term 
cryptogenetic  septicemias,  suggested  in  1878  by  W.  v.  Leube — cases  of  gen- 
eral septicemia  with  concealed  local  infection  undiscoverable  even  at 
necropsy,  characterized  by  a  fever  that  persists  for  weeks.  Many  of  these 
recover  completely,  including  cases  in  which  the  natural  doubt  as  to  whether 
they  are  of  malarial  or  tubercular  origin  is  settled  in  the  usual  way,  against 
malarial  by  the  inefficiency  of  quinin.  and  against  tuberculosis  by  reason  of 
recovery.  J.  ]\I.  Da  Costa  well  described  such  cases  in  a  paper  on  "  Pro- 
tracted Simple  Continued  Fever.  "  f     Some  of  the  more  serious  forms  have 

*  Abbott,  A.  C,  "  Effects  of  the  Gaseous  Products  of  Decomposition  on  the  Health,"  etc.  "  Trans, 
of  the  Assoc,  of  Am.  Phj-sicians,"  vol.  x.,  1803. 

t  "  Trans,  of  the  Assoc,  of  Am.  Physicians,"  vol.  xi.,  1896. 


PROTRACTED  SIMPLE  CONTINUED  FEVER.  299 

been  traced  after  death  by  the  aid  of  the  bacteriological  examination,  to  the 
streptococcus,  staphylococcus,  and  even  pneumococcus  infection.  Cases  of 
prolonged  fever,  succeeding  pneumonia  and  pleurisy,  which  subsequently 
recover  may  well  be  ascribed  to  any  of  these  organisms. 

Symptoms. — It  can  scarcely  be  said  of  the  symptomatology  of  the  milder 
forms  of  these  fevers,  to  w^hich  reference  is  here  intended,  that  it  includes 
more  than  a  mild  fever,  seldom  reaching  103°  F.  (39.4°  C),  with  slight 
morning  remission  and  evening  rise,  and  the  usual  high-colored  urine;  it 
may  be,  with  mild  gastro-intestinal  derangement,  such  as  a  slightly  coated 
tongue,  but  no  diarrhea,  no  lung  complication,  nothing  essential  but  the  mild 
fever.  The  latter  is,  however,  rarely  high,  and  there  is  occasionally  enlarge- 
ment of  the  spleen. 

These  fevers  admit,  moreover,  of  a  certain  classification,  based  on 
locality  and  perhaps  on  modifying  local  cause.  This  would  be  the  case  with 
the  thermic  fever  of  the  South,  described  by  John  Guiteras,  characterized 
lay  wakefulness,  great  nervous  excitement,  and  disordered  muscular  function, 
but  without  eruption  or  other  symptoms  of  typhoid  fever,  and  lasting  for 
several  weeks.  This,  as  suggested  by  Da  Costa,  is  probably  also  the  ardent 
fever  of  the  older  writers ;  in  its  severer  form,  the  inflammatory  fever, 
described  by  Copeland.  On  thermic  fever,  Guiteras  tells  me  he  has  changed 
his  views  and  is  forced,  in  the  light  of  modern  studies,  to  ascribe  it  to  some 
unknown  infectious  cause.  To  this,  he  says,  he  has  been  led  by  two  facts, 
first,  that  he  finds  it  farther  north  than  he  originally  thought  it  occurred — ■ 
his  original  studies  w^ere  made  at  Key  West — and,  second,  its  occurrence  in 
more  than  one  member  of  a  family. 

Such,  too,  may  be  the  "  Asthenic  Fever  "  of  Murchison,  and  the  "  Star- 
vation Fever,"  described  by  Da  Costa  ;*  the  "  Atypical  Continued  Fever  of 
Nashville,"  described  by  Cain  ;t  "  Simple  Continued  Fever,"  described  by 
Baumgarten,$  of  St.  Louis ;  the  "  Malta "  or  "  Rock  Fever."  already 
described ;  the  "  Innominate  Fever  "  of  Goodhart,§  who  says  in  his  paper, 
"  There  is  too  great  a  tendency  to  label  all  continued  fevers  by  some  definite 
name";  and  the  "  Inexplicable  Fever,"  of  Hale  White. || 

Diagnosis. — The  cases  are  to  be  distinguished,  above  all,  from  irregu- 
lar and  mild  forms  of  typhoid  fever,  similar  forms  of  intermittent  and 
remittent  fever,  miliary  tuberculosis,  the  fever  which  sometimes  attends 
chlorosis,  hysteria  at  times,  and  some  other  nervous  disorders.  Da  Costa 
emphasizes  a  feverish  state  caused  by  lithemia ;  another  in  rapidly  advancing 
spinal  sclerosis,  which  may  be  recognized  by  other  distinctive  signs,  usually 
evident  when  sought  for.  In  cases  where  there  is  enlargement  of  the  spleen 
the  resemblance  to  typhoid  is  closer,  and  the  diagnosis  may  have  to  remain 
in  doubt  until  settled  by  the  Widal  test  or  by  time.  The  tubercle  bacillus 
should  always  be  sought  for  in  doubtful  cases ;  also  the  plasmodium  of 
malaria. 

Prognosis. — This  is  generally  favorable,  except  in  some  of  the  severer 
cases  ultimately  traceable  to  true  infection.  Some  cases  of  the  so-called 
thermic  fever,  reported  by  Guiteras,  died  and  came  to  autopsy  without  defi- 
nite lesions  being  discovered. 

Treatment. — The  treatment  of  simple  continued  fever  of  longer  dura- 

*  "  Trans,  of  the  Colleg-e  of  Physicians  of  Philadelphia,"  Third  Series,  vol.  v.,  1881. 

+  "  Southern  Practitioner,"  December.  i8gi. 

J  "Trans,  of  the  Assoc,  of  Am.  Phj'sicians,"  vol.  viii.,  1893. 

§  "  Guy's  Hospital  Reports,"  xxx.,"  1888. 

II  "Brit.  Med.  Jour.,"  vol.  ii.,  1886.  p.  1096. 


300  INFECTIOUS  DISEASES. 

tion,  as  well  as  of  the  shorter  forms,  is  symptomatic,  and  remedies  for  the 
relief  of  symptoms  are  for  the  most  part  alone  indicated.  With  continued 
fever  there  is  always  a  tendency  to  weakness,  and  supporting  measures  are 
indicated,  including  quinin,  strychnin,  and  small  doses  of  iron.  Due  atten- 
tion to  the  bowels  should  be  given,  as  the  effect  of  constipation  in  keeping 
up  fever  is  well  known. 


WEIL'S  DISEASE. 
Synonyms. — Acute  Febrile  Jaundice;  Bilious  Typhoid. 

Definition. — An  acute  infectious  disease,  characterized  by  jaundice 
and  fever,  described  by  Weil  in  1886. 

Etiology. — The  cause  is  as  yet  undetermined,  but  it  affects  males  in 
preference  to  females,  especially  butchers,  laborers,  and  brewers,  and  its 
subjects  are  from  twenty-five  to  forty  years  of  age.  A  few  cases  have 
occurred  in  this  country,  two  having  been  reported  from  the  Philadelphia 
Hospital  by  J.  H.  Musser  and  John  Guiteras.  Weiss  considers  that  the 
symptoms  and  lesions  most  resemble  the  bilious  typhoid  described  by  Gries- 
inger,  while  the  latter  has  been  claimed  to  be  identical  with  the  typhoid 
icterodes  of  Egypt. 

It  occurs  commonly  in  the  summer  months,  and  nearly  always  in  groups 
of  cases.  But  for  the  last  fact  I  should  regard  the  disease  as  catarrhal 
jaundice. 

Symptoms. — The  disease  sets  in  suddenly,  after  exposure  to  cold,  as 
in  a  beer  vault,  most  frequently  with  a  chill  and  without  prodrome.  There 
is  fever,  with  temperature  of  102°  to  104°  F.  (38.9°  to  40°  C.),  headache, 
muscular  and  joint  pains,  and  epigastric  pain,  which  is  characteristic.  There 
is  especially  tenderness  in  the  calf  muscles.  Jaundice  promptly  makes  its 
appearance.  The  fever  lasts  usually  from  ten  to  fourteen  days,  and  is  char- 
acterized by  decided  remissions.  The  liver  and  spleen  are  both  enlarged; 
the  former  may  be  tender.  Associated  with  the  jaundice  are  the  usual 
clay-colored  stools  of  obstructive  jaundice.  Beyond  the  epigastric  pain, 
which  may  be  hepatic  in  origin,  gastro-intestinal  symptoms  are  not  marked, 
though  the  tongue  is  coated,  and  there  may  be  vomiting  and  diarrhea.  There 
may  be  dizziness,  confusion  of  mind,  and  even  delirium.  The  urine  con- 
tains biliary  coloring-matter ;  sometimes  albumin  with  casts  and  even  blood. 

After  a  duration  of  from  eight  to  fourteen  days,  convalescence  sets  in, 
usually  slowly,  and  it  may  be  prolonged. 

Diagnosis. — The  conditions  with  Vv^hich  Weil's  disease  might  be  for  a 
time  confounded  are  bilious  remittent  fever,  acute  yellow  atrophy  of  the 
liver,  phosphorus  poisoning,  and  catarrhal  jaundice.  The  first  would  be 
excluded  by  the  absence  of  the  plasmodium  of  malaria,  while  the  mildness 
and  favorable  termination  would  exclude  the  second  and  third.  Catarrhal 
jaundice  is  distinguished  by  the  absence  of  fever,  and  of  muscular,  joint, 
and  epigastric  pain,  which  characterize  Weil's  disease. 

Prognosis. — Recovery  is  usual,  but  a  few  autopsies  have  been  made, 
with  the  discovery  of  no  definite  morbid  anatomy.  There  is  cloudy  swell- 
ing and  even  fatty  degeneration  of  the  cells  of  the  heart,  liver,  kidney, 
stomach,  and  intestines. 

Treatment. — This  is  symptomatic. 


MILIARY  FEVER.  301 


MILIARY  FEVER. 

Synonyms. — Fehris    miliaris;    Sudor    anglicus;    Sweating    Sickness;    the 
Siveating  Disease  of  Picardy;  the  English  Szveat. 

Definition. — An  infectious  fever  of  unknown  cause,  characterized  by 
profuse  sweats  and  an  eruption  of  miliary  vesicles. 

Historical. — The  disease  first  appeared  in  London  in  an  epidemic  of  extreme 
severity  in  the  summer  of  i486,  a  year  characterized  by  very  wet  Aveather.  There 
were  other  epidemics  in  1517,  1518,  and  1529.  During  the  latter  the  disease  passed  on 
to  the  continent  of  Europe.  There  was  not  anotlier  epidemic  until  1718,  when  there 
appeared  "the  sweating  sickness"  of  Picardy,  France,  extending  thence  into  Italy, 
Germany,  Austria,  and  Belgium.     Then  there  followed  194  epidemics  up  to  1879. 

Etiology. — As  to  the  specific  cause  nothing  is  known.  It  is  not  con- 
tagious nor  inoculable,  and. not  favored  by  crowding.  Most  epidemics  occur 
in  summer,  fewest  in  the  autumn ;  second  in  frequency  is  the  spring ;  third, 
the  winter.  Moist,  warm,  and  unchanging  weather  favors  the  disease. 
Contaminations  of  the  soil,  such  as  arise  from  neglected  drains  and  collec- 
tions of  refuse,  also  contribute  to  its  causation.  More  women  are  affected 
than  men,  and  the  vulnerable  age  seems  to  be  between  twenty  and  fifty 
years.  The  healthy  and  strong  are  as  likely  to  be  attacked  as  the  weak, 
and  the  rich  as  well  as  the  poor. 

Morbid  Anatomy. — No  characteristic  anatomical  changes  have  been 
noted  in  miliary  fever.  The  internal  organs  are  generally  hyperemic.  The 
spleen  is  often  enlarged.  The  most  striking  feature  is  the  tendency  to  rapid 
decomposition,  "  beginning  almost  during  life,"  as  has  been  said.  The 
blood  is  thin  and  dark  colored. 

Symptoms. — After  an  incubation  of  two  or  three  days  the  patient  goes 
to  bed  apparently  well,  and  wakes  up  in  the  night  dripping  with  sweat. 
With  this  is  a  sense  of  oppression,  and  even  pain,  in  the  precordial  region, 
ienderness  and  pain  in  the  epigastrium,  palpitation,  headache,  dizziness,  and 
muscular  cramps.  The  temperature  is  abnormally  high,  the  pulse  and 
respirations  are  frequent ;  there  is  even  dyspnea,  sometimes  very  violent. 
The  perspiration  continues,  saturating  the  bed  clothing  and  diffusing  an 
unpleasant  odor  throughout  the  room. 

On  the  third  or  fourth  day,  as  a  result  of  the  profuse  sweating,  miliary 
-vesicles  make  their  appearance,  at  first  so  minute  as  to  be  scarcely  visible, 
though  they  may  be  felt  by  passing  the  hand  over  the  skin.  As  they  become 
larger  they  are  easily  visible  by  their  crystalline  contents,  which  later  become 
turbid  and  even  milky.  They  appear  first  on  the  neck  and  breast,  then  over 
the  back  and  extremities,  less  frequently  on  the  abdomen  and  scalp.  After 
two  or  three  days  they  burst,  dry  up,  and  form  crusts,  which  subsequently 
desquamate.  With  the  appearance  of  the  eruption  the  other  symptoms  dis- 
appear rather  suddenly,  but  there  is  often  noted  a  burning  and  prickling 
sensation  of  the  skin.  There  is  generally  loss  of  appetite,  sometimes  nausea, 
seldom  vomiting,  scanty  urine,  and  especially  constipation. 

The  duration  of  the  disease  is  usually  from  six  to  eight  days,  although 
it  may  be  prolonged  beyond  this,  the  eruption  being  sometimes  delayed  to 
the  seventh,  tenth,  and  even  fifteenth  day.  Relapses  may  occur.  Some- 
times the  disease  assumes  an  intermittent  character. 

Diagnosis.— This  is  not  difficult.  The  prevalence  of  an  epidemic, 
profuse  sweating,  and  rash  scarcely  permit  an  error. 

Prognosis.— The  prognosis  has  varied  greatly  in  different  epidemics. 


302  INFECTIOUS  DISEASES. 

the  mortality  in  some  of  the  earUer  reaching  as  much  as  50  per  cent.,  while 
in  others  none  died.  The  average  may  be  put  down  at  from  8  to  9  per  cent. 
Treatment. — The  treatment  is  mainly  expectant  and  symptomatic. 
Simple  febrifuges  and  acid  drinks  are  indicated.  Warm  baths  and  spong- 
ing of  the  skin  with  warm  water  are  soothing  and  comforting.  The  pre- 
cordial distress  and  apnea  may  rec[uire  anodynes,  preferably  subcutaneously 
administered.  The  sweating  itself,  if  alarming,  may  be  treated  by  hypo- 
dermic injections  of  atropin,  1-160  to  i-ioo  grains  (0.00041  to  0.00066  gm.), 
p.  r.  n.,  or  this  drug  may  be  given  by  the  mouth  in  the  same  dose. 


GLANDULAR  FEVER. 

Synonym. — Drilsen-Fieher. 

Definition. — An  acute  infectious  fever  of  children,  characterized  by 
inflammation  of  the  lymph  glands  of  the  neck,  especially  those  back  of  the 
sterno-cleido-mastoid  muscle. 

History. — The  disease  is  not  a  new  one,  as  descriptions  corresponding  to  acute 
adenitis  of  the  glands  affected  have  appeared  from  time  to  time,  but  the  first  sys- 
tematic account  seems  to  have  been  published  by  E.  Pfeiffer  in  1889  under  the  term 
Driisen-Fieber.  In  1885-87  Filatoff,  of  Moscow,  although  less  completely,  described 
the  same  disease.  Since  then  it  has  been  studied  by  J.  Park  West,  of  Ohio,  by 
Samuel  McHamill  and  Albert  E.  Roussel,  of  Philadelphia,  and  by  Donkin,  Fischer  and 
Dawson  Williams,  in  England. 

Etiology. — No  responsible  bacterium  has  been  found.  The  disease 
may  be  epidemic,  as  was  that  which  occurred  in  Bellaire,  Ohio,  described 
by  West.  It  has  been  observed  to  prevail  more  commonly  between  the 
months  of  October  and  June  in  the  winter  season.  The  infection,  whatever 
it  may  be,  probably  enters  through  the  tonsils  or  the  pharyngeal  mucous 
membrane. 

Morbid  Anatomy. — This  includes  the  enlargement  of  the  glands,  which 
forms  so  essential  a  part  of  the  disease.  The  enlargement  may  involve  not 
only  the  cervical  glands  referred  to,  but  the  axillary,  inguinal,  bronchial, 
and  even  the  mesenteric.  Thus,  in  West's  report  of  96  cases  occurring 
between  the  ages  of  seven  months  and  thirteen  years,  in  three-fourths  of 
them  the  post-cervical,  inguinal,  and  axillary  glands  were  involved,  with 
the  mesenteric  in  37  cases.  The  liver  and  spleen  were  also  enlarged,  the 
former  in  87  and  the  latter  in  57  cases. 

Symptoms. — The  period^  of  incuhation  lasts  from  five  to  eight  days. 
The  disease  is  characterized  by  sudden  onset  of  stiiTness  with  pain  on  mov- 
ing the  head.  Along  with  this  there  is  fever  with  a  temperature  of  101°  to 
103°  F.  (56°  to  57°  C.)  with  sometimes  nausea  and  vomiting.  The  enlarge- 
ment of  the  glands  does  not  make  its  appearance  until  the  second  or  third 
day,  and  may  attain  a  size  from  that  of  a  pea  to  a  hen's  e:gg,  but  rarely  goes 
on  to  suppuration.  The  glands  are  tender  to  the  touch,  but  there  is  not 
usually  redness  of  the  skin.  There  may  also  be  some  hyperemia  of  the 
tonsils,  or  pharyngitis.  More  rarely  there  is  invasion  of  the  tracheal  and 
bronchial  glands  which  may  be  the  occasion  of  cough.  The  swelling  per- 
sists from  two  to  three  weeks,  although  the  fever  does  not  last  nearly  so 
long. 

Complications. — Among  these  which  may  be  named  as  possible  are 
hemorrhagic  nephritis,  post-pharyngeal  abscess,  and  acute  otitis  media. 


GLANDULAR  FEVER.  303 

Diagnosis.— The  disease  is  to  be  distinguished  from  the  various  forms 
of  infectious  sore  throat  found  in  scarlet  fever  and  diphtheria  which  may 
cause  a  similar  affection  of  the  lymphatic  glands. 

Prognosis. — Favorable. 

Treatment.— Active  treatment  is  scarcely  needed.  The  patient  should 
be  put  to  rest.  Cold  or  warm  applications  may  be  made,  whichever  form  is 
found  more  comfortable.  An  aperient,  such  as  a  dose  of  oil  or  calomel, 
may  be  desirable  at  the  very  beginning.  West  recommended  small,  doses  of 
the  latter  drug. 


SECTION    II. 

DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

DISEASES    OF    THE    MOUTH. 

THE  COATED  TONGUE. 

The  natural  color  of  the  tongue  at  its  anterior  two-thirds  is  a  pale  red, 
on  which  the  fungiform  papillse  stand  out  as  brighter  red  points.  The  epi- 
theHum  covering  the  fihform  papillse,  which  are  much  more  numerous  and 
uniformly  spread  over  the  dorsal  surface  of  the  tongue,  is  thicker,  and  they 
are  therefore  less  distinctly  seen.  As  the  base  is  approached,  a  grayish 
color  is  assumed  on  account  of  the  greater  thickness  of  the  epithelium. 
At  the  base  are  seen  the  circumvallate  papillse,  arranged  in  two 
rows  of  red  circles.  In  the  furred  tongue  the  epithelium  is  abundant, 
though  it  is  doubtful  whether  it  is  produced  in  increased  quantity  or  is  simply 
raised  by  hyperemic  swelling  of  the  papillse.  The  "  fur  "  is  also  contributed 
to  by  various  forms  of  fungi.  Too  much  stress  should  not  be  laid  on  the 
coated  tongue.  Some  persons  have  a  coated  tongue  and  are  perfectly 
healthy,  while  others  have  fair-looking  tongues  and  are  ailing  seriously  with 
those  derangements  which  are  commonly  attended  with  coated  tongue,  espe- 
cially gastro-intestinal  disturbances.  F'ood  such  as  milk,  and  licorice  and 
tobacco,  also  contribute  to  the  coating  of  the  tongue. 

The  dry,  brown  color  of  the  tongue  in  low  fevers  is  due  to  a  drying  of 
the  rapidly  exfoliating  epithelium,  admixed  sometimes  with  mucus  or  saliva. 
The  tongue  may  also  be  coated  with  dried  food  and  sometimes  with  dried 
blood,  due  to  capillary  hemorrhage,  which  imparts  to  it  a  black  color — the 
black  tongue  of  certain  malignant  fevers.  The  tongue  is  sometimes  pale 
and  anemic  in  persons  whose  blood  is  poor  and  deficient  in  red  blood-discs. 
The  tongue  in  these  cases  is  sometimes  enlarged  and  flabby,  while  its  edges 
are  easily  indented  and  marked  by  the  teeth.  A  bright  red  or  even  a  raw 
appearance  of  the  tongue  is  met  with  in  certain  fevers,  particularly  in  the 
early  stages,  when  it  may  alsp  be  dry  and  glazed.  It  may  be  coated  at  the 
beginning,  but  later  the  epithelium  desquamates  freely  and  the  whole  surface 
may  be  red ;  or  the  fungiform  papillse  may  be  hyperemic,  swollen,  and  unusu- 
ally distinct,  constituting  the  "  strawberry "  tongue  so  characteristic  of 
scarlet  fever.  The  raw-beef  appearance  of  the  tongue  is  often  seen  toward 
the  close  of  exhausting  diseases,  like  tubercular  consumption. 


DERANGEMENT   DUE   TO    DENTITION. 

The  most  serious  accident  of  dentition  is  what  is  known  as  the  reflex 
convulsion,  which  will  be  considered  among  nervous  affections.  Other 
derangements  of  gastro-intestinal  nature  will  be  discussed  under  diarrhea. 

304 


DERANGEMENT  DUE  TO  DENTITION.  305 

These  are  not  always  reflex.  They  may  be  excited  by  irritation  of  the  swal- 
lowed saliva,  which  is  not  only  increased,  but  also  altered  in  quality.  Other 
anomalous  conditions  are  observed  in  the  natural  order  of  eruption  and  cer- 
tain markings  on  the  teeth,  ascribed  to  stomatitis. 

The  order  of  natural  eruption  of  the  milk  teeth  is  well  shown  in  the 
accompanying  diagram.  The  first  to  appear  are  the  lower  central  incisors 
(i,  i),  at  the  age  of  from  four  to  seven  months,  then  a  few  weeks  later  the 
upper  central  incisors  (2,  2),  and  next  the  upper  lateral  incisors  {2a,  2a). 
Not  until  the  beginning  of  the  second  year  come  the  lower  lateral  incisors 
(3,  2"),  and  almost  simultaneously  the  four  anterior  molars  (4,  4,  4,  4).  In 
the  second  half  of  the  second  year  come  the  four  canines  (5,  5,  5,  5),  includ- 


Fig.  26.  —Diagram  Showing  Eruption  of  Milk  Teeth. 

I,  I.  Between  the  fourth  and  seventh  months,  followed  by  a  pause  of  three  to  nine 
weeks.  2,  2,  2  ,a;,  2  a.  Between  the  eighth  and  tenth  months;  pause  of  six  to 
twelve  weeks.  3,  3,  4,  4,  4,  4.  Between  the  twelfth  and  fifteenth  months;  pause 
until  eighteenth  month.  5,  5,  5,  5.  Between  the  eighteenth  and  twenty-fourth 
months;  pause  of  two  to  three  months.  6,  6,  6,  6.  Between  the  twentieth  and 
thirtieth  months — (from  Lota's  Starr,  slightly  modified). 

ing  the  two  "  eye,"  two  "  stomach  "  teeth  ;  and  finally  the  four  posterior  molars 
(6,  6,  6,  6)  ;  so  that  by  the  end  of  the  second  or  beginning  of  the  third  year 
the  first  dentition  is  completed.  The  milk  teeth  begin  to  be  replaced  by  the 
permanent  set  in  the  fifth  or  sixth  year.  Before  any  of  the  milk  teeth  are 
shed  the  first  grinders  of  the  second  set  are  fully  developed.  Hence  they  are 
called  the  six-year  molars.  About  twelve  years  are  consumed  in  the  cutting 
of  the  remaining  teeth,  but  the  variations  of  the  date  of  appearance  of  each 
tooth  are  so  great  that  it  is  not  worth  while  to  attempt  to  name  the  dates. 

In  some  children  (usually  the  rachitic,  the  feeble,  and  badly  nourished) 
the  appearance  of  the  milk  teeth  is  greatly  delayed — the  lower  incisors  do  not 
appear  until  the  eleventh  or  twelfth  month ;  but  the  completion  of  dentition  is 
not  much  delayed  thereby,  though  under  these  circumstances  dentition  is 
sometimes  not  completed  until  the  end  of  the  third  year.  In  others  they 
appear  earlier, — in  the  third  or  fourth  month,^and  occasionally  children  are 
born  with  them.  It  has  always  seemed  to  me  that  the  first  appearance  of  the 
teeth  is  more  apt  to  be  delayed  in  blondes  and  anticipated  in  brunettes. 

The  diet  of  children  during  dentition  should  be  very  carefully  watched, 
as  the  whole  gastro-intestinal  tract  is  sensitive  and  irritable  and  readily 
thrown  into  inflammation.  The  mouth  is  tender,  the  saliva  flows  freely, 
and    the    child    is    disposed    to   bite    on   anything.     The    term    tooth   rash 


3o6 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


is  applied  to  certain  eczematous  eruptions  that  sometimes  appear  during 
teething.     Their  relation  to  teething  is  not  certainly  established. 

A'ery  rarely  a  purulent  conjunctivitis  makes  its  appearance  during  the 
eruption  of  the  upper  canines  or  "  eye  teeth,"  which  is  ascribed  to  dentition 
and  explained  by  contiguous  extension  of  inflammation  through  the  antrum 
of  Highmore  and  the  lachrymo-nasal  duct. 

Certain  markings  are  often  found  on  the  teeth  as  a  consequence 
of  stomatitis.  They  include  pittings  and  linear  depressions,  the  result  of 
defects  in  the  development  of  the  enamel.  Extreme  degrees  produce  a  honey- 
combed appearance.  These,  as  well  as  the  syphilitic  teeth  of  children,  have 
been  studied  by  Jonathan  Hutchinson,  and  are  not  to  be  confounded  with 
the  latter.      '  See  Figs.  27  and  28.)      The  "  honeycomb  ""  changes  are  most 


Fig.  28. — The  Permanent  Front  Teeth 
of  a  Boy,  aged  Fifteen,  who  had 
Taken  Much  Mercury  in  Infanc3^ 

The  teeth  are  all  of  yellow  color,  some- 
what pitted  in  their  surfaces,  and 
very  thickly  coated  with  tartar. 
Near  the  edges  of  the  lower  set  a 
horizontal  line  extends  similar  to 
that  in  Fig.  27 — {after  Hutchin- 
son). 


Fig.  27. — Thin-edged  and  Broken  Teeth, 
not  Syphilitic,  from  a  Woman,  aged 
Twenty. 

The  notches  in  the  upper  teeth  differ 
markedly  from  those  shown  in 
Fig.  19.  In  these  they  result  not 
so  much  from  the  softness  and  orig- 
inal malformation  of  the  teeth  as 
from  their  preternatural  thinness 
and  brittleness.  Near  the  edges  of 
the  lower  set  a  horizontal  line  of 
notches  is  seen  to  extend — {after 
Hicic/iinson). 

conspicuous  in  the  permanent  teeth,  of  which  the  first  molars,  according  to 
Hutchinson,  are  the  test  teeth,  though  he  says  the  incisors  are  almost  as  con- 
stantly pitted,  eroded,  and  discolored,  often  showing  a  transverse  line  which 
crosses  all  the  teeth  at  the  same  level.  These  transverse  furrows  are  also 
ascribed  bv  !Magitot  to  infantile  convulsions  or  other  severe  illness  in  early 
life. 

STOMATITIS. 

Simple  Acute  Catarrhal  Stomatitis. 


Definition  and  Etiology. — A  simple  erythematous  inflammation  of 
the  mouth,  commonly  caused  by  diffuse  chemical  or  mechanical  irritants, 
such  as  overheated  food  (very  hot  drinks),  acids,  alkalies,  stimulating  con- 
diments (red  pepper,  horse-radish,  and  the  like),  by  excessive  smoking  and 
use  of  alcohol.  It  occurs  in  adults  and  children  from  the  action  of  such 
causes,  independently  of  the  state  of  health,  but  is  prolonged  when  its  sub- 
jects are  unhealthy  and  ill-nourished.  Dentition  is  also  a  cause,  while 
stomatitis  may  accompany  also  indigestion  and  the  acute  fevers. 


STOMATITIS.  307 

Symptoms. — The  mucous  membrane  is  reddened  wherever  the  irrita- 
tion has  reached,  but  the  redness  may  be  greater  in  certain  situations,  as  on 
the  tongue,  gums,  lips,  and  cheeks.  There  may  be  at  the  very  beginning 
dryness,  but  it  is  soon  followed  by  increased  secretion  and  slight  swelling. 
There  is  always  discomfort  that  may  amount  to  pain,  which  is  increased  by 
the  introduction  of  food  and  its  mastication.  A  corresponding  slight  febrile 
movement  may  be  present. 

Treatment. — The  treatment  of  simple  catarrhal  stomatitis  will  be  con- 
sidered in  connection  with  that  of  the  other  forms  of  stomatitis  to  be 
described. 

Aphthous    Stomatitis. 

Synonyms. — Vesicular  or  Herpetic  Stomatitis;  Aphtha;  Canker;  Follicular 

Stomatitis. 

Description  and  Symptoms. — Some  confusion  attends  the  use  of  this 
term.  The  term  "  aphtha  "  from  the  Greek  means  "  an  eruption."  Aph- 
thous stomatitis  is  sometimes  confounded  with  thrush,  but  it  is  not  commonly 
regarded  as  a  parasitic  disease,  as  is  thrush,  nor  as  a  follicular  disease.  Some 
speak  of  it  as  herpetic  or  vesicular.  The  Uttle  grayish-white  spots  which  char- 
acterize it  consist  primarily  of  an  exudate  of  fibrin  and  wandered-out  leuko- 
cytes, which  pervades  the  superficial  layer  of  the  mucous  membrane  and  is  at 
first  covered  by  epithelium.  Hence,  an  attempt  to  remove  the  spots  by 
forceps  is  futile  and  follow^ed  by  bleeding.  They  are  small,  round,  usually 
not  more  than  a  few  millimeters  in  diameter,  and  surrounded  by  a  red  areola 
of  hyperemia.  They  are  most  common  on  the  cheeks  and  lips,  especially  in 
the  gingival  groove  at  the  base  of  the  latter.  They  also  occur  on  the  tip 
and  edges  of  the  tongue,  more  rarely  on  the  dorsum.  The  epithelium  dies 
and  desquamates,  leaving  a  superficial  ulcer,  which  under  favorable  circum- 
stances heals  up  rapidly.  Under  more  unfavorable  conditions  the  ulcer 
grows  deeper  and  becomes  more  painful,  constituting  one  of  the  forms  of 
vilcerative  stomatitis.  Young  children  are  especially  subject  to  it,  but  it  is 
common  also  in  adults,  especially  at  times  of  temporary  physical  depression, 
as  in  women  during  menstruation,  pregnancy,  and  lactation. 

The  aphthse  are  commonly  associated  with  a  variable  amount  of  simple 
stomatitis,  with  increased  secretion  of  saliva,  a  slight  "  heaviness  "  of  the 
breath,  but  without  fetor.  There  is  commonly  a  stinging  sensation,  espe- 
cially when  brought  in  contact  with  food,  and  even  when  the  tongue  and 
lips  are  moved  in  speaking.  There  is  often  some  constitutional  disturbance, 
including  fever. 

A  similar  condition  is  Riga's  disease,  in  which  a  pearly-colored  mem- 
brane with  induration  forms  on  the  frenum  of  the  tongue.  It  occurs  in 
Southern  Italy  in  unhealthy  and  cachectic  children  about  the  time  of  eruption 
of  the  temporary  teeth,  and  may  be  epidemic. 


Thrush — Mycotic  Stomatitis. 

Synonyms. — Parasitic  Stomatitis;  Soor;  Miguet. 

Definition. — Thrush  is  characterized  by  grayish-white  deposits  in  the 
buccal  and  pharyngeal  mucous  membranes,  due  to  the  development  and  inter- 


3o8  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

penetration  of  the  epithelium  by  a  fungus  variously  known  as  old  hi  in 
albicans  or  saccharoniyccs  albicans.  It  is  a  variety  of  yeast  fungus  made  up 
of  branching  filaments,  at  the  ends  of  which  oval  cells  develop.  It  does  not 
grow  on  the  normal  mucous  membrane.  It  forms  minute  white  and  yel- 
lowish spots  scattered  copiously  over  the  palate,  tongue,  and  cheeks,  uniting 
at  times  to  form  larger  areas.  It  may  extend  into  the  esophagus  and  even 
larynx.  In  severe  cases  the  entire  buccal  mucous  membrane  may  be  cov- 
ered. Stenoses  of  the  esophagus  have  resulted  from  its  accumulation.  The 
little  areas  are  commonly  surrounded  by  an  inflammatory  areola,  and  may  be 
scraped  off,  though  with  some  difficulty,  leaving  the  mucous  membrane 
sometimes  intact  and  sometimes  slightly  excoriated  and  bleeding. 

Thrush  is  chiefly  a  disease  of  nursing  children,  and  is  favored  by  feeble 
and  dyscrasic  states  and  by  the  w^ant  of  cleanliness,  especially  in  the  care  of 
nursing-bottles  and  nipples  when  children  are  brought  up  on  the  bottle.  It 
may  be  associated  with  any  of  the  diseases  of  children  or  may  occur  inde- 
pendent of  them.  It  also  occurs  in  adults  after  long  illness  or  in  dyscrasic 
diseases  like  diabetes  mellitus  and  tubercular  consumption.  Thrush  is  often 
vmattended  by  other  symptoms,  though  the  mouth  may  be  sensitive  and  nurs- 
ing painful.  There  should  be  no  difficulty  in  diagnosis.  In  thrush  the  spots 
are  smaller  than  in  aphthous  stomatitis,  and  the  microscope  at  once  removes 
all  doubt.  The  mouth  is  dry  as  contrasted  with  the  moist  mouth  of  aphthous 
sore  mouth,  where  there  is  free  salivation. 

Other  Varieties  of  Stomatitis  Due  to  Fungi. — The  mouth  is  a  favorite 
seat  for  the  development  of  fungi,  because  of  the  warmth,  moisture,  and 
organic  matters  constantly  present.  Though  ordinarily  harmless,  in  certain 
states  of  the  system  they  may  play  an  important  role  in  producing  ulcerative 
stomatitis,  as  already  suggested.  Especially  worthy  of  mention  are  the 
diplococcus  of  Frankel  and  the  pneumonia  bacillus  of  Friedlander ;  also  the 
delicate,  thread-like  Icptothrix  buccalis,  thought  to  exert  a  significant  part  in 
the  production  of  caries. 


Ulcerative  Stomatitis. 
Synonyms. — Stoniacace;  Fetid  Stomatitis;  Putrid  Sore  Mouth. 

Definition. — This  is  a  much  more  serious  disease  of  the  mucous  mem- 
brane of  the  mouth,  attended  with  necrosis  of  the  mucous  membrane  and 
resulting  ulceration. 

Etiology. — Any  one  of  the  above  named  diseases  may  become  ulcer- 
ative. It  may  begin  as  an  aphthous  stomatitis,  taking  on  the  more  serious 
form  in  the  ill  fed  and  badly  cared  for.  or  in  those  who  are  indifferent  in 
the  care  of  their  mouths.  In  these,  an  abrasion  or  laceration  due  to  any 
cause,  as  the  tooth-brush  or  a  sharp  carious  tooth,  may  be  the  initial  lesion. 
An  ulcer  may  begin,  too,  in  a  herpetic  vesicle,  which,  on  rupturing,  leaves 
a  raw  surface  that  may  remain  isolated  or  unite  with  others.  It  is  a  fre- 
quent attendant  of  mercurialization — mercurial  stomatitis.  The  ulcer  some- 
times starts  in  the  mucous  follicles  of  the  mouth.  In  all  these  cases  the 
stomatitis  is  probably  the  result  of  infection  by  some  organism  as  yet  not 
isolated ;  it  may  be  the  omnipresent  streptococcus  or  staphylococcus,  to  w^hich 
the  sound  mucous  membrane  in  health  is  invulnerable,  but  which  finds  a 
nidus  in  the  abrasions  and  conditions  referred  to. 


STOMATITIS. 


309 


Symptoms. — The  ulcers  may  occur  in  any  of  the  situations  already 
named,  the  lips,  cheeks,  and,  more  rarely,  the  tongue.  They  vary  in  size, 
but  are  usually  of  an  ashen-gray  color,  with  red  areolae,  and  often  exhibit  a 
tendency  to  bleed. 

Additional  symptoms  are  profuse  secretion,  exquisite  pain  and  tender- 
ness in  the  ulcers  and  vicinity,  a  fetid  odor  of  the  breath,  which  sometimes 
pervades  the  apartment.  The  gttms  become  spongy  and,  in  extreme  cases, 
the  teeth  are  loosened.  There  are  proportionate  constitutional  disturbances, 
fever,  and  often  swelling  of  the  glands  at  the  angle  of  the  jaw. 

With  reference  to  mercurial  stomatitis,  or  mercurial  ptyalism,  previously 
mentioned,  this  condition  is  due  to  mercury  administered  as  a  medicine 
or  absorbed  in  the  course  of  occupations  in  which  mercury  is  handled. 
Acquired  in  the  former  way,  ptyalism,  at  the  present  day,  is  usually  acci- 
dental rather  than  designed,  in  persons  exhibiting  a  peculiar  susceptibility. 
In  such  persons  even  fractional  doses  frequently  repeated  sometimes  produce 
salivation  in  a  day  or  two.  The  symptom  first  observed  is  usually  fetor  of 
the  breath,  unless  the  patient  be  closely  watched  during  the  administration 
of  the  drug,  when  tenderness  may  be  ascertained  on  closing  the  jaws  with 
some  force.  Examination  will  then  discover  a  swelling  of  the  gums  about 
the  teeth.  Or  a  metallic  taste  may  make  its  appearance  as  the  first  symp- 
tom. To  these  symptoms  salivation  is  soon  added,  and  becomes  more  or 
less  profuse  according  to  the  severity  of  the  poisoning.  In  severe  cases, 
the  entire  mucous  membrane  of  the  mouth  becomes  swollen,  as  does  also 
the  tongue.  In  such  cases,  also,  ulceration  and  loosening  of  the  teeth  take 
place.  This  form  of  stomatitis  was  not  infrequent  in  the  older  treatment  of 
syphilis,  which  used  to  fill  a  hospital  ward  with  a  sickening  fetor  at  once 
recognizable.  Actual  loss  of  teeth  was,  perhaps,  less  common  than  is  sup- 
posed even  in  those  days,  yet  necrosis  of  the  jaw  has,  in  rare  instances, 
resulted. 

Syphilitic  stomatitis  is  also  ulcerative,  and  the  ulcers  exhibit  the  same 
gray  color.  But  the  syphilitic  ulcers  are  found  in  the  throat  as  well  as  on 
the  gums  and  cheeks  and  in  the  angles  of  the  mouth.  They  are  less  disposed 
to  bleed  than  those  of  non-specific  ulcerative  stomatitis,  and  are  really  less 
angry-looking,  but  penetrate  to  greater  depth. 

Parrot's  ulceration  is  a  form  of  ulceration  occurring  in  new-born  chil- 
dren, consisting  of  small,  symmetrically  placed  ulcers  on  the  hard  palate  on 
both  sides  of  the  median  line.  Bednar's  aphthce,  two  symmetrically  placed 
ulcers,  also  occurring  on  the  hard  palate  on  either  side  of  the  mesial  line 
near  the  velum,  are  similar,  though  not  regarded  as  identical.  This  variety 
is  thought  to  be  traumatic  in  origin,  at  least  in  most  cases,  either  the  result  of 
pressure  of  an  artificial  nipple  against  the  hard  palate,  or  of  undue  pressure 
in  washing  the  mouth.  Both  are  described  as  usually  harmless,  but  in 
poorly  cared  for  children  may  be  converted  Into  extensive  and  deep  ulcers. 
Especially  is  this  the  case  in  the  form  described  by  Parrot,  which  may  invade 
the  adjacent  bone. 

Diagnosis. — Scurvy,  though  a  general  disease,  happily  rare  of  late,  is 
characterized  by  local  symptoms  about  the  mouth,  which  include  ulceration. 
There  are  swelling  and  bleeding  of  'the  gums,  which  rise  up  around  the 
teeth.  The  latter  become  loosened  and  ulceration  may  extend  even  to  the 
lips  and  cheeks.  The  tongue  and  fauces  are  not  invaded  by  ulcers,  but  are 
subject  to  ecchymoses.  Salivation  and  fetor  of  the  breath  are  also  symp- 
toms, though  less  decided  than  in  severe  ulcerative  stomatitis.    On  the  other 


310 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


hand,  in  extreme  cases  deep-seated  gangrenous  processes  are  met. 
Along  with  these  are,  however,  the  general  symptoms  of  scurvy,  by  which 
it  is  commonly  easily  recognized. 

Treatment  of  Different  Forms  of  Stomatitis. — Prophylaxis  is  ex- 
ceedingly important  in  averting  these  various  mouth  affections.  In  the  case 
of  infants  the  mouth  should  be  washed  out  with  antiseptics  after  each  nurs- 
ing. Nothing  is  better  than  a  saturated  solution  of  chlorate  of  potash,  boric 
acid,  or  sulphate  of  sodium,  15  grains  to  the  ounce  (i  gm.  to  30  c.  c.)  of 
water.  So,  too,  the  adult  should  cleanse  the  teeth  after  each  meal.  Listerin, 
diluted  with  twice  as  much  water,  is  an  elegant  and  efficient  wash.  Equal 
parts  of  phenol-sodique  and  water  are  also  efficient.  Compounds  similar  to 
listerin  and  much  cheaper  may  be  made  up.  The  following  is  one  known 
as  spiritus  thymol  comp.  in  the  Dispensary  of  the  University  of  Pennsyl- 
vania : 


i^     Acid,  benzoic, 
Pulv.  sodii  borat. 
Acid,  borac, 
Thymol, 
Eucalyptol, 
01.  gaultherise, 
01.  menthee  pip., 
01.  thymi, 
Spt.  vini  rect., 
Aquae  destillat., 

Mix  and  filter,  and  color  \v 


gr.  64 
gr.  64 
gr.  128 
gr.  20 
m  5 
in  5 
m  3 
in  I 

q.  s.  ad    I  xvj 
ith  fluid  extract  of  hydrastis. 


Any  of  these  substances  may  be  used  on  the  tooth-brush  as  a  simple 
mouth-wash.  The  tincture  of  myrrh,  a  teaspoonful  to  four  ounces  of  water, 
should  not  be  forgotten,  and  though  less  agreeable,  carbolic  acid  may  be 
used  in  the  same  proportion.  Permanganate  of  potassium  in  the  shape  of 
Condy's  fluid,  a  teaspoonful  to  a  tumbler  of  water,  is  an  excellent  wash. 

If  stomatitis  is  established,  cleanliness  is  no  less  important  and  may 
be  secured  by  the  same  antiseptic  measures.  In  addition,  the  mouths  of 
children  may  be  treated  with  honey  and  borax, — ^the  mel  horacis  of  the 
pharmacopoeia, — to  which  alum  may  be  added.  Alum  itself  is  an  admirable 
astringent,  too  much  overlooked  of  late.  A  moderately  strong  solution  may 
be  made,  30  grains  (2  gm.)  to  the  ounce  (30  c.  c),  or  the  powdered  alum 
itself  may  be  applied,  to  the  aphthous  sore  mouth. 

For  the  painful  aphthous  ulcers  of  adults  there  is  really  nothing  so 
efficient  as  touching  with  a  pointed  piece  of  nitrate  of  silver.  A  single  appli- 
cation will  often  suffice,  but  when  healing  does  not  follow,  it  may  be  made 
daily.  A  very  good  application  also  is  a  solution  of  equal  parts  of  tincture 
of  the  chlorid  of  iron  and  glycerin,  applied  to  the  ulcers  with  a  brush. 
Chlorate  of  potassium  in  saturated  solution  is  also  a  very  good  mouth-wash, 
to  eight  ounces  (240  c.  c.)  of  which  1-2  a  fluidram  to  a  dram  (2  c.  c. 
to  4  c.  c.)  of  tincture  of  the  chlorid  of  iron  may  be  added. 

General  treatment  should  not  be  overlooked.  Many  persons  the  sub- 
ject of  stomatitis  are  much  run  down,  and  require  iron,  quinin,  and  strych- 
nin, with  nutritious  food,  to  build  them  up.  Attention  should  also  be  paid 
to  the  bowels. 

The  management  of  mercurial  stomatitis  is  in  no  way  different  from 
that  of  other  forms.  Astringents  and  disinfectants  are  especially  indicated. 
It  goes  without  saying  that  the  administration  of  the  drug  itself  must  cease. 


STOMATITIS.  3U 

Cancrum  Oris. 
Synonyms. — Gangrenous  Stomatitis;  Water  Cancer;  Noma. 

Definition. — A  rare  disease,  characterized  by  hard  infiltration  of  the 
cheek  near  the  angle  of  the  mouth,  succeeded  by  rapid  gangrene  proceed- 
ing outward  and  inward  from  the  central  focus  until  the  cheek  is  perforated, 
and  the  gangrenous  mass  separates.  It  may  start  in  the  gums  and  produce 
necrosis  of  the  jaws.     It  is  confined  to  one  side  of  the  face. 

Etiology. — A  parasitic  origin  seems  likely,  but  has  not  been  proven. 
It  occurs  in  girls  and  boys  from  two  to  five  years  old,  affecting  more  of  the 
former  than  of  the  latter.  Rarely  it  affects  adults.  It  is  usually  confined 
to  those  badly  fed  and  surrounded  by  unsanitary  conditions,  especially  when 
convalescent  from  infectious  fevers,  one-half  of  all  cases  having  arisen 
during  convalescence  from  measles,  scarlet  and  typhoid  fevers.  It  may, 
however,  be  primary.     Damp  regions  seem  to  favor  it. 

Symptoms. — Its  approach  is  insidious,  and  it  is  generally  well  ad- 
vanced when  discovered.  In  its  extreme  severity  it  may  involve  the  bones 
of  both  jaws,  the  eyelids,  and  ears ;  but  in  its  mildest  form  its  results  are 
limited  to  perforation  of  the  cheek.  The  dead  tissue  comes  away  in  dark, 
offensive  shreds. 

The  constitutional  disturbance  corresponds  to  the  degree  of  local 
involvement,  there  being  high  fever,  reaching  often  104°  F.  (40°  C),  with 
frequent  pulse  and  rapid  exhaustion.  The  adjacent  lymphatics  are  swollen. 
Inhalation-pneumonia  of  corresponding  virulence  often  succeeds,  while 
intense  irritation  of  the  stomach  and  bowels  follows  the  swallowing  of  the 
ichorous  discharge. 

Diagnosis.— Noma  has  rarely  to  be  discriminated  from  anything  else. 
Malignant  pustule  is  less  local  in  its  invasion,  furnishes  the  history  of  con- 
tagion, is  even  more  severe  in  its  constitutional  effects,  and  exhibits  the 
appropriate  bacillus.  Very  bad  cases  of  11-lcerative  stomatitis  sometimes 
suggest  cancrum  oris,  but  the  devastation  is  not  so  rapid,  nor  is  there  such 
a  tendency  to  invasion  of  the  external  integument. 

Prognosis. — This  is  almost  invariably  fatal  at  the  end  of  three  or  four 
days,  only  the  promptest  and  most  energetic  treatment  occasionally  saving 
life. 

Treatment. — This  consists  in  the  prompt  use  of  the  glowing  cautery, 
Paquelin's  being  sufficient.  In  its  absence  cauterization  with  strong  nitric 
acid  may  be  substituted.  Local  antiseptic  treatment  should  be  carried  out 
in  the  most  thorough  manner,  syringing  with  antiseptics  being  most  efficient, 
while  stimulating  and  nourishing  food  should  be  administered. 

Glossitis. 

Parenchymatous  glossitis,  or  inflammation  of  the  substance  of  the 
tongue,  is  a  rare  disease,  but  occurs  as  the  result  of  violent  injury  to  the 
organ,  as  by  accidental  biting  or  poisonous  stings.  Apparently  idiopathic 
inflammations  are  probably  the  result  of  concealed  causes  of  the  kind  de- 
scribed. 

Symptoms. — The  tongue  is  enormously  szvollen  and  painful,  and  some- 
times extruded  from  the  mouth.     There  is  great  difficulty  in  speech,  masti- 


312  DISEASES  OE  THE  DIGESTIVE  SYSTEM. 

cation,  and  deglutition,  and  in  extreme  degrees  these  are  scarcely  possible. 
The  discomfort  is  almost  indescribable,  and  there  may  even  be  obstruction  to 
breathing.  If  exposed,  the  tongue  becomes  dry  and  fissured.  There  may 
be  suppuration.  There  is  fcz'cr  corresponding  to  the  amount  of  local  dis- 
turbance. 

Treatment. — This  consists  in  the  constant  application  of  ice,  of 
frequent  antiseptic  cleansing  of  the  mouth,  and  sometimes  of  scarification. 
Evidence  of  the  presence  of  pus  must  be  followed  by  the  prompt  use  of  the 
lancet. 

Glossitis  dcsiccans  is  a  more  chronic  affection  of  the  tongue,  character- 
ized by  deep  fissures  and  indentations,  giving  it  an  uneven,  ragged  appear- 
ance. Associated  therewith  are  excoriations  and  occasionally  superficial 
ulcers.  Severe  pain  is  caused  by  contact  of  acids  and  even  the  usual  food. 
Its  etiology  is  not  known,  but  it  is  sometimes  associated  with  gastro-intes- 
tinal  derangements. 

Treatment. — This  should  be  directed  to  the  cause,  if  it  can  be  dis- 
covered. Washes  of  chlorate  of  potash  should  be  employed,  and  if  there 
are  ulcers,  they  should  be  touched  with  solid  silver  nitrate. 

Eczema  of*  the  Tongue. 
Synonym. — Geographical  Tongue. 

Definition  and  Symptoms. — A  localized  superficial  hyperplasia  and 
desquamation  of  the  epithelium  of  the  tongue,  sometimes  associated  with 
similar  spots  in  the  cheeks  and  lips.  The  central  parts  tend  to  heal,  while 
the  periphery  spreads,  producing  circinate  patches.  The  patches  fuse  and 
extensive  areas  are  formed,  bounded  with  sinuous  outlines.  The  appear- 
ance has  been  compared  to  that  of  a  map — lingua  geographica.  The  con- 
dition is  chronic,  sometimes  lasts  years,  but  does  not  usually  cause  incon- 
venience save  by  the  itching  and  burning  it  occasions  and  the  apprehension 
of  more  serious  disease.  It  is  occasionally  mistaken  for  syphilitic  disease. 
It  is  best  treated  by  solutions  of  nitrate  of  silver,  which  relieves  the  itching. 
Weak  solutions  of  iodin  may  be  useful,  applied  with  a  brush. 

Leukoplakia   Buccalis. 

Synonyms. — Ichthyosis    Ungnalis;    Buccal    Psoriasis;    Keratosis   mucosa; 

oris;  Smoker's  Tongue. 

Definition  and  Symptoms. — A  condition  in  which  there  are  intense 
white  spots  on  the  mucous  membrane  of  the  mouth  and  tongue,  consisting, 
in  thickened  epidermis.  They  are  also  sometimes  mistaken  for  syphilitic 
plaques.  The  spots  on  the  sides  of  the  tongue  are  often  notched,  giving 
them  a  scar-like  appearance.  Those  on  the  inner  surface  of  the  cheek  are 
simply  flat,  tabular  swellings.  They  disappear,  to  be  replaced  by  others ; 
they  rarely  give  rise  to  inconvenience.  Sometimes  those  on  the  sides  of  the 
tongue  become  ulcerated,  when  they  are  painful  if  brought  into  contact  with 
irritants.  They  have  been  ascribed  to  smoking,  and,  though  acknowledged 
to  be  of  non-syphilitic  nature,  it  is  said  they  occur  in  those  who  have  had 
syphilis.  They  occur  in  adults  of  both  sexes.  They  sometimes  become  papil- 
lomatous, and  are  said  to  have  been  the  starting-point  of  true  epithelioma,, 
as  often  as  once  in  every  three  cases. 


FUNCTIONAL  DERANGEMENTS. 


313 


Treatment. — They  are  harmless  and  require  no  treatment  unless 
ulcerated,  when  the  usual  stimulating  measures  for  healing  ulcers  may  be 
applied.  Hot  and  irritating  substances  should  be  kept  from  the  mouth, 
and  smoking  interdicted.  Should  the  spots  develop  into  papillomatous  or 
epitheliomatous  structures,  they  should  be  operated  on  by  the  surgeon. 

Mucous   Patches. 

The  true  mucous  patches  or  flat  condylomata  are  opaque,  white,  flat, 
tabular  swellings  on  the  lips,  tonsils,  tongue,  and  arches  of  the  palate,  and 
especially  at  the  border-line  between  skin  and  mucous  membrane.  They 
consist  of  an  irregular  imbricated  thickening  of  the  superficial  layers  of  the 
skin ;  the  cells  are  swollen  and  papillae  of  the  mucous  corium  hypertro- 
phied. 

Treatment. — The  treatment  of  the  mucous  patches  of  syphilis  is  that 
of  syphilis  constitutionally,  and  locally  by  applications  of  nitrate  of  silver. 


DISEASES  OF  THE   SALIVARY  GLANDS. 

FUNCTIONAL  DERANGEMENTS. 

Ptyalism,  or  excessive  secretion  of  saliva,  is  a  symptom  of  mercurial 
poisoning,  also  of  poisoning  by  gold,  copper,  and  iodin.  Some  persons 
are  very  susceptible  to  iodin,  so  that  a  few  grains  of  iodid  of  potassium 
will  cause  intense  salivation,  with  pain  in  the  saJivary  glands.  Vegetable 
substances  producing  the  same  effect  are  jaborandi,  muscarin,  tobacco. 
Indeed,  almost  anything  which  admits  of  constant  chewing  without  solution 
or  destruction  produces  salivation.  This  is  the  mechanism  of  the  various 
agents  used  in  the  disgusting  practice  of  chewing  gum. 

Xerostomia,  or  dry  mouth,  is  the  opposite  condition  of  arrest  of  sali- 
vary and  buccal  secretion,  not  due  to  fever, — a  rare  condition,  first  described 
by  Jonathan  Hutchison.  As  a  consequence  the  tongue  and  mucous  mem- 
brane are  red,  dry,  and  shining.  It  is  more  common  in  women,  in  whom  it 
follows  intense  emotion,  such  as  fright,  or  is  associated  with  hysteria  and 
hypochondriasis.  It  is  probably  a  neurosis,  the  result  of  some  cause  oper- 
ating on  the  center  which  controls  the  secretion  of  saliva  and  other  buccal 
glands. 

Treatment. — The  treatment  of  ptyalism  and  xerostomia  is  that  of  the 
conditions  producing  them. 


INFLAMMATION  OF  THE  SALIVARY  GLANDS. 

Acute  Parotitis,  or  Parotid  Bubo. — Apart  from  mumps,  or  specific 
parotitis,  considered  under  infectious;  diseases,  in  which  any  or  all  of  the 
salivary  glands  may  be  involved,  the  parotid  is  subject  to  inflammation  from 
the  following  causes : 

I.  In  the  course  of  infectious  diseases,  especially  typhoid  fever,  but 
also  scarlet  fever,  typhus  fever,  pneumonia,  pyemia,  and  secondary  S3-philis. 


314  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

2.  In  connection  with  diseases  or  injury  of  organs  in  the  abdomen  or 
pelvis,  including  the  alimentary  canal,  urinary  tract,  abdominal  wall,  perito- 
neum, pelvic  cellular  tissue,  or  genital  organs — a  very  interesting  group  of 
cases,  which  have  been  especially  studied  by  Stephen  Paget.  Sometimes 
simple  transient  irritation,  such  as  a  blow  on  the  testis  or  the  introduction 
of  a  pessary,  may  produce  it. 

3.  In  association  with  facial  neuritis.  A  fatal  case,  apparently  of  such 
origin,  has  been  reported  by  Gowers. 

In  (i)  and  (2)  septic  infection  is  doubtless  the  cause  of  the  inflam- 
mation, which  is  often  intense,  going  on  to  suppuration  in  more  than  one- 
half  of  the  cases.  Its  possible  origin  through  the  duct  of  Steno  was  con- 
sidered in  treating  typhoid  fever.  In  (3)  there  is  probably  some  vasomotor 
disturbance  which  is  responsible. 

Treatment. — This  should  consist,  at  first,  in  attempts  to  allay  the 
inflammation  by  leeches  and  the  application  of  cold,  especially  ice.  Fail- 
ing in  this,  fomentations  should  be  applied,  while  the  lancet  should  be  used 
at  the  first  indication  of  suppuration. 

Chronic  Parotitis  sometimes  succeeds  on  acute  inflammation,  as  that 
of  mumps ;  also  on  mercurialization  or  lead  poisoning,  syphilis,  and  Bright's 
disease.  Sometimes  no  cause  is  discoverable.  It  may  be  painful  or  tender 
or  painless.  It  may  be  treated  by  ointments  reputed  to  promote  absorption 
— ointments  of  iodin  and  mercury. 


ANGINA  LUDOVICI. 

Synonyms. — Ludwig's  Angina;  Cellulitis  of  the  Neck;  Cynanche 

Gangrcenosa. 

Definition  and  Symptoms. — An  inflammation  of  the  floor  of  the 
mouth,  beginning  in  the  submaxillary  gland ;  it  occurs  first  on  one  side  as  a 
secondary  inflammation  in  the  specific  fevers,  including,  especially,  typhoid, 
diphtheria,  and  scarlet  fever,  but  it  may  also  be  primary.  It  is  probably  a 
streptococcus  infection.  It  spreads  rapidly  over  the  floor  of  the  mouth  and 
the  anterior  surface  of  the  throat,  sometimes  invading  the  glottis  by  edema, 
and  sometimes  terminating  in  sloughing  of  the  soft  parts — cynanche  gan- 
grccnosa.  Or  it  may  go  on  to  abscess  pointing  externally  or  internally. 
More  rarely,  resolution  takes  place. 

Further  symptoms  are  sivelling  and  extreme  pain,  first  in  the  neighbor- 
hood of  the  submaxillary  gland,  increased  by  chewing,  swallowing,  and  talk- 
ing. The  swelling  may  produce  compression  of  the  larynx,  with  resulting 
dyspnea,  which  is  suffocative  if  the  glottis  becomes  involved.  Constitutional 
infection  may  take  place,  with  its  grave  array  of  symptoms  and  fatal  termi- 
nation.    There  may  be  remissions  and  exacerbations. 

Treatment. — This  should  consist  in  energetic  measures  calculated  to 
combat  the  inflammation,  such  as  the  use  of  ice  and  leeching,  but  very  early 
surgical  interference  is  likely  to  be  called  for. 


QUINSY.  315 

DISEASES  OF  THE  TONSILS  AND  PHARYNX. 

OUIXSY. 

Synonyms. — Acute  ParencJiyniatons   Tonsillitis;  Phlegmonous  Tonsillitis; 
Tonsillar  Abscess;  Cynanche  tonsillaris. 

Definition. — An  acute  inflammation  of  the  substance  of  the  tonsil. 

Etiology. — Quinsy  is  a  disease  of  later  youth  and  adults,  being  rarelv 
found  in  children  under  ten  years  of  age,  and  not  often  in  adults  over  fortv. 
Some  persons  are  much  disposed  to  tonsillitis,  scarcely  a  season  passing  for 
them  without  an  attack,  and  sometimes  more  than  one  attack.  In  such, 
almost  every  cold  terminates  in  acute  tonsillitis.  Others,  after  a  single 
attack,  never  have  another,  and  others  still  are  entirely  exempt.  Tonsillitis 
is  probably  always  the  result  of  infection.  Exposure  to  wet  and  cold  cer- 
tainly often  precedes  it.  Persons  predisposed  to  tonsillitis  are  often  the  sub- 
ject of  chronically  enlarged  tonsils.  Overdistention  of  the  follicles  with 
inspissated  secretion  may  also  be  a  cause  of  inflammation  and  suppuration. 

Morbid  Anatomy. — The  tonsil,  more  frequently  on  one  side,  some- 
times on  both,  or  on  two  sides  in  succession,  becomes  rapidly  enlarged,  red, 
and  painful.  It  is  at  first  hard  and  resistant  and  very  tender  to  the  touch, 
but,  if  suppuration  takes  place,  it  gradually  softens  until  rupture  happens  or 
the  abscess  is  opened  with  the  knife.  The  lymphoid  parenchyma  of  the 
gland  becomes  more  and  more  distended  with  leukocytes  until  the  entire 
gland,  or  a  large  part  of  it,  is  converted  into  a  pus  sac.  When  both  tonsils 
are  involved,  the  throat  is  often  almost  closed  by  the  swelling. 

Symptoms. — The  superadded  symptoms  are  pain  and  difficultx  of 
deglutition,  attended  by  increased  pain,  which  is  often  agonizing.  The  jaws 
are  stiff  and  the  mouth  cannot  be  opened  above  half  an  inch  without  extreme 
suffering.  The  difficulty  in  opening  the  mouth  is  increased  by  the  swell- 
ing of  the  external  glands  of  the  neck.  The  pain  is  not  confined  to  the 
interior,  but  extends  to  the  neighborhood  of  the  angle  of  the  jaw,  the  front 
of  the  ear,  and  the  floor  of  the  mouth.  The  voice  is  greatly  altered,  having 
the  characteristic  nasal  draAvl,  and  the  diagnosis  can  sometimes  be  made  from 
the  altered  speech  alone.  There  is  increased  salivation,  and  the  saliva 
dribbles  from  the  mouth  because  of  the  pain  in  swallowing  it,  while  it  also 
often  becomes  fetid.     Respiration  may  be  seriously  interfered  with. 

There  is  high  fever,  the  temperature  reaching  104°  and  105^  F.  (40^ 
to  40.5°  C),  while  the  pulse  is  full,  bounding,  and  frequent,  no  to  130  a 
minute.  The  face  is  anxious  and  tells  the  tale  of  suffering.  From  two  to 
six  days  are  occupied  in  the  completion  of  the  process,  at  the  end  of  which 
time  the  abscess  begins  to  point,  usually  toward  the  interior  of  the  mouth, 
when  relief  is  obtained  by  spontaneous  rupture.  But  more  fortunate  is  the 
patient  who  is  relieved  early  by  the  lancet.  Sometimes  the  abscess  points 
toward  the  pharynx.  The  importance  of  relief  at  the  earliest  possible  date 
is  emphasized  by  the  fact  that  death  by  suffocation  has  resulted  from  the 
discharge  of  a  quinsy  passing  into  the  larynx. 

Prognosis. — Apart  from  the  rare  accident  just  referred  to,  the  prog- 
nosis is  favorable,  though  it  must  be  mentioned  also  that  death  from  suffo- 


3i6  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

cation  has  occurred  where  the  obstruction  by  double-sided  quinsy  was  so 
great  as  to  prevent  respiration. 

Treatment. — The  physician  who  suggests  a  successful  plan  for 
"  backing  "  of  a  quinsy  will  well  deserve  the  thanks  of  untold  sufferers. 
As  yet  such  measure  remains  hidden.  Free  scarification  is  sometimes  use- 
ful in  shortening  an  attack,  but  it  is  painful,  unreliable,  and  sometimes  diffi- 
cult to  do  thoroughly.  If  deferred  until  about  the  third  day,  it  will  often 
co-operate  with  the  advancing  suppuration  and  favor  an  early  rupture. 
Other  applications  to  the  tonsils  are  of  doubtful  efficacy,  though  some 
relief  from  pain  may  be  secured  by  painting  the  surface  with  a  lo  per  cent, 
solution  of  cocain.  Painting  with  a  40-grain  (2.6  gm.)  solution  of  nitrate 
of  silver,  after  thorough  cleansing  with  a  cotton  swab,  is  recommended. 
Parenchymatous  injections  of  carbolic  acid  are  also  advised  by  Kramer,* 
wath  a  view  to  prevent  abscess  formation.  The  part  is  made  completely 
anesthetic  by  cocain,  a  sterilized  needle  attached  to  a  hypodermic  syringe 
gently  introduced  into  the  gland,  and  through  this  are  injected  from  7  to  15 
minims  (0.5  to  i  c.  c.)  of  a  two-  to  three-per  cent,  solution  of  carbolic  acid. 
This  may  be  repeated  once  or  twice  a  day. 

Cold,  so  soothing  in  other  forms  of  sore  throat,  often  occasions  more 
discomfort  than  relief.  Then  poultices  and  fomentations  to  the  exterior  of 
the  throat  are  apt  to  be  more  soothing.  And  since  little  can  be  done  to 
prevent  suppuration,  these  measures  are  indicated  to  hasten  it.  The  tonsil 
should  be  frequently  felt  with  the  finger,  and  as  soon  as  there  is  evidence 
of  suppuration,  the  lancet  should  be  used.  A  curved  bistoury,  guarded 
with  adhesive  plaster  almost  to  the  end,  is  best.  The  incision  should  be 
made  from  above  downward,  parallel  to  the  anterior  half-arch.  If  danger 
of  suffocation  is  imminent,  the  tonsil  must  be  shaved  off,  while  extreme 
cases  may  even  demand  tracheotomy. 


FOLLICULAR  TONSILLITIS. 
Synonyms. — Angina  foUicularis;  Lacunar  Tonsillitis. 

Definition  and  Symptoms. — A  form  of  catarrhal  inflammation  of 
one  or  both  tonsils,  associated  with  whitish-yellow^  spots  corresponding  in 
situation  with  the  lacunae  or  follicles  of  the  gland.  The  inflammation  may 
rarely  extend  to  the  soft  palate^  but  the  white  or  yellow  spots  are  the  most 
conspicuous  feature.  In  a  day  or  two  they  drop  out  or  may  be  pressed 
out,  when  they  are  found  composed  of  epithelial  cells,  pus-corpuscles,  bac- 
teria, and  debris,  to  which  are  sometimes  added  cholesterin  plates  and  fat- 
crystals.  If  let  alone,  they  may  disappear  rather  suddenh%  so  that  if  seen 
one  day  they  may  be  gone  the  next,  having  evidently  disintegrated  and 
dropped  out  spontaneously.  IMore  rarely  the  little  follicle  is  converted  into 
a  small  abscess. 

The  disease  occurs  in  children  and  young  adults,  and  is  one  of  the 
affections  sometimes  mistaken  for  diphtheria,  and  is  also  called  diphtheritic 
sore  throat.  It  is,  however,  something  very  different.  It  is  a  much  less 
serious  disease,  of  shorter  duration,  and  patients  never  die  of  it.  It  is,  how- 
ever, probably  infectious  in  origin,  caused  by  a  germ  other  than  the  diph- 

*''  Anales  del  Circulo  Medico  Argentino,"  October  15,  1897. 


CHRONIC  TONSILLITIS.  317 

theritic,  perhaps  the  streptococcus  or  staphylococcus.     There  is  often  very 
decided  fever. 

Treatment. — The  treatment  of  this  form  of  tonsilhtis  is  definite  and  easily 
carried  out.  In  the  first  place,  cold  should  be  applied  to  the  neck  by  cloths 
wrung  out  in  cold  water  or  by  ice,  which  is  conveniently  applied  in  little 
muslin  bags  made  to  fit  under  the  angle  of  the  jaw  and  held  in  place  by  a 
bandage.  Then  iron  and  chlorate  of  potassium  are,  without  doubt,  the 
remedies  par  excellence,  and  to  these  may  be  added  the  bichlorid  of  mercury, 
if  diphtheria  is  not  certainly  eliminated  from  the  diagnosis.  The  antiseptic 
measures  recommended  for  the  throat  in  diphtheria  are  not  necessary.  The 
disease  is  an  acute  one  and  subsides  rapidly  without  any  of  these  applica- 
tions. There  is,  however,  a  very  decided  drain  on  the  strength  of  the  pa- 
tients thus  affected,  however  short  the  duration  of  the  illness.  Hence,  qui- 
nin  and  iron  should  be  given  and  continued  during  convalescence. 


CHRONIC  TONSILLITIS   AND  HYPERTROPHY  OF  THE  ADE- 
NOID TISSUE  OF  THE  PHARYNX. 

Synonyms. — Chronic  Enlargement  of  the  Tonsils;  Chronic  Naso- pharyn- 
geal Obstni'Ction;  Mouth  Breathing;  Aprosexia. 

Definition. —  A  chronic  inflammatory  enlargement  of  the  tonsils  or  of 
the  adenoid  tissue  of  the  pharynx,  of  the  lingual  tonsil,  or  of  two  or  more  of 
these  structures. 

Etiology, — The  most  frequent  cause  is  repeated  attacks  of  acute  ton- 
sillitis and  of  inflammatory  processes  associated  with  hyperemia  of  the  ton- 
sils and  vicinity,  including  scarlet  fever  and  diphtheria,  while  chronic  illness, 
especially  skin  affections,  bad  hygienic  surroundings,  and  insufficient  and 
unsuitable  food  favor  it.  It  is,  therefore,  naturally  more  common  in  chil- 
dren, in  whom  it  is  also  sometimes  congenital,  but  it  is  found  usually  at  the 
ages  of  five  to  fifteen  years,  and  rather  more  frequently  in  boys.  Adenoid 
overgrowths  of  the  pharynx  and  lingual  tonsil  are  due  to  the  same  causes. 

Morbid  Anatomy. — The  enlargement  of  the  tonsils  is  a  true  lymphoid 
overgrowth,  usually  symmetrical.  The  occasional  presence  of  fibrous  stroma 
produces  a  harder  and  smoother  tissue.  The  lumen  of  the  throat  is  vari- 
ously encroached  upon,  sometimes  almost  closed.  The  pharyngeal  adenoid 
overgrowths  vary  in  extent  from  a  slight  increase  in  natural  unevenness  to 
the  formation  of  actual  sessile  and  pedunculated  tumors.  The  same  is  true 
of  the  tonsillar  structures  at  the  base  of  the  tongue,  which  may  encroach 
upon  the  glottis. 

Symptoms. — Simple  chronic  enlargement  of  the  tonsils  may  give  rise  to 
no  symptoms  except  when  the  seat  of  further  enlargement  due  to  acute 
inflammation.  Then  obstructed  breathing  is  immediate,  while  it  is  also  a 
permanent  symptom  in  the  more  advanced  forms.  It  is  proportionally  con- 
tributed to  by  overgrowth  in  any  of  the  situations  named.  The  result  is 
month  breathing,  which  is,  perhaps,  earlier  necessitated  by  pharyngeal  than 
tonsillar  overgrowth,  while  it  may  be  due  altogether  to  the  former,  the  latter 
being  entirely  absent.  Tonsillar  obstruction  is,  however,  more  frequent. 
The  effects  are  usually  first  apparent  at  night,  when  the  child  is  found  to  be 


3i8  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

breathing,  more  or  less  noisily,  with  its  mouth  open  and  head  thrown  back. 
Disturbed  rest  is  an  inevitable  consequence,  the  patient  often  waking  up  with 
a  start,  again  relapsing  into  sleep,  or  continuing  permanently  aroused 
because  of  the  dyspnea,  which  often  only  gradually  passes  away. 

As  the  conditions  persist  a  changed  expression  of  countenance  is  gradu- 
ally acquired.  The  face  becomes  apathetic,  staring,  and  vacant,  an  appear- 
ance chiefly  produced  by  the  constantly  open  mouth.  To  this  may  succeed 
actual  mental  failure  and  even  stupidity,  with  sullenness  and  general  bad 
temper.  Further  changes  in  expression  are  occasioned  by  contraction  of 
the  nostrils  and  projection  of  the  upper  jaw  and  lip.  If  the  condition  is  still 
unrelieved,  deformities  of  the  chest  make  their  appearance,  of  which  the 
most  conspicuous  is  the  well-known  chicken  breast.  In  it  the  upper  sternum 
projects,  the  manubrio-gladiolar  articulation  being  most  prominent,  while 
the  lower  part  is  depressed,  causing  a  groove  at  the  gladiolo-xiphoid  articu- 
lation. There  is  a  cup-like  depression  of  the  lower  costal  cartilages  and  a 
horizontal  circular  depression  (Harrison's  groove)  in  the  thorax  correspond- 
ing to  the  attachment  of  the  diaphragm.  The  ribs  are  separated  from  each 
other  anteriorly  and  closely  approximate  posteriorly,  especially  in  the  lower 
thorax.  Posteriorly  the  lower  angle  of  the  scapula  projects.  This  is  the 
result  of  the  act  of  breathing,  a  study  of  which  during  sleep  will  recognize 
the  retraction  of  the  lower  part  of  the  thorax  during  inspiration,  caused  by 
the  action  of  the  diaphragm. 

Another  form  of  chest  is  the  round  or  barrel  chest,  such  as  is  commonly 
associated  with  chronic  asthma,  due  to  the  same  cause.  Still  another  said 
to  be  caused  by  mouth  breathing  is  the  funnel  breast,  or  Trichterbrust  of  the 
Germans,  in  which  there  is  a  deep  central  depression  at  the  epigastrium. 

Other  symptoms  are  an  altered  nasal  voice  in  which  the  letters  m  and 
n  are  especially  badly  articulated,  the  special  senses  of  smell,  taste,  and  hear- 
ing are  deranged,  the  breath  is  fetid  from  decaying  secretion,  the  appetite  is 
impaired,  and  with  it  the  nutrition  of  the  body.  A  gradual  mental  as  well 
as  physical  deterioration  takes  place. 

Among  the  symptoms  ascribed  to  this  condition  are  habit  chorea  and 
stuttering.  The  former  will  be  considered  in  a  later  section.  There  is  an 
almost  constant  cough,  which  is  well  termed  "  throat  cough,"  since  it  is  due 
to  irritation  of  the  respiratory  passages  by  the  throat  outgrowths  and  the 
secretion  caused  by  them.  This  secretion  is  generally  swallowed  by  chil- 
dren, but  is  in  part  expectorated  by  adults  by  the  aid  of  troublesome  hawk- 
ing and  coughing,  which  is  stimulated  by  a  sensation  as  of  "  something  in 
the  throat  "  or  larynx  which  demands  clearing.  The  absence  of  discharge 
from  the  nose  in  both  children  and  adults  is  surprisingly  frequent,  sometimes 
misleading  the  physician  as  to  the  trvie  cause. 

Defective  hearing  is  another  symptom  due  to  obstruction  of  the  Eusta- 
chian tube  by  encroachment  of  the  adenoid  growths,  or  by  inflammations, 
or  to  retraiction  of  the  drum.  Impaired  taste  and  smell  are  due  to  involve- 
ment of  the  gustatory  papillse  and  the  terminal  distribution  of  the  olfactor}^ 
nerve.  Extreme  fetor  of  the  breath  is  sometimes  present,  due  to  retention 
of  cheesy  masses  in  the  crypts  of  the  tonsils.  These  are  often  easily  visible, 
are  sometimes  expectorated,  and  can  usually  be  expressed.  The  odor  of 
these  masses  when  compressed  between  the  fingers  is  indescribably  disagree- 
able. Sometimes  they  are  found  in  the  tonsils  of  persons  not  otherwise 
affected.  The  very  great  susceptibility  of  the  subjects  of  this  disease  to 
"  cold  "  is  constantly  adding  aggravation  to  the  symptoms  described. 


CHRONIC  TONSILLITIS.  319 

Diagnosis. — This  is  not  usually  delayed  at  the  present  day,  siujce  the 
more  thorough  examination  of  the  throat  and  nose  has  become  common — 
thanks  to  the  throat  and  nose  specialists.  Most  important  is  it  to  remember 
that  there  may  be  no  tonsillar  disease,  and  all  the  symptoms  may  be  due  to 
advanced  adenoid  growths  of  the  pharynx.  Digital  examination  by  the 
finger  affords  the  most  ready  and  accurate  means  of  diagnosis.  Especially 
thorough  must  be  the  examination  behind  the  pillars  of  the  fauces.  In  chil- 
dren this  can  only  be  done  with  the  finger,  but  in  adults  the  half-arches  may 
be  drawn  forward,  while  the  laryngeal  mirror  is  availed  of. 

The  "  chicken  breast  "  of  mouth  breathing  in  childhood  is  different  from 
the  "  violin  "  shaped  chest  of  the  rickety  child.  In  the  latter  there  are  a 
prominence  of  the  zvhole  sternum  and  a  vertical  flattening  of  the  sides  of 
the  thorax,  leaving  a  large  curve  behind  the  costo-chondral  articulation  and 
a  similar  one  in  front,  in  addition  to  the  horizontal  depression  of  the  lower 
thorax  which  is  common  to  both  kinds  of  deformity. 

Prognosis. — This  depends  upon  the  early  discovery  of  the  condition, 
before  the  secondary  effects  have  established  themselves.  If  the  trouble  is 
purely  a  tonsillar  one,  it  is  comparatively  easily  removed  by  shaving  off  the 
organ.  If  the  overgrowth  is  pharyngeal,  little  can  be  done  until  children 
are  old  enough  to  submit  to  the  proper  treatment.  This  miay  be  done  by  the 
aid  of  ether  as  early  as  the  second  year.  Hypertrophied  tonsils  begin  to 
atrophy  of  themselves  after  puberty,  and  they  have  generally  disappeared 
by  thirty.  The  face  and  chest  deformity  may  be  outgrown  if  the  cause  be 
removed. 

Treatment. — Most  important  are  local  measures  to  reduce  the  size  of  the 
overgrowth  or  to  remove  it  and  to  prevent  recurrence  of  acute  attacks.  The 
patient  should  be  discouraged  from  hawking  and  clearing  his  throat.  If  the 
tonsils  manifestly  encroach  on  the  faucial  lumen,  they  should  be  shaved  off 
by  the  guillotine  or  a  bistoury  or  galvano-cautery  loop.  The  same  treatment 
is  demanded  by  the  pharyngeal  adenoid  growths.  They  may  be  curetted 
and  sometimes  scraped  off  by  the  finger-nail.  There  is  sometimes  copious 
hemorrhage,  but  it  is  usually  easily  controlled.  If  not  requiring  this,  they 
should  receive  on  alternate  days  or  every  third  day  applications  of  powdered 
alum ;  solution  of  iodin  of  the  strength  of  iodin  8  grains  (0.5  gm.)  ;  iodid  of 
potassium  24  grains  (1.5  gm.),  glycerin  half  ounce  (30  c.  c.)  ;  of  tincture  of 
the  chlorid  of  iron  and  glycerin  equal  parts ;  glycerole  of  tannin ;  or  silver 
nitrate  i  to  20.  The  solid  stick  of  the  latter  may  be  used  if  there  be  evident 
lacunar  disease,  but  far  better  is  electrolysis,  by  which  the  crypt  is  obliterated 
and  the  gland  may  be  gradually  destroyed.  Spraying  the  nose  with  anti- 
septic solutions  twice  daily  is  helpful  in  maintaining  cleanliness  and  purity 
of  breath.  Dobell's  solution  may  be  thus  used;  also  dilute  listerin  or  the 
spiritus  thymol  comp.  given  on  page  310.  Tablets  containing  various  pro- 
portions of  the  ingredients  therein  named  are  made  for  solution  in  the  little 
cup  of  the  spraying  apparatus.  Great  patience  and  perseverance  are 
required,  for  the  result  is  but  slowly  attained. 

The  general  health  of  the  patient  should  be  carefully  looked  after. 
Suitable  woolen  underclothing  should  be  worn,  and  it  should  be  graduated 
to  temperature  and  exposure.  Cod-l^ver  oil,  iron,  quinin,  and  strychnin  are 
the  best  roborants.  It  is  most  important  that  every  effort  should  be  made 
in  the  direction  of  so  hardening  the  patient  that  he  may  be  able  to  resist  the 
effects  of  exposure,  a  task  not  easy  to  accomplish.  Cold  bathing  of  the  neck 
and  throat,  indeed,  of  the  whole  body  is  useful,  while  nourishing  food,  physi- 


320  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

cal   exercise,   and   outdoor   life,   with   suitable   clothing,   are   means   to   this 
end. 

SIMPLE  CIRCULATORY  DERANGEMENTS  OF  THE  PHARYNX. 

Hyperemia  of  the  pharynx  is  a  very  common  condition  in  smokers.  It 
is  also  almost  always  present  when  there  is  chronic  nasal  catarrh.  Under 
these  circumstances  the  mucous  membrane  is  constantly  red,  angry  looking, 
often  streaked  with  mucus,  and  is  very  easily  thrown  into  a  state  of  active 
inflammation. 

In  such  obstructions  to  the  circulation  as  are  caused  by  mitral  valvular 
disease,  cirrhosis  of  the  liver,  or  pressure  upon  the  ascending  vena  cava  by 
aneurysm  or  tumor,  there  is  venous  stasis  and  the  venules  may  often  be  seen 
distended.  Occasionally  they  burst,  producing  small  hemorrhages  which 
stain  the  mucous  secretion.  The  same  causes  may  produce  edema  of  the 
mucous  membrane  of  the  pharynx,  and  especially  does  this  occur  in  Bright's 
disease.  The  edema  may  extend  thence  to  the  uvula,  which  becomes  greatly 
swollen.  In  aortic  regurgitation  the  capillary  pulse  may  be  seen  in  the 
pharynx,  and  the  internal  carotid  also  seen  to  throb  strongly. 


ACUTE  CATARRHAL  PHARYNGITIS. 
Synonyms. — Sore  Throat ;  Simple  Angina. 

Definition.— An  acute  inflammation  of  the  mucous  membrane  cover- 
ing the  pharynx  and  tonsils,  sometimes  extending  upon  the  palate. 

Etiology. — Acute  pharyngitis  occurs  at  all  ages,  but  is  more  frequent 
in  children.  Exposure  to  cold  and  wet  is  its  most  frequent  exciting  cause. 
The  delicate  are  more  predisposed  than  the  robust,  and  where  there  is  the 
hyperemia  above  referred  to,  a  trifling  cause  lights  up  an  inflammation. 
Rheumatism  and  gout  are  also  frequent  causes.  Pharyngitis  and  tonsillitis 
are  often  associated. 

Symptoms. — The  first  symptom  is  usually  pain  on  swallowing,  which 
is  associated  at  first  with  a  dryness  and  soreness,  producing  a  desire  to  "  clear 
the  throat."  To  this  is  soon  added  a  full  feeling,  and  then  pain  independent 
of  swallowing.  The  inflammation  may  extend  into  the  Eustachian  tube, 
producing  partial  deafness,  or  into  the  larynx,  producing  hoarseness.  There 
is  a  varying  degree  of  constitutional  disturbance,  and  sometimes  the  fever  is 
quite  high. 

On  examining  the  throat  it  will  be  found  red  and  congested,  sometimes 
plainly  swollen,  especially  over  the  tonsils.  There  is  often  considerable 
mucous  secretion.  The  various  forms  of  ulcer  of  the  tonsils  described  under 
tonsillitis  may  be  associated  with  the  pharyngitis.  Increasing  the  constitu- 
tional disturbance  and  local  discomfort. 

Treatment. — Many  simple  sore  throats  pass  away  without  treatment. 
Astringent  washes  and  gargles  are  indicated,  but  the  patient  should  be 
warmly  housed  and  even  in  mild  cases  had  better  go  to  bed.  Twenty-four 
hours  in  bed  is  by  far  the  best  medicine  for  an  ordinary  cold.  A  gargle  of 
alum  or  tincture  of  the  chlorid  of  iron  in  the  proportion  of  a  teaspoonful  of 
either  to  a  full  tumbler  of  water  may  be  used,  while  applications  of  a  mixture 


CHROXIC  CATARRHAL  PHARYXGITIS.  321 

of  equal  parts  of  the  iron  tincture  and  glycerin  may  be  applied  to  the  throat 
two  or  three  times  a  day.  Solution  of  nitrate  of  silver,  20  grains  (1.3  gm.) 
to  the  ounce  (30  c.  c.j,  may  be  similarly  applied,  also  the  glycerole  of 
tannin. 

In  severe  cases  cold  cloths  wrung  out  in  ice  water  and  applied  to  the 
outside  of  the  throat,  the  clothing  being  protected  by  the  interposition  of  a 
dry  towel,  make  an  excellent  measure ;  or  the  little  ice  bags  referred  to  in 
the  treatment  of  acute  tonsillitis  may  be  applied  to  the  throat,  with  a  dry 
towel  outside  of  them.  Occasionally  counterirritation  by  mustard  is  more 
efficient,  as  every  throat  does  not  bear  cold  equally  well. 

The  fever  should  be  met  in  the  usual  way  by  aconite,  sweet  spirit  of 
niter,  and  citrate  of  potash,  while  chlorate  of  potash  and  chlorid  of  iron 
should  also  be  administered  internally.  The  bichlorid  of  mercury  may  be 
added  under  the  same  circumstances  as  in  diphtheroid  tonsillitis.  There  is 
no  advantage  in  giving  large  doses  of  iron.  They  are  not  absorbed  and  the 
excess  remaining  in  the  alimentary  canal  locks  up  the  secretions  and  causes 
irritation.  From  two  to  ten  minims  (0.12  to  0.6  gm.)  every  two  hours  are 
quite  sufficient.  The  bowels  should  be  kept  open,  and  the  treatment  may  be 
advantageously  commenced  with  a  saline  aperient,  such  as  calcined  mag- 
nesia, the  solution  of  the  citrate  of  magnesium,  or  Hunyadi  water. 

\A'here  the  disease  is  traceable  to  rheumatism  or  gout,  suitable  treatment 
for  these  diseases  should  be  instituted.  The  salicylates  are  the  best  remedies 
for  both,  but  guaiacum  has  some  reputation,  the  tincture  or  ammoniated 
tincture  being  the  best  preparation,  given  in  doses  of  5  to  60  drops  (0.35  to 
4gm.). 


CHROXIC    CATARRHAL    PHARYXGITIS. 

Synonyms. — Clergyman's    Sore    Throat;    Granular    Pharyngitis;    Chronic 
Angina;  Chronic  FoVicular  Pharyngitis. 

Definition. — Chronic  pharyngitis,  when  not  associated  with  ulceration, 
presents  much  the  same  appearance  as  chronic  hyperemia,  plus  the  addition 
of  a  granular  appearance  due  to  enlargement  of  lymphatic  glandules,  with 
which  the  pharynx  is  studded. 

Etiology. — The  disease  is  rather  one  of  adults  than  children.  Its  causes 
are  repeated  attacks  of  acute  pharyngitis  and  excessive  smoking  and  alcohol 
drinking.  Chronic  nasal  catarrh  with  its  irritating  discharges  trickling 
down  the  fauces  is  a  frequent  cause,  as  is  also  nasal  obstruction  and  disease 
of  the  third  or  Luschka's  tonsil.  It  also  occurs  in  those  who  use  their  voices 
largely,  as  hucksters,  public  speakers,  and  singers,  while  the  inhalation  of 
dust  and  irritating  gases  is  also  held  responsible. 

Treatment. — This  is  very  much  more  unsatisfactory  than  in  the 
acute  type.  It  is  most  important  to  treat  the  causes  or  remove  them.  Post- 
nasal catarrh  is  responsible  for  so  many  cases  that  the  post-nasal  region 
should  at  once  be  investigated  and  its  diseases  treated.  Smoking  and  the 
use  of  alcohol,  if  responsible,  should  'at  once  be  discontinued.  The  same 
local  measures  useful  in  the  acute  disease  mav  be  employed  in  the  chronic, 
but  they  are  less  promising  as  to  results.  The  little  granules,  which  are 
apparently  a  source  of  irritation  as  well  as  a  result,  can  be  removed  only  by 
the  galvano-cauterv  needle.     Other  measures  to  this  end  are  unsatisfactory 


322  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

and  insufficient.  The  general  health  of  the  patient  should  be  carefully 
looked  after,  and  occupations  tending  to  keep  up  the  irritation  should  be 
discontinued. 


Ulceration  of  the  Pharynx. 

The  ordinary  form  of  chronic  pharyngitis  rarely  produces  ulceration. 
Syphilis,  tuberculosis,  diphtheria,  inflammation,  and  lowered  nutrition,  such 
as  is  found  after  the  infectious  diseases,  like  typhoid  fever  and  scarlet  fever, 
are  frequent  causes  of  sluggish  ulcers  indisposed  to  heal.  The  chief  symp- 
tom of  these  various  varieties  of  ulceration  is  pain,  increased  during  deglu- 
tition, with  more  or  less  copious  mucous  secretion,  which  often  adheres  firmly 
to  the  pharynx. 

Diagnosis. — It  is  not  always  easy  to  distinguish  the  different  forms  of 
ulceration.  The  syphilitic  nicer  is  least  painful,  in  fact  often  painless,  and 
is  commonly  situated  in  the  posterior  wall  of  the  pharynx.  It  occurs  both 
as  a  secondary  and  tertiary  symptom.  As  a  secondary  symptom  it  is  super- 
ficial and  associated  with  mucous  patches,  while  as  a  tertiary  it  forms  the 
cavity  left  by  a  softened,  gummy  tumor,  and  is  correspondingly  deep.  It  is 
associated  with  the  history  of  syphilis. 

The  tubercular  ulcer  is  more  painful — indeed,  the  most  painful  of  all. 
It  is  irregular,  not  very  deep,  has  a  grayish  base,  and  is  also  seated  in  the 
posterior  wall  of  the  pharynx,  considerable  areas  of  which  may  be  involved, 
producing  an  uneven,  worm-eaten  appearance.  It  is  associated  with  tuber- 
culosis elsewhere.  The  indolent  ulcers  of  lowered  nutrition  are  also  often 
insidious  and  occasion  few  active  symptoms.  After  the  separation  of  the 
membrane  in  diphtheritic  pharyngitis  there  are  sometimes  left  ulcers  more 
or  less  extensive,  which  are  slow  to  heal. 

Treatment. — This  consists  locally  in  the  application  of  stimuli  and  anti- 
septics, the  former  represented  by  nitrate  of  silver  and  the  latter  by  thymol 
and  its  class,  together  with  general  treatment  appropriate  to  the  condition, 
such  as  tonics  of  which  iron  and  quinin  are  the  types. 


Phlegmonous  Pharyngitis. 

Definition. — This  term  is  applied  to  any  suppurating  inflammation 
involving  the  pharynx,  however  induced,  except  post-pharyngeal  abscess, 
which  is  a  separate  condition.  It  may  be  a  part  of  the  process  which  con- 
stitutes suppurating  tonsillitis  or  quinsy,  extending  to  the  adjacent  pharyn- 
geal structures.  It  may  include  the  acute  infectious  phlegmon  of  the 
pharynx  described  by  Senator,  in  which,  along  with  swelling  of  the  external 
neck,  the  pharyngeal  mucous  membrane  is  swollen  and  injected,  and  becomes 
rapidly  the  seat  of  suppuration.  It  may  include  similar  conditions  induced 
by  injury,  the  inhalation  of  scalding  liquids,  or  the  swallowing  of  corrosive 
poisons.  Or  it  may  be  the  result  of  pharyngeal  erysipelas  or  of  the  lodg- 
ment of  foreign  bodies. 

Symptoms. — These  are  correspondingly  intense.  There  is  painful 
STvelling,  interfering  not  only  with  deglutition,  but  also  with  respiration. 
There  is  high  fever  and  rapid  exhaustion-.  It  may  terminate  in  gangrene  of 
the  part  or  gangrenous  pharyngitis. 


EXPLORATION  OF  THE  ESOPHAGUS.  323 

Treatment. — The  treatment  is  locally  antiphlogistic,  including  cold  by 
ice  or  otherwise,  scarification  and  liberation  of  pus  at  the  earliest  possible 
moment,  together  with  restorative  and  stimulating  internal  measures.  If 
gangrene  results,  cauterization  and  antiseptic  applications  must  be  added. 
The  aid  of  the  surgeon  should  be  early  sought. 


Post-Pharyngeal  Abscess. 

Definition. — A  phlegmonous  inflammation  behind  the  proper  pharyn- 
geal tissue,  subperiosteal  in  some  instances,  arising  in  suppurative  inflam- 
mation of  the  post-pharyngeal  lymphatic  glands  or  caries  of  the  cervical 
vertebrae.  It  is  a  disease  of  children  and  adults,  more  frequently  of  the  for- 
mer, often  a  sequel  of  one  of  the  pharyngeal  conditions  already  considered, 
favored  by  bad  hygiene  and  depraved  constitutional  states,  hereditary  or 
acquired. 

Symptoms. — Its  symptoms  are  intense  pain,  stvelling,  and  interference 
with  deglutition  and  respiration,  with  more  or  less  early  appearance  of  a 
tumor  in  the  posterior  wall  of  the  pharynx,  which  can  generally  be  recog- 
nized by  the  finger  before  it  can  be  seen — a  fact  which  emphasizes  the  impor- 
tance Oi  frequent  examination  of  the  throat  by  the  finger  in  diseases  of  these 
parts.  There  is  also  stiffness  of  the  neck,  sometimes  nasal  voice  or  even 
hoarseness,  suggesting  croup  and  edema  of  the  glottis,  but  there  is  never 
absolute  loss  of  the  voice,  as  in  the  latter,  while  croup  and  edema  are  not 
associated  with  painful  deglutition. 

Treatment. — This  consists  of  incision  of  the  abscess  as  soon  as  dis- 
covered. It  should  be  made  in  the  median  line  and  the  head  should  be 
brought  forward  to  avoid  the  entrance  of  pus  into  the  larynx.  Anodynes 
are  necessary  to  overcome  the  intense  pain,  but  it  is  to  be  remembered  that 
they  may  so  mask  the  symptoms  as  to  permit  destructive  inroads  of  the 
disease  before  it  is  discovered. 


DISEASES  OF  THE  ESOPHAGUS. 

EXPLORATION  OF  THE  ESOPHAGUS. 

This  is  a  manipulation  so  frequently  necessary  that  its  description  is 
demanded  at  the  outset. 

The  esophageal  bougie  is  made  of  flexible  whalebone,  on  the  end  of 
which  is  firmly  fixed  an  olive-shaped  piece  of  ivory.  The  ivory  ends  are 
made  of  different  sizes.  The  ordinary  stomach  tube  may  also  be  used  for 
the  same  purpose,  and  is  the  safest  instrument  to  use  in  earlier  explo- 
ration. 

In  introducing  the  bougie,  or  tube,  the  patient  should  sit  on  a  low  chair 
with  his  head  thrown  back.  The  index-finger  of  the  left  hand  is  then 
introduced  well  back  into  the  pharynx,  along  the  median  line.  The  bougie, 
or  tube,  is  then  passed  along  the  side  of  the  finger  to  the  posterior  wall  of 
the  pharynx  and  then  down  into  the  gullet.  Usually  a  slight  resistance  is 
encountered  at  the  level  of  the  cricoid  cartilage,  but  it  is  easily  overcome, 


324  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

and  after  this  the  descent  is  easy.  Caution  should,  however,  always  be 
exercised,  as  the  bougie  has  a  few  times  been  pushed  through  an  ulcer  of 
the  esophagus  into  the  pleural  cavity  or  lung,  while  I  have  also  known 
ulceration  to  be  produced  by  its  repeated  use  in  simple  nervous  spasmodic 
obstruction. 

ESOPHAGITIS. 

Acute  Esophagitis. — An  acute  inflammation  of  the  esophagus  is  prac- 
tically limited  to  inflammation  induced  by  the  swallowing  of  very  hot 
or  corrosive  liquids,  such  as  strong  acids  and  alkalies,  or  by  the  lodgment 
of  foreign  bodies.  It  is  true,  diphtheritic  inflammation  sometimes  extends 
from  the  pharynx  downv^'ard,  while  the  esophagus  has  also  been  invaded 
by  a  vesicle  of  smallpox,  but  these  conditions  are  not  likely  to  be  differen- 
tiated from  the  primary  disease.  Mycotic  esophagitis,  producing  stenosis 
of  the  esophagus  in  sucklings,  has  been  alluded  to  as  a  possibility  on  page 
308. 

Morbid  Anatomy. — Appearances  vary  with  the  cause.  In  addition 
to  the  usual  redness,  sloughing  and  disintegration  of  tissue  may  result. 
Milder  degrees  of  inflammation  produce  less  conspicuous  alteration.  A 
granular  appearance  may  succeed  desquamation  of  the  epithelium.  Diph- 
theritic false  membrane  presents  the  same  characters  here  as  elsewhere. 

Symptoms. — These  are  chiefly  pai)i  beneath  the  sternum,  increased  by 
swallowing,  which  in  extreme  degrees  of  inflammation  becomes  agonizing 
and,  indeed,  renders  swallowing  impossible.  Copious  mucous  secretion  is 
sometimes  present,  which  may  be  raised  or  regurgitated  to  the  fauces  and 
expectorated  or  passed  into  the  stomach.  Milder  grades  of  inflammation 
are  without  symptoms,  intermediate  grades  present  corresponding  symptoms. 
If  healing  results  after  destructive  inflammation,  the  cicatricial  tissue  behaves 
as  it  does  everywhere  else,  contracting  and  distorting  the  parts,  oftentimes 
with  resulting  stenosis. 

Treatment. — Little  can  be  done  to  aid  heaUng.  For  the  most  part, 
therefore,  it  must  be  given  over  to  nature.  If  deglutition  is  possible,  demul- 
cents may  be  used,  while  the  swallowing  of  pieces  of  ice  sometimes  gives 
comfort.  When  deglutition  is  impossible,  the  patient  must  be  fed  with  nutri- 
tious enemas.  The  treatment  of  resulting  stenosis  is  that  of  stricture  of  the 
esophagus,  which  see. 

Chronic  Catarrhal  Esophagitis. — This  affection  is  sometimes  fav- 
ored by  valvular  heart  diseases,  cirrhosis  of  the  liver,  or  other  cause  of  venous 
obstruction.  The  resulting  affection  is  a  catarrhal  inflammation  associated 
with  mucus-secretion.  A  hemorrhoidal  state  of  the  veins  may  be  thus 
caused,  which  may  proceed  to  rupture,  with  fatal  termination. 


SPASM  OF  THE  ESOPHAGUS. 

Synonym. — Esophagismus. 

This  is  not  an  unusual  aft'ection  in  hysterical  women,  and  even  in  male 
hypochondriacs.  These  are  generally  past  middle  life.  It  also  occurs  in 
hydrophobia,  chorea,  and  epilepsy.     The  spasm  is  commonly  excited  by  an 


CANCER  OF  THE  ESOPHAGUS.  325 

effort  to  swallow  solid  food,  and  rarely  even  liquids  act  similarly.  A  pos- 
sible result  of  spasm  is  a  dilatation,  as  shown  in  a  case  of  my  own,  to  be 
again  referred  to. 

Diagnosis. — The  diagnosis  is  readily  made  by  the  bougie,  which, 
though  it  may  be  stayed  for  a  minute  at  the  seat  of  spasm,  ultimately  passes 
it  without  the  application  of  force.  It  is  also  associated  with  other  symp- 
toms of  hypochondriasis,  while  extreme  pain,  the  gradual  emaciation,  weak- 
ness, and  ultimate  cachexia  of  cancer  are  absent.  Errors  of  diagnosis  have, 
however,  been  made,  and  death  has  even  occurred  when  autopsy  disclosed 
no  lesion  to  explain  it. 

Treatment. — This  is  that  of  the  hypochondriacal  state  and  the  frequent 
use  of  the  bougie,  of  which  the  moral  effect  is  also  good.  One  introduction 
has  sometimes  been  sufficient.  On  the  other  hand,  I  have  known  the  repeated 
passage  of  a  bougie  to  have  produced  ulceration,  whence  the  caution  already 
enjoined  in  the  use  of  the  instrument. 


CAAXER  OF  THE  ESOPHAGUS. 

This  is  usually  a  hard  epithelial  tumor,  most  frequent  in  the  middle 
third  of  the  esophagus,  though  it  may  involve  the  cardiac  orifice  of  the 
stomach,  and  more  rarely  other  portions.  E.  Rindfleish,  especially,  describes 
a  softer  and  more  superficial  form,  which  invades  larger  areas  in  a  diffuse 
way.  It  is  rather  more  frequent  in  men,  and  appears  first  as  zonular  infil- 
tration of  the  mucous  membrane,  which  ulcerates.  The  resulting  ulcer  may 
also  extend  around  the  tube,  acquiring  a  width  of  two  or  three  inches  (5  to 
6  cm.).  The  primary  and  usually  permanent  result,  unless  ulceration  does 
away  with  it,  is  a  stenosis  of  the  esophagus,  followed  by  dilatation  of  the 
tube,  with  hypertrophy  of  the  walls  above  the  stenosis. 

Symptoms. — Diificidt  and  painful  deglutition  is  usually  the  first  symp- 
tom of  stenosis,  though  pain,  independent  of  deglutition,  may  precede. 
Szvallowing  becomes  more  and  more  difficult,  and  ultimately,  even  liquids 
may  be  regurgitated.  Regurgitation  of  food  may  not  be  immediate,  and  the 
date  of  its  appearance  is  usually  dependent  on  the  seat  of  the  obstruction 
and  extent  of  dilatation  above  it.  A  discharge  of  hlood  and  mucus  may 
attend  an  effort  to  introduce  the  bougie.  Death  commonly  takes  place  from 
exhaustion  or  actual  starvation.  But  before  this  happens  there  may  be  a 
rupture  into  the  larynx  or  a  bronchus,  producing  death  by  suffocation,  by 
gangrene,  or  by  an  inhalation  pneumonia.  There  may  be  ulceration  into  the 
aorta  or  one  of  its  large  branches,  causing  fatal  hemorrhage ;  into  the  peri- 
cardium, producing  fatal  pericarditis.  Ulceration  into  the  mediastinum  or 
erosion  of  the  cervical  vertebrae  sometimes  occurs,  with  more  delayed  fatal 
ending.  Emphysema  is  a  sign  of  rupture  into  the  lung.  The  adjacent 
lymphatic  glands  of  the  neck  are  sometimes  invaded.  Rarely  the  disease  is 
latent  throughout  its  entire  course. 

Diagnosis. — This  may  have  to  be  delayed  a  short  time,  but  is  soon 
clear.  The  continued  obstruction,  the  ^emaciation,  and  the  weakness  soon  dis- 
tinguish the  case  from  one  of  spasmodic  stenosis.  Compression  by  adjacent 
growths  should  be  remembered  as  a  source  of  obstruction,  aneurysm  being 
perhaps  the  most  frequent  cause  of  this  kind;  but  aneurysm  may  generally 
be  recognized  by  its  other  signs. 


326  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Prognosis. — This  is  always  ultimately  fatal. 

Treatment. — Treatment  can  only  be  made  to  prolong  life.  The 
bougie  should  not  be  used  after  the  diagnosis  of  cancer  is  established, 
because  of  the  danger  of  causing  perforation.  So  long  as  liquid  food  can 
pass  the  obstruction  it  should  be  used ;  after  this,  nutritious  enemas  in  the 
manner  recommended  under  cancer  of  the  stomach.  Esophagostomy  or 
gastrostomy  may  be  presented  for  the  patient's  consideration.  The  former 
promises  nothing,  but  life  may  be  prolonged  by  the  latter. 


STRICTURE  OF  THE  ESOPHAGUS  OTHER  THAN  CANCEROUS. 

Etiology. — The  most  frequent  cause  after  carcinoma  is  contraction 
of  the  scar  tissue  of  a  healed  ulcer,  caused,  commonly,  by  some  corrosive 
agent  or  syphilis.  Next  in  frequency  is  pressure  by  external  tumors,  such 
as  aneurysm,  enlarged  lymphatic  glands,  or  mediastinal  tumors.  Next  is  con- 
genital narrowing,  and,  finally,  polypoid  tumors  projecting  from  the  mucous 
membrane.  If  the  stenosis  be  cicatricial,  the  precise  cause  is  to  be  determined 
by  the  history  of  the  case,  and  its  situation  by  the  esophageal  bougie. 

Symptoms. — These  are  those  of  obstruction,  described  under  cancer 
and  spasm,  with  or  without  the  painful  element;  to  which  may  be  added 
those  of  dilatation  of  the  esophagus,  to  be  next  considered. 

Treatment. — This  is  altogether  by  the  careful  use  of  the  bougie. 
Dilatation  of  the  cicatricial  stenosis  is  often  quite  successful.  The  largest 
bougie  should  be  first  introduced  very  gently,  without  force,  really  as  a 
sound,  as  far  as  the  obstruction  only.  Then  smaller  sizes  should  be  tried 
until  one  is  found  which  will  pass,  and  from  this  point,  again,  larger  sizes 
should  be  successively  employed.  At  each  sitting  the  bougie  originally 
passed  with  ease  should  be  started  with  and  followed  more  rapidly  by  the 
larger  sizes,  as  the  physician  becomes  familiar  with  his  patient's  case. 

In  congenital  cases  less  is  to  be  expected,  while  obstruction  by  external 
growths,  unless  they  be  removable,  is  practically  irremediable,  and  grows 
gradually  worse.  Even  cicatricial  stenosis  may  be  such  that  the  smallest 
bougie  cannot  pass,  in  which  event  nourishment  by  the  rectum  alone  remains, 
unless  gastrostomy  be  decided  on. 


DILATATION  OF  THE  ESOPHAGUS. 

Dilatation  of  the  esophagus  may  involve  the  whole  circumference  of 
tube,  when  it  is  known  as  diffuse  or  total;  or  it  may  afifect  only  one  spot, 
when  it  is  circumscribed,  or  constitutes  a  diverticulum. 

Diffuse  Dilatation. — In  every  case  of  stenosis  of  the  esophagus,  from 
whatever  cause,  there  is  sooner  or  later  dilatation  above  it,  delayed  at  first 
by  hypertrophy  of  the  muscular  coat,  which  is  thus  enabled  to  force  the 
food  through  the  narrowing.  Sooner  or  later  this  coat  becomes  paralyzed, 
the  wall  yields  to  the  pressure  of  accumulated  food,  and  dilatation  follows. 
The  resulting  sac  is  usually  spindle-shaped,  but  may  be  cylindrical,  and  is 
naturally  larger  the  lower  the  seat  of  obstruction. 

Rarely  dilatation  occurs  without  previous  organic  stenosis.     It  would 


DILATATION  OF  THE  ESOPHAGUS.  327 

appear,  however,  that  it  must  be  preceded  either  by  some  traumatic  cause 
which  weakens  the  wall  of  the  tube,  or  by  repeated  spasmodic  stenoses. 
The  fact  remains  that  such  dilatations  occur. 

Diverticula.-— D'w eviiculd,  or  circumscribed  pouches  in  the  walls  of  the 
esophagus  are  of  two  varieties.  They  have  been  especially  studied  by 
Zenker,  who  has  divided  them  into  pressure  diverticula  and  traction  diver- 
ticula according  to  their  mode  of  origin. 

Traction  diverticula  are  the  more  frequent,  yet  clinically  are  of  less 
interest  because  often  not  recognized  until  their  subjects  are  on  the  necropsy 
table."  They  are  small,  scarcely  ever  exceeding  a  centimeter  (0.4  in.)  in 
diameter,  and  relatively  frequent  in  children.  They  are  ascribed  to  some 
traction  effect  exerted  on  the  wall  of  the  esophagus.  This  may  be,  as 
Rokitansky  and  Zenker  suggested,  due  to  the  contraction  of  a  tissue  which 
has  formed  adhesions  to  the  esophagus.  Such  a  tissue  is  afforded  by  the 
bronchial  glands,  which  become  inflamed,  caseate,  and  contract,  and  as  they 
are  situated  at  the  bifurcation  of  the  trachea,  the  more  frequent  occurrence 
of  traction  diverticula  at  this  situation  in  the  anterior  wall  of  the  gullet  is 
thus  explained.     Such  diverticula  may  be  multiple. 

Pressure  diverticula  are  much  rarer.  They  occur  almost  always  in  men, 
rarely  in  children.  They  are  found  most  frequently  at  the  junction  of  the 
pharynx  and  esophagus,  where  the  muscular  wall,  formed  chiefly  by  the 
inferior  constrictor  of  the  pharynx,  is  weakest,  and  are  caused  by  pressure 
from  within.  This  may  be  exerted  by  the  bolus  of  food  itself,  especially  if 
it  be  habitually  large,  as  in  rapid  eaters,  while  its  operation  may  be  further 
facilitated  by  some  traumatic  injury  to  this  part  of  the  throat,  such  as  may 
be  caused  by  the  lodgment  of  a  bone. 

The  sac  is  found  to  be  bounded  by  mucous  membrane  and  thickened 
subrn.ucous  coat,  the  muscular  coat  giving  way  to  let  the  mucous  coat  pass 
through  it,  as  in  a  hernia.  It  is  found  invariably  in  the  posterior  wall,  and 
hangs  in  front  of  the  spinal  column. 

Symptoms. — In  cases  of  diffuse  dilatation  originating  in  stenosis, 
apart  from  the  inference  that  where  there  is  stenosis  there  must  ultimately 
be  dilatation,  the  first  symptom  to  attract  attention  is  the  feeling  on  the  part 
of  the  patient  that  his  food  does  not  enter  the  stomach,  but  lodges  higher  up, 
though  the  quantity  swallowed  is  evidently  more  than  would  be  held  by  an 
esophagus  of  ordinary  caliber ;  usually,  sooner  or  later,  follow^s  the  regur- 
gitation, or  gulping  up  of  this  accumulation.  The  same  symptoms  are  said 
to  attend  dilatation  without  stenosis.  The  latter  event  can  only  be  explained 
on  the  supposition  that,  in  consequence  of  the  paralyzed  state  of  the  muscular 
wall  of  the  esophagus,  there  is  no  force  to  push  the  food  down,  while  the 
gradual  widening  of  the  tube  affords  support  for  its  lodgment,  which  is 
further  favored  if  the  enlargement  takes  the  shape  of  sacculations  or  a 
pocket. 

Traction  diverticulum  rarely  causes  symptoms.  Those  arising  from 
pressure  diverticulum  are  first  those  of  dysphagia,  as  the  diverticulum  grows 
larger,  and  the  food  lodges  more  and  more ;  regurgitation,  though  the  sac 
is  rarely  thoroughly  emptied,  and  the  retained  food  sometimes  undergoes 
decomposition,  giving  rise  to  fetid  ,breath.  The  difficulties  increase  until 
after  a  while  it  is  almost  impossible  to  get  food  into  the  stomach,  though 
extraordinary  efforts  are  made  by  the  patient  to  do  so,'  with  greater  or  less 
success.  Complete  closure  results  when  the  diverticulum  becomes  so  large 
as  to  flex  upon  the  gullet  and  compress  it. 


328  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  sound  should  be  used  in  the  study  of  all  forms  of  the  disease.  By- 
its  means  the  situation  of  the  stenosis  can  be  ascertained.  Should  it  pass, 
readily  into  the  stomach,  there  is  no  stenosis,  but  there  may  still  be  a  divertic- 
ulum, for  at  one  sitting  the  sound  may  pass  the  opening  into  the  sac,  while 
at  another  it  may  enter  it  and  resist  further  attempts  to  complete  the  transit. 
Zenker  and  v.  Leube  have  devised  a  diverticulum-sound  bent  at  an  angle, 
so  as  to  facilitate  its  entrance  into  the  diverticulum,  advantage  being  taken 
of  the  fact  that  we  know  about  where  these  diverticula  are  most  frequently 
found — that  is,  opposite  the  cricoid  cartilage. 

With  the  prolongation  of  the  condition  the  proper  nourishment  of  the 
patient  becomes  more  and  more  difficult ;  he  emaciates,  grows  weaker,  and 
ultimately  perishes  from  exhaustion  unless  carried  off  by  some  other  disease. 

The  following  case,  recently  under  my  care,  illustrates  the  symptoms 
of  the  condition :  C.  G.  was  an  actor,  thirty-three  years  old  when  he  came 
under  observation.  When  only  twelve  years  of  age,  while  eating  his  supper, 
his  food  suddenly  regurgitated  and  he  had  to  leave  the  table.  Returning, 
another  effort  was  followed  by  the  same  result.  The  next  morning  his 
breakfast  came  up  in  the  same  manner.  After  a  time  he  discovered  that 
by  rapidly  drinking  a  large  amount  of  liquid  after  each  meal  he  could,  by 
a  great  effort,  cause  most  of  the  food  to  enter  the  stomach.  This  had  to 
be  done  at  every  meal  by  some  indescribable  effort,  which  was  painful  and 
exhausting.  Furthermore,  it  was  rarely  completely  successful,  some  food 
being  always  regurgitated,  commonly  later  in  the  day.  Since  twelve  years 
of  age  this  regurgitation  has  continued,  and  he  loses,  on  the  whole,  about 
one-third  of  the  food  ingested,  while  at  times  his  efforts  to  get  it  down  are 
totally  unsuccessful,  in  which  event  the  full  amount  is  regurgitated.  Fur- 
ther, the  difficulty  of  successfully  getting  food  into  the  stomach  is  gradually 
increasing. 

In  this  case  there  would  appear  to  be  a  certain  degree  of  stenosis,  for 
while  a  part  of  the  food  can  be  forced  to  enter  the  stomach,  and  small  sounds 
can  be  passed  into  that  organ,  larger  ones  cannot  be  made  to  enter.  Yet 
from  the  suddenness  of  its  occurrence  and  the  early  age  of  the  patient,  the 
stenosis,  if  one  is  present,  has  not  arisen  from  the  usual  causes.  Can  there 
be  a  diverticulum?  If  so,  it  is  lower  than  pressure  diverticula  generally 
are,  and  larger  than  other  traction  diverticula. 

Treatment. — The  treatment  of  diffuse  dilatation  and  diverticula  is 
essentially  the  same.  It  consists,  first,  in  measures  to  maintai  i  the  nutrition 
of  the  patient.  Generally  he  is  able  to  ingest  a  certain  amount  of  food  by 
his  own  eft'orts,  of  which  thosfe  detailed  in  the  case  of  my  own  patient  are 
an  illustration.  After  this  the  stomach  tube  becomes  the  most  ready  way. 
This,  too,  he  should  be  taught  to  use  himself.  Rectal  alimentation  may 
help  somewhat,  but  is  alone  inadequate  for  any  length  of  time,  while  the 
inconvenience  of  any  and  all  of  these  procedures  renders  the  patient  anxious 
for  more  complete  relief. 

This  may  be  accomplished  by  operation,  by  which  diverticula  have 
been  successfully  removed.  The  difficulties  in  the  way  of  operation  are, 
however,  great.  The  operative  treatment  of  dilatations  due  to  stenoses 
resolves  itself  into  that  of  the  stenoses  themselves.  In  both  forms  gas- 
trostomy may  be  the  ultimate  measure  that  promises  relief  for  a  time. 


DIAGNOSTIC  TECHNIQUE.  329 

DISEASES    OF  THE  STOMACH    AND  INTESTINES. 

DIAGNOSTIC   TECHNIQUE. 

The  very  great  value  that  modern  medicine  has  discovered  in  a  proper 
technique  for  the  diagnosis  of  diseases  of  the  stomach  makes  its  prehminary 
consideration  indispensable  to  their  sufficient  and  exact  study.  It  is  con- 
veniently divided  into  the  external  and  internal  examinations. 

External  Examination. 

This  embraces  inspection,  palpation,  percussion,  and  succussion  or 
splashing.  Because  of  the  difficulty  of  separating  the  external  examination 
of  the  stomach  from  that  of  the  intestines  they  are  usually  considered  jointly. 

The  most  important  point  to  be  remembered  in  the  medical  anatomy 
of  the  stomach  is  that  a  very  small  part  of  it  Hes  to  the  right  of  the  median 
line,  not  more  than  one-fourth,  the  remainder  occupying  the  upper  left 
quarter  of  the  abdominal  cavity.  The  cardiac  orifice  is  fixed  behind  the 
sternal  attachment  of  the  sixth  or  seventh  cartilage  on  the  left  side,  while 
the  pylorus,  more  movable,  lies  on  the  right  side,  between  the  tip  of  the 
sternum  and  the  conjoined  seventh  and  eighth  cartilages,  and  under  the  left 
lobe  of  the  liver.  The  seats  of  both  orifices — the  cardiac  and  pyloric — and 
the  outline  of  the  stomach  vary  somewhat  with  the  degree  of  distention, 
but  when  the  stomach  is  moderately  distended  the  highest  part  of  the 
fundus  is  in  the  fifth  interspace,  at  the  mammillary  line,  and  the  lowest  part 
of  the  organ  in  the  median  line,  three  to  five  cm.  (i  to  2  inches)  above  the 
umbilicus  in  men  and  four  to  seyen  cm.  (1.5  to  3  inches)  in  women. 

The  information  given  by  inspection  may  be  of  no  value  whatever,  or 
may  possess  considerable  import.  Commonly,  the  stomach  and  bowels 
are  the  seat  of  a  moderate  distention  with  gas — just  enough  to  make  precise 
information  by  this  method  unattainable.  This  is  especially  the  case  in 
little  children  and  in  men  past  fifty.  In  very  thin  subjects  the  stomach 
may  be  recognized  in  outline,  and  exaggerated  contractions  may  even  be 
seen  in  it  and  in  the  intestines.  Such  contraction  does  not,  however,  imply 
of  necessity  an  effort  to  overcome  obstruction  at  the  pylorus  or  in  the  bowel 
below.  It  may  be  purely  nervous.  Morbid  growths  in  the  stomach  may 
sometimes  be  recognized  by  inspection.  So  may  many  uneven  growths  of 
the  liver  in  thin  persons,  while  the  end  of  a  distended  gall-bladder  may,  in 
rare  instances,  project  at  the  edge  of  the  thorax,  near  the  end  of  the  cartilage 
of  the  tenth  rib  on  the  right  side.  Epigastric  pulsation  is  sometimes  strik- 
ingly conspicuous.  Enlargement  of  the  superficial  epigastric  and  abdominal 
veins  is  always  to  be  looked  for.  More  frequently  there  is  a  circumscribed 
distention  recognized  in  the  region  of  the  stomach,  or  the  entire  abdomen 
may  be  distended,  a  symptom  which  may  be  due  to  atony,  or,  among  others, 
points  to  some  obstruction  in  the  lower  part  of  the  bowels.  In  other  instances 
the  opposite  state  of  undue  flaccidity  is  observed — the  belly  flattening  out 
laterally  as  the  patient  lies  on  his  back,  or  falling  forward  when  he  stands 
up.  The  latter  condition  occurs  especially  in  persons  who  have  been 
corpulent  and  have  grown  thin,  and  in  women  who  have  borne  many  chil- 
dren.    The  patient  may  also  be  examined  in  the  knee-elbow  position,  which 


OJ^ 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


will  permit  movable  tumors  to  fall  forward  and  facilitate  their  recognition 
by  inspection  as  well  as  by  palpation. 

Palpation  furnishes  at  times  more  definite  information  than  inspection. 
It  should  be  practiced  by  laying  the  hand  flat  upon  the  abdomen  and  depress- 
ing the  ends  of  the  fingers  as  the  hand  is  moved  about,  rather  than  by 
"  poking  "  with  the  fingers  of  the  extended  hand  obliquely  placed.  The 
abdominal  walls,  too,  should  be  relaxed  by  semi-flexing  the  thighs  on  the 
abdomen  and  the  legs  upon  the  thighs.  Thus  we  learn  of  the  consistency 
and  situation  of  various  organs  and  abnormal  growths,  whether  they  are 
smooth  or  uneven,  whether  there  is  tenderness  or  tenseness,  softness  or  hard- 
ness. In  so  doing,  the  degree  of  pressure  must  vary.  Some  pains  are 
relieved  by  pressure,  others  aggravated.  The  former  are  more  apt  to  be 
due  to  neuralgia  or  colic,  the  latter  to  be  inflammator\-.  Our  knowledge 
of  the  precise  situations  of  morbid  growths  is  often  aided  by  changing  the 
position  of  the  patient.  A  tumor  of  the  pyloric  orifice  of  the  stomach,  which 
is  more  apt  to  be  felt  toward  the  median  line,  above  the  umbilicus,  is  also 
characterized  by  its  greater  mobility,  as  well  as  change  of  location  with 
varying  degrees  of  distention  of  the  stomach.  Such  a  tumor  may  be  subject 
to  a  peculiar  rotary  motion. 

Percussion  of  the  gastro-intestinal  region  is  practiced  with  the  patient 
on  his  back  in  a  relaxed  position,  like  that  described  for  palpation.  A 
pleximeter  is  here  conveniently  used,  and  auscultatory  percussion  may  be 
practiced  with  advantage.  The  phonendoscope  may  also  be  used  to 
determine  the  outlines  of  these  organs  during  scraping  or  rubbing.  The 
stomach  and  intestines  approach  the  surface  in  health  in  such  a  way  as  to 
make  their  limitation  quite  possible  by  percussion.  They  require,  also, 
delicacy  in  discriminating  shades  of  sound,  more  particularly  as  to  pitch. 
The  quality  met  with  in  percussing  these  organs  is,  for  the  most  part, 
tympanitic,  and  it  is  chiefly  variations  in  the  pitch  which  are  to  be  discrimi- 
nated. The  same  organ  may  exhibit  diflferent  degrees  of  pitch  under  different 
conditions.  Thus,  the  stomach,  when  moderately  distended  with  gas,  gives 
a  low-pitched  tympanitic  sound  when  percussed ;  when  more  fully  distended, 
it  gives  a  higher  pitch ;  when  distended  to  a  maximum,  it  may  give  a  dull 
sound,  because  all  vibration  is  stopped.  Given  the  stomach  and  intestine  in 
an  equal  degree  of  tension,  the  stomach  will  respond  to  percussion  with 
a  lower-pitched  tympany  than  the  intestine  because  it  is  a  larger  cavity. 
This  is  sometimes  spoken  of  as  less  tvmpanitic.  Sometimes  the  stomach 
percussion  note  is  ringing,  amphoric,  echoing.  By  means  of  these  differ- 
ences, when  present,  we  may  distinguish  one  hollow  organ  from  another. 
Again,  the  presence  of  liquids  or  solids  in  the  stomach  influences  the  per- 
cussion note. 

The  hollow  viscera  en  masse  can  be  mapped  out  by  determining  the 
boundaries  of  the  solid  viscera  around  them.  But  we  want  to  do  more  than 
this :  Ave  want  to  separate  one  hollow  organ  from  another — the  stomach 
from  the  small  intestine,  the  small  intestine  from  the  large.  For  this  the 
patient  must  be  recumbent.  As  stated,  the  stomach  tympany  is  ordinarily 
lower  pitched  than  the  bowel  tympany.  Bearing  this  in  mind,  we  can  gen- 
erally determine  the  stomach  boundaries  when  the  organ  is  moderately  dis- 
tended with  gas.  The  upper  limit  of  stomach  tympany,  recognizable  by 
percussion,  corresponds  with  the  lower  edge  of  the  left  lobe  of  the  liver.  To 
the  left  of  the  apex  of  the  heart,  the  stomach  tympany  is  mixed  with  the 
resonance  of  the  lung.    At  this  point,  about  the  fifth  rib,  is  the  cardiac  end 


DIAGNOSTIC  TECHNIQUE.  331 

of  the  stomach.  Percussing  downward  and  a  Httle  backward  from  this  point, 
we  are  generally  able  to  find  a  difference  of  note — a  higher  pitch,  a  purer 
tympany,  belonging  to  the  transverse  colon.  Keeping  close  to  this  line  and 
following  it  anteriorly,  we  find  it  crosses  the  left  edge  of  the  thorax  at  about 
the  cartilaginous  attachment  of  the  tenth  rib,  the  median  line  just  above  the 
umbilicus,  and  passes  thence  upward  to  the  junction  of  the  right  lobe  of 
the  liver  with  the  edge  of  the  thorax.  It  is  the  line  of  the  greater  curvature 
of  the  stomach. 

Traube's  half-moon  space  is  a  term  applied  to  the  area  bounded  above 
by  the  lower  border  of  the  left  lung,  approximately  determined  by  the  upper 
edge  of  the  sixth  rib  as  far  as  the  axillary  line ;  on  the  right  by  liver  dullness, 
on  the  left  by  splenic  dullness ;  and  below  by  the  costal  arch,  yielding  a 
tympanitic  note  when  the  stomach  is  empty  and  distended,  but  a  flat  note 
to  percussion  when  the  stomach  is  full  or  there  is  pleural  effusion  on  the 
left  side.  Leichtenstern  has  applied  the  name  pulmono-hepatic  angle  to  the 
point  of  junction  between  the  lower  edge  of  the  left  lobe  of  the  liver  and 
the  lower  border  of  the  left  lung.  The  tip  of  this  angle  is  behind  the  sixth, 
rib,  just  below  the  apex  seat,  and  is  bisected  by  the  pleural  space,  which  is 
filled  by  the  lung  only  during  deep  inspiration.  The  stomach  fills  in  this 
angle,  and  it  is  an  area  pretty  constantly  maintained.  The  outline  of  the 
stomach  may  be  made  more  distinct  by  having  the  patient  drink  a  glass  of 
water  just  before  the  examination ;  or,  as  originally  suggested  by  Frerichs, 
by  taking  in  rapid  succession  the  two  portions  of  a  Seidlitz  powder — tartaric 
acid  and  sodium  bicarbonate — or  a  glass  of  soda-water. 

A  better  method  of  outlining  the  stomach  is  to  inflate  it  with  air,  as  sug- 
gested by  Runeberg,  by  means  of  the  double  bulb  of  a  spray  apparatus. 
This  should  be  done,  if  possible,  in  connection  with  the  use  of  the  tube  for 
some  other  purpose,  as  removing  the  stomach  contents  after  a  test  meal. 
The  possibility  of  air  passing  through  the  pylorus  is  to  be  remembered,  but, 
commonly,  if  any  excess  is  introduced  it  passes  out  alongside  of  the  tube. 
This  is  not  the  case  with  carbonic  acid  gas,  which  excites  rather  a  spasmodic 
contraction  of  the  cardiac  orifice.  Both  gas  and  water  may  distend  the 
stomach  beyond  the  limits  described,  but  the  normal  limit  of  the  lower 
curvature  may  be  put  above  the  umbilicus,  although  it  cannot  be  said  to  be 
abnormally  low  when  at  the  umbilicus,  an  event  not  unusual  after  fifty  years 
of  age.  As  already  mentioned,  the  greater  curvature  is  not  quite  so  low  in 
women  as  in  men,  and  in  working  women  not  so  low  as  in  those  of  leisure. 
When  the  lower  curvature  is  below  the  umbilicus,  the  stomach  may  be  said  to 
be  dilated.  It  is  always  desirable,  if  possible,  to  examine  the  stomach  with 
the  patient  standing  as  well  as  lying. 

As  stated,  the  percussion  note  of  the  large  intestine  is  higher  pitched 
and  more  purely  tympanitic  than  that  usual  to  the  stomach.  When  contain- 
ing feces  it  is  rendered  duller,  and  in  consequence  of  this  fact  there  is  often 
less  resonance  in  the  left  iliac  fossa  than  in  the  right,  although  feces  may 
also  accumulate  in  the  latter,  and  an  impaction  in  the  head  of  the  colon  may 
give  positive  dullness.  The  colon  may  also  be  artificially  distended  per  rec- 
tum with  air,  if  desired,  for  examination. 

The  percussion  note  of  the  small  intestine  is  usually  still  higher  pitched 
than  that  of  the  large,  and  by  this  it  may  be  distinguished  from  that  bowel, 
if  not  filled  with  solid  matter  or  liquid.  The  differences  in  percussion  note 
referred  to  are  not  always  equally  well  marked,  and  it  is  not  always  possible 
in  consequence,  to  demark  the  organs.    Especially  difficult  is  it  at  times  thus 


332  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

to  distinguish  the  transverse  colon,  when  distended  with  gas,  from  the  stom- 
ach above  it.  If  the  stomach  be  filled  with  water,  a  dull  note  is  brought 
out  on  percussion,  which  contrasts  strongly  with  the  tympanitic  note  of  the 
gas-distended  colon. 

Whether  determined  by  inspection,  palpation,  or  percussion,  a  stomach 
the  greater  curvature  of  which  reaches  the  umbilicus  or  below  is  abnormally 
dilated,  while  certain  dilated  stomachs  go  far  below  the  umbilicus.  The 
vertical  diameter  of  the  normal  stomach,  from  the  highest  to  the  lowest 
points  of  tympany,  as  determined  by  Wagner,  was  ii  to  14  cm.  (4.4  to  5.6 
inches)  in  men,  and  about  10  cm.  (4  inches)  in  women.  The  width  of  the 
zone  was  21  cm.  (8.4  inches)  and  18  cm.  {y.2  inches).  Other  measurements 
are  somewhat  different,  so  that  some  latitude  must  be  allowed. 

Auscultation  has  a  less  useful  application  to  diagnosis  of  diseases 
of  the  stomach.  It  is  confined  to  the  so-called  deglutition  murmurs,  of  which 
there  are  two.  They  are  best  heard  with  the  stethoscope  to  the  left  of  the 
spinal  column,  behind,  in  the  neighborhood  of  the  ninth  or  tenth  rib;  in 
front,  to  the  left  of  the  xiphoid.  One  is  heard  at  the  beginning  of  swallow- 
ing, when  the  food  is  transmitted  from  the  pharynx  into  the  esophagus, 
and  is  termed  by  Ewald  the  prini-ary  deglutition  sound.  It  is  heard  all 
along  the  esophagus,  and  has  no  significance.  It  is  a  hissing  sound,  as  if 
produced  by  fluid  squirted  directly  into  the  stethoscope  (Spritzgerausch). 
Six  or  seven  seconds  later,  corresponding  with  the  contraction  of  the  lower 
segment  of  the  esophagus,  may  be  heard  the  second  deglutition  sound,  con- 
sisting of  a  series  of  tones  rapidly  following  one  another,  either  gurgling, 
clucking,  sprinkling,  or  splashing  (Pressgerausch).  It  is  said  to  denote  a 
relaxation  of  the  cardia  and  the  direct  passage  of  food  into  the  stomach.  It 
is  quite  constant,  and  is  usually  absent  when  there  is  obstruction  of  the  cardiac 
orifice. 

It  is  the  absence  of  the  deglutition  murmurs  rather  than  their  presence 
on  which  diagnostic  value  depends ;  that  is,  they  are  apt  to  be  wanting  in 
obstructive  disease  of  the  cardiac  orifice,  although  too  much  stress  must 
not  be  laid  upon  such  absence,  since  they  are  not  always  present  in  health, 
and  repeated  observation  is  required  before  conclusions  dare  be  drawn. 

Gastroscopy  and  Gastrodiaphany  have  not  as  yet  been  sufficiently  per- 
fected to  be  available  in  diagnosis  of  stomach  affections. 

The  investigation  of  the  large  intestine  by  percussion  is  sometimes  aided 
by  distending  the  bowel  with  gas  or  air  per  rectum  in  one  of  the  various 
M^ays  suggested  for  the  stomach,  the  bowel  being  previously  evacuated  by 
an  enema.  The  large  bowel  may  also  be  explored  for  a  considerable  distance 
from  its  anal  end  by  specula. 

IXTERXAL   EXAMIXATIOX  OR  ChE^IICAL  EXA:snXATIOX   OF    CONTENTS. 

For  removing  the  gastric  contents  for  examination  the  stomach  tube  or 
catheter  is  used.  That  usually  employed  is  a  thoroughly  soft,  flexible,  red 
rubber  tube,  open  at  the  inner  end.  or,  if  closed  at  the  end,  provided  wdth 
lateral  openings,  like  a  Xelaton's  soft  catheter.  (The  latter  is  advised  because 
it  has  happened  with  the  open-end  tube  that  a  portion  of  sound  gastric 
mucous  membrane  has  been  aspirated  into  it.)  The  tube  should  be  about 
95  cm.  (about  3  feet)  long.  From  the  fundus  of  the  stomach  to  the  incisor 
teeth  is  60  to  65  cm.  (about  2  feet),  and  the  tube  is  usually  marked  at  this 
point,  thus  enabling  one  to  judge  whether  it  has  entered  the  fundus.     Suf- 


DIAGNOSTIC  TECHNIQUE.  333 

ficient  lubrication  is  secured  by  moistening  it  with  water.  It  is  carried  into 
the  back  part  of  the  pharynx  in  the  manner  described  for  the  sound  (p.  323), 
when  the  patient  is  directed  to  swallow.  At  the  end  of  the  act  of  deglutition 
the  tube  is  pushed  gently  downward,  and  the  patient  again  directed  to 
swallow.  This  is  kept  up  until  the  tube  enters  the  stomach.  A  long  tube 
permits  the  stomach  to  be  emptied  by  siphonage  after  a  little  pressure  on  the 
abdomen  has  been  exerted  by  the  hand  to  start  the  motion  of  the  contents. 
This  is  safer  than  aspiration  by  a  pump,  as  sometimes  practiced. 

For  analysis  of  the  gastric  contents  the  test  meal  commonly  employed 
is  the  test  breakfast  of  Ewald  and  Boas,  consisting  of  an  ordinary  roll  * 
w^eighing  about  35  gm.  (9  drams)  and  300  c.  c.  (10  fl.  oz.)  of  water  or  weak 
tea  without  milk  and  sugar.  At  the  end  of  one  hour  after  the  meal  is  in- 
gested the  stomach  is  emptied  by  expression  and  siphonage,  as  described. 
There  should  be  20  to  40  c.  c.  It  has  happened  to  me  to  fail  to  secure  any- 
thing after  such  a  test  meal  from  the  rapid  disappearance  of  the  products  of 
digestion.  In  such  event  two  rolls  may  be  taken  at  the  next  meal  and  the 
liquid  increased  to  400  c.  c.  (13  fl.  oz.).  It  is  first  examined  by  the  micro- 
scope for  blood  or  other  abnormal  morphological  constituents,  and  then 
filtered,  being  previously  well  shaken. 

The  Leube-Riegel  test  dinner  may  be  used.  It  consists  of  beef-soup, 
400  gm.  (13.3  oz.)  ;  beefsteak.  200  gm.  (6.6  oz.)  ;  bread,  50  gm.  (1.6  oz.), 
and  water  200  c.  c.  (6.6  fl.  oz.).  This  should  be  removed  for  testing  at  the 
end  of  four  hours. 

Acids  of  Digestion. — In  healthful  conditions,  in  ten  or  fifteen  minutes 
after  food  ingestion  the  gastric  contents  are  acid,  the  acidity  depending  on 
free  acids  or  acid  salts,  the  latter  including  chiefly  acid  phosphates  of  sodium 
and  potassium  introduced  in  various  amounts  with  food.  At  this  stage  the 
free  acid  recognized  is  lactic,  which  is  either  introduced  with  food  or  is 
formed  in  the  lactic  acid  fermentation  out  of  carbohydrates,  especially  sugar. 
Up  to  thirty  to  forty-five  minutes  the  lactic  acid  predominates,  while  the 
tests  for  hydrochloric  acid  may  be  negative.  Then  comes  a  stage  in  which 
traces  of  HCl  can  be  demonstrated,  coexisting  with,  it  may  be,  lactic  acid. 
Finally,  the  lactic  acid  disappears  altogether,  and  at  the  end  of  an  hour  HCl 
only  should  be  present.  HCl  is  present  from  the  beginning,  but  its  recog- 
nition is  interfered  with,  partly  because  the  first  secreted  immediately  com- 
bines with  bases  until  these  are  neutralized.  Free  HCl  gradually  increases 
in  amount  until  at  the  acme  of  digestion  it  reaches  0.15  to  0.2  per  cent,  after 
a  light  meal,  and  0.2  to  0.33  per  cent,  after  an  abundant  meal. 

The  reaction  of  the  removed  contents  may  be  determined  by  blue  litmus, 
but  Congo-red  paper  or  tropaolin  paper  f  may  be  used,  the  former  being 
turned  blue  and  the  latter  brown.  These  reactions  point  also  to  free  acids 
in  general,  being  uninfluenced  by  acids  when  com.bined  with  bases.  Nor  can 
Congo-red  or  tropseolin  be  relied  upon  to  dififerentiate  between  mineral  acids 
and  organic  acids. 

'  *  Such  a  roll,  containing  about  7  per  cent,  of  nitrogen,  s  per  cent,  fat  and  4  per  cent,  sugar,  52.5 
per  cent,  of  non-nitrogenous  extractive  substances,  and  i  per  cent,  of  ash,  includes,  therefore,  the 
usual  elements  of  a  mixed  diet. 

t  These  papers  are  made  by  dipping  strips  of  filtering  paper  into  watery  or  alcoholic  solutions  of 
the  anilin  dyes,  Congo-red  or  tropseolin  00  (I'orange  Poirier),  allowing  to  dry,  and  preserving  for 
use.    The  paper  is,  however,  less  delicate  than  tl^e  solution. 

The  Congo-red  strikes  a  beautifullv  skv-blue  reaction  with  a  solution  containing  but  0.02  per  1000  of 
HCl;  a  purplish,  but  not  distinctly  different,  reaction  with  lactic  acid.  Acid  salts  produce  no  change. 
The  tropseolin  solution  is  dark  vellowish-red,  and  a  solution  of  free  acid,  0.025  to  1000,  changes  it  to  a 
deep  dark  brown.  It  is  slightly  less  delicate,  therefore,  than  the  Congo-red.  Acid  salts,  as  acid  so- 
diutn  phosphate,  make  it  straiv-vellow.  In  all  of  these  tests  it  is  necessary  to  use  an  excess  of  the  fluid 
to  be  tested.  This  is  accomplished  by  placing  five  or  ten  drops  of  the  reagent  in  a  test  glass  or  por- 
celain capsule  and  adding  one  or  two  c.  c.  of  the  filtered  contents. 


334  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

To  Test  Qualitatively  for  Free  Hydrochloric  Acid  Only. — For  this  Giinz- 
biirg's  phloroglucin  vanillin  or  Boas's  resorcin  test  is  used.  Giinzburg's 
reagent  consists  of  phloroglucin  two  grams  (30  grains),  vanillin  one  gram 
(15  grains),  alcohol  30  c.  c.  (fSJ)-  The  solution  is  pale  yellow,  and  has  a 
decided  odor  of  vanilla.  On  exposure  to  light  it  assumes  a  dark  golden- 
yellow.  It  must,  therefore,  either  be  kept  in  dark-hued  bottles  or  freshly 
made  as  required.  A  drop  or  two  of  the  reagent  is  placed  on  a  porcelain 
plate  or  capsule  with  an  ecjual  quantity  of  the  gastric  filtrate,  and  a  gentle 
heat  applied,  not  to  boil,  but  simply  to  evaporate.  If  free  HCl  is  present, 
very  soon  a  beautiful  rose-red  tinge  appears  at  the  edge  of  the  mixture,  or 
red  stripes  will  be  observed.  Blowing  at  the  edge  will  favor  the  appear- 
ance of  the  red  stripes.  This  test  is  unmistakable,  and  surpasses  all  others 
in  delicacy,  being  available  when  HCl  is  present  in  the  proportion  of 
I  to  20,000  or  0.5  mille.  The  reaction  is  not  simulated  by  albuminates  nor 
interfered  with  by  salts  present  in  the  normal  proportion,  nor  by  organic  acids. 

Boas's  test  for  free  HCl  is  based  upon  the  fact  that  resorcin  strikes  a 
similar  reaction  with  hydrochloric  acid.    The  solution  consists  of : 

Resublimed  resorcin, 5  parts  (gr.  Ixxv) 

White  sugar,  .         .         .         .  ■      .         .         .         .3  parts    (gr.  xlv) 

Dilute  alcohol,       .........    100  parts  (f  §  iiiss) 

Three  to  five  drops  of  the  reagent  are  poured  into  a  porcelain  dish  and 
an  equa'  quantity  of  stomach  contents  added.  Heat  is  applied  as  in  Giinz- 
burg's test,  and  a  piwple-red  color  appears  at  the  edge  of  the  drop.  It  is 
said  also  to  detect  0.05  per  mille  of  HCl. 

To  Estimate  the  Total  Acidity,  Including  Free  and  Combined  A^cids  and 
Acid  Salts. — The  total  acidity  of  gastric  contents  includes  free  acids,  viz., 
hydrochloric,  lactic,  and  sometimes  other  organic  acids ;  combined  acids, 
consisting  of  acid  phosphates ;  and  loosely  combined  acids,  in  the  shape  of 
HCl-albumins,  HCl-albumoses,  and  peptones.  The  reaction  of  the  filtered 
fluid  being  determined  by  litmus  paper,  the  total  acidity  is  then  determined 
by  titration.  A  Mohr's  burette  is  filled  with  a  decinormal  solution  of  caustic 
soda.  Ten  c.  c.  of  the  filtered  solution  are  placed  in  a  beaker  and  one  or  two 
drops  of  an  alcoholic  solution  of  phenol-phthalein  added  as  an  indicator. 
The  solution  is  then  slowly  dropped  from  the  burette  until  the  red  color  pro- 
duced in  the  fluid  by  the  action  of  the  alkali  on  the  phenol-phthalein  no 
longer  disappears  on  shaking.  As  a  rule,  the  acidity  of  the  gastric  contents, 
an  hour  after  such  a  meal,  requires  4  to  6  c.  c.  of  the  decinormal  solution  to 
neutralize  it  in  normal  digestion.  Figures  above  and  below  this  are  there- 
fore abnormal.  The  acidity  may  be  expressed  in  percentage  according  to  the 
amount  of  decinormal  solution  used.  Thus  if  4  c.  c.  were  required  to  neutralize 
10  c.  c,  there  would  be  40  per  cent.,  or  if  6  c.  c,  60  per  cent,  total  acidity. 

If  the  acid  reaction  is  due  to  free  HCl  alone, — i.  e.,  if  there  are  no 
organic  acids  present  to  contribute  to  the  total  acidity, — this  titration  will 
represent  the  total  quantity  of  HCl,  and  its  percentage  is  easily  estimated. 
One  c.  c.  of  the  decinormal  soda  solution  is  equivalent  to  0.00365  gm.  HCL'"" 
If,  therefore,  the  number  of  cubic  centimeters  used  to  neutralize  10  c.  c.  of 
the  solution  be  multiplied  by  0.00365,  and  again  by  10,  the  result  will  be  the 
actual  percentage  of  HCl.  Thus,  if  6  c.  c.  of  the  decinormal  solution  be  used, 
the  percentage  will  be  6  X  0.00365  X  10  =  0.219,  within  the  normal  range, 

N 

*  Decinormal  solution  of  soda NaHO=4  gm.  Na  HO  dissolved  in  looo  c.c.  distilled  water. 

10 
Each  cubic  centimeter  of  this  solution  exactly  neutralizes  0.00365  gva.  HCl. 


DIAGNOSTIC  TECHNIQUE.  335 

which  is  from  0.15  to  0.24  per  cent.;  if  4  c.  c.  be  used,  the  HCl  percentage 
will  be  3  X  0.00365  X  10  =:  o.io,  or  less  than  normal. 

Total  Free  HCl. — The  quantitative  estimation  of  free  hydrochloric  acid 
may  be  made  by  Mintz's  method,  the  Krieger-Cohnheim  method,  or  by 
Topfer's  method.  The  former  is  as  follows  :  To  10  c.  c.  of  the  filtered  gastric 
contents  add  the  decinormal  soda  solution  from  a  burette  until  Giinzburg's 
reagent  no  longer  gives  a  reaction  with  a  drop  of  the  gastric  fluid.  Thus, 
if  2.8  of  the  decinormal  solution  are  so  used,  the  percentage  of  free  hydro- 
chloric acid  will  be  2.8  X  0.00365  X  10  ^  o.i  per  cent. 

^The  Krieger-Cohnheim  method  is  regarded  by  David  Edsall  as  far 
superior  to  Topfer's  method.*  It  is  based  upon  the  fact  that  phosphotungstic 
acid  and  the  salts  of  this  acid  precipitate  native  albumins  and  the  products 
of  their  digestion  in  combination  with  phosphotungstic  acid.  The  method, 
as  given  by  Edsall,  is  as  follows :  The  calcium  phosphotungstate  is  prepared 
by  making  a  4  per  cent,  solution  of  commercial  phosphotungstic  acid,  heat- 
ing, and  adding  calcium  carbonate  until,  after  gentle  boiling,  the  reaction 
becomes  neutral ;  then  filter.  The  solution  may  be  kept  indefinitely.  In 
carrying  out  the  test  determine  the  total  acidity ;  then  to  10  c.  c.  of  gastric  con- 
tents add  30  c.  c.  of  the  calcium  phosphotungstate  solution,  filter  off  the  pre- 
cipitate, wash  the  filter,  collecting  the  washings  with  the  filtrate,  and  titrate  the 
filtrate  and  washings.  Subtract  the  second  result  from  the  first,  and  the 
figures  obtained  represent  the  acidity  due  to  combined  HCl.  Rosolic  acid 
is  used  as  an  indicator  in  each  case.  The  free  HCl  is  estimated  by  titration 
with  phloroglucin-vanillin,  and  the  total  amount  of  HCl  is  obtained  by  adding 
the  results  for  the  free  and  the  combined  HCl. 

If  free  HCl  is  absent  decinormal  solution  is  added  until  a  marked  reac- 
tion for  free  HCl  appears,  the  amount  added  being  known,  and  the  method 
is  then  carried  out.  Any  excess  over  the  amount  added  that  may  be  found 
is  then  due  to  combined  HCl.  Dr.  Edsall  suggests  a  modification  of  the 
process  that  hastens  the  result,  viz.,  filtering  into  a  graduated  cylinder  after 
the  precipitation,  taking  20  c.  c.  of  the  filtrate,  titrating  this,  and  doubling 
the  result.  This  avoids  loss  of  time  in  filtering  and  washing.  The  results 
in  the  first  titration  are  better  if  the  stomach  contents  are  diluted  about  five 
times,  as  the  color  change  with  rosolic  acid  is  then  sharper. 

For  Topfer's  method  the  reader  is  referred  to  treatises  on  diseases  of  the 
stomach,  and  manuals  on  diagnostic  technique. 

To  Determine  the  Loosely  Combined  HCl. — It  may  be  that  there  is  no 
evidence  of  the  presence  of  free  acids,  inorganic  or  organic,  and  yet  the  gas- 
tric contents  will  redden  litmus.  Such  acidity  is  due  to  loosely  combined 
acids.  These  are  decomposed  by  calcic  and  sodic  carbonate,  and  are  there- 
fore included  in  the  estimation  of  total  acidity,  but  do  not  respond  to  the 
test  for  free  acids.  The  acid  thus  combined  is  commonly  HCl,  forming  HCl- 
albuminates,  HCl-albumoses,  and  peptones.  While  organic  acids  may  be 
similarly  combined,  they  are  insignificant  in  amount  and  may  be  ignored. 
These  loosely  combined  acids  are  also  destroyed  by  combustion. 

When  free  HCl  is  present,  the  estimation  of  the  loosely  combined  HCl 
is  an  easy  matter.  We  have  simply  to  estimate  the  total  acidity  and  the  HCl, 
preferabl}^  by  Topfer's  method, — wh,ich  removes  also  the  organic  acids  and 
acid  salts, — subtract  the  latter  from  the  former,  and  the  difiference  is  the 
loosely  combined  HCl. 

*  See  "  A  Critique  on  Certain  Methods  of  Gastric  Analysis,"  by  David  L.  Edsall,  "  University  of 
Pennsylvania  Medical  Bulletin, "  April,  igoi. 


336 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


In  cases  where  there  is  no  free  HCl  and  the  contents  are  still  acid, 
quantitative  methods  are  complicated  and  only  approximate  at  best.  We 
may,  however,  by  a  qualitative  test  for  chlorin  by  the  Ewald-Sjoqvist 
method,  which  tests  only  the  chlorin  in  the  organic  combination,  ascertain 
whether  some  of  the  combined  acid  is  HCl,  and  thence  whether  the  deranged 
acid  secretion  implies  a  diminution  or  a  total  loss  of  function  of  the  secret- 
ing cells.  Mix  lo  c.  c.  of  the  contents  with  0.5  gm.  (half  a  salt-spoonful) 
of  barium  carbonate  in  a  platinum  capsule.  This  mixture  is  evaporated  and 
the  residue  fused  to  a  red  heat  only  in  order  to  avoid  too  high  a  temiperature. 
The  fused  mixture  is  treated  with  50  to  75  c.  c.  boiling  water  and  filtered. 
To  this  filtrate,  when  cooled,  5  to  10  c.  c.  of  a  saturated  solution  of  sodium 
carbonate  are  added,  by  which  the  entire  BaCl^  is  converted  into  BaCOj, 
and  thrown  down  as  a  flocculent  precipitate  if  chlorin  is  present.  The  pres- 
ence of  organic  chlorin  compounds  thus  shown  indicates  that  some  of  the 
combined  acid  is  HCl. 

To  Determine  Acid  Salts. — To  15  c.  c.  of  gastric  contents  in  a  beaker 
add  enough  calcium  carbonate  to  neutralize  the  free  and  organically  com- 
bined acids.  Stir  the  mixture  thoroughly,  expelling  the  carbonic  acid  gas 
generated  by  passing  a  current  of  air  through  it,  using  for  this  purpose 
a  glass  tube  attached  to  the  bulb  of  a  Davidson's  syringe.  Avoid  blowing 
air  from  the  lungs,  as  this  contains  CO„.  Filter,  take  10  c.  c.  of  the  filtrate 
and  titrate  with  the  decinorm,al  soda  solution,  adding  phenolphthalein  as  an 
indicator.  The  number  of  cubic  centimeters  used  indicates  the  acid  salts, 
and  this,  divided  by  .2,  gives  the  acid  phosphates. 

Determination  of  Organic  Acids. — These  include  lactic  acid,  acetic  acid, 
and  the  true  fatty  acids,  especially  butyric.  Acetic  acid  and  fatty  acids  are 
not  formed  during  normal  digestion,  and,  if  present,  as  they  sometimes  are, 
they  are  either  introduced  with  the  food  or  are  produced  in  a  fermentation 
of  the  carbohydrates  set  up  by  bacteria  introduced  with  the  saliva. 

The  physiological  presence  of  lactic  acid  during  what  may  be  termed 
the  first  stage  of  digestion,  heretofore  regarded  as  physiological,  is  now 
called  in  question,  especially  by  Boas.  Boas,  because  of  his  recent  discovery 
that  all  baker's  bread  contains  lactic  acid,  substitutes  for  the  ordinary  test 
meal  a  thin  gruel  made  of  a  tablespoon  ful  of  oatme.al  flour  to  a  quart  of  water 
and  seasoned  with  salt.  With  this  meal  he  maintains  that  lactic  acid  is  never 
found  in  the  stomach  nnless  cancer  is  present.  The  matter,  however,  is  still 
snh  pidice,  though  the  following  careful  data,  gathered  from  the  experiments 
of  Ellenburger  *  and  Ewald,  on  the  subject  indicate  that  there  is  a  primary 
evolution  of  lactic  acid: 


Time  (in 

Number 

Number  of 

Minutes) 

Number 

i^f  Times 

Times    Lac- 

afterTaking 

Kinds  of  Food. 

of  Obser- 

Lactic 

tic  Acid  was 

Food  at 

Free  HCl, 

vations. 

Acid  was 

Absent  after 

which  Lactic 

When  First  Appeared: 

Found. 

Taking 
Food. 

Acid  was 
Found. 

Mixed  diet. 

31 

26 

5 

10-100 

After  120  minutes. 

Bread. 

31 

13 

18 

10-30 

After  30  minutes. 

White  of  egg. 

15 

I 

14 

75 

Seldom  before  6ominutes. 

Scraped  meat. 

23 

17 

6 

10-100 

Seldom  after i2ominutes. 

*  Boas,  "  Deutsche  med.  Wochenschrift,"  1803,  PP-  913-940;  Ellenburger  and  Hoffmeister,  "  Du 
Bois  Reymond's  Archiv  f.  Physiologie,"  1890,  p.  280;  Ewald  and  Boas,  "  Virchow's  Archiv,"  loi,  pp. 
325.  375- 


DIAGNOSTIC  TECHNIQUE.  ^^^-^ 

Uffelmaiin's  Test. — Lactic  acid  is  recognized  by  its  effect  upon  a  very 
dilute,  almost  colorless,  solution  of  neutral  ferric  chlorid,  which  is  converted 
into  a  canary-yellow  color  by  its  action.  This  is  Uft'elmann's  test.  It  is  ren- 
dered more  certain  if  the  solution  is  made  by  adding-  carbolic  acid  to  the  iron 
solution  until  it  assumes  an  amethyst-blue  color.  To  lo  c.  c.  (2  1-2  fluid 
drams)  of  two  to  five  per  cent,  solution  of  carbolic  acid  the  iron  solution 
may  be  added  until  the  proper  tint  is  attained.  A  few  drops  of  even  a  0.05 
per  mille  solution  of  lactic  acid  (i  to  20,000)  will  change  the  blue  to  the 
distinctive  yellow  color. 

There  are,  however,  sources  of  error.  The  lactates  cause  the  same  reac- 
tion, but  this  matters  not,  because  we  desire  to  recognize  the  lactic  acid, 
whether  in  combination  or  not.  The  reaction,  however,  takes  place  with 
alcohol,  sugar,  and  certain  salts,  especially  phosphates,  which  are  often  found 
in  gastric  contents.  The  color  produced  by  phosphates  is  not  identical,  but 
if  the  filtrate  operated  with  has  a  yellow  tinge  the  resulting  color  may  ap- 
proximate it  very  closely.  Under  these  circumstances  the  lactic  acid  must 
be  extracted  with  ether.  Two  to  five  c.  c.  (1-2  to  i  1-2  fluid  drams)  of  the 
stomach  contents  are  thoroughly  shaken  with  three  or  four  times  the  amount 
of  ether.  The  ether  is  allowed  to  rise  to  the  top,  which  it  does  rapidly,  and 
is  then  poured  off  into  a  glass  beaker.  More  ether  is  added  and  the  washing 
repeated  until  in  all  about  one  fluid  ounce  (30  c.  c.)  of  ether  has  been  used, 
The  ether  is  then  evaporated  by  placing  the  beaker,  with  its  contents,  in  a 
vessel  of  hot  water.  The  residue  is  redissolved  in  a  few  drops  of  water  and 
one  or  tzvo  drops  of  Uffelmann's  reagent  allowed  to  fall  from  a  pipette  into 
the  solution.     Too  much  of  the  solution  may  mask  the  reaction. 

The  fatty  acids,  especially  butyric,  strike  a  tawny  yellow  color  with  a 
reddish  tinge  with  Uffelmann's  chlorid  of  iron  solution,  but  0.5  per  1000 
or  I  to  2000  is  required  before  the  reaction  occurs. 

Fatty  acids  may  also  be  detected  by  heating  to  the  boiling-point  a  few 
cubic  centimeters  of  the  gastric  filtrate  in  a  test-tube  over  the  mouth  of  which 
a  strip  of  moistened  neutral  or  blue  litmus  paper  is  placed.  On  this  the 
vaporized  acid  will  produce  the  usual  change. 

The  oily  particles  of  pure  fat  may  be  recognized  floating  in  the  gastric 
contents  or  in  the  aqueous  solution  of  the  residue  after  evaporating  the 
ethereal  extract.  Butyric  acid  may  also  be  separated,  in  the  form  of  drops 
by  adding  small  pieces  of  calcium  chlorid. 

Acetic  acid  is  easily  recognized  by  its  odor,  but  it  may  also  be  detected 
by  neutralizing  with  sodium  carbonate  the  watery  residue  after  the  removal 
of  the  ethereal  extract,  and  then  adding  neutral  ferric  chlorid  solution.  A 
striking  blood-red  color  appears,  also  produced  by  formic  acid,  but  this  is 
never  a  constituent  of  gastric  contents. 

Alcohol,  v^hxch.  is  sometimes  formed  in  the  stomach  in  intense  yeast 
fermentation,  may  be  detected  by  Lieben's  iodoform  test  applied  to  the  dis- 
tillate of  the  stomach  contents,  as  follows :  To  a  portion  of  the  distillate  add 
a  small  quantity  of  liquor  potassse,  then  a  few  drops  of  a  solution  of  iodin 
and  iodid  of  potassium  (i,  2,  50).  If  alcohol  be  present,  a  yellowish  pre- 
cipitate of  iodoform  ta'kes  place  slowly,  which  may  also  be  recognized  by 
its  odor.     The  same  precipitate  occurs  with  acetone,  but  rapidly. 

Examination  of  Products  of  Albumin  Digestion. — The  term  proteol- 
ysis is  applied  to  albumin  digestion,  in  which,  if  complete,  all  proteid  food- 
stuffs are  converted  into  soluble  and  diffusible  peptone.  It  takes  place  partly 
in  the  stomach  through  the  agency  of  pepsin-hydrochloric  acid,  but  probably 


338 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


even  to  a  greater  degree  in  the  small  intestine,  by  the  action  of  trypsin,  the 
pancreatic  digestive  ferment.  In  this  process  the  first  step  is  the  production 
of  certain  substances  intermediate  between  albumin  and  peptone.  Those 
which  are  of  chief  importance  in  the  study  of  gastric  digestion  are  syntonin 
or  acid  albumin  and  the  so-called  proteoses  '•'  or  albumoses.  In  the  ordinary 
process  of  digestion,  with  a  normal  gastric  juice,  some  or  all  of  these  sub- 
stances should  be  at  some  time  present.  So  far  as  they  are  the  products  of 
gastric  dig'estion,  they  may  be  studied  by  the  aid  of  a  test  meal  and  removal 
of  the  gastric  contents,  as  already  described. 

The  products  of  pepsin  proteolysis  may,  in  a  general  way,  be  divided 
into  three  groups : 

1.  Those  precipitated  by  neutralization  and  represented  mainly  by  syn- 
tonin or  acid  albumin. 

2.  Those  precipitated  by  saturation  of  the  neutralized  fluid  with  am- 
monium sulphate  and  represented  by  the  proteoses. 

3.  Those  non-precipitable  by  ammonium   sulphate  and  represented  by 
what  is  commonly  known  as  peptone. 

The  relation  of  these  products  to  each  other  is  shown  by  the  following 
diagram,  proposed  by  Xeumiester : 


Native  Proteid. 


Svntonin  or  acid-albumin 


Protoproteose 
Soluble  in  water  onlv 


Deuteroproteose 


Heteroproteose 

1  (dysproteose) 

Soluble  in  salt  solution,  dilute 
acids,  and  alkalies 


Deuteroproteose 


Peptone  Peptone 

Non-preciptable  by  ammonium  sulphate. 

Proto-  and  hetero-proteoses  are  primary  bodies  formed  directly  from  the 
initial  product  syntonin  by  the  further  action  of  the  ferment.  Again,  deu- 
teroproteose is  a  secondary  proteid.  being  formed  by  the  further  hydration 
of  the  primary  body.  Finally,  peptone,  the  ultimate  product  of  pepsinpro- 
teolysis.  is  the  result  of  the  hydration  and  possible  cleavage  of  deuteropro- 
teosis.  The  two  primary  proteoses  differ  from  each  other  more  particularly 
in  that  protoproteose  is  readily  soluble  in  water  alone,  while  heteroproteose 
is  soluble  only  in  salt  solution,  dilute  acids,  and  alkalies. 

To  Separate  Proteoses  (Propeptone)  and  Peptone. — Take  two  or  three 
c.  c.  of  the  stomach  filtrate  and  remove  any  acid  albumin  or  S5-ntonin  by 
neutralization  and  filtration.    The  proteoses  and  peptones  remain  in  solution. 


'■  The  so-called  propeptone  or  hemialbumose  is  a  mixture  of  proteoses. 


DIAGNOSTIC  TECHNIQUE.  339 

To  a  portion  of  the  filtrate  apply  the  biuret  test — viz.,  one  c.  c.  of  liquor 
potassae  and  a  few  drops  of  a  one  per  cent,  solution  of  cupric  sulphate.  A 
purple-red  color  indicates  the  presence  of  proteoses  and  peptone. 

Another  portion  of  the  neutral  filtrate  is  then  treated  with  an  equal 
quantity  of  a  saturated  solution  of  sodium  chlorid  and  one  or  two  drops 
of  strong  acetic  acid  added.  Proteoses,  if  present,  are  precipitated,  and  may 
be  filtered  out.  To  the  filtrate  again  apply  the  biuret  test.  A  purple-red 
color  indicates  the  presence  of  peptone,  and  its  quantity  may  be  approxi- 
mately estimated  by  the  intensity  of  the  reaction,  provided  we  always  use 
the  same  proportion  of  stomach  contents,  solution  of  potash,  and  cupric 
sulphate.  Should  it  happen  that  a  handsome  biuret  reaction  is  struck  before 
removing  the  proteose,  or  but  a  faint  one  or  none  at  all  afterward,  the  pro- 
portion of  proteose  is  large  and  peptone  small.  Cahn  has  shown  that  in 
dogs,  at  least,  the  quantity  of  peptone  remains  at  a  certain  percentage,  being 
probably  kept  at  that  figure  by  its  removal  as  formed.  Hence,  the  only 
index  of  the  rapidity  and  extent  of  albumin  transformation  is  the  amount 
of  proteose  formed  or  remaining.  Finally,  Ewald,  Gumlich,  and  R.  A. 
Chittenden  conclude  that  the  formation  of  true  peptone  in  the  human 
stomach  is  small.  It  is  true,  peptone  may  be  found  in  relatively  large 
amount,  but  a  quantitative  estimation  of  the  proteoses  and  peptone  always 
shows  the  former  to  be  in  excess.  Gastric  digestion  is  rather,  there- 
fore, to  be  considered  as  a  preliminary  step  in  proteolysis,  and  is  preparatory 
to  the  more  thorough  office  of  pancreatic  digestion. 

To  Estimate  the  Activity  of  Proteolysis,  or  Albumin  Digestion. — By 
Ewald's  method,  coagulated  white  of  tgg  is  cut  into  thin  slices  and  out  of 
these  small  discs  are  cut  by  a  cork-borer  or  similar  instrument.  These  may 
be  prepared  in  quantity  and  kept  for  use  in  glycerin,  which  should,  how- 
ever, be  washed  off  before  using.  An  equal  quantity  of  the  filtered  gastric 
fluid  is  placed  in  four  small  test-tubes  and  one  or  two  discs  of  albumin  put 
into  each.  To  the  first  nothing  else  is  added ;  to  the  second,  enough  hydro- 
chloric acid  to  make  a  solution  of  about  *  0.3  to  0.5  per  cent.  This  is  accom- 
plished by  adding  two  drops  of  hydrochloric  acid  to  90  minims  (5  c.  c.)  of 
stomach  contents.  To  the  third  is  added  a  definite  quantity  of  pepsin,  about 
3  to  7  1-2  grains  (0.2  to  0.5  gm.)  ;  to  the  fourth,  both  hydrochloric  acid  and 
pepsin. 

The  test-tubes  are  placed  in  an  incubator  at  about  100°  F.  (37.8°  C.)  and 
from  time  to  time  examined  with  a  view  to  learning  how  far  the  liquefaction 
of  the  discs  of  albumin  has  proceeded.  The  rate  of  this  will  inform  us 
whether  digestion  would  have  occurred  without  the  addition  of  anything,  or 
whether  acid  or  pepsin  or  both  were  necessary.  We  will  learn,  also,  whether 
by  adding  more  hydrochloric  acid  we  have  made  the  acidity  excessive. 

It  must  be  remembered,  however,  that  after  the  peptone  has  reached 
a  certain  percentage  its  further  production  is  retarded,  or  even  suspended, 
so  that  there  may  be  an  apparently  slow  reaction  with  even  a  very  active 
gastric  juice.  Ewald  correctly  reminds  us  that  all  laboratory  attempts  to 
imitate  digestion  are  defective  in  the  important  respect  that  with  our  test- 
tubes  and  flasks  we  can  neither  imitate  absorption  on  the  one  hand,  nor,  on 
the  other,  allow  for  the  onward  movement  to  the  intestines  of  the  gastric 
contents,  two  important  functions  by  which  the  stomach  strives  to  maintain 
a  fairly  uniform  degree  of  concentration  of  its  contents. 

*The  difference  between  the  strength  of  the  acetic  acid  of  the  German  phamacopoeia  (25  per 
cent,  of  the  anhydrous  acid),  intended  by  Ewald,  and  that  of  the  U.  S.  P.  (32  per  cent.)  is  not  suffi- 
cient to  necessitate  a  change  of  proportion. 


340  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  Action  of  Rennet,  or  Lab-fcnnent,  the  Milk-coagnlating  Element 
of  the  Natural  Gastric  Juice. — The  simplest  method  of  estimating  the  action 
of  rennet  is  that  of  Leo.  To  lo  c.  c.  (3.6  tiuicl  drams)  of  raztr  milk  are  added 
two  to  five  drops  of  stomach  contents.  Raw  milk  is  used  because  it  coagu- 
lates ten  times  more  rapidly  than  boiled  milk,  while  neutralization  is  unneces- 
sary because  of  the  relatively  small  cjuantity  of  gastric  juice  used.  The 
mixture  is  placed  in  the  warm  chamber  at  100°  F.  (37.8°  C),  and  coagu- 
lation should  take  place  in  from  one  minute  to  several  hours.  The  character- 
istic coagulating  of  rennet  is  a  cake  of  casein  floating  in  clear  serum,  while 
acids  produce  lumpy  and  flaky  masses. 

The  rennet-ferment,  or  enzyme,  does  not  exist  primarily  as  such,  but 
as  a  rennet-zymogen  or  proenzyme,  which  itself  has  no  action  on  milk,  but 
is  converted  into  rennet  by  the  action  of  any  acid,  as  hydrochloric,  or  of 
warm  chlorid  of  calcium.  This  may  be  shown  as  follows :  If  the  spon- 
taneous coagulating  action  of  gastric  juice  or  milk  be  destroyed  by  neutral- 
ization by  an  alkaline  carbonate,  this  property  may  be  restored  by  digesting 
with  dilute  hydrochloric  acid,  or  by  the  addition  of  a  five  per  cent,  solution 
of  calcium  chlorid.  While  fasting,  and  at  the  beginning  of  digestion, 
zymogen  only  is  present  in  the  stomach,  but,  later,  both  it  and  the  ferment 
are  found.  An  acid  reaction  for  the  curdling  action  of  rennet  is  not  abso- 
lutely necessary.  As  pepsin  and  rennet  usually  accompany  each  other  the 
presence  of  one  may  be  inferred  from  the  presence  of  the  other. 

Digestion  of  Starch  and  Sugar. — It  is  well  known  that  during 
digestion  starch  is  .converted  into  grape  sugar,  and  cane  sugar  is  converted 
into  invert  sugar — a  mixture  of  cane  and  grape  sugar.  This  action,  com- 
menced in  the  mouth  by  the  ptyalin  of  saliva,  is  continued  to  a  less  degree 
in  the  stomach  so  long  as  the  acidity  is  slight  (o.oi  per  cent,  for  HCl,  o.i  or 
0.2  per  cent,  for  lactic,  0.4  per  cent,  for  butyric),  and  is  finished  in  the  small 
intestine  by  the  trypsin  (amylolypsin)  of  the  pancreatic  juice.  As  in  albu- 
min digestion,  there  are  intermediate  substances  between  albumin  and  pep- 
tone, so  between  starch  and  grape  sugar  there  are  similar  intermediate  prod- 
ucts.   The  order  is  as  follows : 

I.  Starch.  2.  Dextrins  (Erythrodextrin,  Achroodextrin).  3.  Maltose. 
4.  Dextrose,  or  grape  sugar. 

Starch  is  recognized  by  the  deep  blue  color  struck  with  iodin  or 
Lugol's  solution  (iodin  i,  iodid  of  potassium  2,  distilled  water  200),  and 
the  reaction  grows  less  vivid  as  the  starch  is  converted.  Of  the  dextrins, 
erythrodextrin  strikes  not  a  blue,  but  a  purple  color,  while  solutions  of 
achroodextrin,  maltose,  and  grape  sugar  take  on  only  the  yellow  color  of 
the  iodin  solution.  Where  a  mixture  of  these  substances  occurs,  the  first 
few  drops  of  the  iodin  solution  produce  no  color  at  all,  or  only  a  transitory 
one,  being  taken  up  by  the  dextrose  and  maltose,  while  the  addition  of  more 
iodin  strikes  the  purple  of  erythrodextrin  or  the  blue  of  starch. 

If,  therefore,  amylaceous  transformation  has  progressed  normally  in  the 
mouth  and  stomach,  so  much  starch  should  be  changed  into  achroodextrin, 
maltose,  or  dextrose  that  the  addition  of  small  quantities  of  Lugol's  solution 
does  not  strike  the  characteristic  color.  If,  however,  the  blue  or  purple 
reactions  appear,  conversion  has  not  been  sufficiently  rapid  into  maltose,  the 
principal  product  of  gastric  conversion,  the  change  into  dextrose  being  com- 
pleted in  the  small  intestine.  This  may  be  due  either  to  a  deficiency  of 
ptyalin  or  a  too  rapid  production  of  acid  in  the  stomach.  From  such  event 
we  might  also  infer  a  hyperacidity  of  the  gastric  juice. 


DIAGNOSTIC  TECHNIQUE. 


341 


To  Determine  the  Rate  of  Absorption  from  the  Stomach. — Penzoldt's 
and  Faber's  method  is  that  generally  followed.  A  capsule  containing  iodid 
of  potassium,  o.i  gm.  (i  1-2  grains),  is  swallowed,  being  first  carefully 
wiped  to  remove  any  adherent  particles.  The  appearance  of  the  iodid  in 
the  saliva  indicates  that  absorption  has  taken  place  from  the  stomach.  To 
determine  this,  starch  paper  is  first  prepared  by  moistening  with  starch  paste 
and  drying.  Then,  after  the  salt  is  swallowed,  a  piece  of  the  paper  is  moist- 
ened every  five  minutes  with  the  saliva,  and  the  moistened  spot  touched  with 
fuming  nitric  acid.  As  soon  as  the  iodin  appears  in  the  saliva  the  character- 
istic blue  reaction  is  struck. 

When  absorption  is  normal,  this  reaction  usually  takes  place  in  ten  or 
fifteen  minutes,  but  when  absorption  is  abnormally  delayed,  the  reaction  is 
also  delayed  half  an  hour  or  more,  or  it  may  not  occur  at  all. 

To  Test  the  Motor  Function  of  the  Stomach. — Three  methods  are 
practiced.  In  v.  Leube's  method  the  gastric  contents  are  withdrawn  six  to 
seven  hours  after  the  ingestion  of  a  large  meal,  or  two  and  a  half  hours  after 
an  Ewald's  breakfast.  There  should  be  no  solid  residue.  The  more  suitable 
meal  for  this  purpose  is  the  larger  one  given  on  page  333. 

In  a  second  method,  suggested  by  Ewald  and  Sievers,  salol  is  admin- 
istered, and  the  products  of  its  lysis  are  sought  for  in  the  urine.  This, 
though  not  without  drawbacks,  is  preferred.  Salol  is  composed  of  phenol 
and  salicylic  acid,  into  which  it  is  broken  up  by  the  action  of  the  pancreatic 
juice,  but  not  by  the  acid  gastric  contents.  Salicyluric  acid,  a  product  of 
decomposition  of  salicylic  acid,  appears  in  the  urine  forty  to  sixty,  or  at  most 
seventy-five,  minutes  after  taking  15  grains  (i  gm.)  of  salol  when  gastric 
peristalsis  is  normal.  Salicyluric  acid  is  readily  detected  in  the  urine  by  the 
violet  color  produced  on  the  addition  of  neutral  ferric  chlorid  solution.  The 
method  employed  is  to  place  a  drop  of  urine  on  a  piece  of  filter-paper  and 
bring  in  contact  with  this  a  drop  of  a  ten  per  cent,  ferric  chlorid  solution. 
The  edge  of  the  drop  will  strike  a  violet  color  in  the  presence  of  a  mere  trace 
of  salicyluric  acid.  Decomposition  of  salol  may  be  delayed  by  extreme  acid- 
ity of  the  gastric  contents  as  discharged  into  the  duodenum.  Practically 
this  is  not  a  serious  drawback,  tolerably  constant  results  being  obtained.  To 
meet  it,  however,  Huber  suggested  that  the  outside  limit  of  excretion  of 
salicyluric  acid  be  determined — that  is  the  point  noted  when  salicyluric  acid 
fails  to  appear  in  the  urine  after  the  ingestion  of  15  grains  (i  gm.)  of  salol. 
This  should  occur  at  the  end  of  twenty-four  to  thirty  hours.  If,  therefore, 
it  continues  after  this,  persistalsis  must  be  slow. 

A  third  test  of  the  motor  function  is  Klemperer's  oil  test,  in  which  100 
c.  c.  (3  1-2  ounces)  of  olive  oil  are  introduced  into  the  stomach  by  the  tube 
after  the  organ  is  thoroughlv  washed  out.  Two  hours  later  the  stomach  is 
aspirated,  and  if  there  is  motor  sufficiency,  there  should  be  a  very  small 
residue,  not  more  than  20  to  40  c.  c.  If  any  decided  quantity  above  this 
remain,  it  is  fair  to  conclude  that  peristalsis  is  slow.* 

*MaxEinhorn  (Article  "Diseases  of  the  Stomach,"  in  "Twentieth  Century  Practice  of  Medi- 
cine," vol.  vii;'..  t8q6)  divides  motor  function  of  the  stomach  into  two  parts— viz.,  that  consisting-  in 
the  transportation  of  the  stomach  contents  into  the  smaller  intestine,  which  he  calls  firocIi07-esis 
(lyi  7rpoxwpr)o-t5,  advancing-l,  and  that  consistins:  in  tyierely  mechanical  motion  to  which  the  ingesta  are 
subjected  within  the  organ,  which  he  calls  akinesis  (r\  aKiVT/trts,  shaking).  The  former  is  teste^  m  the 
manner  described;  the  latter,  by  a  mechanical  appliance  connected  with  a  battery,— the  whole  too 
complex  for  introduction  here. 


342  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ACUTE  CATARRHAL  GASTRITIS. 

Synonyms. — Acute  Gastric  Catarrh;  Acute  Dyspepsia;  Gastric  Fever. 

Definition. — Acute  inflammation  of  the  stomach,  of  moderate  intensity, 
due  to  simple  non-specific  irritation  or  to  irritation  from  the  products  of 
decomposing  and  fermenting  foods. 

Etiology. — This  form  of  inflammation  occurs  at  all  ages,  and  is  often 
due  to  the  irritant  efifect  of  indigestible  food  or  food  in  a  state  of  incipient 
decay  and  fermentation.  Simply  overloading  the  stomach,  even  though  the 
food  be  wholesome,  may  be  a  sufficient  cause.  The  introduction  of  large 
quantities  of  strong  alcoholic  drinks,  as  often  happens  in  a  debauch,  is  one 
of  the  most  common  causes  of  acute  gastritis  of  the  simple  variety.  The 
susceptibility  of  different  individuals  and  of  different  families  to  the  fore- 
going causes  of  irritation  varies  greatly. 

Morbid  Anatomy. — A  more  or  less  uniform  coating  of  the  stomach 
with  mucus  is  the  most  constant  feature  of  simple  acute  gastritis,  and  justi- 
fies for  it  the  name,  gastric  catarrh.  The  removal  of  this  mucous  coating 
reveals  a  hyperemic  redness,  which  in  the  highest  degrees  may  be  associated 
with  punctiform  hemorrhages  and  hemorrhagic  erosions.  The  mucous  mem- 
brane is  swollen  and  edematous,  and  minute  examination  recognizes  numer- 
ous mucus-laden  cylinder  cells,  which  have  been  extruded  from  the  mucus- 
glands  everywhere  -present,  while  even  the  peptic  gland  cells  are  cloudy  and 
granular. 

Symptoms. — These  are  a  natural  sequence  of  the  morbid  state.  A 
7vant  of  appetite  and  loathing  of  food,  nausea,  more  rarely  pain — these  are 
the  more  constant  subjective  symptoms.  To  them  may  be  added  an  unpleas- 
ant taste  in  the  mouth,  sometimes  bitter,  sometimes  metallic,  a  pasty  sensa- 
tion of  dryness,  and  even  thirst,  a  sense  of  fullness  in  the  head  rather  than 
headache,  and  di::ciness,  and  often  extreme  mental  depression. 

Objective  symptoms  are  epigastric  distention,  more  rarely  tenderness, 
a  coated  tongue,  dryness  of  the  lips,  rarely  herpes,  a  heavy  breath,  acid  or 
bitter  eructations,  sometimes  a  scanty  secretion,  at  others  an  excess  of  saliva, 
finally  retching  and  vomiting  with  greater  or  less  relief.  The  hotvels  are, 
constipated,  though  sometimes  there  is  diarrhea.  Jaundice  is  occasionally 
present,  and  indicates  that  the  inflammiation  extends  into  the  duodenum  and 
produces  obstruction  of  the  common  bile-duct.  There  may  be  slight  fever, 
sometimes  decided,  with  a  temperature  of  ioi°  F.  (38.3°  C),  or  slightly  more, 
and  a  corresponding  pulse.  On  the  other  hand,  the  pulse  is  not  infrequently 
slowed  below  the  normal,  being  inhibited  by  the  gastric  irritation.  The 
nrine  is  "  feverish,"  scanty,  and  high  colored,  with  a  corresponding  specific 
gravity  and  a  tendency  to  deposit  urates.  Most  cases  are  without  febrile 
symptoms.  Indeed,  v.  Leube  says  that  in  a  few  instances  only  is  fever  the 
result  of  acute  gastric  catarrh,  and  that  when  the  two  are  associated,  the 
gastric  catarrh  is  rather  the  result  of  some  acute  febrile  process,  as,  for  ex- 
ample, one  of  the  infectious  fevers.  It  has  occasionally  happened  that  gas- 
tritis has  been  ushered  in  with  a  chill. 

Gastric  Contents. — The  vomited  matter  and  gastric  contents  removed 
after  a  test  meal  are  deficient  in  hydrochloric  acid,  but  contain  an  excess 
of  mucus,  lactic  and  fatty  acids,  and  more  than  the  normal  residue  of  undi- 
gested food.     Digestion  is  prolonged,  the  stomach-washings  exhibiting  a 


CHRONIC  CATARRHAL  GASTRITIS.  343 

considerable  amount  of  undigested  food  seven  hours  after  the  ingestion  of 
a  test  meal.  Indeed,  it  often  happens  that  in  from,  twelve  to  twenty-four 
hours  after  the  beginning  of  such  an  attack  large  quantities  of  undigested 
food  are  vomited  in  much  the  same  condition  in  which  they  were  swallowed. 

Diagnosis. — This  is  not  usually  difficult,  except  in  the  case  of  the 
febrile  form.  In  this  form,  especially  when  the  disease  has  been  ushered  in 
with  chill,  it  is  sometimes  difficult  to  decide  between  it  and  some  one  of  the 
infectious  fevers,  but  a  few  days'  waiting  will  soon  remove  the  doubt  by  the 
appearance  in  the  latter  of  eruptions  or  other  distinctive  symptoms.  The 
presence  of  a  cause  sufficient  to  excite  gastric  inflammation  will  add  to  the 
probability  of  the  presence  of  acute  catarrhal  gastritis. 

Prognosis. — This  is  invariably  favorable  in  cases  of  true  simple  gas- 
tritis. 

Treatment. — ^Many  mild  cases  recover  spontaneously,  if  let  alone  and  if 
all  food  is  withdrawn  for  twenty-four  hours.  The  symptoms  gradually  sub- 
side and  the  patient  recovers.  In  a  few  cases  where  there  is  evidently 
retained  food,  an  emetic  will  give  relief;  in  all,  a  brisk  saline  purge  is  help- 
ful. A  bottle  of  cold  solution  of  citrate  of  magnesium  in  divided  doses,  say 
a.  fourth  every  half  hour,  is  one  of  the  most  agreeable  and  efficient  aperients 
to  relieve  the  congestion  and  the  symptom^iS.  Or  some  one  of  the  natural 
aperient  zixiters,  such  as  Hunyadi  Janos  or  Friedrichshalle,  Apenta,  Ruba- 
inat,  Veronica,  or  Carlsbad,  may  be  substituted.  If  there  be  great  sensitive- 
ness of  the  stomach,  small  doses  of  calomel,  frequently  repeated,  say  1-6  to 
1-4  grain  (o.oii  to  0.016  gm.)  every  hour,  may  be  substituted,  or  7  1-2  to 
10  grains  (0.5  to  0.666  gm.)  may  be  given  in  one  dose..  In  either  event 
a  saline  should  be  given  sooner  or  later,  as  in  this  way  is  secured  copi- 
ous depletion  of  the  upper  alimentary  canal.  The  alkaline  mineral  zvaters, 
represented  by  the  Vichy,  Vals,  and  Contrexville  waters  in  France,  but  which 
have  unfortunately  no  equivalent  in  any  of  the  natural  mineral  waters  of 
this  country,  are  admirable  adjuvants,  since  they  aid  in  clearing  the  stomach 
of  mucous  secretion  and  in  producing  osmosis.  The  saline  mineral  waters 
represented  by  the  well-known  Saratoga  waters  of  this  country  are  also  effi- 
cient, more  especially  by  their  aperient  qualities. 


CHRONIC    CATARRHx\L   GASTRITIS. 
Synonyms. — Chronic  Gastric  Catarrh;  Chronic  Catarrhal  Dyspepsia. 

Definition. — A  condition  of  chronic  hyperemia,  associated  wath  ex- 
cessive mucus-secretion  and  deranged  gastric  juice  formation,  with  ultimate 
structural  changes  in  the  mucosa. 

Etiology. — Any  cause  which  will  produce  continuous  moderate  irri- 
tation of  the  mucous  membrane  of  the  stomach  is  capable  of  producing 
chronic  catarrhal  gastritis.  The  immoderate  use  of  alcohol  is  probably  the 
most  frequent  of  these  causes,  but  constant  overeating  is  also  a  common  cause, 
especially  rapid  eating. 

Very  frequently,  too,  chronic  gastritis  is  secondary  to  primary  disease 
elsewhere,  and  especially  mitral  disease  of  the  heart  and  interstitial  hepatitis. 
Both  of  these  affections  cause  a  passive  congestion  of  the  stomach,  which 
ultimately  produces  the  lesions  characteristic  of  chronic  gastritis.  Throm- 
bosis of  the  portal  vein  acts  similarly.    Chronic  pulmonary  disease,  and  even 


344  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

diseases  of  the  pleura  impeding  the  circulation  in  the  lungs,  produce  similar 
effects  through  stasis.  A  predisposition  exists  in  certain  families  to  chronic 
gastric  catarrh. 

Morbid  Anatomy. — The  fundamental  condition  is  a  hjperemic  swelling 
of  the  gastric  mucosa.  This  is  favored  by  the  superficial  situation  of  the 
venous  plexus  about  the  mouths  of  the  gastric  glands  as  contrasted  with  the 
deep-seated  position  of  the  arterial  network  around  their  bases,  by  the  thin- 
ness and  compressibility  of  the  venous  walls,  and  by  the  sluggishness  of  cir- 
culation necessitated  by  the  peculiar  secretory  function  of  the  stomach.  The 
hyperemic  surface  is,  however,  more  or  less  obscured  by  a  tough  yellowish- 
white  covering,  made  up  of  mucus  and  emigrant  pus-cells.  The  changes  are 
more  marked  at  the  pyloric  end. 

These  may  constitute  the  sum  of  changes,  but  in  more  chronic  cases 
minute  examination  reveals  a  varying  degree  of  hyperplasia  of  the  connective 
tissue,  and  even  of  the  mucous  glands,  which  exhibit  in  places  an  atypical 
branching,  like  the  fingers  of  a  glove.  The  tubules  are  distended  by  secre- 
tion in  some  places,  and  in  others  stenosed  by  the  contraction  of  the  over- 
grown connective  tissue  surrounding  them.  The  hyperplastic  process  may 
result  in  plication  of  the  mucous  membrane,  such  as  is  natural  at  the  pyloric 
end,  and  lead  finally  to  the  rnaminillated  stomach  by  atrophy  and  contraction 
of  certain  portions,  and  to  more  pronounced  swelling  of  the  remaining  parts. 
An  ultimate  result  is  sometimes  the  rare  condition  known  as  polyposis  ven- 
triciili.  Atrophy  of  the  mucous  membrane  may  be  extensive,  and  even  almost 
total. 

Symptoms. — These  naturally  result  from  the  morbid  state.  The 
mucous  membrane  is  bathed  with  mucus.  The  gastric  juice  is  imperfect  in 
quality  and  quantity.  Especially  is  the  hydrochloric  acid  deficient.  Diges- 
tion is  therefore  imperfect,  the  residue  of  ingested  food  undergoes  fermen- 
tation and  decomposition,  generating  lactic,  acetic,  and  butyric  acids  and 
alcohol.  Peristalsis  is  delayed  because  of  the  absence  of  its  natural  stimulus, 
and  thence  follows  a  further  retention  of  food  in  the  stomach.  The  natural 
consequence  of  such  morbid  changes  is  loss  of  appetite  and  even  disgust  for 
food,  an  unpleasant  taste,  a  pasty  sensation  in  the  mouth,  a  coated  tongue, 
and  discomfort  after  taking  food,  including  nausea,  often  vomiting,  some- 
times immediately,  sometimes  an  hour  or  two  after  taking  food.  The  vom- 
itus  consists  of  undigested  food,  usually  mixed  with  a  large  arnount  of  mucus. 
Its  reaction  may  be  neutral  or  acid,  sometimes  even  acridly  so,  but  the  acidity 
is  not  due  to  hydrochloric  acid,  which  is  diminished,  but  to  the  organic  acids 
generated  in  fermentation. 

To  these  symptoms  may  be  added  headache,  or  a  dull,  unpleasant  feeling 
in  the  head,  vertigo,  disturbed  sleep,  depression  of  spirits,  a  sense  of  v/eaii- 
ness  and  disgust  with  life.  Very  disagreeable  is  the  distention  and  sense  of 
fullness  in  the  epigastrium,  causing  even  pain,  which  adds  further  to  exist- 
ing discomforts.  There  may  be  tenderness,  but  it  is  diffuse,  and  not  circum- 
scribed. There  is  usually  constipation,  while  the  urine  may  be  scanty.  Re- 
flected symptoms  are  palpitation ;  frequent,  slozv,  or  irregular  pulse ;  shortness 
of  breath.  There  is  no  fever.  Cough — the  so-called  "  stomach  cough  " — is 
sometimes  present,  but  more  frequently  what  is  called  by  the  patient 
stomach  cough  is  the  cough  of  tubercular  phthisis,  which  the  sanguine  pa- 
tient easily  convinces  himself  is  due  to  stomach  derangement. 

Gastric  Contents. — Analysis  of  the  gastric  contents,  withdrawn  after  a 
test  meal,  shows  a  similar  deficiency  of  pepsin  as  well  as  of  hydrochloric  acid, 


CHROXIC  CATARRHAL  GASTRITIS.  345 

while  the  other  tests  described  discover  retarded  peristalsis  and  delayed  ab- 
sorption. Occasionally  there  is  a  little  blood  present,  and  frequently  fungi, 
especially  yeast-spores  and  sarcin^  ventriculi. 

Should  the  disease  progress  to  total  atrophy,  the  gastric  contents,  after 
a  test  meal,  may  even  be  devoid  of  mucus  as  well  as  of  free  and  combined 
hydrochloric  acid,  and  pepsin,  blood,  and  epithelium,  may  be  made  up  mainly 
of  undigested  food,  with  bacteria  and  a  few  round  cells.  Repeated  examina- 
tions of  stomach  contents,  after  a  test  meal,  may  be  necessary  before  a  con- 
fident knowdedge  of  its  features  can  be  arrived  at. 

Diagnosis. — With  the  symptoms  detailed,  and  the  altered  state  of  the 
secretory,  absorptive,  and  motor  functions  of  the  stomach,  ascertained  as 
directed,  there  is  usually  no  difficulty  in  diagnosing  a  condition  of  chronic 
gastric  catarrh.  It  is  to  be  remembered,  however,  that  chronic  gastric  catarrh 
may  accompany  ulcer  and  carcinoma  of  the  stomach,  in  which  the  otherwise 
distinctive  symptoms  of  the  former  are  obscured,  while  with  the  exception  of 
tumor  and  occasional  coffee-grounds  vomit  the  symptoms  of  carcinoma  may 
not  differ  from  those  of  chronic  gastric  catarrh,  hydrochloric  acid  and  pepsin 
being  deficient  in  both.  Dilatation  of  the  stomach  is  also  accom-panied  with 
symptoms  of  gastric  catarrh,  including  even  the  clinical  characters  of  the 
gastric  juice,  and  careful  examination  must  always  be  made  for  the  physical 
signs  of  dilatation. 

Prognosis. — The  prognosis  and  treatment  will  depend  upon  the  etiology. 
If  the  chronic  gastric  catarrh  is  a  result  of  chronic  cardiac  or  hepatic  disease, 
it  is  curable  only  so  far  as  these  affections  are  curable,  and  is  relieved  as  these 
are  relieved.  Careful  physical  examination  is  always  necessary  in  each  case, 
that  obscure  cases  may  be  recognized. 

Chronic  gastric  catarrh  not  the  result  of  organic  heart  or  pulmonary 
or  liver  disease,  and  which  has  not  already  resulted  in  atrophy  of  the  mucous 
membrane,  may  be  cured  by  careful  and  persevering  treatment.  If  there  be 
extensive  atrophy  of  the  gastric  mucous  membrane,  a  proper  assimilation  of 
food  becomes  impossible,  and  the  symptoms  of  anemia  are  ultimately  added. 
Their  close  resemblance  to  those  of  pernicious  anemia  has  been  pointed  out, 
while  an  essential  cause  of  pernicious  anemia  has  been  held  to  be  gastric 
atrophy,  in  evidence  of  which  a  case  of  William  Osier  and  Frederick  P. 
Henry  is  often  quoted. 

Treatment. — The  treatment  of  chronic  gastric  catarrh  caused  by  chronic 
liver  or  heart  disease  is  largely  that  of  these  affections,  but  the  treatment 
useful  in  the  ordinary  primary  forms  of  the  disease  may  be  with  advantage 
associated  with  that  of  the  more  chronic  affection. 

A  successful  treatment  of  catarrhal  dyspepsia  requires  considerable 
patience,  but  if  the  diagnosis  be  correctly  made  and  the  cause  removed,  the 
patient  may  be  promised  a  cure  in  time.  Of  primary  importance  is  the  elimi- 
nation of  file  cause,  whether  it  be  alcohol  or  injudicious  eating.  Simple, 
wholesome,  and  properly  cooked  food,  thoroughly  masticated  and  slowly 
taken,  should  be  the  rule  of  every  life,  and  the  simple  forms  of  the  disease 
may  sometimes  be  cured  by  a  return  to  such  a  habit,  especially  if  a  proper 
action  of  the  bowels  is  also  habitually  secured. 

It  is  not  easy  to  select  a  diet  which  will  suit  every  case,  and  after  the 
injunction  that  articles  evidently  difficult  of  digestion,  such  as  pastry,  oils, 
and  fats,  are  to  be  excluded,  it  is  often  sufficient,  and  even  necessary,  to  leave 
the  choice  of  special  articles  to  the  patient,  with  the  direction  to  discard  what 
his  experience  teaches  is  harmful.     Often,  however,  the  patient  cannot  be 


346  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

trusted  to  do  this,  while  the  moral  effect  of  specific  directions  is  good,  but 
even  then  our  bill  of  fare  must  often  be  tentative.  The  measures  by  which 
the  regular  habit  of  bozvcl  movement  is  brought  about  must  vary  with  cir- 
cumstances, but  when  it  is  remembered  that  we  have  to  deal  with  a  congested 
mucous  membrane,  it  is  plain  why  the  salines  which  deplete  the  upper  ali- 
mentary canal  are  so  efficient,  especially  when  associated  with  mercurials. 
Among  these  are  the  numerous  natural  aperient  waters,  such  as  Friedrichs- 
halle,  Hunyadi  Janos,  Apenta,  Carlsbad  waters,  and  our  own  Saratoga  and 
Bedford  waters,  all  of  which  are  said,  in  common  parlance,  to  act  upon  the 
liver,  though,  in  fact,  they  simply  deplete  the  alimentary  canal.  The  use- 
ful eft'ect  of  these  waters  is  so  often  availed  of  to  remove  the  uncomfortable 
effect  of  a  debauch  in  eating  that  their  use  is  abused.  No  remedies  are,  how- 
ever, so  useful  when  needed,  and  the  fact  that  almost  any  of  them  can  be 
taken  before  breakfast,  :ecuring  an  effect  after  that  meal,  makes  them  doubly 
convenient.  A  fit  substitute  for  the  water,  especially  when  traveling,  is  the 
Carlsbad  Sprudel  Salt,  obtained  by  evaporating  the  Carlsbad  water.  Carls- 
bad salt,  of  which  the  dose  is  usually  a  teaspoonful,  is  best  taken  in  a  glass  of 
hot  water.  An  artificial  Carlsbad  salt  may  be  made  as  follows :  Sodium  sul- 
phate, 50  parts ;  sodium  bicarbonate,  6 ;  sodium  chlorid,  3.  The  dose  is  a 
teaspoonful  dissolved  in  half  a  glass  to  a  glass  of  water.  The  natural  waters 
are,  however,  to  be  preferred,  if  they  can  be  obtained. 

The  occasional  associated  treatment  by  mercurials,  especially  blue  mass, 
in  doses  of  three  to  ten  grains  (0.2  to  0.66  gm.)  the  evening  previous,  some- 
times adds  to  the  efficiency  of  the  salines.  Calomel  may  be  substituted  in 
doses  of  five  to  ten  grains  (0.33  to  0.66  gm.) ,  \\\\h  as  much  sodium  carbonate. 
If  there  be  nausea,  calomel  may  be  given  in  smaller  doses,  say  i-io  to  1-5 
grain  (o.ooii  to  0.0132  gm.)  hourly.  Podophyllin  may  be  substituted  for 
the  mercurials  or  added  to  them  in  doses  of  i-io  to  1-4  grain  (0.006  to  0.06 
gm.).  Cascara  sagrada  is  one  of  the  most  valuable  of  aperients.  The  best 
preparations  are  the  solid  and  fluid  extracts.  The  former  may  be  given 
in  two-grain  doses  (0.132  gm.)  in  a  pill  after  dinner  and  after  supper.  The 
fluid  extract,  in  15-  or  20-minim  (i  to  1.3  gm.)  doses,  can  be  given  in  the 
same  manner,  but  the  dose  of  each  must  be  modified  to  suit  the  requirements 
of  individual  cases.  In  lieu  of  the  saline  aperients  before  breakfast,  a  glass 
of  hot  water  alone,  slowly  sipped  while  dressing,  is  often  useful  and  tends  to 
relieve  the  morning  sickness  that  sometimes  attends  chronic  gastric  catarrh. 
It  probably  liquefies  the  mucus  and  washes  it  away  into  the  duodenum. 

As  to  medicines  intended  to  aid  digestion,  the  most  efficient  is  hydro- 
chloric acid,  which  may  sometimes  be  replaced  by  nitro-muriatic  acid.  It  seems 
now  definitely  settled  that  hydrochloric  is  the  acid  to  which  the  gastric  juice 
owes  its  efficiency,  and  as  well  settled  that  it  is  diminished  in  chronic  gastric 
catarrh.  Another  very  important  role  is,  however,  assigned  to  hydrochloric 
acid,  viz.,  an  antiseptic  effect,  in  checking  the  multiplication  of  pathogenic 
bacteria — bacteria  of  fermentation  and  decomposition — which  are  continually 
introduced  with  the  food  into  the  stomach.  A  third  role  performed  by 
hydrochloric  acid  is  the  conversion  of  the  granular  pepsinogen  in  the  proto- 
plasm of  the  peptic  cells  into  the  enzyme,  pepsin.  Its  scantiness,  therefore, 
not  only  impairs  the  activity  of  the  gastric  juice,  but  also  favors  the  acetic 
and  lactic  acid  fermentations,  the  products  of  which  keep  up  irritation.  On 
the  other  hand,  pepsin  is  seldom  abnormally  scanty,  because  so  little  is 
required  for  its  purpose.  As  it  does  no  harm,  however,  it  may  with  pro- 
priety be  administered  with  hjdrochloric  acid.     The  latter  has,  heretofore, 


CHRONIC  CATARRHAL  GASTRITIS.  347 

been  administered  in  too  small  doses. "^  Not  less  than  15  minims  (i  gm.) 
of  the  dilute  acid  should  be  given,  and  from  30  to  60  minims  (2  to  4  gm.)  are 
sometimes  required.  It  should  be  given,  further  diluted,  fifteen  minutes  after 
a  meal,  through  a  glass  tube  carried  back  into  the  fauces,  not  merely  to  save 
the  teeth,  but  also  to  avoid  the  unpleasant  taste.  The  pepsin  should  be  given 
in  solution  with  the  hydrochloric  acid  in  doses  of  five  to  ten  grains  (0.33  to 
0.66  gm.).  The  wine  of  pepsin  has  always  been  a  favorite  preparation  with 
me,  notwithstanding  the  small  proportion  of  pepsin  contained  in  it.  I  have 
been  in  the  habit  of  combining  it  with  nitro-muriatic  acid  rather  than  with 
hydrochloric,  and  not  infrequently  adding  1-30  grain  (0.002  gm.)  of  strych- 
nin to  each  dose  of  1-2  ounce  (15  c.  c.)  or  two  fluid  dram,s  (7.5  c.  c.)  of  the 
wine. 

Trypsin  or  pancreafin  is  also  much  used.  It  is  commonly  prescribed  in 
the  tablet  form,  five  grains  (0.33  gm.)  at  a  dose,  sometimes  keratin  coated, 
that  it  may  not  be  dissolved  until  it  passes  into  the  small  intestine,  where 
alone  in  the  presence  of  an  alkali  it  is  capable  of  acting. 

It  is  usual  also  to  employ  the  bitter  tonics  in  the  treatment  of  this  form 
of  dyspepsia,  including  gentian,  quassia,  columbo,  angostura,  cardamom,  and 
nux  vomica.  They  are  supposed  to  stimulate  the  secretion  of  gastric  juice, 
and  should  be  taken  immediately  before  meals  or  with  food.  A  moderate 
amount  of  alcohol  in  the  shape  of  a  little  whisky  with  water  during  meals 
or  a  glass  of  dry  sherry  is  often  serviceable,  but  care  should  be  taken  in  the 
use  of  alcohol  lest  a  habit  be  contracted.  The  persons  to  whom  it  is  advised 
should  be  well  selected,  and  it  should  not  be  recommended  to  the  young. 
Stimxilating  condiments,  such  as  red  pepper  and  mustard,  often  give  tem- 
porary relief,  but  they  ultimately  aggravate  the  local  congestion  and  should 
be  forbidden.  Common  salt,  on  the  other  hand,  is  a  rational  adjuvant,  fur- 
nishing chlorin  for  the  formation  of  hydrochloric  acid. 

Nitrate  of  silver  is  also  a  useful  drug  in  pases  of  chronic  gastric  catarrh, 
in  doses  of  1-4  grain  (0.0165  gm.)  fifteen  minutes  to  half  an  hour  before 
meals,  dissolved  in  a  quarter  of  a  glass  of  water.  I  have  never  found 
bismuth  of  much  use  in  this  form  of  dyspepsia.  In  fact,  its  tendency  to  pro- 
duce constipation  is  a  contra-indication  to  its  use.  Where  there  is  acidity  it 
may  be  useful,  as  may  also  be  sodium  bicarbonate  and  mint,  but  it  is  better, 
if  possible,  to  strike  at  the  root  of  the  evil  by  preventing  the  fermentations 
which  produce  the  flatulence  and  acid. 

In  obstinate  cases  the  milk  treatment  may  be  resorted  to  with  advan- 
tage, and  should  be  carried  out  with  skimmed  milk  or  whole  milk  diluted 
with  water  or  Vichy.  The  efficiency  of  the  milk  treatment  is  largely  due  to 
the  fact  that  the  quantity  of  food  taken  is  greatly  reduced.  Not  more  than 
two  ounces  should  be  given  at  first,  every  two  hours,  the  quantity  increased 
only  as  the  hunger  of  the  patient  demands  more.  There  will  be  at  first  a 
loss  of  weight,  but  this  is  again  recovered  with  the  increase  in  quantity. 
Having  secured  a  tolerance  for  milk,  of  which  from  three  to  five  pints  (i  1-2 
to  2  1-2  liters)  are  required  in  twenty-four  hours,  the  interval  may  be  pro- 
longed and  other  articles  of  food  cautiously  added — a  little  bread  and  butter, 
an  egg,  a  chop,  or  a  small  piece  of  steak,  broiled.  Gradually  the  simpler 
vegetables,  such  as  rice  and  potatoes,  may  be  added,  then  weak  tea  and 
cofifee  cautiously,  the  effect  of  each  article  being  carefully  watched.     If  flatu- 

*  Since  4.5;  liters  (g  pints)  of  0.2  per  cent,  solution  of  HCl  are  required  to  saturate  100  grn.  (about 
3  oz.)  of  dry  fibrin,  and  this  amount  of  acid  utilized  in  combining  with  the  albumin  leaves  none  ap- 
parent as  free  HCl,  it  is  plain  why  the  small  doses  often  prescribed  are  insufficient, 


348 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


lence  is  caused  by  the  farinacea  and  sugars,  they  should  be  withdrawn. 
Hot  bread  and  fats  will  rarely  ever  be  permissible  to  such  patients.  The; 
same  may  be  said  of  ice-cream  and  iced  water  with  meals,  though  a  moder- 
ate amount  may  be  permitted  between  meals,  especially  of  iced  water.  Ripe 
fruits,  on  the  other  hand,  are  very  desirable  foods  and  should  be  allowed 
tentatively. 

In  bad  cases  of  chronic  gastric  catarrh  lavage  is  one  of  the  most  useful 
measures.  Not  only  does  it  wash  away  the  coating  of  mucus  which  is  at 
once  a  hindrance  to  the  secretion  of  the  gastric  juice  and  a  cause  of  nauseous 
discomfort  to  the  patient,  but  it  also  stimulates  glandular  activity.  It  should 
be  done  in  the  morning  before  breakfast,  with  the  stomach  tube  already 
described,  with  funnel  attachment.  Simple  water  as  hot  as  can  be  borne, 
may  suffice,  or  if  there  be  much  mucus,  a  two  per  cent,  solution  of  sodium 
bicarbonate  or  Carlsbad  salt,  or  a  one  per  cent,  solution  of  sodium  chlorid 
may  be  used.  If  antiseptic  fluids  are  indicated,  a  two  per  cent,  solution  of 
resorcin  may  be  substituted,  or  a  one  per  cent,  solution  of  salicylic  acid. 

The  stomach  tube  having  been  introduced,  as  directed  on  page  333,  the 
tepid  water  or  solution  employed  is  run  in  slowly  and  removed  by  siphonage, 


'Fig.  29. — Leube-Rosenthal  Arrangement  for  Auto-lavage. 

the  outer  end  of  the  tube  being  lowered  for  the  latter  purpose.  This 
process  is  repeated  until  the  stomach  is  thoroughly  washed  out.  x*\uto-lavage 
is  easily  practiced  by  the  patient  himself  by  means  of  the  apparatus  illus- 
trated in  the  text. 

It  is  in  these  cases,  too,  that  a  course  at  Carlsbad  is  very  efificient,  and 
remarkable  cures  are  reported.  Here,  too,  the  restricted  dietary  and  deple- 
tion of  the  upper  alimentary  canal  by  the  natural  mineral  waters  are  the  bene- 


TRAUMATIC  AND  TOXIC  GASTRITIS.  349 

iiting  agents.  Similar  courses  are  carried  out  at  Kissengen,  Wiesbaden,  and 
Ems,  but,  unfortunately,  we  have  no  such  places  in  America.  Saratoga 
fulfills  the  conditions  so  far  as  an  aperient  water  is  concerned,  but  the 
majority  of  persons  who  go  to  Saratoga  continue  eating  and  drinking  as  at 
home.  Finally,  the  habitual  use  between  meals  of  the  alkaline  mineral 
waters  alluded  to — viz.,  Vichy,  Vals,  and  Contrexville — is  undoubtedly  use- 
ful, relieving  and  averting  gastric  catarrh. 


PHLEGMONOUS  OR  SUPPURATIVE  GASTRITIS. 

Definition. — A  rare  form  of  gastritis,  in  which  there  is  diffuse  puru- 
lent infiltration  of  the  submucosa,  but  sometimes  also  circumscribed  abscess, 
causing  a  possibly  detectable  tumor  in  the  gastric  region,  a  tumor  which  dis- 
appears if  the  abscess  ruptures. 

Etiology. — Phlegmonous  gastritis  is  a  result  of  infectious  processes, 
among  which  have  been  puerperal  fever  and  other  forms  of  pyemia.  It  has 
been  found  associated  with  peritonitis  and  trauma.  In  more  cases  a  cause  is 
not  discoverable.     It  has  been  met  more  frequently  in  men  than  in  women. 

Symptoms  and  Diagnosis. — Epigastric  pain  and  tenderness,  general 
abdominal  pain  and  tympany,  vomiting,  diarrhea,  fever,  delirium,  dry  tongue, 
small,  frequent  pulse,  coma,  collapse,  and  death — symptoms  that  closely 
resemble  those  of  peritonitis,  with  which,  as  has  been  said,  it  is  sometimes 
associated — are  those  met  in  phlegmonous  gastritis.  The  vomited  matter 
very  rarely  contains  pus.  It  is  plain,  therefore,  that  these  symptoms,  asso- 
ciated with  an  infectious  process,  can  only  give  rise  to  suspicion  that  the  dis- 
ease is  present,  since  the  same  symptoms  may  be  caused  by  peritonitis.  Even 
the  vomiting  of  pus  is  not  diagnostic,  because  pus  may  arise  from  other 
sources  between  the  mouth  and  stomach.  The  presence  of  a  tumor  which 
subsides  after  vomiting  of  pus  furnishes  better  ground  for  suspicion,  though 
vomited  pus  may  also  come  from  an  abscess  in  the  vicinity  of  the  stomach 
which  has  ruptured  into  that  organ. 

Treatment. — ^This  can  only  be  symptomatic,  as  nothing  can  be  done  to 
avert  a  termination  which  is  invariably  fatal. 


TRAUMATIC  AND  TOXIC  GASTRITIS. 

Definition. — An  inflammation  of  the  stomach  caused  by  the  ingestion  of 
corrosive  poisons,  such  as  the  strong  mineral  or  organic  acids,  caustic  alka- 
lies, phosphorus,  arsenic,  corrosive  sublimate,  and  the  like. 

Morbid  Anatomy. — The  appearance  differs  a  good  deal,  according  to 
the  degree  of  irritation.  In  extreme  degrees,  such  as  are  produced  by  the 
strongest  acids  and  alkalies,  the  mucous  membrane  is  disintegated,  shredd)'', 
and  may  be  converted  into  a  black  eschar,  the  borders  of  which  are  lighted 
up  with  intense  inflammation.  In  milder  forms,  such  as  are  produced 
by  phosphorus,  arsenic,  and  strong, alcohol,  there  are  cloudy  swelling  and 
fatty  degeneration  of  the  gastric  gland  cells  and  vessel-Avalls,  producing  ulcer- 
ation and  hemorrhagic  extravasation.  The  fury  of  the  irritation  is  expended 
on  the  fundus,  as  the  part  first  reached,  and  its  ravages  become  less  exten- 
sive as  the  pylorus  is  approached. 


350  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Symptoms. — These  also  vary  with  the  degree  of  irritation,  but  there  are 

always  intense  burning  pain,  tenderness  on  pressure,  thirst,  and  vomiting 
of  blood  and  even  of  fragments  of  mucous  membrane.  To  these  are  added, 
in  severe  cases,  small,  frequent  pulse,  cold  sweat,  and  collapse.  These  latter 
symptoms  point  to  peritonitis,  a  very  frequent  complication,  the  direct  result 
of  the  deep-seated  action  of  the  irritant.  If  the  patient  does  not  perish 
promptly,  symptoms  indicating  blood  dyscrasia  supervene,  including  albu- 
minuria, hematuria,  jaundice,  subcutaneous  blood  extravasations,  and  the 
like.  When  recovery  takes  place  or  death  is  long  delayed,  varying  areas  of 
mucous  membrane  may  be  replaced  by  cicatricial  tissue,  and  there  may  be 
subsequent  contraction  and  distortion. 

Diagnosis. — This  is  based  on  a  knowledge  that  the  patient  has  swal- 
lowed a  corrosive  poison.  In  the  absence  of  this  knowledge  the  odor  of  the 
breath  may  suggest  the  cause,  and  evidences  of  corrosive  action  in  the  mouth 
and  pharynx  often  disclose  unfailing  signs. 

Prognosis. — This  varies  with  the  degree  of  lesion.  The  gastritis  caused 
by  the  powerful  corrosive  poisons  is  always  fatal.  The  lesser  degrees  may 
be  followed  by  recovery. 

Treatment. — This  consists,  first,  in  the  use  of  chemical  opposites,  as 
vinegar  and  other  weak  acids  for  alkalies  and  alkalies  for  acids.  The  anti- 
dotes called  for  by  special  substances  are  freshly  prepared  ferric  hydrate  for 
arsenic,  lime-water  for  oxalic  acid,  cold  water  and  ice  after  the  specific  action 
of  the  poison  has  been  counteracted,^  and  ice  externally  to  the  abdominal  walls. 
These  should  be  followed  by  the  free  use  of  diluents  and  demulcents,  of 
w^hich  the  various  mucilages  and  milk  are  examples.  (See  concluding  sec- 
tion of  book  on  the  Treatment  of  Poisons.) 

Diphtheritic  Gastritis. — This  occurs  sometimes  as  an  extension  from 
faucial  or  laryngeal  diphtheria,  but  more  frequently  it  is  secondary  to  typhus 
or  typhoid  fever,  smallpox,  scarlet  fever,  pneumonia,  and  sometimes  pri- 
marily in  weak  children.  There  is  no  way  to  recognize  such  condition  dur- 
ing life. 

Mycotic  Gastritis. — It  is  very  doubtful  how  far  fungi  can  cause  in- 
flammation of  the  stomach.  The  bacteria  which  flourish  in  the  mouth  are 
destroyed  by  the  acid  gastric  juice,  while  the  fungi  that  thrive  in  acid  fluids, 
such  as  the  yeast  fungus,  the  penicilium,  and  the  sarcina,  are  probably  acci- 
dental results  of  the  retention  of  the  gastric  contents  beyond  the  natural  time 
and  are  not  harmful.  The  possibility  of  their  producing  noxious  results  can- 
not, however,  be  denied.  Ulceration  has  even  been  ascribed  to  them.  On 
the  other  hand,  the  larvae  of  certain  insects  must  also  be  acknowledged  as 
possible  causes  of  inflammation. 


NERVOUS  DYSPEPSIA. 

Synonym. — Gastric  Neurasthenia. 

Definition. — A  form  of  dyspepsia  due  to  nervous  influence,  in  which, 
notwithstanding  the  presence  of  a  train  of  annoying  symptoms,  the  act  of 
digestion  is  completely  accomplished  within  the  normal  time  of  seven  hours, 
and  seven  hours  after  an  ordinary  dinner  the  stomach  is  free  from  residue. 


NERVOUS  DYSPEPSIA.  351 

Etiology. — The  nervous  temperament  and  feminine  gender  predispose 
to  nervous  dyspepsia.  Any  cause  that  develops  an  overexcitabihty  of  the 
nervous  system  may  become  a  factor  of  nervous  dyspepsia.  It  is  this  form 
to  which  the  neurasthenic  and  overworked,  and  also  women  with  pelvic 
trouble,  are  especially  prone. 

Symptoms. — It  must  be  admitted  that  the  only  constant  feature  of 
nervous  dyspepsia  is  the  etiological  one,  yet  we  may  find  symptoms  to  aid 
a  diagnosis  apart  from  the  cause.  Pyrosis,  accompanied  by  loud,  noisy 
eructations,  is  quite  characteristic,  while  noisy  rumbling  of  the  bowels  is 
often  heard,  caused  by  hyperperistalsis.  On  the  other  hand,  vomiting  is 
rare.  There  is  also  often  palpation  of  the  heart,  with  other  nervous  symp- 
toms. Constipation  is  sometimes  present.  The  nervous  dyspeptic  is  less 
disposed  to  be  anxious  about  himself  or  to  dwell  on  his  ills  than  is  he  with 
catarrhal  dyspepsia,  but  may  also  be  restless  and  sleepless,  and  depressed  in 
spirits.  As  in  catarrhal  dyspepsia  there  may  be  loss  of  appetite,  an  unpleas- 
ant taste  in  his  mouth,  nausea,  di::::;iness,  headache — pressure  on  the  head. 
So,  too,  a  sense  of  discomfort  in  contrast  to  sharp  pain ;  also  distention  dur- 
ing digestion,  but  in  nervous  dyspepsia,  if  the  interest  of  the  patient  is 
strongly  excited  by  external  matters,  as,  for  example,  pleasant  society  or 
even  business  interest,  he  may  for  the  time  forget  it.  Gastralgia  may,  how- 
ever, be  associated,  especially  the  form  attended  by  hyperacidity. 

Wilhelm  v.  Leube,  who  has  given  the  subject  of  nervous  dyspepsia  much 
attention,  makes  three  clinical  varieties : 

1.  Those  in  which  the  hydrochloric  acid  is  present  in  normal  amounts, 
which  he  says  may  be  regarded  as  a  fundamental  type. 

2.  Those  in  which  the  HCl  is  diminished. 

3.  Those  in  which  the  HCl  is  in  excess. 

In  each  of  these  cases  the  digestion  is  complete  at  the  end  of  the  normal 
time,  except  that  sometimes  it  may  be  delayed  for  starches  in  the  third  type 
of  hyperacidity.  Thus,  while  nervous  dyspepsia  is  chiefly  a  sensory  neu- 
rosis, it  is  to  a  less  degree  secretory  and  also,  to  a  degree,  motor,  as  evidenced 
by  the  occasionally  associated  hyperperistalsis. 

An  annoying  symptom  that  is  sometimes  associated  with  nervous  dys- 
pepsia and  is  at  times  its  chief  manifestation  is  peristaltic  unrest.  Bor- 
borygmi  and  gurgling  set  up  very  soon  after  eating,  so  loud  as  to  be  heard 
at  a  distance,  and  thus  to  become  often  a  mortification  to  the  patient,  while 
this  very  emotion  reacts  to  increase  it.  The  movement  extends  to  the  lower 
bowels.  The  associated  discomfort  varies  greatly  and  is  sometimes  extreme. 
Peristalsis  may  be  reversed,  and  in  extreme  cases  it  is  said  that  enemas  and 
even  fecal  matter  have  been  discharged  per  orem. 

Diagnosis. — The  frequent  dependence  of  nervous  dyspepsia  on  other 
conditions  requires  a  broad  etiological  study.  Thus,  as  v.  Leub)e  suggests, 
we  have  first  to  settle  the  question  as  to  w^hether  it  is  an  independent  affection 
or  a  part  of  a  neurasthenia.  The  urine  should  be  studied,  because  the  phe- 
nomena of  nervous  dyspepsia  are  sometimes  a  manifestation  of  uremic 
intoxication  of  a  mild  degree  in  contracted  kidney.  The  spleen  should  also 
be  explored,  because  the  malady  is  sometimes  a  result  of  malaria.  In  still 
other  cases  it  is  a  symptom  of  chlprosis  or  hysteria.  In  all  these  cases 
the  nervous  dyspepsia  is  the  effect  of  the  operation  of  the  disease  on 
the  nervous  system,  and  again  in  other  cases  it  is  the  result  of  sympathy 
with  sexual  diseases,  especially  in  women  wath  disease  of  the  uterus  and 
ovaries. 


352  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Again,  we  have  to  distinguish  it  from  ulcc)'  of  the  stomach,  which  the 
hyperacid  form  resembles,  but  from  which  it  differs  in  that  the  pain  is  reheved 
by  pressure  and  sometimes  by  taking  food,  both  of  which  acts  increase  the 
pain  in  ulcer.  The  occurrence  of  hemorrhage  from  the  stomach,  of  course, 
under  these  circumstances  points  definitely  to  ulcer.  Nervous  dyspepsia 
may,  however,  continue  as  a  sequel  of  both  healed  ulcer  and  gastric  catarrh, 
since  their  effect  is  a  neurasthenic  one.  Finally,  it  is  to  be  distinguished 
from  the  form  of  catarrhal  dyspepsia  with  similar  symptoms  by  the  delayed 
completion  of  the  digestive  act  characteristic  of  the  latter,  as  well  as  the  etio- 
logical factor,  which  is  the  most  important  criterion. 

Treatment. — The  treatment  of  nervous  dyspepsia  varies  with  the  cause, 
but  it  is  desirable  also  to  determine  by  chemical  examination  the  state  of 
secretion,  whether  normal,  hyperacid,  or  of  diminished  acidity.  The  treat- 
ment of  all  three  forms  is,  however,  largely  a  moral  one,  since  nervous  influ- 
ence may  be  at  once  a  cause  of  increased  or  diminished  HCl  secretion,  but 
this  is  especially  true  of  the  type  attended  with  normal  secretion.  The 
patient  must  be  assured  that  there  is  no  organic  disease  and  be  compelled 
to  desist  from  self-study.  Along  with  this,  his  general  muscular  and  nerv- 
ous tone  must  be  improved.  He  must  be  encouraged  to  take  food  and  not 
to  avoid  it,  and  the  moral  effect  of  a  systematic  arrangement  of  diet  is  good. 
The  neuro-tonics,  strychnin,  gentian,  nux  vomica,  taken  with  meals  are  help- 
ful, but  too  much  medicine  is  harmful.  Occasionally  the  nervous  sedatives, 
including  the  bromids  and  valerian,  are  of  service. 

When  there  is  scanty  secretion  of  HCl  this  acid  must  be  given  according 
to  the  rules  already  laid  down,  15  to  30  minims  ( i  to  2  gm.)  of  the  dilute 
hydrochloric  acid  fifteen  minutes  to  half  an  hour  after  a  meal.  On  the  other 
hand,  if  there  is  excessive  HCl,  alkalies  must  be  prescribed  as  directed  in  the 
section  on  Hyperchlorhydria. 

Atonic  Dyspepsia — Simple  Atony  of  the  Stomach  of  Nervous  Origin. — 
Atonic  dyspepsia  is  a  variety  of  nervous  dyspepsia,  especially  common  in 
neurasthenics,  which  scarcely  deserves  separate  description;  but  as  the  term 
is  frequently  employed,  some  attempt  should  be  made  to  direct  its  correct 
application.  If  used,  it  should  be  applied  to  cases  in  which  delayed  gastro- 
intestinal activity  or  muscular  atony,  with  stasis  of  the  gastric  contents,  is 
the  characteristic  feature.  As  such  it  may  be  a  variety  of  catarrhal  dys- 
pepsia or  of  dilated  stomach.  In  such  cases  a  considerable  portion  of  a  test- 
meal  may  be  withdrawn  at  the  end  of  seven  hours.  It  is  probably  associated 
with  more  or  less  deficient  secretory  activity,  though  not  always.  Under 
these  circumstances,  too,  there  is  apt  to  be  flatulent  distention  of  the 
abdomen,  whence  the  terms  flatulent  dyspepsia  and  intestinal  dyspepsia.  A 
further  natural  consequence  of  such  delayed  mobility  is  constipation. 

True  gastric  atony  is  also  characterized  by  other  symptoms  which  are 
not  commonly  included  under  those  of  atonic  dyspepsia.  Such  condition 
undoubtedly  plays  a  part  in  dilatation  of  the  stomach,  an  important  morbid 
state  to  be  separately  considered.  Such  atony,  also,  involving  the  cardiac 
orifice,  favors  eructation  and  regurgitation  from  the  stomach,  an  extreme 
degree  of  which  is  the  rare  condition  of  rumination,  or  merycismns,  in  which 
the  patient  regurgitates  the  swallowed  food,  ofttimes  voluntarily,  and  chews 
it  again  like  ruminants.  Such  a  power  of  regurgitation  had  the  late  Brown- 
Sequard.     It  is  sometimes  hereditary,  and  may  be  taught  to  others. 


GASTRALGIA. 


GASTRALGIA. 


353 


Definition. — A  term  applied  to  recurring  attacks  of  gastric  pain  of  great 
severity  without  discoverable  organic  lesion  or  deranged  function. 

Etiology. — The  disease  is  confined  almost  exclusively  to  women,  but 
does  occur  occasionally  in  stalwart  men.  It  is  more  frequent  in  weak, 
anemic  women,  and  those  subject  to  menstrual  derangement,  in  brunettes 
rather  than  in  blondes.  It  is  especially  frequent  and  severe  about  the  meno- 
pause, but  does  not  cease  with  it.  Excessive  secretion  of  gastric  juice,  or 
hyperchlorhydria,  is  a  cause  of  gastralgia,  but  the  condition  is  one  for  sepa- 
rate consideration.  It  is  usually  independent  of  exciting  cause,  such  as  the 
taking  of  food,  but  it  may  be  thus  induced. 

Symptoms. — The  attack  may  come  on  suddenly  or  with  gradually 
increasing  severity  first  in  the  neighborhood  of  the  ensiform  cartilage,  whence 
it  radiates  into  the  back  and  around  the  lower  ribs.  It  is  a  boring,  hurning 
pain  of  extreme  severity,  sometimes  causing  fainting  and  collapse,  relieved 
by  pressure,  such  as  is  produced  by  boring  the  fist  into  the  epigastrium  or 
pressing  it  against  some  hard  substance.  On  the  other  hand,  it  is  sometimes 
excited  by  pressure.  Its  most  striking  feature,  after  its  agonizing  severity, 
is  its  intermittent  paroxysmal  character,  whence  it  has  been  held  to  be  ma- 
larial in  origin.  The  pain  is  usually  the  sole  symptom,  but  it  may  be  asso- 
ciated with  nausea  and  vomiting  or  with  nervous  symptoms,  such  as  globus 
hystericus  and  nnnatural  hunger.  The  attack,  after  a  variable  duration  of 
from  a  few  minutes  to  an  hour  or  more,  may  subside  gradually  or  suddenly 
without  other  symptoms,  though  sometimes  with  vomiting  and  eructations, 
at  others  with  the  discharge  of  a  large  quantity  of  pale  urine.  One  case 
under  my  care  almost  always  began  with  a  chill,  more  or  less  typical,  and 
it  is  certain  that  there  was  no  malaria.  The  interval  between  the  attacks 
varies  greatlv.     It  may  be  a  week  or  it  may  be  months. 

Diagnosis. — Essential  gastralgia  is  to  be  differentiated  from  intercostal 
neuralgia  and  the  so-called  symptomatic  gastralgia  due  to  ulcer,  rarely  cancer, 
from  the  gastric  crises  of  tabes,  and  from  biliary  and  intestinal  colic. 

In  intercostal  neuralgia  the  pain  is  not  so  severe  and  the  paroxysms  are 
of  longer  duration,  while  careful  examination  will  discover  its  focus  in  an 
intercostal  situation  as  compared  with  an  epigastric.  In  nicer  of  the  stomach 
there  is  not  that  total  intermission  or  longer  interval  of  total  intermission 
characteristic  of  gastralgia,  while  the  general  health  of  the  patient  with  ulcer 
is  commonly  more  seriously  affected.  This  is,  however,  not  always  so,  as 
gastric  ulcer  may  be  associated  with  robustness  of  appearance.  In  gastric 
ulcer  pressure  increases  the  pain,  while  in  gastralgia  it  tends  to  relieve  it. 
Carcinoma,  as  contrasted  with  gastralgia,  always  visibly  affects  the  general 
health.  Careful  examination  will  generally  discover  a  different  seat  of  the 
pain  in  biliary  colic,  while  the  almost  invariable  presence  of  jaundice  settles 
the  question.  In  a  well-established  case  of  tabes  there  need  be  no  difficulty 
in  diagnosis,  but  in  cases  where  the  diagnosis  is  not  well  established  there 
may  be  much  doubt.  The  history  of  attacks  in  comparatively  early  life  and 
thence  throughout  life  point  to  gastralgia.  Abdominal  colic  has  a  different 
focus  and  is  more  apt  to  be  associated  with  gaseous  distention. 

Prognosis. — True  gastralgia  never  destroys  life,  but  the  attacks  may 
continue  to  recur  at  intervals  throughout  it. 

Treatment. — The  severest  attacks  of  gastralgia  can  only  be  relieved 

23 


354  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

by  the  use  of  morphin,  which  is  best  given  hypodermically  in  the  smallest 
doses  which  will  suffice.  Exceeding  care  must,  however,  be  exercised  to 
avoid  a  morphin  habit.  In  milder  cases  chloroform  may  answer  the  purpose, 
or  a  combination  long  prescribed  in  the  clinics  of  the  University  of  Penn- 
sylvania and  deservedly  popular  is,  eqvial  parts  of  chloroform,  compound 
tincture  of  cardamom,  aromatic  spirit  of  ammonia,  and  brandy,  of  which 
a  teaspoonful  may  be  given  every  half  hour  or  fifteen  minutes  until  relief 
occurs.  If  needed,  a  few  drops  of  deodorized  tincture  of  opium  may  be 
added  to  each  dose  to  increase  the  anodyne  effect. 

Anemia  should  be  treated  with  iron  and  arsenic,  and  a  change  of  scene 
is  often  beneficial,  while  sea-bathing  is  a  form  of  hygiene  which  is  sometimes 
especially  useful.  The  bowels  should  receive  careful  attention.  If  neuras- 
thenia or  hysteria  be  present,  the  rest  cure,  associated  with  massage,  as- 
described  under  the  appropriate  section,  is  often  an  efficient  cure. 


HYPERCHLORHYDRIA. 
Synonyms. — Nervous  Hypersecretion  of  Hydrochloric  Acid;  Hyperpepsia. 

Definition. — Hyperchlorhydria,  or  an  excess  of  hydrochloric  acid  in 
the  gastric  juice,  is  a  symptom  of  different  morbid  conditions  of  the  stomach,, 
notably  ulcer  and  nervous  dyspepsia.  In  a  certain  number  of  cases,  how- 
ever, being  the  chief  symptom  and  apparently  independent  of  any  stimulus 
like  the  presence  of  food,  it  may  be  studied  as  an  independent  neurosis. 
The  term  hyperpepsia,  suggested  by  Hayem,  is  not  correct,  since  this  state  is 
not  characterized  by  excess  of  the  digestive  ferment,  but  of  the  chlorin 
element,  especially  hydrochloric  acid.  In  normal  digestion  the  total  acidity 
as  represented  by  free  and  combined  HCl  may  be  put  down  at  1.8  to  2 
parts  per  looo,  while  in  hyperchlorhydria  it  may  reach  3  and  4  parts  in 
1000. 

Eliminating  the  hyperchlorhydria  included  under  nervous  dyspepsia  and 
ulcer  of  the  stomach,  there  remain  two  varieties : 

1.  Simple  paroxysmal  hyperchlorhydria,  lasting  for  an  hour  or  several 
days. 

2.  Continuous  chronic  hypersecretion,  which  takes  place  spontaneously 
during  fasting,  or,  even  though  excited  by  food  stimulus,  continues  after  the 
latter  has  ceased  to  act.  The  latter  variety  is  also  called  Reichmann's  dise2.se, 
after  him  who  first  described  it. 

Etiology. — Both  forms  "of  hyperchlorhydria  are  most  frequent  in 
neurasthenics  and  emotional  persons,  but  occur  also  in  connection  with  other 
neuropathies,  such  as  migraine,  chlorosis,  and  tabes.  The  simple  form  occurs 
also  where  there  is  ulcer  of  the  stomach,  and  more  rarely  with  cancer  and 
gastritis. 

Symptoms. — In  paroxysmal  hyperchlorhydria  there  are  pain  and  epi- 
gastric discomfort,  eructations,  heartburn,  thirst,  nausea,  and  even  vomiting, 
headache,  and  constipation.  The  attacks  may  last  for  an  hour,  or  may  extend 
over  several  days,  terminating  in  vomiting;  or  by  remedial  measures,  such 
as  drinking  large  quantities  of  water,  which  dilutes  the  acids,  or  by  satura- 
tion with  albuminous  food,  with  which  it  enters  into  combination.  The 
urine,  because  of  much  ingestion  of  albuminous  food,  is  apt  to  be  highly 
charged  with  urea. 

In  the  continuous  form  the  same  symptoms  are  present,  but  without 


HYPERCHLORHYDRIA.  355 

intermission.  The  pain  is  even  more  severe,  and  is  especially  prone  to  come 
on  at  night;  there  is  a  capricious  appetite,  which  is  often  excessive.  Where 
the  appetite  remains,  pain  may  occur  several  hours  after  taking  food.  The 
vomiting  is  often  copious,  gaseous,  may  contain  remnants  of  undigested 
starchy  food,  and  is  of  intensely  acid  reaction.  It  is  likely  to  take  place  sev- 
eral hours  after  a  meal,  also  at  night.  The  unnc  is  scanty  and  there  is  con- 
stipation.  The  patients  gradually  emaciate  and  become  anemic,  even  though 
they  may  take  a  good  deal  of  food. 

A  very  frequent  consequence  of  continuous  hyperchlorhydria  is  dila- 
tation of  the  stomach,  as  originally  pointed  out  by  Riegel,  the  distinctive 
symptoms  of  which  may  ultimately  be  added.  The  dilatation  may  be  caused 
by  spasmodic  contraction  of  the  pylorus,  due  to  the  irritation  of  the  hyper- 
acid gastric  juice,  or  to  the  accumulation  of  fluid  and  undigested  food  in 
connection  with  a  nervo-motor  atony  of  the  muscular  coat  of  the  stomach. 
As  the  dilatation  increases  there  may  ensue  atrophy  of  the  glandular  struc- 
ture of  the  stomach,  and  while  the  hypersecretion  persists  the  hyperchlor- 
hydria gradually  diminishes  and  may  disappear.  In  such  event  there  may 
be  an  excess  of  fixed  chlorids  in  the  gastric  juice  secreted  by  the  mucous 
membrane,  which  is,  however,  incapable  of  elaborating  hydrochloric  acid. 
Gastritis  is  also  a  result  of  hyperchlorhydria  and  contributes  further  to  the 
symptoms,  especially  to  pain. 

Diagnosis. — A  positive  diagnosis  of  hyperchlorhydria  can  only  be 
made  through  analysis  of  the  gastric  contents.  This  is  done  in  the  sixth 
hour  after  a  test  dinner,  with  a  view  to  discovering  the  presence  of  an  excess 
of  hydrochloric  acid.  The  same  symptoms  may,  indeed,  be  caused  by 
organic  acids,  while  the  hydrochloric  acid  is  in  normal  amount.  If  the 
stomach  is  washed  out  in  the  evening  and  the  next  morning,  no  food  being 
ingested  in  the  meantime,  the  contents  are  expressed  and  found  to  be  hyper- 
chlorhydric,  the  condition  is  one  of  continuous  hyperchlorhydria.  ^vlicro- 
scopic  examination  of  the  gastric  contents  may  also  aid  in  the  diagnosis. 
Such  examinations  made  one  to  one  and  a  half  hours  after  a  test  breakfast 
or  three  to  four  hours  after  a  test  dinner,  will  often  reveal  a  large  number  of 
unaltered  starch-corpuscles,  instead  of  only  a  few  as  in  normal  digestion, 
while  the  so-called  snail-like  cells  are  often  found  in  this  condition,  as  orig- 
inally shown  by  Jaworski.  They  are  also,  however,  found  in  patients  with 
normal  secretion. 

Prognosis. — The  prognosis  of  simple  hyperchlorhydria  is  favorable ; 
that  of  the  continuous  form  is  grave,  the  disease  being  incurable  after  a 
certain  stage  has  been  reached.  It  becomes,  therefore,  important  to  treat 
the  simple  form  promptly  and  intelligently  before  it  passes  over  into  the 
continuous  form. 

Treatment. — The  indications  for  treatment  in  hyperchlorhydria  are 
evident.  Their  measure  should,  however,  be  based  upon  the  estimation  of 
the  acidity  of  the  gastric  contents.  They  are  fi)  to  neutralize  the  excessive 
acid  secretion,  and   (2)  to  restrain  its  formation. 

The  first  indication  is  met  in  two  ways  : 

(a)  By  saturating  the  acid  b}'  nitrogenous  food. 

(b)  By  the  administration  of  alkalies. 

(a)  The  former  is  fulfilled  by  the  use  of  meat  and  milk  diet.  It  has, 
however,  its  limits,  because  when  the  tendency  to  acid  secretion  exists,  it  is 
often  maintained  even  after  that  present  is  combined  with  any  albuminous 
food  that  may  be  in  the  stomach.    Hence  it  is  that  the  pain  is  felt  some  hours 


356  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

after  a  meal  when  the  albumin  is  digested,  (b)  Since  there  is  a  hmitation 
to  the  ingestion  of  meat  its  use  must  be  supplemented  by  antacids,  which 
further  neutralize  the  effect  of  the  acid.  The  alkali  most  frequently  employed 
for  this  purpose  is  sodium  bicarbonate,  though  calcined  magnesia  is  in  some 
respects  better  because  of  its  greater  saturating  power.  Prepared  chalk  was 
far  more  efficient  than  any  other  alkali  in  one  case  under  my  care.  An  idea 
of  the  amount  of  hydrochloric  acid  secreted  may  be  obtained  from  the  fact 
that  probably  a  half  liter  (about  a  pint)  of  gastric  juice  is  secreted  in  an  hour, 
four  or  five  liters  (8.4  to  10.5  pints)  in  three  hours,  and  should  such  gastric 
juice  contain  3  parts  of  HCl  in  1000,  a  proportion  often  exceeded  in  hyper- 
chlorhydria,  there  would  be  some  12  to  15  gm.  (180  to  225  grains)  of  the 
HCl  to  neutralize.  Since  i  gm.  of  hydrochloric  acid  requires  1.48  gm. 
sodiimi  carbonate,  20  to  25  gm.  (300  to  375  grains)  would  be  required  to 
neutralize  the  whole  amount  of  acid — a  large  quantity.  The  sodium  car- 
bonate should  be  administered  some  time  after  meals,  just  before  the  time 
the  pains  are  expected.  It  should  be  dissolved  in  water  or  milk,  or  put  in 
capsules  or  cachets.  The  doses  should  be  sufficient  to  counteract  the 
aciditv — /.  e.,  10  to  20  grains  (0.66  to  1.3  gm.)  or  more.  The  quantity  of 
carbonic  acid  evolved  sometimes  distends  the  stomach  uncomfortably.  Smaller 
doses  of  calcined  magnesia'  suffice,  and  if  is  surprising  that  its  use  is  not 
more  general.  It  has  the  disadvantage  of  being  insoluble  in  water,  but  not 
only  are  smaller  doses  sufficient,  but  there  is  also  absence  of  carbonic  acid 
evolution.     It  is  indicated  especially  where  there  is  constipation. 

Other  alkalies  .may  be  used,  such  as  the  potassium  salts,  and  the 
officinal  liquor  potasscc  in  15  to  to  30  drops  (0.8  to  1.7  c.  c.)  in  milk  may  be 
used  with  benefit.  The  benzoate  of  sodium  miay  be  prescribed  in  lo-grain 
(0.66  gm.)  doses  where  antisepsis  is  required  or  fermentation  is  present. 
Limc-ii'ater  is  also  useful,  but  large  doses  are  required,  as  its  neutralizing 
power  is  small.  One-half  ounce  to  an  ounce  (15  to  30  c.  c.)  or  more  should 
be  given.  Lime  dissolves  more  largely  in  saccharine  solution  than  in  pure 
water,  and  larger  doses  may  thus  be  given  in  smaller  bulk.  Dilute  alkaline 
mineral  waters,  such  as  Vichy  or  A'als  or  Contrexville,  may  be  used  during 
a  meal. 

(2)  Constitutional  treatment  should  be  directed  to  the  cause,  if  it  can 
be  ascertained,  neurosis  by  suitable  remedies,  chlorosis  by  iron  and  arsenic. 
Of  course,  it  is  better,  if  possible,  to  prevent  the  excessive  secretion  of  the 
juice.  For  this  purpose  sodium  sulphate  has  been  recommended,  more  par- 
ticularly in  the  shape  of  Carlsbad  water.  Or  the  sodium  sulphate  ma}-  be 
dissolved  in  Vichy,  say  45  to  90  grains  (3  to  6  gm.)  in  a  glass.  It  is  given 
in  the  morning  before  breakfast,  or,  if  necessary,  may  be  given  before  the 
other  meals. 

Diet. — While  the  medicinal  treatment  of  hyperchlorhydria  is  in  most 
cases  indispensable,  the  diet  is  equally  important.  It  has  already  been  said 
that  theoretically  a  meat  and  milk  diet  is  indicated,  because  meat  and  milk 
consume  in  their  digestion  the  excess  of  HCl.  On  the  other  hand,  the  starchy 
foods  are  but  imperfectly  digested.  Imbibing  the  acid  secretion,  they  swell 
up,  but  do  not  dissolve,  while  they  favor,  on  the  other  hand,  irritating  acid 
fermentation.  Others  object  to  meat  diet  because  of  its  overstimulating 
effect  on  the  acid  secretion,  and  recommend  vegetables  instead.  This  is, 
however,  fallacious,  and  experience  sustains  the  verdict  in  favor  of  meat 
and  a  minimum  of  starchy  foods.  It  should  be  finely  cut  and  well  masti- 
cated, while  meat  pow^der  may  be  substituted.     ]\Iilk  should  be  the  drink, 


HYPERCHLORHYDRIA.  357 

though  the  alkaUne  mineral  waters  may  be  taken  at  meals.  In  extreme  cases 
a  pure  meat  diet,  the  meat  raw  or  nearly  so,  finely  minced  and  spread  on 
bread,  may  be  necessary.  A  meal  may  consist  of  about  3  1-2  ounces  (100 
gm.)  of  raw  meat,  a  couple  of  thin  slices  of  stale  bread  or  Zwieback,  a  little 
butter,  and  a  glass  of  plain  water  or  weak  alkaline  water,  such  as  Vals  or 
Vichy.  Or  an  exclusive  milk  diet  may  be  tried,  in  which  event  the  milk 
should  be  well  alkalized  or  peptonized.  To  these  are  added,  as  the  case  im- 
proves, raw  meat  or  meat  powder  or  meat  juice  and  eggs,  and  later  still 
starchy  foods  may  be  tentatively  given,  associated  with  diastasic  malt. 
Where  acid  secretions  and  undigested  residue  of  food  remain  in  the  stomach 
long  after  the  ingestion  of  food,  the  organ  should  be  washed  out.  This  may 
be  done  two  or  three  times  a  week,  or  even  daily. 

In  these  cases  overstimulation  of  the  stomach,  induced  especially  by 
alcohol,  or  by  pepper,  mustard,  and  other  condiments,  should  be  avoided. 
In  like  manner  coarse  food  of  any  kind  is  contra-indicated  in  these  cases. 
On  this  account  constipation  is  sometimes  best  treated  by  enemas,  in  order 
to  avoid  the  administration  of  irritating  medicines  by  the  stomach. 

Of  medicines  other  than  those  intended  to  meet  the  symptoms,  arsenic, 
in  the  shape  of  Fowler's  solution,  is  sometimes  efficient.  Long  courses  of 
it  should  be  practiced,  but  large  doses  are  not  often  allowable  because  of 
the  irritation  excited  by  them.  Silver  nitrate  may  also  be  employed  in  doses 
of  1-4  grain  (0.0165  gm.),  in  which  dose  it  is  sometimes  sedative  when 
given  on  an  empty  stomach. 

Anorexia  Nervosa. — This  term  is  applied  to  a  condition  in  which 
absolute  loss  of  appetite  is  the  chief  and  characteristic  symptom.  Asso- 
ciated with  this  are,  naturally,  great  debility,  shortness  of  breath,  dizziness, 
constipation,  and  sometimes  headache ;  rarely,  also,  vomiting ;  sooner  or  later, 
emaciation.  In  women,  in  whom  the  symptoms  usually  occur,  there  is 
cessation  of  the  catamenia.     The  name  was  suggested  by  Sir  William  Gull. 

Prognosis. — This  is  favorable,  cases  being  rarely,  if  ever,  fatal. 

Treatment. — The  usual  tonic  measures  are  likely  to  fail  to  excite 
appetite  in  these  cases,  and  nourishment  must  often  be  given  either  by  the 
rectum  or  by  forced  feeding.  The  latter  is  done  as  follows :  A  short  rubber 
tube,  long  enough  to  reach  just  below  the  cricoid  cartilage,  is  introduced  as 
directed  on  page  323.  A  bottle  or  funnel  should  be  attached,  and  from  this 
liquid  nourishment  is  slowly  introduced.  This  may  be  milk,  plain  or  pep- 
tonized, broths  or  eggs,  Murdoch's  or  Mellin's  food.  Estimating  that  3  1-2 
ounces  fioo  gm.)  of  albumin,  5  ounces  (150  gm.)  of  fat,  and  10  ounces 
(300  gm.)  of  carbohydrates  are  a  sufficient  amount  per  diem,  Wiessner 
recommends  i  quart  (i  liter)  of  milk,  2  ounces  (60  gm.)  of  butter,  6  eggs, 
and  3  1-2  ounces  (100  gm.)  of  sugar  to  be  mixed  and  warmed  while  stir- 
ring. One-third  of  this  amount  is  introduced  three  times  daily.  The  food 
is  usually  easily  digested,  for  it  is  not  the  digestion  which  is  at  fault,  but 
the  appetite,  and  the  patient,  encouraged  by  the  result  of  forced  feeding,  is 
stimulated  to  eat  for  herself. 

Nervous  Vomiting. — A  form  of  vomiting  resulting  from  direct  or 
reflex  irritation  of  the  centers  presicling  over  vomiting,  and  independent 
of  anatomical  lesion  in  the  stomach.  Like  nervous  dyspepsia,  it  is  probably 
an  expression  of  a  general  irritable  condition  of  the  gastric  nerves — a 
manifestation  of  a  general  neurasthenia.  It  has  been  suggested  that  the 
exciting  cause  is  some  irritating  leukomain  of  unknown  nature. 


358  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Etiology. — Its  subjects  for  the  most  part  are  hysterical  and  neuras- 
thenic women,  more  often  of  dark  complexion;  but  it  is  also  the  result  of 
disease  of  the  brain  and  its  membranes  and  of  the  medulla  and  spinal  cord, 
such  as  tabes  dorsalis,  when  it  may  take  the  place  of  other  symptoms  of 
gastric  crisis.  It  is  apt  to  be  associated  with  headache  and  gnawing  sensa- 
tions in  the  stomach,  with  diseases  of  the  kidneys,  liver,  uterus,  and  other 
distant  organs.  While  more  usual  in  adults,  it  may  also  occur  in  children. 
Pure  nervous  vomiting  is  especially  seen  in  neurotic  families  in  which  there 
is  a  tendency  to  nervous  disease,  including  insanity  and  epilepsy.  On  the 
other  hand,  the  absence  of  the  hysterical  temperament  is  often  conspicuous. 
It  affects  rather  the  upper  classes. 

Symptoms. — Especially  characteristic  of  nervous  vomiting  are  the 
absence  of  nausea,  the  suddenness  of  the  act  of  vomiting,  and  the  absence  of 
the  straining.  ]\Iore  rarely  there  is  nausea.  The  appetite  is  good  and  the 
vomiting  generally  follows  a  meal,  but  it  may  also  occur  at  irregular  intervals. 
In  the  absence  of  organic  nervous  disease  the  patient  may  be  well  nourished. 
There  may  also  be  constipation,  headache,  dizziness,  and  epigastric  pulsation. 
Intense  acidity  of  the  vomited  matter  may  be  present.  To  this  condition 
Rosenbach  has  applied  the  term  nervous  gastroxynsis.  In  one  of  his  cases 
the  HCl  reached  four  per  cent.  In  the  typical  form,  however,  the  vomitus 
is  not  abnormally  acid,  and  in  this  respect  it  differs  from  acid  dyspepsia  and 
Reichmann's  disease.  The  duration  of  the  vomiting  varies.  It  may  be  a 
single  act  or  it  may  last  for  twenty-four  hours. 

Diagnosis. — This  is  based,  in  the  first  place,  on  the  exclusion  of  those 
organic  diseases  of  the  stomach  which  cause  vomiting,  and,  in  the  second 
place,  on  the  presence  of  any  one  of  the  affections  named  as  possible  causes. 

Prognosis. — Except  when  associated  with  organic  nervous  disease,  this 
is  ultimately  favorable.  George  M.  Garland  *  reported  a  fatal  case  of  ap- 
parently pure  nervous  vomiting.  At  autopsy  the  mucous  membrane  of  the 
stomach  was  found  thin,  and  reddened  on  its  inner  surface  with  minute 
hemorrhagic  points.  There  was  slight  interstitial  nephritis  too  insignificant 
to  have  had  any  effect,  and  the  gastric  changes  were  probably  secondary, 
so  that  the  case  may  be  regarded  as  purely  neurotic. 

Treatment. — When  vomiting  is  the  result  of  organic  nervous  disease, 
the  fundamental  treatment  must  be  that  of  the  disease  itself.  Temporary 
relief  may  be  afforded  such  cases  by  measures  which  make  a  profound 
nervous  impression.  Such,  pre-eminently,  is  the  blister  to  the  epigastrium. 
The  suddenness  and  irregularity  of  the  vomiting  make  it  almost  impossible 
to  provide  against  a  given  event.  So  that  ice,  internal  or  external,  sinapisms, 
dry  cupping,  and  similar  measures  efficient  in  continuous  vomiting  or  in 
vomiting  preceded  by  nausea  are  scarcely  available.  When,  however,  cir- 
cumstances permit  their  employment,  they  should  be  used. 

Nerve  sedatives,  including  the  bromids  and  valerian,  may  be  used,  but 
hypodermic  injections  of  inorphin  are  often  necessary,  and  are  usually  very 
efficient.  When  practiced  by  the  physician  only,  they  become  a  safe  measure. 
Rectal  alimentation  should  be  employed  when  the  vomiting  is  obstinate,  and 
has  apparently  saved  life  in  many  instances.  When  there  is  nervous  gas- 
troxynsis, lavage  with  warm  water  may  be  used  with  advantage,  as  recom- 
mended by  Rosenbach.  The  headache,  etc.,  apt  to  be  associated  with  this 
form  is  at  once  relieved. 

*  Garland,  G.  M.,  "  Trans,  of  the  Assoc,  of  Am.  Physicians,"  vol.  iv.,  i88g. 


GASTRIC  AND  DUODENAL  ULCERS.  359 


GASTRIC  AND  DUODENAL  ULCERS. 

Synonyms. — Ulcus  ventriculi  pepticum;  Peptic   Ulcer;  Simple  or  Round 

Ulcer. 

Etiology. — There  is  probably  more  than  one  mode  of  origin  of  gastric 
ulcer.  It  may  have  its  origin  in  mechanical  injury  associated  with  feeble 
nutrition,  which  permits  the  gastric  juice  to  digest  out  the  mucous  mem- 
brane to  various  depths,  resulting  in  the  formation  of  an  ulcer.  Such 
mechanical  injury  may  be  due  to  pressure  exerted  in  the  course  of  one's 
occupation,  such  as  shoemaking,  washing,  tailoring,  and  the  like,  in  which 
pursuits  the  costal  cartilages  are  pressed  against  the  stomach.  The  second 
of  these  conditions — for  it  is  likely  that  neither  would  be  alone  sufficient  to 
produce  the  lesion — is  produced  by  such  states  as  aner/iia,  chlorosis,  heart 
disease,  Bright's  disease,  and  the  like.  Over  distention  of  the  stomach,  it  is 
claimed,  may  be  a  predisposing  cause  by  interfering  with  its  proper  nutri- 
tion and  thus  favoring  the  action  of  the  gastric  juice. 

Thrombosis  and  embolism  have  been  held  responsible  for  a  certain  num- 
ber of  cases  of  ulcer  since  Virchow  called  attention  to  such  causes.  Embo- 
lism of  the  gastric  blood-vessels  is  extremely  rare,  but  thrombosis  is  a  not 
infrequent  result  of  obstinate  vomiting,  as  is  also  punctiform  hemorrhage. 
The  stasis  of  circulation  thus  resulting  affords  favorable  foci  for  the  sol- 
vent action  of  the  gastric  juice,  and  certainly  no  theory  explains  so  satisfac- 
torily the  crater  shape  of  many  gastric  ulcers.  Bottcher  ascribes  ulcer  of  the 
stomach  to  micrococci,  numbers  of  which  have  been  found  by  him  in  the 
margins  of  gastric  ulcers.  The  well-known  clinical  fact  that  the  gastric  juice 
in  ulcer  of  the  stomach  exhibits  intense  acidity,  while  traumatic  ulcers  of  the 
stomach  produced  under  ordinary  circumstances  tend  to  heal  promptly,  has 
led  to  the  suggestion  that  undue  acidity  plays  an  important  role  in  the  causa- 
tion of  ulcer.     The  same  causes  operate  to  produce  the  duodenal  ulcer. 

The  statements  of  authors  as  to  the  frequency  of  ulcer  of  the  stomach 
vary  greatly.  Thus,  Ewald  says  5  per  cent,  of  Germans  have  ulcer.  Truly, 
the  disease  is  not  nearly  so  common  in  America.  Yet  the  discovery  at 
autopsies  of  unexpected  ulceration  goes  to  show  that  it  may  be  more  frequent 
than  is  supposed.  Women  are  much  more  frequent  victims  than  men. 
While  both  the  very  young  and  the  very  old  are  commonly  exempt,  the  period 
being  between  seventeen  and  twenty-five,  gastric  ulcer  has  been  found  in 
infants  and  in  adults  as  old  as  sixty.  In  women  gastric  ulcer  usually  occurs 
between  the  ages  of  twenty  and  thirty ;  in  men,  between  thirty  and  forty. 

Duodenal  nicer,  on  the  other  hand,  is  more  common  in  males,  in  the 
proportion  of  178  to  41,  in  the  combined  statistics  of  Kraus,  Chvostek,  Lebert, 
Trier,  and  William  Osier.  The  last-named  observer  found  it  once  in  a  boy  of 
twelve.  Its  association  with  extensive  superficial  burns  and  tuberculosis 
should  be  mentioned.  It  is  commonly  situated  within  i  I-2  inches  of  the 
pylorus,  though  Schwartz  reports  a  case  where  perforation  was  found  on  a 
level  with  or  a  little  below  the  ampulla  of  Vater,  permitting  a  free  escape  of 
bile  into  the  peritoneal  cavity.*  This  condition  is  much  more  apt  to  be  con- 
founded with  other  surgical  lesiohs  of  the  abdomen,  and  especially 
appendicitis. 

*  Quoted  bv  Robert  F.  Weir  in  an  admirable  paper  on  "  Perforating  Duodenal  Ulcers,"  in  "  The 
Medical  News,"  May  s,  igoo,  p.  690. 


360  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Morbid  Anatomy, — Gastric  ulcer  must  be  distinguished  from  post- 
mortem softening  or  digestion,  which  is  found  after  death  in  stomachs  in 
which  gastric  juice  happens  to  be  present  at  the  moment  of  death.  In  this 
there  may  be  erosion  of  the  superficial  mucosa,  but  nothing  comparable  to 
ulcer.  The  seat  of  postmortem  softening  is  more  commonly  the  fundus  and 
posterior  surface,  where  the  gastric  juice  naturally  collects. 

The  typical  gastric  ulcer  is  circular  in  outline,  often  with  sloping,  clean- 
cut  sides,  furnishing  a  crater  or  truncated  cone  shape,  with  the  broad  end 
superficially  placed,  corresponding  to  that  of  an  infarcted  area  due  to  embo- 
lism or  thrombosis.  The  term  "  punched  out  "  has  long  been  applied  to  char- 
acterize the  appearance  of  a  gastric  ulcer.  The  sides  are  not  always,  how- 
ever, smooth,  being  sometimes  uneven  or  "  terraced."  Aery  rarely  ulcer 
mav  be  multiple.  It  is  far  more  frequent  on  the  posterior  wall  of  the 
stomach  near  the  lesser  curvature.  W.  H.  Welch's  extensive  studies  of  hos- 
pital records  furnish  the  total  of  783  cases,  of  w-hich  288  were  in  the  lesser 
curvature,  225  on  the  posterior  wall.  95  at  the  pylorus.  69  on  the  anterior  wall, 
50  at  the  cardia,  29  at  the  fundus,  and  27  in  the  greater  curvature.  The 
lesser  curvature  and  posterior  wall  are,  therefore,  the  miore  frequent  seats. 
This  is  the  result  also  of  Langerhans'  studies,  though  Ewald  and  Nolte,  from 
a  very  much  smaller  number  of  cases,  conclude  that  more  ulcers  are  found  at 
the  greater  curvature  and  pylorus.  The  duodenal  ulcer  is  found  just  out- 
side the  pylorus,  but  m.ay  occur  as  low  dovrn  as  the  biliary  papule.  It  pre- 
sents the  same  appearance  as  the  characteristic  gastric  ulcer. 

The  floor  of  the  ulcer  is  usually  the  muscular  coat,  but  it  may  be  the 
serous  coat,  which  is  sometimes  perforated  so  that  the  floor  may  be  formed 
by  an  adjacent  organ  to  which  the  stomach  has  been  glued  by  adhesive  inflam- 
mation. The  ulcer  is  usually  small,  not  larger  than  a  pea,  but  it  may  be  10 
or  even  15  cm.  (4  to  6  inches)  in  diameter,  covering  the  whole  lesser  curva- 
ture and  part  of  the  anterior  and  posterior  walls.  Ulcers  may  heal,  leaving 
a  cicatrix,  which,  if  large,  causes  contraction  and  deformity,  distorting  the 
organ  even  to  an  hour-glass  shape  and  producing  stenosis  of  the  pylorus.  It 
is  not  unusual  to  find  healed  ulcers  at  autopsies.  Or  tJie  ulcer  may  perforate, 
causing  fatal  peritonitis  when  in  the  anterior  wall ;  or,  if  apposed  to  neighbor- 
ing organs,  these  may  be  burrowed  into.  Thus  the  pericardium  and  left  ven- 
tricle, the  spleen,  the  head  of  the  pancreas,  the  left  lobe  of  the  liver,  the  gall- 
bladder, the  omental  tissues,  the  pleura,  and  even  the  lungs  have  been  invaded, 
while  fistulous  communications  have  been  formed  with  the  duodenum,  the 
colon,  and  even  the  external  air  jn  the  neighborhood  of  the  umbilicus.  Per- 
foration of  the  posterior  wall  opens  the  lesser  peritoneal  cavity,  and  may  per- 
forate the  pleura,  producing  subphrenic  pyopneumothorax. 

It  is  not  unusual  to  see  at  the  bottom  of  an  ulcer  an  eroded  blood-vessel 
from  which  there  has  been  a  fatal  hemorrhage.  The  vessels  invaded  may 
be  the  gastric  artery  of  the  lesser  curvature,  or  the  splenic  artery  in  the  pos- 
terior wall ;  or,  in  the  case  of  a  duodenal  ulcer,  the  pancreatico-duodenal 
artery;  or  it  may  be  the  hepatic  artery,  and  even  the  portal  vein.  Small 
aneurysms  have  been  found  in  the  floor  of  an  ulcer. 

Gastric  ulcer  may  be  multiple,  it  is  said,  as  often  as  once  in  every  five 
cases.  Osier  records  a  case  in  which  there  were  5  ulcers  and  refers  to  a  case, 
reported  by  Berthold,  in  which  there  were  34. 

Symptoms. — The  most  prominent  symptoms  of  ulcer  of  the  stomach 
are  pain,  tenderness,  vomiting,  hciuorrhage,  and  sometimes  a  tumor,  but 
none  of  these  is  invariably  present.     They  require  to  be  separately  considered. 


GASTRIC  AND  DUODENAL  ULCERS.  361 

Pain,  with  tenderness,  is  the  most  constant  symptom.  It  is  character- 
istic of  the  pain  of  ulcer  of  the  stom^ach  that  it  occurs  almost  immediately 
after  taking  food,  especially  after  cold  or  hot  and  indigestible  food;  but  it 
may  also  occur  in  an  empty  stomach — that  is,  several  hours  after  a  meal, 
when  all  food  has  disappeared.  The  latter  pain  is,  however,  of  a  different 
kind,  being  of  a  gnawing  character,  and  is  even  temporarily  relieved  by  tak- 
ing food.  The  pain  typical  of  ulcer — a  gastralgia,  coming  on  in  from  ten 
minutes  to  half  an  hour  after  eating — is  perhaps  due  not  so  much  to  the 
presence  of  the  food  as  to  the  irritant  effect  of  the  acid  gastric  juice  called 
out  to  digest  it.  It  varies  greatly  in  severity,  and  is  further  characterized  by 
having  a  definite  center  of  greatest  intensity,  commonly  in  the  epigastrium 
near  the  xiphoid,  less  often  at  a  point  behind  the  shoulders,  from  which  it 
radiates  in  all  directions.  A  change  of  position  also  sometimes  increases  it, 
especially  turning  to  the  right  side,  probably  due  to  the  irritation  of  the  ulcer 
by  the  moving  gastric  contents.  The  paroxysms  are  sometimes  of  inde- 
scribable severity,  requiring  the  hypodermic  use  of  morphin  to  relieve  them, 
though  they  may  also  be  relieved  at  times  by  a  full  dose  of  sodium  bicarbon- 
ate, the  effect  of  which  also  explains  their  immediate  causation.  Commonly 
increased  by  pressure,  it  is  sometimes  relieved  by  it.  and  the  patient  will  bend 
over,  pressing  his  fist  into  the  epigastrium  or  leaning  over  the  back  of  a  chair 
to  secure  relief. 

Tenderness  on  pressure  is  a  characteristic  symptom,  apart  from  the  par- 
oxysms of  pain ;  and  in  order  to  guard  against  it,  the  patient  may  wear  the 
waistband  low.  Boas  has  devised  an  instrument  by  which  circumscribed 
pressure  may  be  conveniently  induced  and  diagnosis  facilitated.  It  is,  how- 
ever, necessary  to  exercise  care  in  such  pressure,  as  perforation  mav  be  pro- 
duced. The  tender  point  is  more  frequently  an  inch  or  tzuo  above  the  um- 
hiliciis.  In  cases  of  ulcer  of  long  standing  palpation  may  recognize  a 
tumor,  the  result  of  inflammatory  thickening  in  the  vicinity,  and  I  well 
remember  a  case  where,  in  consequence  of  the  distinctness  of  the  tumor,  I 
diagnosed  with  some  confidence  a  cancer  of  the  pylorus,  and  a  few  days 
later  the  patient  died  of  a  hemorrhage  from  the  stomach.  An  autopsy 
revealed  extraordinary  thickening  of  the  pylorus,  penetrated  to  a  great  depth 
by  an  ulcer,  at  the  bottom  of  which  lay  a  little  perforated  artery,  whence  came 
the  fatal  hemorrhage. 

Vomiting  is  not  so  frequent  a  symptom.  When  present,  it  occurs 
usually  soon  after  the  ingestion  of  food,  about  the  same  time  as  the  pain.  It 
often  includes  acrid  acid  matters. 

And  this  brings  us  to  hemorrhage — hematemesis — a  most  valuable  sign 
of  gastric  ulcer.  Given  a  copious  hemorrhage  of  pure  red  blood  from  the 
stomach,  with  the  symptoms  described,  or  even  no  other  symptoms,  it  can 
scarcely  be  due  to  any  other  cause  ;  since  although  cancer  gives  rise  to  hemor- 
rhage, the  blood  is  mixed  with  mucus ;  it  is  usually  less  copious,  while  a 
cancer  with  hemorrhage  rarely  fails  to  furnish  also  the  other  symptoms  of 
cancer.  In  a  few  instances  in  ulcer  the  hemorrhage  is  small,  when,  of  course, 
the  diagnosis  becomes  more  difficult.  When  the  hemorrhage  is  large,  blood 
quite  black  is  found  also  in  the  stools.  Indeed,  sometimes  the  presence  of 
blood  in  the  stools  is  the  first  intimation  of  gastric  hemorrhage.  Especially 
is  this  the  case  when  the  ulcer  is  duodenal.  A  very  remarkable  case  of  this 
kind  came  under  my  care  in  a  nurse  at  the  Philadelphia  Hospital.  When  I 
first  saw  her,  her  appearance  and  condition  suggested  hemorrhage  from 
somewhere.     She  was  extremely  weak,  and  her  lips  were  bloodless.     Her 


362  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

skin  was  as  white  as  marble.  Yet  no  sign  of  hemorrhage  appeared  at  the 
time  of  examination.  Three  hours  later  she  had  a  copious  hemorrhage  from 
the  stomach,  and  further  examination  elicited  the  fact  that  Jier  stools  had 
contained  blood  for  tz^'o  days.  Hemorrhages  from  ulcer  are  also  often  recur- 
rent, and  result  at  times  in  intense  anemia  of  the  subject.  They  are  not 
rarely  fatal,  more  frequently  syncopal,  bringing  their  subjects  to  the  verge 
of  the  grave,  from  which  there  are  often  also  surprising  recoveries.  A  hema- 
temesis  of  10  pounds  (41-2  kilos)  is  said  to  have  been  followed  by  recovery. 
Vicarious  hemorrhage  in  menstruating  women  is  to  be  remembered  as  a 
possible  event,  but  the  hemorrhage  is  not  usually  copious,  and  its  associa- 
tion with  amenorrhea  aids  in  clearing  up  doubt.  Hemorrhage  occurs  in 
more  than  half  the  cases,  at  least  in  hospital  practice,  since  the  severest  cases 
come  to  hospitals.     In  private  practice  the  proportion  is  smaller. 

In  this  place  it  may  be  appropriate  to  mention  what  has  been  called 
parenchymatous  hemorrhage,  in  which  there  has  been  fatal  hematemesis  in 
which  no  ulcer  has  been  found  at  necropsy.  It  is  more  than  likely  that  some 
of  these  cases  may  have  been  cases  in  which  the  ulcer  eluded  examination, 
but  others  are  too  well  authenticated  to  be  thus  explained. 

Perforation  is  a  rare  accident  in  ulcer  of  the  stomach.  It  is  variously 
stated  at  from  6  to  18  per  cent,  of  all  cases.  Its  characteristic  symptoms  are 
sudden  and  violent  pain,  extreme  tenderness,  rigid  contraction  of  the 
abdominal  muscles,  profound  shock,  shallow  breathing,  and  absence  of  the 
normal  hepatic  dullness — in  a  word,  the  symptoms  of  peritonitis,  followed  by 
those  of  shock.  Perforation  is  much  more  frequent  when  the  ulcer  is  in  the 
anterior  wall.  Thus,  in  13  cases  reported  by  A.  B.  Mitchell  to  the  "  British 
Aledical  Journal,"  March  10,  1890,  all  were  in  the  anterior  wall. 

The  milder  symptoms  of  dyspepsia  may  also  be  present  in  various 
degrees,  including  a  sense  of  fullness  in  the  epigastrium,  acid  eructations, 
heartburn,  and  loss  of  appetite. 

Patients  with  gastric  ulcer  lose  in  weight  and  become  gradually  anemic, 
quite  independent  of  hemorrhage,  a?  evidenced  by  a  blood  count,  which  some- 
times finds  the  red  corpuscles  less  than  a  million  to  the  cubic  millimeter. 
This  is  probably  due  to  the  fact  that  they  are  afraid  to  eat  enough  because  of 
the  pain  food  gives  them  when  taken  into  the  stomach.  This  anemia  is  even 
a  characteristic  symptom,  and  should  at  once  suggest  a  close  examination  as 
to  a  possible  cause  in  ulcer. 

Chemical  examination  of  the  stomach-contents  after  a  test  meal  almost 
invariably  shows  an  increase  oi  HCl.  Exception  sometimes  occurs  when 
chronic  catarrhal  gastritis  is  associated. 

Finally,  it  is  to  be  remembered  of  gastric  ulcer  that  it  is  often  latent 
throughout,  quite  without  symptoms  during  life,  and  recognized  for  the  first 
time  at  necropsy,  when,  also,  as  already  stated,  healed  ulcers  are  sometimes 
found. 

Course  and  Termination. — The  course  of  ulcer  is  usually  slow,  some- 
times very  protracted.  One  case,  which  had  lasted  twenty  years,  confirmed 
hy  autopsy,  came  under  my  treatment.  A  few  cases  are  acute  and  rapidly 
fatal.  The  symptoms  of  gastric  ulcer  quite  frequently  disappear,  and  after  a 
time,  even  considerable  time,  recur  giving  rise  to  the  so-called  recurrent 
forms. 

Diagnosis. — In  some  cases  this  is  easy ;  in  others,  difificult  or  impossible. 
If  hemorrhage  of  the  kind  described  is  present  in  connection  with  the  other 
symptoms  named,  it  affords  conclusive  evidence  of  ulcer,  but  in  its  absence 


GASTRIC  AND  DUODENAL  ULCERS.  363 

there  must  often  remain  doubt.  Aside  from  hemorrhage  the  most  character- 
istic symptom  is  pain,  and  only  in  gastralgia  and  tabes  dorsahs  do  such  pains 
occur. 

In  gastralgia,  as  in  ulcer,  hydrochloric  acid  is  increased,  and  the  ques- 
tion often  becomes  a  m.ost  difficult  one  to  settle.  In  gastralgia,  however,  the 
general  health  of  the  patient  is  less  severely  affected,  there  is  less  chlorosis  or 
menstrual  derangement,  and  the  pain  has  a  less  definite  relation  to  taking 
food, — indeed,  is  often  relieved  by  food, — while  in  ulcer  the  symptoms  of  dys- 
pepsia are  more  constant.  There  are  longer  intervals  between  the  attacks  in 
gastralgia.  Above  all,  in  ulcer  there  is  tenderness  on  pressure  between  the 
attacks  of  pain,  a  symptom  absent  from  gastralgia,  while  pressure  always 
relieves  the  pain  of  the  latter.  Indeed,  in  gastralgia  dyspeptic  symptoms  be- 
tween the  attacks  are  generally  absent.  If  palpation  recognizes  a  hardening, 
there  is  further  reason  to  believe  the  case  is  one  of  ulcer,  ^^'e  may  look  for 
assistance  from  the  standpoint  of  etiology.  Given  the  causes  of  ulcer,  espe- 
cially valvular  heart  disease  with  possible  embolism,  the  vomiting  which  pro- 
duces thrombosis,  or  the  occupations  which  favor  gastric  ulcer,  their  import 
should  be  recognized.  Gastralgia  occurs  in  neurotic  individuals — those  sub- 
ject to  hysteria  and  uterine  disease.  \'on  Leube  has  called  attention  to  an 
electrical  test  between  gastralgia  and  ulcer — viz.,  if  during  digestion  an  elec- 
trical current,  especially  with  the  anode  as  a  testing-pole,  be  applied,  and  the 
pain  disappears  completely,  it  is  indicative  of  gastralgia ;  if,  however,  it  does 
not  cease,  it  may  be  either  gastralgia  or  ulcer.  Only  the  positive  effect,  the  sud- 
den cessation  of  pain  on  the  application  of  the  current,  is  of  diagnostic  value. 

In  tabes  the  gastric  crises  are  almost  identical  with  the  severe  gastralgic 
attacks  of  ulcer.  But  in  tabes  the  appearance  of  good  health  is  preserved, 
while  it  is  not  long  before  the  distinctive  symptoms  of  the  disease  show  them- 
selves, if  they  are  not  already  present — viz.,  lightning  pains,  ocular  symp- 
toms, and  absence  of  knee-jerks.  In  tabes  the  extreme  acidity  of  the  gastric 
contents   characteristic  of  ulcer  is  wanting  in  most  instances. 

In  rare  cases  intercostal  neuritis  may  be  mistaken  for  ulcer,  if  there  be 
pain  in  the  epigastrium  associated  with  accidental  dyspeptic  symptoms.  But 
in  this  aft'ection  painful  points  will  also  be  found  in  the  course  of  the  inter- 
costal nerves,  while,  if  a  large  fold  of  the  abdominal  wall  be  raised,  tender 
points  will  be  found  in  it. 

From  cancer  of  the  stomach  ulcer  sometimes  is  distinguished  with  diffi- 
culty in  the  absence  of  the  more  distinctive  symptoms  of  the  former  disease. 
Heretofore  much  reliance  has  been  placed  on  the  absence  or  extreme  dimi- 
nution of  free  hydrochloric  acid  in  cancer  as  contrasted  with  its  excess  in 
ulcer.  It  has,  however,  been  realized  also  that  it  occasionally  happens  that 
the  association  of  chronic  catarrhal  gastritis  with  ulcer  may  work  reduction 
of  HCl.  The  recent  researches  of  Boas  have,  if  confirmed,  added  a  very 
much  more  reliable  diagnostic  sign  in  the  invariable  presence  of  lactic  acid 
in  cancer  and  its  constant  absence  in  ulcer,  and,  indeed,  under  all  circum- 
stances in  which  it  has  not  been  introduced  from  without.  Other  facts  to 
be  weighed  in  the  balance  as  to  the  existence  of  cancer  are  a  palpable  tumor, 
the  greater  age  of  the  patient  (always  over  thirty),  the  extreme  emaciation 
and  cachectic  appearance,  and  the  intermittent  vomiting  of  large  quantities 
of  accumulated  ingesta,  sometimes  of  blood  mixed  with  mucus,  or  blood  pre- 
senting the  "  coft'ee-grounds  "  character  as  contrasted  with  the  bright  clear 
blood  of  ulcer. 

Rarelv  is  duodenal  ulcer  distinguished  before  death  from  gastric  ulcer, 


364  DISEASES  OF   THE  DIGESTIJ^E  SYSTEM. 

though  Burwinkel  claims  that  by  a  careful  study  of  the  symptoms  he  has 
been  able  to  diagnose  five  cases  of  duodenal  ulcer  in  the  last  five  years.  The 
former  mav  be  suspected  when  pain  is  in  the  right  hypochondriac  region 
two  or  four  hours  after  eating :  also,  if  the  blood  be  discharged  by  the  bowel 
rather  than  vomited.  \'omiting  is  less  frequent  than  in  gastric  ulcer,  and 
does  not  afford  relief,  as  in  the  former.  Jaundice  is  more  frequent  in  duo- 
denal ulcer.  Jaundice  is,  however,  more  constantly,  though  not  invariably, 
associated  with  biliary  colic,  which  has  also  been  mistaken  for  ulcer.  In 
biliary  colic  the  liver  may  be  enlarged  and  tender  and  the  gall-bladder  dis- 
tended, while  the  vomiting,  which  attends  it  as  well  as  ulcer,  is  much  less  acid 
in  reaction. 

Attempts  to  locate  the  ulcer  still  more  precisely  have  generally  proved 
fruitless.  Even  when  a  single  painful,  unchanging,  circumscribed  spot  has 
been  noted,  the  apparent  seat  so  rarely  coincides  with  the  actual  seat  that  little 
encouragement  is  afforded  further  attempt.  When  pain  immediately  suc- 
ceeds deglutition,  especially  of  solids  and  hot  and  cold  liquids,  there  is  some 
reason  to  believe  that  the  ulcer  is  in  the  neighborhood  of  the  cardia,  but  it  is 
by  no  means  conclusive. 

Prognosis. — Xot  only  the  disappearance  of  symptoms,  but  also  the  dis- 
covery of  numerous  healed  ulcers  at  autopsies  of  patients  dying  from  other 
causes,  attest  the  fact  that  recoveries  are  not  infrequent.  Death  is  caused,  as 
a  rule,  by  hemorrhage  or  perforation,  the  latter  followed  by  fatal  peritonitis. 
At  least  six  per  cent,  of  all  cases  terminate  in  perforation,  which,  previous  to 
the  institution  of  operative  treatment,  was  followed  by  death  in  the  vast 
majority  of  cases,  in  a  few  hours.  The  proportion  of  death  in  all  cases  is 
estimated  by  \\\  H.  Welch  and  A.  B.  ]\Iitchell  at  15  per  cent.  ;*  by  Heyden- 
reich  at  from  25  to  30  per  cent.  ;t  by  v.  Leube  at  10  per  cent. 

Treatment. — The  indications  for  treatment  are  evident,  and  are,  in  the 
main,  easily  fulfilled.  It  is  plain,  in  the  first  place,  that  food  which  taxes  the 
secretory  or  motor  functions  of  the  stomach  is  harmful,  and  that  recovery 
will  be  still  more  likely  to  occur  if  the  stomach  can  be  placed  at  total  rest,  a 
condition  easily  met  by  rectal  alimentation.  It  is  clear,  too,  that  absolute  rest 
of  body  further  fulfills  such  conditions.  The  greater  the  stringency  with 
which  these  measures  can  be  carried  out.  the  greater  the  chances  of  a  cure, 
which  is  always  possible.  It  goes  without  saying  that  all  solid  food  should 
be  disallowed.  The  typical  nourishment  in  my  experience  is  peptonized 
milk,  which  should  be  given  at  stated  intervals,  the  quantity  adapted  to  the 
urgency  of  the  symptoms,  say  2. ounces  (60  c.  c.)  every  two  hours,  though 
even  this  amount  may  have  to  be  reduced  in  serious  cases,  to  be  increased  as 
danger  subsides  and  the  appetite  of  the  patient  demands  it.  Beef  peptonoids 
and  egg-albumen  may  be  substituted  for  milk,  or  they  may  be  conjoined 
with  it. 

So,  too.  when  extreme  danger  of  repeated  hemorrhages  is  present,  it  is 
a  warning  that  rectal  alimentation  alone  should  be  relied  upon :  for  which 
purpose,  too.  peptonized  milk  is  also  the  best  nutrient.  Great  care  must  be 
exercised  in  the  use  of  enemas  not  to  exhaust  the  toleration  of  the  bowel. 
To  this  end  they  should  be  given  at  first  tentatively  and  never  oftener  than 
once  in  eight  hours,  and  should  not  at  first,  at  least,  exceed  four  ounces.  This 
quantity,  if  borne,  may  be  increased  to  six  ounces.  The  various  meat  pep- 
tones, bouillon,  or  beef-juice  may  be  substituted  for  or  alternated  with  the 

*  "  British  Med.  Jour.,"  March  lo,  looo.  p.  560. 

t  Ibid.s  p.  364;  quoted  by  Mayo-Robson  from  "Semaine  Medicale,"  February  2,  1898. 


GASTRIC  AND  DUODENAL  ULCERS.  365 

peptonized  milk,  or  an  egg  may  be  beaten  up  with  the  milk,  though  such  addi- 
tion is  not  often  necessary.  A  nutrient  injection  which  has  given  great  satis- 
faction at  the  Hospital  of  the  University  of  Pennsylvania  consists  of  four 
ounces  of  milk  (130  c.  c),  to  which  are  added  tv/o  eggs,  a  pinch  of  salt  and 
three  drops  of  laudanum,  the  whole  being  predigested  with  pancreatin.  The 
enema  should  be  given  through  a  long  rectal  tube,  the  patient  having  the  hips 
elevated  and  the  position  maintained  for  an  hour  after  the  injection.  In  this 
way  patients  may  be  nourished  for  weeks  with  peptonized  food,  but  it  is  rarely 
necessary  to  continue  the  rectal  alimentation  for  more  than  a  week  or  ten 
days.  As  the  hemorrhage  and  vomiting  cease  the  stomach  may  be  tested, 
first  with  small  amounts  of  peptonoids,  gradually  increased ;  and  for  a  time 
the  two  methods  may  be  pursued  jointly,  feeding  by  the  mouth  being 
increased,  while  that  by  the  rectum  is  gradually  withdrawn.  Plain  milk  and 
beef- juice  may  be  substituted  for  peptonized  milk,  and  various  thin  gruels 
made  with  flour  may  be  used  as  a  change  is  demanded. 

Lavage,  which  is  of  such  signal  service  in  chronic  gastric  catarrh,  is 
hardly  safe  in  ulcer  on  account  of  the  danger  of  producing  perforation ;  but  in 
some  cases,  when  vomiting  has  been  obstinate,  lavage  has  been  found  bene- 
ficial. To  arrest  the  vomiting,  it  is  safer  to  rely  on  rectal  alimentation, 
though  the  usual  remedies  may  be  tried,  including  blisters  to  the  epigastrium. 

Medicines  are  not  to  be  decried  in  ulcer  of  the  stomach.  Silver  nitrate 
maintains  the  reputation  it  has  so  long  enjoyed  in  the  treatment  of  gastric 
ulcer.  One  quarter  of  a  grain  (0.016  gm.)  three  times  a  day  or  1-6  of  a 
grain  (o.oii  gm.)  four  times  are  the  usual  doses,  given  on  an  empty 
stomach.  Of  late  I  have  been  giving  it  by  preference  in  solution  in  about  2 
ounces  (60  c.  c.)  of  water.  If  there  is  pain,  the  extract  of  opium  should  be 
combined  in  pill  in  the  same  or  larger  doses,  but  should  be  dispensed  with  as 
soon  as  not  needed.  The  extract  of  belladonna  in  small  doses  may  be  sub- 
stituted as  the  opium  is  withdrawn.  Its  anodyne  effect  is  perhaps  slight, 
but  it  has  a  good  effect  upon  the  bowels.  Local  measures  may  be  employed 
to  relieve  the  pain,  such  as  warm  poultices  and  other  hot  fomentations  to  the 
epigastrium ;  and  when  more  potent  measures  are  needed,  morphin  may  be 
used  hypodermically. 

The  hemorrhage  requires  also  to  be  met  by  remedies.  For  the  present 
all  astringent  remedies  have  given  place  to  suprarenal  extract  or  its  active 
principle  adrenalin,  of  which  5  drops  of  a  solution  i  to  1000  are  a  dose 
repeated.  Gelatin  is  a  modern  remedy  of  which  the  value  is  exaggerated. 
It  may,  however,  be  used,  especially  as  it  serves  also  the  purposes  of  a  food. 
Two  to  three  ounces  may  be  given  every  six  hours.  Among  the  older 
remedies  tannic  acid  is  one  of  the  best — in  15-grain  (i  gm.)  doses,  every 
fifteen  minutes,  until  the  bleeding  ceases.  In  the  absence  of  this  drug 
alum  may  be  given,  dissolving  a  teaspoonful  in  a  glass  of  water,  of  which 
one-fourth  should  be  given  at  short  intervals.  Pieces  of  ice  may  also  be 
swallowed.  After  the  attack  is  controlled  the  persulphate  of  iron,  in  doses 
of  1-4  to  1-2  grain  (0.0165  to  0.033  gm.),  in  a  pill  three  or  four  times  a 
day,  may  be  used  to  prevent  recurrence.  Recently  Tripier  has  called  at- 
tention to  copious  enemas  of  hot  water  for  gastric  hemorrhage,  repeated 
twice  daily,  at  a  temperature  of  112°  tp  120°  F.  (44.4°  to  48.8°  C),  conjointly 
with  small  doses  of  hot  water  by  the  stomach. 

The  acidity  which  is  characteristic  of  the  secretion  in  gastric  ulcer  has 
sometimes  to  be  met,  and  for  this  purpose  full  doses  of  sodium  carbonate  or 
bismuth  subnitrate,   15  to  30  grains    (i   to  2  gm.),  may  be  given.     When 


366  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

aperients  are  needed,  as  is  sometimes  the  case,  the  Carlsbad  salt  becomes 
suitable,  because  of  its  alkalinity  and  its  adaptation  to  the  catarrhal  state 
often  associated  with  ulcer.  A  teaspoonful  may  be  given  in  the  morning  dis- 
solved in  a  glass  of  warm  water,  or  a  tablespoonful  may  be  added  to  a  pint 
of  warm  water  and  taken  in  divided  portions  during  the  day.  Small  doses  of 
magnesium  sulphate  may  be  substituted,  though,  as  a  rule,  the  bowels  should 
be  regulated  by  enemas  rather  than  by  purgatives. 

Tlie  resulting  chlorosis  or  anemia  may  be  treated  with  iron  and  arsenic. 
Of  the  former,  the  neutral  preparations  are  to  be  preferred ;  of  the  latter^ 
Fowler's  solution,  because  of  the  easy  regulation  of  the  dose.  Large  doses  of 
iron  should  not  be  given,  since  the  excess  of  such  doses  remains  unabsorbed, 
astringing  and  irritating  the  alimentary  canal.  The  tincture  of  the  chlorid, 
so  valuable  usually,  is  especially  contra-indicated,  because  it  increases  the 
acidity  of  the  gastric  juice  and  thus  favors  the  solution  of  the  gastric  wall. 

Operative  Treatment  of  Gastric  Ulcer. — This  has  become  an  impor- 
tant measure  of  curative  treatment,  not  only  after  perforation,  but  also  for  the 
cure  of  non-perforating  ulcer  causing  recurrent  hemorrhage.  Operation  for 
non-perforating  gastric  ulcer  is  recommended  by  modern  surgeons  in  serious 
cases,  and  cases  are  considered  serious  where  there  is  either  very  copious 
single  hemorrhage  or  recurring  hemorrhage.  Thus,  Dieulafoy  advises  oper- 
ation after  the  first  hemorrhage  if  as  much  as  half  a  liter  (500  c.  c.)  of  blood 
is  lost  and  if  the  bleeding  is  repeated  in  twenty-four  hours.  W.  L.  Rodman  * 
says  that  "  as  soon  as  the  bleeding  from  a  second  serious  hemorrhage  ceases 
and  the  patient  has  rallied  from  the  shock  and  is  in  good  condition,"  some 
operation  should  be  performed.  Rodman  tabulates  63  operations  for  acute 
and  chronic  hemorrhage  with  20  deaths,  or  a  mortality  of  32.6  per  cent. 

It  is  scarcely  possible  for  recovery  to  take  place  after  perforation  with- 
out operation,  but  after  operation  at  the  present  day  at  least  50  per  cent, 
recover.  The  first  successful  operation  was  by  Kriege,  in  Germany,  in  1892. 
Up  to  1894  results  were  far  from  satisfactory,  when,  of  85  cases  collected  by 
Mikulicz,  only  one  recovered.  On  the  other  hand,  out  of  125  cases  collected 
by  Gofife  up  to  the  end  of  1897,  63,  or  50  per  cent.,  recovered.  Hence,  opera- 
tion should  be  borne  in  mind  as  a  treatment  for  which  w^e  should  always  be  in 
readiness.f 


CANCER  OF  THE  STOMACH. 

Synonyms. — Carciiwiua  ventriciiU;  Gastric  Cancer. 

Etiology. — Little  definite  is  known  of  the  etiology  of  cancer.  Heredity- 
is  an  acknowledged  factor,  though  it  is  less  potent  than  is  commonly  sup- 
posed. W.  H.  Welch  i  was  able  to  trace  cancer,  or  at  least  a  family  history 
of  cancer,  in  242  out  of  1744  cases.  There  is  some  evidence  to  show  that 
abuse  of  the  stomach  by  eating  and  drinking  may  be  influential  in  causing 
the  disease,  though  it  is  not  conclusive.  The  same  has  been  claimed  for  the 
depressing  emotions.  There  is  better  reason  to  believe  that  ulcer  is  a  predis- 
posing cause,  since  autopsies  have  disclosed  cancer  developing  in  the  floor  of 

*  Oration  on  Surgerj-  delivered  at  the  Fifty-first  Anrmal  Meeting  of  the  American  Medical  Associ- 
ation. Atlantic  Citv.  June  5-8,  iqoo. 

t  See  also  Dr.  Weir's  article,  referred  to,  on  "Perforating  Duodenal  Ulcers,"  "  Medical  News," 

Maj'  5,  iqoo. 

X  "  System  of  Medicine  by  American  Authors,"  vol.  ii.  Philadelphia,  1886. 


CANCER  OF  THE  STOMACH.  367 

ulcers  and  in  cicatrices.  Mention  should  be  made  of  the  fact  that  a  parasitic 
origin  of  cancer  is  claimed  by  some,  but  the  subject  is  altogether  too 
unsettled  to  justify  more  than  reference  in  a  text-book. 

Gastric  cancer  is  a  disease  of  mature  life,  three-fourths  of  all  cases 
occurring  between  the  fortieth  and  seventieth  year.  One  of  my  patients  was 
thirty-two  when  he  first  consulted  me,  and  died  just  one  year  later.  Adolf 
Struempell  has  seen  cases  between  twenty-two  and  twenty-five.  George 
Dock  *  reports  three  cases  occurring  in  his  own  practice,  where  the  patients 
were  twenty,  twenty-four,  and  twenty-one  years  of  age,  confirmed  by 
autopsy,  and  Marc  Mathieu  published  in  1884  a  monograph,  "  Du  cancer 
precose  de  I'estomac."  The  disease  is  slightly  more  frequent  in  men  than 
in  women. 

Pathology  and  Morbid  Anatomy. — After  the  uterus,  the  stomach  is 
the  organ  most  frequently  attacked  by  cancer,  a  little  more  than  one-fifth  of 
all  cases  of  primary  cancer  being  found  in  this  organ — according  to  Welch, 
21.4  per  cent.,  from  an  analysis  of  the  very  large  number  of  30,000  cases.  It 
is  far  more  common  in  the  pyloric  end  and  on  the  lesser  curvature,  1300  cases 
collected  by  Welch  being  distributed  as  follows:  pyloric  region,  791;  lesser 
curvature,  148 ;  cardia,  104 ;  posterior  wall,  68 ;  whole  or  greater  part  of  the 
stomach,  61;  multiple,  45;  greater  curvature,  34;  anterior  wall,  30;  fundus, 
19.  Every  variety  of  cancer  is  found  in  the  stomach,  in  the  following  order 
of  frequency : 

1.  Cylinder-celled  epithelioma,  most  frequent  at  the  pylorus. 

2.  Medullary  or  soft  cancer,  most  frequent  in  the  smaller  curva- 
ture. 

3.  Scirrhus,  at  the  pylorus  and  in  the  smaller  curvature,  causing,  espe- 
cially, stenosis  of  the  pyloric  orifice. 

4.  Colloid,  diffuse  infiltration  with  a  tendency  to  spread  to  the  perito- 
neum and  adjacent  organs. 

5.  Melanotic. 

6.  Squamous  epithelioma,  near  the  cardia. 

All  the  forms  start  from  the  gland  cells  of  the  mucous  membrane. 

The  medullary  variety  is  prone  to  ulcerate  and  to  form  extensive  fun- 
goid ulcerated  surfaces,  from  which  there  may  or  may  not  be  hemorrhage. 
It  may  be  associated  with  scirrhus.  While  nodular  outgrowths  are  usual,  the 
cancerous  tissue  may  infiltrate  the  walls,  producing  diffuse  thickening. 

Secondary  cancer  of  the  stomach  is  an  occasional  event:  in  17  out  of  37 
cases,  according  to  Welch,  secondary  to  primary  cancer  of  the  breast.  I 
have  met  one  case  succeeding  epithelioma  of  the  lip.  Much  more  frequently 
primary  cancer  of  the  stomach  is  a  cause  of  secondary  cancer  elsewhere,  most 
often  in  the  adjacent  lymphatic  glands,  which  were  the  secondary  foci  in  551 
out  of  1574  cases  collected  by  Welch;  the  liver  was  involved  secondarily 
475  times  ;  the  peritoneum,  omentum,  and  intestine,  357 ;  pancreas,  122  ;  pleura 
and  lung,  98 ;  spleen,  26 ;  brain  and  meninges,  9 ;  other  localities,  92 ;  among 
the  latter  is  to  be  included  adjacent  integument,  especially  about  the  navel. 

Marked  changes  in  the  size,  shape,  and  position  of  the  organ  occur  as  a 
result.  Most  common  is  dilatation,  sometimes  due  to  pyloric  obstruction. 
Medullary  cancer,  on  the  other  hand,  is  apt  to  produce  a  reduction  in  the 
size  of  the  stomach  and  its  cavity.  A  reduction  in  size  may  attend  obstruc- 
tion at  the  cardiac  orifice,  because  of  disuse  of  the  organ,  while  the  esophagus 

*  "  Transactions  of  the  Association  of  American  Physicians,"  vol.  xii.,  1897. 


368  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

itself  may  be  dilated.  The  same  effect  may  be  produced  by  cancerous  infiltra- 
tion of  the  stomach  walls,  by  which  the  capacity  of  the  organ  is  greatly 
reduced — in  one  instance,  a  case  of  Livingstone's,  to  12  ounces.  Further 
reference  will  be  made  to  extraordinary  dislocation  of  parts  of  the  organ  in 
treating  of  symptoms.  Adhesions  may  also  form  between  the  stomach  and 
adjacent  organs,  and  between  it  and  the  anterior  abdominal  wall.  Peritonitis 
may  occur;  also  perforation  into  an  adjacent  organ,  as  the  transverse  colon, 
and  even  the  small  intestine. 

Symptoms. — The  initial  symptoms  in  almost  every  form  of  cancer  of 
the  stomach  are  those  of  indigestion,  including  anorexia,  eructations,  vomit- 
ing, constipation,  discomfort,  and  pain,  more  rarely  acidity.  These  are 
present  for  a  variable  time  before  a  more  serious  condition  is  suspected. 
Increase  in  the  severity  of  symptoms  despite  the  use  of  remedies,  progressive 
debility,  emaciation,  and  cachexia  invite  closer  examination,  which  may  or 
may  not  result  in  the  discovery  of  a  tumor.  Before  a  tumor  is  recognized 
there  is  often  tenderness,  which  follows  sooner  or  later,  if  it  does  not  precede 
tumor.  Cachexia  and  wasting  may  also  be  present  a  long  time  before  the 
tumor  is  discovered. 

A  chemical  examinaton  of  the  gastric  contents  after  a  test  meal  may  dis- 
close the  absence  of  free  and  combined  hydrochloric  acid  or  a  minimum  of 
it,  and  Boas'  results  are  confirmatory  of  the  persistent  presence  of  lactic 
acid  in  decided  quantity,  to  which,  as  well  as  to  the  absence  of  hydro- 
chloric acid,  attention  was  originally  called  by  von  der  Velden.  As  to  hydro- 
chloric acid,  it  must  be  remembered  that  it  is  also  diminished  in  gastric 
catarrh,  in  atrophy  of  the  mucous  membrane,  in  amyloid  degeneration,  and 
even  in  nervous  dyspepsia  at  times,  while  in  rare  instances  it  happens  that 
hydrochloric  acid  is  increased  in  cancer.  The  motor  as  well  as  the  secre- 
tory and  absorbing  functions  will  be  found  impaired,  undigested  food  being 
found  long  after  the  seven  hours'  limit.  Such  motor  delay  characterizes 
more  particularly  the  pyloric  situation  of  cancer,  with  its  resulting 
obstruction. 

The  Oppler-Boas  bacillus  was  first  described  by  Oppler  in  1895,  as  an 
unusually  long  and  thread-like  bacillus,  non-motile,  found  in  the  contents  of 
carcinomatous  stomachs.*  The  bacilli  lie  either  end  to  end,  in  long  thread- 
like chains,  or  at  right  angles  to  one  another.  They  stain  readily  with  ani- 
lin  dyes.  They  prefer  a  medium  containing  lactic  acid ;  indeed,  Kauffmann 
ascribes  to  the  bacillus  the  power  of  forming  lactic  acid  from  various  kinds 
of  sugar.  Hydrochloric  acid  in  any  large  proportion  causes  it  to  disappear. 
Schlesinger  and  Kauffmann  declare  the  presence  of  large  numbers  of  the 
bacilli  in  association  with  pyloric  stenosis  to  be  an  indication  of  carcinoma, 
and  their  absence,  associated  with  the  absence  of  lactic  acid,  to  be  evidence 
against  carcinoma.  Riegel  does  not  consider  the  organism  pathognomonic 
of  carcinoma,  but  very  important  in  its  diagnosis.  Stockton  says  it  is  often 
present  in  carcinoma,  and  has  not  been  found  in  other  diseases  of  the  stomach. 
The  Oppler-Boas  bacillus  and  sarcinse  do  not  coexist  for  any  length  of  time 
in  carcinomatous  stomachs.  The  sarcina  thrives  in  the  presence  of  hydro- 
chloric acid,  and  disappears  with  it,  being  replaced  by  the  Oppler-Boas 
bacillus  and  lactic  acid.  Even  when  introduced  into  the  stomach  in  cases  of 
obstruction  due  to  carcinoma,  the  sarcinae  disappeared  in  twenty-four  hours, 
the  Oppler-Boas  bacillus  seeming  to  replace  them. 

*  Boas,  "  Specielle  Diagnostik  tind  Therapie  der  Magenkrankheiten."  Oppler,  "  Deutsche  medi- 
cinische  Wochenschrift,"i8g5,  No.  5. 


CANCER  OF  THE  STOMACH. 


369 


In  evidence  of  the  value  of  the  Oppler-Boas  bacillus  in  diagnosis  of  gas- 
tric carcinoma  it  may  be  said  that  Kauffmann  *  found  it  in  19  out  of  20  cases, 
and  in  the  one  in  which  it  was  absent  there  was  no  lactic  acid.  John  C. 
Hemmeter  informs  me  that  he  found  the  bacillus  in  52  out  of  55  cases, 
that  he  regards  it  "  an  important  diagnostic  sign  in  carcinoma  of  the 
stomach,  within  limitations,  and  though  it  is  by  no  means  pathognomonic." 
He  has  found  it  in  a  case  of  benign  pyloric  stenosis,  and  also  in  such  cases 
when  HCl  was  still  present.  Ullman,  of  Buffalo,  N.  Y.,  found  it  in  all  of 
lo^cases. 

If  this  test  should  prove  reliable  at  an  early  stage  of  the  disease,  the 
■chances  of  success  of  operative  treatment  will  be  greatly  enhanced. 


Fig.  30.— Oppler-Boas  Bacillus,  from  Co-ntents  of  a  Carcinomatous  Stomach— 

{Hefn/neter). 

At  a  later  stage  periodic  vomiting  of  large  quantities  of  fluid  containing 
the  ingesta  of  hours  and  even  days  previous  is  a  characteristic  symptom, 
and  a  dilated  stomach  may  now  be  easily  demonstrated.  The  vomitus  may 
also  contain  blood,  and  that  peculiar  mixture  of  blood  and  gastric  juice  which 
is  called  "  coffee-grounds  "  vomit.  If,  owing  to  their  disintegration,  the 
microscope  does  not  recognize  blood  discs,  Teichmann's  hemin  crystals  may 
be  easily  prepared  as  directed  on  page  79,  footnote.  The  vomited  matter  is 
sometimes  very  foul-smelling,  as  are  also  at  times  the  eructations.  Vomiting 
is  by  no  means  an  invariable  symptom,  though  even  when  there  is  no  vomit- 
ing, nausea  is  commonly  present.  The  absence  of  vomiting  generally  means 
that  the  cancer  is  not  at  the  pylorus.  It  may  be  at  the  middle  belt,  at  the 
fundus,  or  at  the  cardiac  end.  When  at  the  latter  point,  there  is  almost 
always  difficult  and  painful  deglutition. 

By  this  time  the  patient  is  emaciated,  anemic,  cachectic,  with  a  peculiar 
yellowish,  sallow,  swollen  appearance,  and  now  a  tumor  is  commonly  easily 
recognized  by  palpation.  Very  interesting  is  the  varying  situation  of  the 
tumor,  as  well  as  at  times  its  great  mobility.  Almost  never,  in  my  experi- 
ence, is  the  tumor  of  pyloric  cancer  found  in  the  normal  situation  of  the 
pylorus,  even  when  the  patient  is  lying  on  his  back,  but  rather  in  the  neigh- 
borhood of  the  umbilicus,  a  little  to  the  right  or  left.  It  is  the  weight  of 
the  tumor  which  drags  it  out  of  the  normal  position  of  the  pylorus,  and 
it  may  be  found  even  lower  down,  toward  the  symphysis  pubis,  as  in  a  case 


*  KaufEmann  and  Schlesinger,  "  Wiener  klinische  Rundschau,"  1895,  No.  5. 


24 


370  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  Struempell's.  The  tumor  itself  may  be  fixed  in  the  position  it  assumes, 
or  it  may  be  freely  movable.  Its  location  is  usually  uninfluenced  by  breath- 
ing, and  in  this  respect  it  contrasts  with  tumors  of  the  liver  and  spleen. 
It  rarelv  gives  a  positive  dull  note  on  percussion — rather  a  muffled  note. 
In  a  certain  number  of  cases  no  tumor  can  be  detected  throughout  the  whole 
course  of  the  disease,  it  is  said  in  20  per  cent.  Especially  is  this  the  case 
when  the  disease  is  toward  the  cardiac  end.  A  rotary  motion  is  sometimes 
characteristic  of  the  tumor. 

Toward  the  end  of  life  edema  of  the  legs  and  ankles  often  appears,  and 
an  intensity  of  cachexia,  which  simulates  pernicious  anemia, — in  fact,  even 
furnishes  the  blood  changes  characteristic  of  this  affection, — with  extreme 
weakness  and  death.  The  urine  is  often  scanty,  and  may  give  a  decided 
reaction  for  indican.  In  a  few  cases  a  febrile  movement  makes  its  appear- 
ance, with  chills  and  szveating  at  intervals,  probably  due  to  intercurrent  in- 
flammation. To  these  symptoms  are  often  added  those  of  secondary  cancer^ 
especially  of  the  liver,  including  enlargement  of  this  organ  and  jaundice. 
The  signs  of  secondary  cancer  elsewhere  than  in  the  liver  should  be  sought. 
The  duration  of  cases  of  gastric  cancer  is  from  one  to  two  years ;  it  may  be 
less,  especially  if  the  cancer  is  ingrafted  pn  a  pre-existing  ulcer.  Slow  de- 
velopment is  said  to  be  characteristic  of  cases  in  younger  persons. 

Diagnosis. — This  is  generally  easy  if  time  and  opportunity  be  allowed 
for  the  study  of  a  given  case.  Ulcer  is  perhaps  the  disease  which  furnishes 
most  difficulty,  especially  as  cancer  may  succeed  it.  On  the  other  hand, 
the  earliest  symptoms  of  gastric  cancer  are  also  those  of  gastric  catarrh, 
which  in  many  cases  is  mistaken  for  cancer.  The  pain  and  the  peculiar  in- 
termittent vomiting  are  the  first  distinctive  signs,  and  while  coffee-grounds 
vomit  may  occur  whenever  moderate  quantities  of  blood  are  poured  into 
the  stomach  and  mixed  with  gastric  juice,  the  causes  other  than  cancer  are 
rare.  The  copious  hemorrhage  of  ulcer  gives  bright  red  blood.  Bloody 
vomiting  is  by  no  means  always  present  in  cancer.  To  the  symptoms  de- 
scribed are  soon  added  the  emaciation  and  cachexia,  and  the  palpable  tumor 
more  evident  after  the  stomach  has  been  emptied  out  by  vomiting  or  washing. 
In  the  meantime,  however,  the  gastric  contents  will  have  been  examined,  and 
furnish  their  quota  of  information,  not  pathognomonic,  but  contributory. 
Very  rarely  does  it  happen  that  in  the  vomitus  or  washings  of  the  stomach  we 
obtain  particles  of  morbid  growth  whose  examination  will  disclose  the  struc- 
ture of  cancer. 

There  is  not  usually  much,  difficulty  in  fixing  the  location  of  the  tumor 
supposed  to  be  in  the  stomach.  If  there  is  doubt,  it  may  be  eliminated  in 
part  or  altogether  by  filling  the  stomach  with  liquid  and  noting  the  efifect 
upon  the  tumor. 

In  one  instance  I  mistook  cancer  of  the  gall-bladder  for  cancer  of  the 
stomach,  though  I  scarcely  think  it  would  happen  again.  The  chief  reason 
was  because  the  tumor  due  to  cancer  of  the  gall-bladder  was  in  the  situation 
where  the  tumor  of  the  pylorus  might  reasonably  be  expected  to  have  been. 
There  was  jaundice  with  tenderness  in  the  hepatic  region,  there  were  no 
signs  of  dilatation  of  the  stomach,  and  the  mistake  was  scarcely  excusable. 
There  is  usually  less  interference  with  digestion  in  cancer  of  the  gall-bladder, 
no  mobility  of  the  tumor,  and  often  suppuration  with  incident  fever. 

The  distinction  of  gastric  from  pancreatic  cancer  demands  some  con- 
sideration. The  tumor  may  be  in  the  same  position,  but  in  a  large  propor- 
tion of  cases  of  cancer  of  the  pancreas  there  is  jaundice.     The  tumor  of  a 


CAXCER  OF  THE  STOMACH.  371 

pancreatic  cancer  is  often  inaccessible.  In  the  latter  there  are  also  symptoms 
of  indigestion,  like  those  of  gastric  cancer,  but  there  is  often  also  diarrhea, 
and  frequently  the  liquid  stools  contain  oil.  Such  diarrhea  may  be  checked 
for  a  time  by  ordinary  remedies,  but  in  a  few  days  the  liquid  discharges 
seem  to  burst  through  a  barrier  which  held  them  temporarily  in  check.  The 
pancreatic  tumor,  if  felt,  is  also  more  immovable. 

Tumors  of  the  liver  and  spleen  are  continuous  with  these  organs,  while 
the  gastric  tumor  is  generally  easily  distinguished  from  them  by  palpation  or 
by  an  intervening  tympanitic  area.  A  cancer  of  the  transverse  colon  may 
occupy  much  the  same  position  in  the  abdomen  as  one  of  the  stomach,  and 
be  also  quite  movable.  The  filling  of  the  colon  and  stomach  with  water  or 
air  may  also  be  availed  of  in  diagnosis.  As  the  growth  in  the  intestine  in- 
creases, obstruction  may  result  and  the  tumor  increase  by  the  accumulation 
of  fecal  matter  behind  the  stenosed  portion.  A  rare  complication,  increasing 
the  difficulty  in  diagnosis,  is  adhesion  between  the  bowel  and  stomach,  re- 
stricting motion  and  possibly  causing  perforation,  through  which  fecal  mat- 
ter may  enter  the  stomach.  Still  more  difficult,  nay,  even  impossible,  in 
most  instances,  is  the  distinction  between  duodenal  and  gastric  cancer.  The 
absence  of  hydrochloric  acid  would  point  to  gastric  cancer,  though  such 
absence,  being  due  to  atrophy  of  the  gastric  tubules  caused  by  dilatation, 
may  also  occur  in  obstructive  duodenal  cancer.  The  acid  might  also  be 
neutralized  by  regurgitated  bile,  regurgitation  being  favored  by  the  stenosis 
of  the  gut.     The  presence  of  jaundice  would  point  to  duodenal  cancer. 

Gastric  tumors  may  be  confused  with  omental  tumors,  which  may  also 
cause  dyspeptic  symptoms.  But  the  omental  tumor  is  usually  a  more 
nodular,  uneven  tumor,  and  is  sooner  or  later  associated  with  peritoneal 
effusion. 

2\Ioreover,  every  tumor  of  the  stomach  is  not  a  cancerous  tumor, 
although  most  of  them  are.  I  have  already  mentioned  my  experience  with 
a  thickened  pylorus  associated  with  gastric  ulcer.  Such  a  circumscribed 
thickening  and  induration  are  always  possible.  We  may  have  the  same 
pyloric  stenosis  and  secondary  dilatation.  Similar  non-cancerous  thickening 
mav  even  occur  without  ulcer.  Other  forms  of  morbid  growths,  such  as 
fibroma,  sarcoma,  and  the  like,  are  too  rare  to  demand  notice  from  the 
clinical  standpoint. 

Finally,  the  gastric  tumor  is  not  always  demonstrable,  and  may  not  be 
throughout  the  whole  course  of  its  existence.  It  is  said  to  be  absent  in 
about  20  per  cent,  of  cases.  Then  the  diagnosis  must  be  made  from  the 
symptoms,  especially  the  rapid  wasting  and  cachexia,  which  are  rarely  simu- 
lated, even  in  ulcer.  The  age  of  the  patient,  generally  past  forty,  the  defi- 
ciency in  HCl,  and  the  presence  of  lactic  acid  must  be  allowed  due  weight. 
The  cachexia  of  pernicious  anemia  resembles  very  closely  that  of  cancer 
of  the  stomach,  and,  in  the  absence  of  appreciable  tumor  in  the  latter,  may 
occasion  difficulty.  But  a  study  of  the  blood  will  in  most  cases  clear  up  a 
doubt.  The  number  of  red  blood-cells  in  cancer  of  the  stomach  is  rarely 
below  2,000,000,  while  in  pernicious  anemia  it  is  often  below  1,000,000 
per  cubic  millimeter.  This  difference  exists  even  while  the  cancerous  sub- 
ject exhibits  more  emaciation  and  weakness  than  that  of  pernicious  anemia. 
As  F.  A.  Henry  well  puts  it :  "  In  cancer  of  the  stomach  the  reduction  in 
the  number  of  red  corpuscles  does  not  keep  pace  with  the  cachexia;  in 
anemia  the  cachexia  does  not  keep  pace  with  the  destruction  of  cancer." 
Cancer  of  the  stomach  mav  be  latent  throughout. 


372  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Prognosis. — This  is  inevitably  fatal,  but  something  may  be  done  toward 
prolonging  life  by  the  proper  cleansing  out  of  the  stomach,  the  selection  and 
regulation  of  food,  and  measures  to  aid  its  digestion.  The  operation  oi 
gastrotomy  should  be  considered,  as  it  sometimes  prolongs  life. 

Treatment. — Since  the  cure  of  cancer  of  the  stomach  is  impossible, 
treatment  must  be  directed  toward  prolonging  the  patient's  life.  I  am  quite 
sure  that  a  great  deal  more  can  be  done  than  is  commonly  thought  possible. 
The  limit  of  life  of  the  victim  of  established  gastric  cancer  does  not  exceed 
two  years. 

The  stomach  has  no  use  outside  of  the  preparation  of  the  food  for 
absorption.  It  is  not  a  vital  organ  in  the  sense  that  the  heart  and  the  lungs 
are  vital  organs.  It  is  important  so  far  as  it  prepares  the  food,  but  if  the 
food  can  be  prepared  for  absorption  outside  of  the  body,  its  importance  is 
diminished.  So  it  is  if  we  introduce  artificially  digested  food  by  the  rectum. 
Or  we  may  use  both  of  these  methods.  We  can,  by  the  use  of  prepared 
food,  diminish  the  labor  of  the  stomach,  and  by  using  the  rectum  we  can, 
while  doing  so,  relieve  the  stomach  of  all  labor.  This  is  rendered  easier  at 
the  present  day  by  the  use  of  peptonized  foods  of  various  kinds.  The  food 
may  be  peptonized  at  home,  or  the  peptonized  products  of  manufacturers 
may  be  substituted.  First  in  order  of  simplicity  is  peptonized  milk.  Three 
to  five  grains  (0.2  to  0.3  gm.)  of  the  extract  of  pancreas  with  about  15 
grains  (i  gm.)  of  sodium  carbonate  are  added  to  a  pint  of  milk,  and  the 
mixture  placed  at  a  temperature  of  100°  F.  (37.8°  C).  In  one  hour  all  the 
casein  will  be  peptonized.  A  curd  is  first  produced,  which  subsequently 
undergoes  solution.  If  peptonizing  is  complete,  the  addition  of  rennet  will 
not  produce  coagulation.  Milk  thus  prepared  makes  little  demand  upon  the 
stomach  for  digestion,  and  it  can  be  introduced  advantageously  by  the  rec- 
tum. Peptonized  milk  has  a  slightly  bitter  taste,  and  unless  this  bitterness 
is  present,  its  digestion  is  unaccomplished.  The  digestion  will  take  place  at 
a  lower  temperature  than  100°  F.  (37.8°  C),  but  it  takes  longer.* 

Beef  may  be  peptonized  for  rectal  alimentation  as  follows :  Take  half 
a  pound  of  beef  with  the  fat  removed  and  a  quarter  of  a  pound  of  fresh 
pancreas.  The  pancreas  is  finely  chopped  and  afterward  bruised  in  a 
mortar  with  tepid  water  at  a  temperature  of  100°  F.  (37.8°  C).  It  is 
then  placed  in  a  saucepan,  and  a  raw  egg  is  beaten  up  and  intimately  mixed 
with  the  meat,  previously  chopped  into  small  pieces.  The  product  is  next 
allowed  to  stand  at  a  temperature  of  100°  F.  (37.8°  C.)  for  two  hours.  It 
is  then  strained,  after  which  it^is  ready  for  use.  This  amount  suffices  for 
two  daily  injections.  The  preparation  decomposes  very  quickly,  so  that  it 
has  to  be  made  fresh  every  day.  I  have  been  surprised  at  what  I  have  ac- 
complished by  this  method,  which  is  essentially  one  recommended  by  Mayer, 
of  Lyons.  In  a  case  where  nothing  could  pass  the  pylorus,  under  the  use 
of  daily  nutritious  enemas  there  occurred  each  morning  an  evacuation  from 
the  bowel  as  natural  as  when  the  patient  was  living  on  a  mixed  diet  and 
digesting  it  properly. 

The   enterprise   of   the   manufacturing   chemists    and    pharmacists   has 

*The  following  method,  slightly  modified  from  that  usually  recommended,  has  been  found 
most  satisfactory  after  numerous  trials  by  patients:  Take  one  pint  of  skimmed  milk,  to  which  add 
one  gill  of  water.  Heat  to  140'  P.  (60°  C.)— a  temperature  at  which  the  finger  can  be  immersed  for 
half  a  minute.  After  taking  from  the  fire  stir  in  three  grains  (0.2  gm.)  of  powdered  pancreatin  and 
15  grains  Ci  gm.)  of  carbonate  of  sodium.  Place  in  a  covered  kettle  or  jug  and  roll  up  in  a  cosey 
(an  ordinary  gossamer  waterproof  coat  answers  admirably  well),  near  a  stove  or  register  to  keep 
warm.  Let  it  remain  thus  for  an  hour  and  a  half.  It  then  resembles  slightly  thickened  milk,  but 
there  is  no  curd.  Pour  it  into  a  covered  pitcher,  and  set  aside  to  cool  in  the  open  air.  Thus  pre- 
pared, it  has  the  slightest  perceptible  tinge  of  bitterness,  and  is  very  palatable. 


DILATATION  OF  THE  STOMACH.  373 

resulted  in  the  preparation  of  a  number  of  beef  peptonoids  and  extracts 
which  may  be  substituted,  but  I  never  feel  quite  so  sure  of  them  as  of  the 
product  made  at  home,  troublesome  as  its  preparation  is,  because  it  seems 
impossible  to  learn  the  nourishment  equivalent  of  the  manufacturers' 
product. 

However  careful  the  preparation  of  food,  when  taken  into  the  stomach 
in  these  cases,  only  a  part  is  used  up,  and  there  accumulates  gradually  a 
quantity  of  unabsorbed  material  which  does  not  pass  the  pylorus,  and  to 
this  a  copious  mucous  secretion  is  added.  Hence,  occasionally,  once  a  day 
or  every  other  day,  it  is  desirable  to  wash  out  the  stomach  with  water  as  hot 
as  can  be  borne,  or  alkaline  waters,  as  described  in  the  treatment  of  gastric 
catarrh.  The  free  use  of  hydrochloric  acid  as  a  medicine  also  aids  not  only 
in  the  solution  of  the  food  ingested,  but  prevents  the  fermentations,  which 
contribute  irritating  acids  to  the  gastric  contents  and  cause  further  mischief 
and  discomfort. 


DILATATION  OF  THE  STOMACH. 

Synonym. — Gastrectasia. 

Definition. — A  permanent  increase  in  the  volume  and  capacity  of  the 
stomach,  the  result  (i)  of  nervo-muscular  atony  or  (2)  of  pyloric  obstruc- 
tion. It  is  to  be  distinguished  from  temporary  distention  and  simple  large 
stomach. 

Etiology. —  (i)  The  nervo-muscular  atony  causing  dilatation  may  be 
the  result  of  habitual  overeating,  especially  food  of  defective  quality,  result- 
ing in  stasis  and  fermentation ;  of  excessive  drinking,  as  in  beer-drinking 
employees  of  breweries ;  of  chronic  gastritis ;  of  diseases  producing  general 
nervo-muscular  atony,  such  as  disease  of  the  spinal  cord,  pulmonary  con- 
sumption, anemia,  chlorosis,  acute  fevers,  affections  of  the  heart,  liver,  and 
kidneys,  and  other  diseases  of' like  import.  (2)  Mechanical  or  obstructive 
dilatation  is  most  frequently  due  to  obstruction  from  cancer  at  the  pylorus 
or  in  the  duodenum,  or  to  cicatricial  contraction,  or  to  hypertrophic  thick- 
ening. Such  obstruction  may  also  be  due  to  pressure  from  without,  as  by 
cicatricial  adhesion  or  tumor  of  an  external  organ  or  a  floating  right  kid- 
ney. It  is  most  frequent  in  middle-aged  persons,  but  may  occur  even  in 
children.  Tight  lacing,  by  producing  dislocation  of  the  stomach  and  ob- 
struction to  the  onward  movement  of  its  contents,  may  also  be  a  cause  of 
dilatation. 

Acute  dilatation  of  the  stomach  is  a  possible,  but  rare,  condition.  It 
may  succeed  the  rapid  ingestion  of  enormous  quantities  of  food  and  drink. 
Extreme  paralytic  dilatation  may  result,  as  in  two  cases  described  by  Hilton 
Fagge,  of  which  one  proved  fatal. 

Morbid  Anatomy. — In  addition  to  the  increase  of  volume  the  coats 
of  the  stomach  may  be  thinned  and  the  glandular  structure  more  or  less 
atrophied.  The  average  normal  stomach  of  an  adult  holds  about  i  1-2  liters 
(three  pints),  while  the  abnormally  dilated  organ  may  attain  a  capacity  of 
three  or  four  liters  (six  or  eight  pints),  and  even  more.  Where  the  dilata- 
tion is  mechanical,  there  is  added  the  lesion  which  is  responsible  for  the 
obstruction. 

Symptoms. — The   symptoms    arising    from   dilatation   are   a   sense   of 


374  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

fullness  in  the  epigastrium,  eructations,  flatulence,  and  vomiting,  often  of 
enormous  quantities.  The  appetite  is  sometimes  poor,  at  others  quite  good, 
and  the  patient  is  hungry  and  thirsty.  The  vomited  matters  are  largely 
water,  but  include  also  remnants  of  food  and  every  variety  of  fungus — viz., 
bacteria,  sarcinse,  yeast  fungi,  etc.  Their  reaction  usually  exhibits  lessened 
acidity,  because  of  diminished  hydrochloric  acid  secretion,  but  it  may  be 
normal  or  even  abnormalh-  acid.  Such  abnormal  acidity  is  the  result  of 
fermentations  producing  lactic,  butyric,  and  acetic  acids.  Various  gases 
are  thus  produced,  including  carbonic  acid  and  hydrogen.  The  latter  may 
also  arise  from  decomposition  of  albuminoid  substances,  whence  too  arises 
sulphureted  hydrogen.  These  fermentations  are  favored  by  the  absence  of 
HCl,  the  importance  of  which  in  preventing  fermentation  has  been  referred 
to,  and  by  a  stasis  of  the  contents  in  the  stomach ;  for  not  only  is  absorption 
delayed,  but  the  transit  of  gastric  contents  into  the  intestine  is  also  hindered. 
Indeed,  in  some  cases  the  stomach  is  never  emptied  unless  by  the  tube. 
Nay,  more ;  it  would  seem  that  at  times  it  contains  more  liquid  than  was 
ingested — a  possible  condition,  since  the  endosmosis  of  crystalloids  (viz., 
sugar,  dextrin,  alcohol,  and  peptones)  is  attended  with  the  exosmosis  of 
water.  From  such  causes,  too,  occur  torpor  of  the  bozvel,  scantiness  of  urine, 
and  dryness  of  the  skin. 

Anemia,  emaciation,  and  debility  sooner  or  later  succeed,  and  in  fatal 
cases  death  is  commonly  preceded  by  a  drozi'si)iess,  which  may  be  due  to  the 
absorption  of  toxic  substances  arising  in  the  decompositions  going  on  in 
the  stomach.  Dilatation  of  the  stomach  is  also  one  of  the  acknowledged 
causes  of  tetany,  as  first  pointed  out  by  Kussmaul.  The  cramps,  though 
often  quite  severe,  are  of  short  duration.  They  occur  chiefly  in  the  muscles 
of  the  hands,  arms,  and  legs.  Von  Leube  suggests  that  this  tetany  may  be 
due  to  a  "  drying  out  "  of  the  nerves  and  muscles,  but  it  may  also  be  the 
result  of  auto-intoxication.     Unconsciousness  may  precede  death. 

Physical  Signs. — These  may  be  elicited  by  inspection,  palpation,  and 
percussion.  Inspection  does  not  always  afford  information,  but  in  emaciated 
cases  the  greater  curvature  of  the  distended  organ  may  be  recognized  as 
low  as  the  navel  and  below,  instead  of  from  1.2  to  2.8  inches  above  it  (3  to 
7  cm.).  When  the  stomach  is  very  low,  even  the  smaller  curvature  may  be 
recognized  about  two  inches  (5  cm.)  below  the  ensiform  cartilage,  uncovering 
the  pancreas.  In  obstruction  of  the  pylorus  the  peristalsis  from  left  to  right 
may  even  be  recognized  stopping  short  at  the  pylorus,  where  the  tumor-like 
thickening  may  sometimes  be  seen.  In  rare  instances  a  reverse  peristalsis, 
from  right  to  left,  takes  place. 

Palpation  may  confirm  inspection,  recognizing  the  contour  of  the 
stomach  by  its  peculiar  consistence,  which  has  been  compared  to  that  of  an 
air-cushion,  but  affords  little  additional  information  unless  there  be  a  tumor 
at  the  pylorus  which  may  be  felt.  Peristalsis,  if  present,  may  also  be  felt, 
and  may  be  stimulated  by  filliping  the  abdominal  walls  with  the  fingers,  by 
which  also  a  splashing  sound  may  be  produced  in  the  water-laden  dilated 
stomach  down  as  low  as  the  greater  curvature.  This  is  to  be  distinguished 
from  a  similar  splashing  which  may  be  obtained  in  the  normal  stomach  and 
adjacent  colon,  the  latter  being  less  constant  and  less  intense. 

If  a  stiff  sound  is  used,  its  end  may  be  felt  through  the  abdominal  walls, 
while  the  unusual  extent  to  which  it  may  be  carried  before  meeting  resist- 
ance will  attract  attention. 

Percussion  affords  the  most  valuable  evidence  as  to  the  presence  of  a 


.  DILATATION  OF  THE  STOMACH.  375 

dilated  stomach,  and  in  the  majority  of  instances  such  evidence  is  conclusive. 
Auscultatory  percussion  is  especially  satisfactory  in  determining  the  outlines 
of  the  stomach,  and  the  phonendoscope  may  be  used  with  advantage.  Per- 
cussion should  be  made  in  the  standing  position,  if  possible,  from  above 
dov^nward,  beginning  at  the  edge  of  the  ribs  in  the  neighborhood  of  the 
right  parasternal  line.  The  note  is  tympanitic  until  the  upper  curvature 
is  reached,  when  it  is  substituted  by  dullness  due  to  the  liquid  contents,  to 
be  succeeded  again  by  tympany  of  the  bowel  when  the  lower  border  of 
the  stomach  is  passed.  If  the  patient  lies  on  his  back,  the  dullness  disappears 
and  is  replaced  by  tympany.  If  there  is  no  liquid  in  the  stomach,  a  change 
in  the  pitch  of  the  tympanitic  note  will  indicate  the  transition  from  the 
stomach  to  the  intestine.  Further  information  can  be  gained  by  means  of 
the  tube,  by  which  the  stomach  can  be  emptied  and  refilled  with  water  and 
its  borders  determined  by  percussion.  This  is  more  satisfactory  than  filling 
the  stomach  with  carbonic  acid  gas  or  air,  and  even  such  procedure  is  not 
always  necessary.  If  the  larger  curvature  be  found  by  percussion  at  the 
navel  or  below,  the  stomach  is  certainly  dilated. 

No  reliable  evidence  of  dilatation  is  furnished  by  auscultation. 

Diagnosis. — This  is  usually  readily  made  by  attention  to  the  symptoms 
and  physical  signs  described.  Dilated  stomach  has,  however,  been  mis- 
taken for  an  ovarian  cyst,  and  abdominal  section  has  been  made  for  its 
relief. 

The  question  whether  the  dilatation  is  dynamic  or  mechanical — that  is, 
whether  it  is  the  result  of  nerve-atony  or  obstruction  by  a  tumor  at  the 
pylorus — can  generally  be  decided  by  recognition  of  a  tumor  at  this  orifice. 
Vomiting  is  also  more  severe  and  frequent,  and  the  peristaltic  unrest  is  more 
active. 

Dilatation  differs  from  falling,  or  gastroptosis,  though  descent  and 
dilatation  are  often  present  in  the  same  organ.  According  to  Boas,  dilata- 
tion can  be  distinguished  from  descent  only  when  the  greater  curvature  is 
below  the  umbilicus,  and  when  the  greatest  vertical  diameter  of  the  stomach 
is  from  10  to  14  cm.  (4  to  5  1-2  inches).  Different  also  is  enteroptosis, 
or  viseroptosis,  which  will  be  considered  later. 

Prognosis, — When  associated  with  malignant  disease  at  the  pylorus, 
recovery  is,  of  course,  impossible,  as,  indeed,  it  is  in  dynamic  dilatation,  but 
in  the  latter  case  much  relief  may  be  afforded  to  the  symptoms. 

Treatment. — The  most  important  part  of  the  treatment  is  zvashing  out 
the  stomach,  after  the  method  detailed  on  page  348.  This  may  be  done 
daily,  but  sometimes  it  is  sufficient  to  do  it  on  alternate  days,  occasionally 
even  twice  daily.  When  practiced  once  a  day,  it  is  usually  best  done  on 
retiring  at  night,  as  the  stomach  is  thus  freed  for  the  night  or  irritating 
material  which,  if  retained,  disturbs  rest  and  aggravates  the  local  condition. 
The  patient  soon  learns  the  most  suitable  time  for  lavage,  and  when  its 
frequent  necessity  is  determined,  he  should  be  taught  to  perform  it. 

Of  drugs,  hydrochloric  acid  is  the  most  likely  to  be  useful,  not  only 
because  of  its  importance  as  a  digestive  agent,  but  also  as  a  preventer  of 
fermentation.  To  this,  pepsin  becomes  a  useful  adjuvant,  because  it  is 
scantily  formed  in  the  dilated  stomach.  Nitro-miiriatic  acid  may  some- 
times be  substituted  with  advantage,  especially  when  a  stimulating  effect  is 
desired  on  the  liver.  It  should  be  freshly  prepared,  and  from  three  to  five 
drops  of  a  pure  acid  should  be  given  to  an  adult  at  a  dose.  Strychnin  is 
a  drug  which  has  much  to  recommend  it  from  the  theoretical  standpoint  as 


376  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

a  muscular  conic,  and  has  the  further  advantage  of  easy  absorption.  It 
should  be  administered  in  full  doses  from  a  small  beginning,  1-30  grain 
(0.002  gm.)  three  times  a  day,  increased  to  1-20  grain  (0.003  gm.)  and  even 
more.  Extract  of  nux  vomica  may  be  substituted,  but  it  is  less  easily 
absorbed.  Tincture  of  nux  vomica  is  better.  It  may  be  given  in  gradually 
increasing  doses  until  30  drops,  or  15  minims,  are  given  three  times  a 
day. 

In  addition  to  the  hydrochloric  acid  as  an  antiferment,  other  reme- 
dies for  this  purpose  are  charcoal  and  crcasotc.  The  power  possessed  by 
charcoal  of  absorbing  gases  cannot  be  utilized,  because  it  possesses  this  prop- 
erty only  in  the  dry  slate.  Yet  it  does  relieve  flatulence  and  is  antiseptic. 
Such  antisepsis  may  be  extended  to  the  intestine.  Doses  of  charcoal  of  5 
to  10  grains  (0.33  to  0.66  gm.)  and  even  more  may  be  given. 

Creasote  is  a  useful  antiseptic,  and  may  be  given  alone,  in  capsule  or 
in  pill,  in  doses  of  1-2  grain  to  a  grain  (0.03  to  0.06  gm.),  or  it  may  be 
given  in  sherry  wine,  whisky  or  brandy,  or  tincture  of  gentian.  The  fol- 
lowing one  per  cent,  solution  of  creasote  is  a  modification,  by  George  Her- 
schell,  of  Bouchard's  well-known  formula: 

ij     Creasoti, ' 10 

Tr.  gentianse, 20 

Vin.  xerici,  ...........     800 

Sp.  vini  gallici, 170 

M.  et  Sig.     One  hundred  minims  contain  one  minim  or  one  grain 
of  creasote 

When  the  condition  is  part  of  the  morbid  anatomy  of  cancer  of  the 
stomach,  only  palliation  may  be  expected. 

Dietetic  Treatment. — Most  important  is  the  selection  of  food  in  these 
cases.  Solids  should  be  almost  totally  prohibited,  while  the  typical  nour- 
ishment is  the  various  kinds  of  artificially  digested  food,  such  as  peptonized 
milk  and  beef  peptonoids.  Of  the  latter,  the  dry  form  of  beef  powder  is 
suitable,  because  it  absorbs  some  of  the  excessive  liquid  sometimes  present 
in  the  stomach.  Beef-juice  and  rare  beef  scraped  are  also  easily  assimilated, 
while  fatty,  and  especially  starchy,  foods  are  to  be  used  sparingly,  if  at  all. 


VISCEROPTOSIS. 

Synonyms. — Splanchnoptosis;      Entero  ptosis;       Gastroptosis;      Glenard's 

Disease. 

Definition. — A  condition  in  which,  as  a  consequence  of  the  relaxation 
of  the  ligaments  of  the  abdominal  viscera,  especially  those  of  the  stomach, 
intestines,  kidneys,  spleen,  and  liver,  these  organs  fall  below  their  normal 
position. 

Etiology. — An  explanation  applicable  to  all  cases  of  visceroptosis  has 
not  as  yet  been  made,  although  several  suggestions  are  more  or  less  appli- 
cable. First,  Glenard,  whose  name  is  so  closely  identified  with  the  subject 
that  the  affection  is  also  called  Glenard's  disease,  holds  that  a  descent  of 
the  right  or  hepatic  flexure  of  the  colon,  followed  by  dislocation  of  the 
transverse  colon,  is  the  primary  disturbance  in  enteroptosis.     The  hepato- 


VISCEROPTOSIS.  377 

colic  ligament,  which  is  the  name  he  applies  to  the  portion  of  the  mesocolon 
that  approaches  the  right  flexure  of  the  colon,  he  says  is  naturally  very 
weak,  and  can  be  loosened  and  stretched  by  the  weight  of  the  transverse 
colon,  particularly  when  this  is  loaded  with  feces.  He  thinks,  too,  that  de- 
bilitating and  emaciating  diseases  or  loss  of  tonicity  of  the  abdominal 
muscles  by  repeated  pregnancies,  by  gastro-intestinal  auto-intoxication,  by 
exhausting  hemorrhage,  or  by  damage  to  the  abdominal  muscles  by  pres- 
sure of  the  clothing,  may  cause  the  same  condition.  The  loss  of  fat  in 
emaciation,  however  caused,  undoubtedly  favors  its  occurrence.  When  the 
hepatic  flexure  of  the  colon  has  sunk,  the  right  half  of  the  transverse  colon 
also  descends  to  the  point  of  connection  by  the  tense  gastrocolic  ligament 
with  the  pyloric  end  of  the  stomach.  At  this  point  the  colon  becomes  kinked, 
causing  stagnation  of  its  contents,  followed  by  dilatation  of  the  colon  in 
front  of  the  constriction.  Beyond  this  it  contracts,  and,  according  to 
Glenard,  can  be  felt  as  a  tense  cord.  As  their  ligaments  become  loosened, 
the  remaining  abdominal  viscera  follow  the  descent  of  the  transverse  colon, 
the  stomach  being  drawn  down  by  the  gastrocolic  ligament,  the  liver  and 
kidneys  following.  Ewald  confirms  Glenard  except  as  to  the  primary  fac- 
tor in  the  causation  of  splanchnoptosis.  What  Glenard  regards  as  the  con- 
tracted- portion  of  the  colon  beyond  the  constriction,  and  calls  "  corde 
colique  transverse,"  Ewald  believes  to  be  the  pancreas.  He  denies  also 
that  simple  kinking  of  the  colon,  uncomplicated  by  peritoneal  adhesions  or 
by  stenosing  neoplasms,  can  cause  stagnation  of  feces.  Without  assigning 
a  distinct  cause,  Ewald  emphasizes  the  fact  that  long-standing  dyspepsias 
and  bodily  overexertion  may  create  altered  relations  of  pressure  and  tension, 
and  thus  lead  to  the  condition.  Landau  especially  emphasizes  disease  of 
the  abdominal  walls  as  the  primary  cause,  though  cases  are  reported  in 
which  there  is  no  such  relaxation.  Recent  studies  are  disposed  to  call  into 
play  a  congenital  factor  the  action  of  which  may  be  intensified  by  any  of  the 
various  causes  named.  In  late  fetal  life  and  early  extra-uterine  life  the 
position  of  the  abdominal  viscera  is  quite  like  that  characteristic  of  the  dis- 
ease. This  is  especially  shown  by  Joseph  Rosengart,  although  Henle  and 
other  earlier  anatomists  described  these  positions  of  the  viscera  in  young 
children.  Kussmaul  *  and  Leichtenstern  are  among  those  who  regard 
the  vertical  position  of  the  stomach  and  colon  in  adults  as  a  congenital 
anomaly.  The  influence  of  adhesions  in  producing  displacements  of  the 
abdominal  viscera  must  not  be  overlooked,  but  these  are  not  included  in  the 
condition  being  described. 

Enteroptosis  is  far  more  frequent  in  women  than  in  men,  306  out  of  404 
cases  collected  by  Glenard  being  women,  tight  lacing  and  pregnancy  being 
regarded  as  the  chief  causes  of  this  difference  in  the  two  sexes.  While  it 
is  true  that  the  majority  of  cases  met  in  practice  are  true  visceroptoses,  yet 
it  must  be  admitted  that  there  are  instances  in  which  one  organ  only — as, 
for  example,  the  stomach,  the  kidneys,  the  spleen,  or  the  liver — may  be  dis- 
located in  the  manner  referred  to. 

Symptoms. — First  of  all  it  must  be  stated  that  such  a  state  of  affairs 
as  that  described  may  exist  without  producing  any  symptoms.  The  symp- 
toms which  are  characteristic  are,  in 'a  word,  those  of  nervous  dyspepsia, 
including  derangement  of  appetite,  and  especially  anorexia,  more  rarely  false 
sensation  of  hunger,  a  sense  of  fullness  in  the  epigastrium,  noisy  belching, 

*  "  Zeitschrift  fur  diatetische  und  physikalische  Therapie,"  Bd.  i,  1898,  S.  220. 


378  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

various  bad  tastes,  and  dryness  of  the  mouth.  To  the  fullness  in  the  epigas- 
trium may  be  added  various  sorts  of  pain — shooting,  burning,  etc. — after 
eating.  There  may  be  constipation  or  an  opposite  condition  of  diarrhea. 
Hard,  scybalous  masses  may  be  removed  by  purgatives  or  enemas,  also 
mucus  in  varying  amounts,  including  casts  like  those  in  membranous  ente- 
ritis. The  lower  portion  of  the  abdomen  is  distended,  and  sometimes,  in 
persons  with  thin-walled  abdomens,  the  dislocated  viscera  may  be  recog- 
nized by  their  outlines.  Especially  is  this  true  if  they  be  dilated  with  air 
or  gas.  By  palpation  or  percussion  displacements  may  be  recognized  with 
more  or  less  ease.  The  transition  from  stomach  to  colon  can  often  be 
recognized  by  change  of  note  on  percussion,  while  the  kidneys,  spleen,  and 
liver  may  be  recognized  by  palpation.  Among  nervous  symptoms  may  be 
named  general  weakness,  depression  of  spirits,  headache  and  fullness  of  the 
head,  vertigo,  and  cold  feet  and  hands.  There  may  be  palpitation  of  the 
heart  and  disturbed  sleep  or  insomnia.  As  the  result  of  all  this  disturbance 
the  patient  may  become  so  emaciated  as  to  suggest  malignant  disease. 
Chlorosis  is  often  present,  and  by  Meinert  is  regarded  as  a  constant  symp- 
tom of  the  disease ;  indeed,  he  holds  that  gastroptosis  is  the  chief  cause  of 
chlorosis  in  women. 

Treatment. — When  there  are  no  syrhptoms  produced  by  this  unusual 
state  of  affairs,  of  course  no  treatment  is  indicated.  When  the  symptoms 
are  due  to  displacement,  it  is  evident  that  mechanical  measures  or  operation 
are  alone  likely  to  be  useful  in  restoring  the  organs  to  their  normal  situa- 
tion. The  former  include  trusses,  pads,  and  springs,  which  must  be  adapted 
to  each  case  after  a  study  by  the  instrument-maker  with  the  aid  of  the  phy- 
sician. In  the  absence  of  more  elaborate  appliances  a  simple  broad  band- 
age may  be  of  service  in  relieving  the  symptom.  Various  degrees  of  suc- 
cess have  been  attained  by  these  measures.  It  is  reasonable  to  suppose  that 
permanent  relief  can  alone  be  obtained  by  operation.  Treves  has  reported 
a  case  of  complete  cure  by  laparotomy  and  stitching  the  stomach.  Lately, 
in  the  Hospital  of  the  University  of  Pennsylvania,  a  patient  of  my  col- 
league's, Alfred  Stengel,  was  operated  upon  by  Alfred  C.  Wood,  with  ap- 
parent success. 

In  a  stomach  thus  dislocated  there  are  apt  to  be  atony  and  sluggish  peri- 
stalsis, which  may  result  in  the  accumulation  of  undigested  matters,  which 
are  better  removed  by  lavage.  Other  measures  useful  in  dilated  stomach 
may  also  be  expected  to  be  useful  as  well  as  those  indicated  for  nervous 
dyspepsia. 


DISEASES  OF  THE    INTESTINES. 

SIMPLE    ACUTE    CATARRHAL    ENTERITIS. 

Synonyms. — Acute  Intestinal  Catarrh;  Acute  Diarrhea;  Acute  Ileo-coUtis. 

Definition. — The  term  employed  is  applied  to  a  diffuse  inflammation 
which  generally  pervades  more  or  less  of  the  small  intestine  and  the  upper 
part  of  the  large  bowel.  More  circumscribed  inflammations  are  described, 
and  doubtless  sometimes  occur,  but  it  is  not  easy  to  localize  them. 

Etiology. — The  usual  causes  of  simple  intestinal  catarrh  are  overeating 
and  excessive  drinking,  or  the  swallowing  of  acid  or  mineral  substances  of 


SIMPLE  ACUTE  CATARRHAL  ENTERITIS.  379 

an  irritating  character.  Impurities  in  drinking-water  and,  in  the  summer  and 
autumn,  unripe  fruit  are  frequent  causes.  The  toxic  products  of  fermented 
and  decomposed  food  (leukomains)  are  also  causes.  These  sometimes  arise 
inexpUcably  from  substances  commonly  harmless,  such  as  milk  or  prepara- 
tions thereof.  Cream-puffs,  and  even  ice-cream,  are  among  these.  Irritat- 
ing minerals  are  corrosive  sublimate  and  arsenic.  Although  hot  weather 
favors  intestinal  catarrhs,  especially  in  infants  and  older  children,  they  are  not 
so  much  the  direct  result  of  the  heat  as  of  its  effect  in  weakening  the  resist- 
ing powers  of  the  child  and  favoring  the  decompositions  and  fermentations 
referred  to.  The  effect  of  heat  on  the  nervous  system  of  the  very  young 
may  reasonably  be  regarded  as  a  factor  in  increasing  irritability  of  the  gastro- 
intestinal tract  or  in  so  diminishing  its  functional  power  as  to  render  the 
ingesta  irritating.  Cold,  or  rather  a  chilling  of  the  body  by  a  fall  in  tem- 
perature, is  often  followed  by  enteritis. 

Secretion  altered  in  quantity  or  quality  has  already  been  mentioned  as 
a  cause  of  simple  non-infectious  intestinal  inflammation.  Much  spoken  of, 
but  of  inferred,  rather  than  of  demonstrated,  import,  is  excessive  biliary 
secretion,  producing  what  is  known  as  bilious  diarrhea.  When  such  diar- 
rhea is  associated  with  a  burning  sensation  at  the  anus  and  with  the  rec- 
ognized presence  of  bile  in  the  stools,  the  term  may  be  justified,  but  it  is 
to  be  remembered  that  an  acid  reaction  of  the  alvine  dejecta  produces  a 
similar  sensation.  A  scanty  supply  of  bile  to  the  intestine,  by  depriving  the 
gut  of  the  important  antiseptic  property  of  this  secretion,  may  also  favor  the 
fermentations  and  decompositions  mentioned. 

Hyperemia,  however  induced,  favors  catarrhal  enteritis.  Such  is  the 
hyperemia  secondary  to  hepatic  and  cardiac  disease,  and  to  inflammation, 
whether  traumatic  or  infectious,  in  adjacent  tissues,  whence  it  extends  by 
contiguity.  Such  is  the  inflammation  occasioned  by  peritonitis,  by  intes- 
tinal obstruction,  and  the  like.  Cachectic  and  anemic  states,  such  as  are 
secondary  to  cancer,  to  Addison's  disease,  and  to  the  last  stages  of  Bright's 
disease  and  of  tuberculosis,  are  also  favoring  causes.  Enteritis  is  also  a 
symptom  of  certain  infectious  diseases  through  their  specific  poisons,  which 
act  directly  on  the  mucous  membrane,  as  in  the  case  of  cholera,  dysentery, 
and  typhoid  fever. 

Apart  from  the  effect  of  nervous  influence  already  mentioned,  this  can- 
not be  said  to  cause  simple  enteritis.  It  is  not  unusual  for  fright  and  other 
causes  of  nervous  excitement  to  produce  diarrhea ;  but  this  is  not  the  result 
of  an  enteritis,  but  of  an  increased  peristalsis  and  disturbed  vasomotor 
regulations,  and  is  properly  called  nervous  diarrhea. 

Morbid  Anatomy. — The  morbid  changes  of  simple  intestinal  catarrh 
are  variously  distinct.  A  hyperemia  is  naturally  to  be  expected,  and  in  the 
more  decided  cases  may  be  manifested  by  a  diffuse  redness  and  injection. 
It  is  not  often,  however,  that  these  are  demonstrable.  A  layer  of  mucus 
covering  the  mucous  membrane  of  the  bowel  more  or  less  interruptedly  is 
mdre  frequently  present.  Nor  is  swelling  often  evident.  At  times  the  soli- 
tary follicles  are  unnaturally  distinct,  surrounded  by  a  hyperemic  circlet. 
Such  enlargements,  commonly  as  distinct  as  a  pin's  head,  may  be  as  large  as 
a  pea,  and,  becoming  filled  with  pus,  'form  little  abscesses,  which  may  rupture, 
leaving  an  ulcer.  They  may  extend  to  Fever's  patches.  More  rarely  chronic 
tilceration  results. 

Symptoms. — Diarrhea  is  the  most  constant  symptom  of  enteritis,  involv- 
ing the  part  of  the  intestinal  tract  named  in  the  definition.     The  resulting 


38o  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

stools  consist  of,  first,  ordinary  fecal  contents  of  the  small  and  large  intestine, 
including  bile ;  but,  as  they  continue,  they  become  more  and  more  watery,, 
almost  colorless.  There  may  be  but  two  or  three,  or  they  may  equal  twenty 
or  more.  They  contain  more  or  less  mucus,  and  are  often  frothy  and  asso- 
ciated with  flatus.  With  diminished  consistence  the  odor  may  grow  less 
obnoxious,  until  totally  absent.  At  other  times  it  is  persistently  offensive. 
Minute  examination  recognizes  in  these  discharges  columnar  epithelium 
variously  altered,  enlarged,  granular,  and  fragmentary,  with  nuclei  obscured 
or  absent,  also  various  non-pathogenic  bacilli  and  cocci,  including  the  bac- 
terium coli  commune,  yeast  fungus,  crystals  of  triple  phosphate,  oxalate  of 
lime,  cholesterin,  and  undissolved  food  matters.  The  reaction  of  the  dis- 
charge may  be  neutral  or  acid. 

Next  to  diarrhea  is  pain,  usually  colicky,  varying  greatly  in  degree ; 
often,  indeed,  in  the  milder  forms,  absent.  There  is  rarely  tenderness,  but 
palpation  may  elicit  gurgling  and  the  signs  of  gaseous  distention.  Thirst 
and  oliguria  are  natural  consequences  of  the  free  discharge  of  water.  There 
is  usually  little  fever,  the  rise  of  temperature  rarely  exceeding  one  or  two 
degrees,  and  the  higher  grades  suggest  specific  inflammation  of  the  bowel. 
The  appetite,  at  first  little  altered,  ultimately  fails.  Very  rarely  do  the  ordi- 
nary diarrheas  in  children  and  adults  terminate  in  collapse. 

It  is  reasonable  to  expect  modifications  of  the  foregoing  symptoms  as 
the  result  of  localized  inflammation,  as  contrasted  with  those  of  the  more 
diffuse  form  just  described.  Thus,  the  presence  of  jaundice  suggests  the 
probability  that  the  duodenum  is  especially  involved.  In  such  cases  the  urine 
may  also  be  jaundiced,  and  there  may  be  added  other  symptoms  commonly 
associated  with  jaundice.  In  the  absence  of  this  symptom  there  is  no  sign 
that  points  to  the  duodenum  as  the  special  seat  of  the  inflammation.  On  the 
other  hand,  jaundice  is  by  no  means  always  present,  even  if  the  duodenum 
is  involved.  Duodenitis  is  often  associated  with  acute  gastritis,  spreading 
from  the  stomach — gastro-duodenitis. 

An  acute  catarrhal  inflammation  of  the  jejunum  and  ileum,  unassociated 
with  inflammation  of  the  large  bowel,  would  be  unattended  with  diarrhea, 
the  slight  acceleration  of  peristalsis  incident  to  such  an  event  being  unlikely 
to  produce  this  symptom.  In  this  respect,  therefore,  it  will  differ.  On  the 
other  hand,  distention  of  the  abdomen,  colicky  pain,  borborygmi,  discharge 
of  flatus,  and  fever  continue.  Nothnagel  has  called  attention  to  the  presence 
of  little  lumps  of  mucus  from  the  inflamed  small  intestine  in  intimate  admix- 
ture with  the  contents  of  the  large  bowel,  often,  however,  requiring  the 
microscope  for  its  recognition.  Even  if  this  be  true,  however,  as  v.  Leube 
says,  it  is  scarcely  available  in  practice.  Whence  it  is  plain  that  a  diagnosis 
of  an  inflammation  of  this  part  of  the  intestinal  tract  is  by  no  means  an  easy 
matter.  It  is  probably  also  a  rare  condition  by  itself.  Nothing  distinctive 
is  added  if  only  the  upper  part  of  the  large  bowel  is  involved. 

Quite  different  is  it  when  there  is  also  involvement  of  the  whole  of  the 
large  intestine — ileo-colitis.  When  this  is  the  case,  while  the  lower  down 
the  inflammation,  the  purer  the  mucus  and  the  more  there  is  of  tenesmus,  the 
mucus  remains  separate  and  unmixed  -with  the  fecal  matter,  which  may  con- 
tain undigested  particles  of  food,  such  as  muscular  fibers,  starch,  and  fat  cor- 
puscles. A  diarrhea  in  which  these  undigested  portions  of  food  are  visible 
to  the  naked  eye  is  known  as  lienferic.  Gmelin's  nitric  acid  test  for  the 
biliary  coloring-matters  ceases  in  health  at  the  sigmoid  flexure,  so  that  if 
this  reaction  is  obtainable  in  the  liquid  discharges,  it  implies  that  the  exces- 


SIMPLE  ACUTE  CATARRHAL  ENTERITIS.  381 

sive  peristalsis  has  affected  also  the  large  bowel,  by  which  the  bile  is  carried 
through  with  abnormal  rapidity.  The  green  stools  of  children,  and  more 
rarely  of  adults,  also  indicate  a  large  quantity  of  bile.  Simple  feverish  states, 
however,  may  have  the  effect  also  of  interfering  with  the  proper  digestion  of 
food  matters,  which  may  appear  in  the  discharges  in  consequence.  Some 
information — not,  however,  too  much  to  be  relied  upon — may  be  derived 
from  the  seat  of  tenderness  and  colicky  pains.  When  these  are  in  the  middle 
or  inferior  part  of  the  abdomen,  they  point  to  the  small  intestine ;  when  in  the 
upper  and  lateral  parts,  to  the  large. 

Diagnosis. — The  diagnosis  of  acute  intestinal  catarrh  is  ordinarily  easy, 
by  attention  to  the  symptoms  previously  detailed,  including  those  more  or  less 
peculiar  to  the  more  circumscribed  localities  referred  to.  From  typhoid 
fever  acute  enteritis  is  usually  easily  distinguished  by  its  short  duration, 
minor  fever,  and  the  absence  of  the  characteristic  course  the  fever  takes 
in  the  infectious  disease,  and  absence  of  the  spots  which  so  invariably 
make  their  appearance  on  the  eighth  day  in  t3^phoid.  The  Widal  test  in  the 
latter  disease  also  aids  the  diagnosis. 

During  cholera  epidemics  mild  cases  of  this  disease  are  not  recognizable 
symptomatically  from  the  severer  colliquative  forms  of  diarrhea.  Under 
these  circumstances,  bacteriological  examination  should  be  made.  The 
importance  of  a  correct  diagnosis  will  be  appreciated  when  it  is  remembered 
that  indifference  in  the  treatment  of  simple  diarrhea  may  not  seriously  affect 
the  result,  while  such  treatment  of  a  case  of  cholera,  however  mild,  may 
result  disastrously. 

Prognosis. — This  is  always  favorable  with  prompt  and  judicious  treat- 
ment, recovery  taking  place  in  from  one  to  three  days,  as  a  rule,  rarely 
longer. 

Treatment. — Many  cases  of  acute  catarrhal  eriteritis  recover  under  rest 
and  restricted  diet,  the  degree  of  which  necessarily  depends  on  the  severity 
of  the  case.  The  simple  withdrawal  of  all  food,  the  substitution  of  plain 
milk,  or,  in  severe  cases,  of  boiled  milk,  for  the  usual  food,  generally  suffices. 
A  few  grains  of  bismuth  subnitrate  every  two  or  three  hours,  fortified  with 
1-8,  1-4,  1-2  grain  (0.0082,  0.015,  0.033  gm.)  of  opium,  or  1-2  ounce 
(15.5  gm.)  of  chalk  mixture  with  a  fiuid  dram  (4  c.  c.)  more  or  less  of  pare- 
goric may  be  added.  No  attempt  should,  however,  be  made  to  lock  up  the 
bowel  until  all  irritating  matters  are  removed,  and  it  is  often  desirable  to  give 
an  aperient,  castor  oil  being  the  best,  though  the  unpleasantness  of  the  dose 
often  precludes  this  valuable  remedy.  In  such  event  the  solution  of  the 
citrate  of  magnesium,  Rochelle  salts,  or  Hunyadi  water  may  be  substituted. 
When  there  is  much  pain,  larger  doses  of  opium  may  be  necessary,  especially 
if  hot  fomentations,  mustard  plasters,  or  turpentine  stupes  fail  to  produce  the 
desired  effect.  When  there  is  elevation  of  temperature,  no  better  means  than 
the  local  application  of  ice  can  be  found  to  relieve  pain.  Astringents  are 
rarely  necessary,  but  in  the  absence  of  other  measures  may  be  used.  Tannic 
or  gallic  acid  in  five-grain  doses  (0.33  gm.)  may  be  given  separately  or  com- 
bined with  opium. 

The  various  chlorodynes  form  convenient  remedies  when  there  is  pain. 
The  dose  varies  from  20  to  30  minims  (i  tO'  2  gm.).  In  severe  cases,  espe- 
cially when  there  is  nausea,  a  hypodermic  injection  of  morphin,  1-8  to  1-4 
grain  (0.0082  to  0.015  gm.),  may  be  given.  For  the  nausea  counterirritation 
by  mustard  plasters  should  be  used,  pieces  of  ice  swallowed  entire,  while 
copious  draughts  of  water  should  be  disallowed.     Champagne  and  cold  car- 


382  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

bonated  waters  may  be  used  for  this  purpose.  The  latter  may  be  combined 
with  milk,  while  the  old  reliable  remedy  of  equal  parts  of  milk  and  lime- 
water  should  not  be  forgotten. 


CHRONIC   CATARRHAL   ENTERITIS. 

Synonyms. — Chronic   Entcro-coUtis;    Ulcerative   Colitis;   Mucous   Colitis; 

Chronic  Diarrhea. 

Definition. — A  chronic  inflammation  of  more  or  less  of  the  large  and 
small  intestine,  with  or  without  ulceration. 

Etiology. — Chronic  enteritis  may  remain  after  repeated  attacks  of  the 
acute  form,  or  it  may  arise  de  novo,  however  induced,  favored  by  whatever 
occasions  passive  congestion.  Such  favoring  causes  are  diseases  of  the  liver 
or  heart,  feeble  and  anemic  states,  and  the  defective  nutrition  consequent 
thereon.  Chronic  exhausting  diseases,  such  as  tuberculosis  and  Bright's  dis- 
ease, may  act  in  this  wa}^  also.  Dysentery  is  a  frequent  cause  of  chronic 
intestinal  catarrh,  a  remnant  of  the  acute  process. 

Morbid  Anatomy. — The  primary  condition  is  that  of  acute  catarrh,  and 
in  many  cases  the  morbid  changes  do  not  exceed  those  of  acute  catarrh,  being 
simply  permanent,  or  later  more  pronounced.  In  others,  still  more  decided 
changes  are  found,  chiefly  in  the  lower  part  of  the  ileum  and  colon.  These 
are  mainly  ulcerative,  but  include  also  discolorations  due  to  hyperemia,  blood 
extravasation  and  pigmentation  succeeding  it,  thickening  of  the  coats  of  the 
bowel,  and  contraction  of  partly  healed  ulcers.  There  may  be  stenosis  or  the 
opposite  condition  of  dilatation.  Such  ulceration  is  distinct  from  that  of 
tuberculosis,  typhoid  fever,  and  syphilis.  It  may  be  follicular,  as  often  seen 
in  the  diarrheal  affections  of  children,  more  rarely  in  adults,  or  there  may  be 
large  ulcers  or  large  areas  of  ulceration.  The  remnant  of  mucous  membrane 
is  often  pigmented  and  slate-colored,  and  a  pseudo-polyposis  sometimes 
results  from  contraction.  In  the  small  intestine  the  pigment  is  apt  to  be 
deposited  on  the  ends  of  the  villi  and  in  rings  around  the  solitary  follicles,  or 
in  their  centers,  producing  the  "  shaven-beard  appearance."  The  surface  of 
the  bowel  is  more  or  less  covered  with  mucus  and  purulent  secretion  incident 
to  the  inflammation.  Still  another  sort  of  ulceration,  from  the  etiological 
standpoint,  is  found  at  the  bottom  of  saccules  of  the  large  intestine  in  which 
scybala  or  hard  fecal  masses  have  lain  a  long  time.  Ulceration,  too,  may 
result,  though  rarely,  from  encroachment  from  without  by  various  kinds  of 
disease  of  the  peritoneum,  including  cancer,  tuberculosis,  and  the  like. 
Atrophy  of  the  mucous  membrane  of  the  bowel  is  also  one  of  the  results  of 
chronic  enteritis,  not  usually  recognizable  before  death. 

There  may  even  be  atrophy  not  only  of  the  mucous  membrane,  with 
destruction  of  the  glands,  but  also  of  all  the  coats  of  the  small  and  large 
intestines. 

Symptoms. — ^These  are  not  uniform.  While  there  is  often  more  or  less 
diarrhea,  this  is  as  often  absent,  or  substituted  by  constipation,  while  con- 
stipation and  diarrhea  frequently  alternate.  More  characteristic  of  the  stools 
is  the  large  amount  of  miucons  matter  contained  in  them.  This  may  be 
present  in  the  shape  of  "  sago  "-like  masses  or  "  mucous  "  granules,  yellow  or 
brownish-vellow,   bile-stained   also   from   the   small   intestine.     Bile-stained 


CHRONIC  CATARRHAL  ENTERITIS.  383 

mucus  is  present  only  when  there  is  abnormally  rapid  peristalsis  of  the  large 
bowel,  which  causes  the  mucus  to  be  passed  out  before  the  bile  is  decom- 
posed. Ulceration  may  be  associated  with  the  presence  of  blood  in  the 
stools. 

A  variety  of  chronic  colitis  known  as  mucous  colitis  or  membranous 
enteritis  is  characterized  by  the  discharge  of  large  masses  of  mucus,  forming 
at  times  complete  casts  of  the  bowel.  It  is  more  frequent  in  women,  this 
sex  including  80  per  cent,  of  recorded  cases,  according  to  W.  A.  Edwards. 
It  may  occur  also  in  children.  Its  subjects  are  usually  women  of  the  nerv- 
ous type.  It  is  commonly  associated  with  constipation.  At  intervals,  how- 
ever, occur  attacks  of  abdominal  pain  and  tenderness,  sometimes  accompanied 
by  tenesmus  and  followed  by  discharges  of  the  mucoid  matter  referred  to. 
Such  attacks  may  be  excited  by  mental  emotion  of  various  kinds.  The 
mucoid  material  itself  seems  to  be  the  direct  result  of  an  increased  activity 
of  the  mucous  glands,  which,  with  the  mucous  membrane,  are,  however,  com- 
monly intact  after  the  separation  of  the  large  mucous  casts.  Minute  exami- 
nation recognizes  more  or  less  numerous  cells,  round  and  columnar,  entangled 
in  the  mucus,  sometimes  also  cholesterin  plates  and  triple  phosphate 
crystals. 

Throughout  the  numerous  attacks  nutrition  is  commonly  well  main- 
tained, and  the  woman  subject  appears  plump  and  well  nourished.  At  other 
times  there  are  gradual  emaciation  and  ultimate  death. 

Diagnosis. — This  is  always  easy,  except  as  to  the  determination  of  the 
portion  of  the  bowel  involved  or  the  presence  of  ulceration.  Differences  in 
the  character  of  the  mucus,  as  previously  noted,  will  aid  in  the  diagnosis,  while 
the  constant  or  intermittent  presence  of  blood  and  pus  or  fragments  of  tissue 
in  the  stools  points  to  the  ulcerative  condition.  Ulceration  is  sometimes 
found  postmortem  where  no  symptoms  were  present  before  death.  In  the 
rectum,  and,  indeed,  as  high  as  the  sigmoid  flexure,  ulcer  may  be  recognized 
by  specular  examination.  Deep-seated  ulceration  may  cause  circumscribed 
peritonitis  or  may  produce  abscess.  The  presence  of  scybala,  surrounded 
with  mucus,  points  to  inflammation  of  the  rectum  or  colon  as  far  up  as  its 
transverse  portion.  It  is  not  possible  to  diagnose  the  presence  of  atrophy  of 
either  bowel. 

Prognosis. — The  prognosis  in  all  forms  of  chronic  intestinal  catarrh  is 
grave  so  far  as  recovery  is  concerned,  and  treatment  avails  little  in  many 
cases.  The  disease,  however,  extends  over  months,  and  even  years,  before 
the  patient  succumbs,  and  recovery  is  sometimes  complete,  quite  independent 
of  treatment. 

Treatment. — xA-S  in  the  case  of  acute  catarrhal  enteritis,  rest  is  an  impor- 
tant condition  of  success  in  the  treatment  of  this  disease.  Next,  we  must 
select  a  diet  with  a  minimum  of  waste,  so  that  there  may  be  as  little  irritating 
residue  as  possible.  Milk  and  the  albuminous  foods  are  the  types  of  these. 
Still  less  irritating  must  they  be  if  partly  digested  before  being  taken  into 
the  stomach.  Thus,  milk  may  be  peptonized,  and  meat  also,  and  the  beef 
peptonoids  of  the  manufacturers  may  be  employed.  It  is  difficult  to  ascer- 
tain the  ratio  of  nourishing  power  of  these  peptonoids  to  that  of  solid  meat. 
This,  then,  should  be  a  fundamental  principle  of  treatment — to  furnish  a  diet 
with  a  minimum  of  waste. 

When  it  is  remembered  that  chronic  intestinal  catarrh  is  seated  mainly 
in  the  large  intestine,  it  is  manifest  that  to  reach  it  with  remedies  admin- 
istered in  the  ordinar}-  way  is  difficult,  and  that  it  is  more  than  likely  that  such 


384  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

remedies  are  absorbed  or  decomposed  before  they  arrive  at  the  seat  of  the  dis- 
ease. It  is  barely  possible  that  after  prolonged  administration  certain  drugs, 
as  nitrate  of  silver,  will  ultimately  reach  the  seat  of  ulceration  and  stimulate 
it  to  heal.  Such  a  course  must,  therefore,  be  pursued  with  any  remedies 
thus  administered.  Nitrate  of  silver  and  the  sulphate  of  copper  are  the  two 
which  possess  most  reputation.  The  doses  are  1-4  grain  (0.0155  gm.)  of 
each  three  times  a  day,  or  a  smaller  quantity  more  frequently.  The  acetate 
of  lead  may  be  substituted  in  doses  of  two  grains  (0.132  gm.).  The  latter 
is  more  astringent,  but  is  less  likely  to  excite  healing.  All  these  remedies  are 
commonly  combined  with  opium  in  suitable  doses.  Subnitrate  of  bismuth  in 
large  doses,  1-2  dram  to  one  dram  (2  to  4  gm.),  is  strongly  recommended  by 
some.  It  undoubtedly  diminishes  the  discharges,  but  how  far  it  is  curative 
is  uncertain. 

The  natural  astringent  waters,  such  as  the  Rockbridge,  and  other  alum 
waters  in  this  country,  have  earned  some  reputation  in  the  treatment  of 
chronic  intestinal  catarrh,  but  improvement  under  their  use  is  always  more 
marked  at  the  springs  themselves,  showing  that  some  effect  must  be  ascribed 
to  the  change  of  scene  and  air  and  to  the  salubrious  climate  of  the 
locality. 

Should  these  measures  fail,  irrigatioii  of  the  bowel  may  be  practiced. 
This  is  done  by  means  of  a  fountain  syringe,  or  a  funnel  in  connection  with 
a  tube,  which  is  carried  high  up  into  the  bowel,  the  patient  being  placed  on 
his  back  with  a  pillow  under  his  hips.  The  fluids  used  are  solutions  of  nitrate 
of  silver,  sulphate  of  zinc,  and  boric  acid.  At  first  tepid  water,  say  at  85°  F. 
(30°  C),  should  be  run  in  very  slowly  to  the  amount  of  two  to  three  pints 
( I  to  I  1-2  liters).  Then  solutions  of  any  of  the  foregoing  substances,  of  the 
strength  of  3  to  4  1-2  parts  to  1000,  or  i  1-2  to  2  grains  to  the  oz.  (o.i  gm. 
to  0.13  gm.  to  30  c.  c.)  of  the  more  active  substances,  beginning  with  the 
weaker  solutions.  Salicylic  acid  may  be  used  in  two  per  cent,  solution,  boric 
acid  in  one  per  cent,  solution,  or  a  one  per  cent,  solution  of  salicylic  and  boric 
acids  combined.  A  one  per  cent,  solution  of  tannic  acid  is  also  recommended, 
as  well  as  of  corrosive  sublimate,  but  the  latter  is  exceedingly  irritating  and 
the  strength  of  the  solutions  should  not  exceed,  at  first,  i  :  15,000,  which  may 
be  increased,  if  well  borne.  The  nitrate  of  silver  has,  on  the  whole,  the  best 
reputation.  A  preliminary  anodyne  enema  of  30  minims  (i  gm.)  of  lauda- 
num may  be  given,  if  needed,  or  a  suppository  of  extract  of  opium,  say  one 
grain  (0.066  gm.).  To  be  effectual,  the  treatment  must  be  patiently  pro- 
longed, especially  the  dietetic  part,  and  not  weeks,  but  months,  of  patient 
perseverance  insisted  upon.  I  have  already  said,  in  treating  of  dysentery, 
that  a  careful  trial  of  this  form  of  treatment  in  my  hands  has  been  disap- 
pointing in  its  results. 


CHOLERA   MORBUS. 

Synonyms. — Cholera  nostras;  Sporadic  Cholera. 

Definition. — An  acute  gastro-intestinal  catarrh,  characterized  by  pro- 
fuse vomiting,  purging,  and  painful  cramp. 

Etiology. — The  intensity  of  the  symptoms  and  their  similarity  to  those 
of  true  cholera  justify  a  suspicion  that  a  specific  organism  is  responsible  for 
cholera  nostras  as  well  as  for  true  cholera.     No  single  bacillus  has,  however. 


CHOLERA  MORBUS.  385 

been  settled  upon,  although  the  bacillus  known  as  the  Finkler  and  Prior 
bacillus,  which  closely  resembles  the  "  comma  "  bacillus  of  true  cholera,  is 
found  in  the  discharges  with  considerable  constancy.  The  disease  may  result 
from  toxins  generated  by  a  variety  of  bacilli,  but  until  more  definite  proof  is 
brought  forward,  cholera  morbus  must  be  regarded  as  a  severe  form  of 
catarrhal  enteritis  associated  with  gastritis  due  to  some  poison  generated  by 
the  noxious  substances  causing  it.  Such  are  indigestible  and  decomposed 
articles  of  food,  unripe  fruit,  and  particularly  mixtures  of  fish,  salads  and 
fruit.  Especially  frequent  are  these  attacks  in  the  hot  weather  of  July  and 
August,  though  cold  and  dampness  are  also  regarded  as  predisposing  causes. 
So  are  fatigue  and  a  debilitated  state  of  the  system.  Young  adults  and  per- 
sons in  the  prime  of  life  are  more  frequently  victims  than  either  the  very  old 
or  very  young. 

Morbid  Anatomy. — This  is  in  no  way  different  from  that  of  catarrhal 
enteritis,  and  visible  alterations  are  not  always  apparent.  The  same 
shrunken,  ashen  appearance  of  the  skin  characteristic  of  cholera  may  be  found 
in  fatal  cases  of  cholera  morbus. 

Symptoms. — 'The  victim  of  cholera  morbus  is  commonly  seized  sud- 
denly, often  at  night,  with  sevci'e  cramp,  vomiting,  and  purging.  The  first 
vomitus  is  the  food  last  ingested,  but  this  is  rapidly  succeeded  by  bilious 
matter,  and  still  later  by  almost  pure  water.  The  same  may  be  said  of  the 
bowel  discharges,  which  follow  each  other  in  rapid  succession — in  fact, 
become  at  times  almost  continuous.  They  present  ultimately  all  the  physical 
characters  of  the  rice-water  discharges  of  true  cholera. 

The  pain  is  at  first  confined  to  the  abdomen,  the  paroxysms  succeeding 
each  attack  of  vomiting.  Later  it  extends  to  the  muscles  elsewhere,  espe- 
cially those  of  the  calves  of  the  legs. 

Corresponding  to  the  loss  of  water  is  thirst,  often  intense.  The  patient 
is  restless  and  anxious.  Collapse  may  supervene,  and  the  skin  become  cold, 
clammy,  and  ashen-hued,  the  eyes  deeply  sunken,  the  pulse  frequent  and 
feeble.  There  is  not  often  fever,  though  the  internal  temperature  is  higher 
than  that  of  the  surface.  The  mind  remains  clear,  even  in  the  event  of  a 
fatal  termination,  almost  to  the  end,  when  it  may  become  clouded. 

Diagnosis. — This  was  fully  considered  when  treating  of  cholera,  to  the 
•section  on  which  the  student  is  referred.  The  symptoms  caused  by  over- 
doses of  arsenic,  antimony,  and  the  poisonous  mushroom  are  similar. 

Prognosis. — This  is  usually  favorable,  the  gravest  cases  recovering,  as 
a  rule.  A  single  night  commonly  measures  the  duration  of  an  attack.  Fatal 
cases,  however,  occur,  the  very  old  and  the  very  young  being  most  often 
victims.  Prompt  treatment  is  of  the  utmost  importance,  as  it  will  usually 
■cut  short  an  attack  which  will  otherwise  last  from  twenty-four  to  thirty-six 
hours  and  be  succeeded  by  a  slow  convalescence. 

Treatment. — Opium  is  almost  indispensable  to  the  successful  treatment 
of  an  attack  of  cholera  morbus.  The  happiest  method  of  exhibition  is  by  the 
hypodermic  needle,  more  especially  because  everything  given  by  the  mouth 
is  apt  to  be  promptly  rejected.  For  an  adult  less  than  1-4  grain  (0.0165  gm.) 
of  morphin  is  hardly  to  be  thought  of.  On  the  other  hand,  such  a  dose  will 
often  act  magically.  It  should  be  associated  with  diffuse  counterirritation 
over  the  abdomen  by  mustard,  while  the  hot  bath  may  be  added,  if  the  symp- 
toms do  not  yield. 

In  the  absence  of  the  hypodermic  needle,  remedies  must  be  given  by 
the  mouth.     The  association  with  morphin  of  the  hot  aromatics,  such  as 

25 


386  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

ginger  and  cloves,  seems  to  aid  its  retention.  Hence  the  efficienqy  of  the 
various  forms  of  "  cholera  drops,"  the  formula  for  some  of  which  are  given 
under  cholera.  Chlorodyne  is  an  admirable  remedy.  Unfortunately,  the 
preparations  by  different  pharmacists  are  not  of  uniform  strengths.  On  the 
other  hand,  the  doses  are  commonly  indicated  on  the  labels,  and  it  is  safe  to 
say  they  may  be  usually  doubled  without  harm  to  the  patient. 

The  nausea  may  be  controlled  by  ice,  by  cold  carbonated  waters,  by 
pieces  of  ice  swallowed  whole,  or  by  champagne.  The  latter  is  particularly 
appropriate  when  stimulants  are  needed,  as  constantly  happens.  When  there 
is  a  tendency  to  collapse,  whisky  and  ether  may  be  injected  under  the  skin, 
while  enteroclysis  and  even  hypodermoclysis  may  be  needed  for  the  same 
reasons  as  in  true  cholera — the  restoration  of  the  water  lost  from  the  system. 


DIARRHEAS  OF  CHILDREN. 

The  importance  of  these,  and  some  specialization  in  their  symptomatol- 
ogy, demand  a  separate  consideration.  Three  forms,  more  or  less  distinct, 
are  recognizable — viz.,  acute  dyspeptic  diarrhea,  cholera  infantum,  and  acute 
entero-colitis. 

Acute  Dyspeptic  Enteritis. 

Definition. — An  acute  inflammation  of  the  small  intestine  due  to  diet 
unsuited  to  the  infant. 

Etiology. — The  errors  in  diet  referred  to  do  not  necessarily  consist  in 
unnatural  foods  substituted  for  the  mother's  milk.  The  latter  itself  may  be 
altered  in  quality  by  emotional  causes,  by  improper  food,  and  by  improper 
hygiene ;  or  the  child  may  be  too  liberally  supplied  by  overfrequent  nursing. 
Milk  itself  may  be  infectious  by  the  presence  of  streptococcus  and  tubercu- 
losis infection  derived  from  suppurating  and  tubercular  udders.  More  often, 
however,  acute  dyspeptic  enteritis  is  the  result  of  ingestion  of  unnatural  food, 
either  of  substances  palpably  unsuitable,  carelessly  allowed,  or  surreptitiously 
taken,  or  of  substitutes  necessarily  employed  for  mother's  milk  when  she  is 
unable  to  nurse  her  infant. 

"  Bottle  food,"  the  most  carefully  selected,  is  unnatural,  and  is  probably 
the  most  frequent  cause  of  dys|)eptic  diarrhea  in  children  otherwise  well  cared 
for.  Two  factors  in  this  are  active :  first,  the  relatively  greater  indigestibility 
of  the  foods  thus  supplied ;  and,  second,  the  bacteria  and  their  toxic  products 
which  develop  in  it  before  or  after  ingestion.  Normally,  the  feces  of  infants 
contain  but  few  species  of  bacteria,  of  which  the  most  important  are  the  ba€- 
teriuni  aerogenes  and  the  bacterium  coli  commune.  The  former  seems  to  be 
an  exclusive  product  of  a  milk  diet,  depending  upon  the  milk-sugar  for  its 
nourishment,  and  is  found  in  the  upper  bowel,  where  it  excites  fermentation 
in  milk.  The  habitat  of  the  bacterium  coli  commune  is  the  lower  part  of  the 
small  intestine  and  the  colon,  where  it  is  probably  also  an  agent  of  fermenta- 
tion. In  infantile  diarrhea  the  number  of  species  of  bacteria  is  greatly 
increased,  but  no  one  or  more  species  has  as  yet  been  shown  to  possess  a 
Specific  causal  eiifect. 

There  are  also  predisposing  influences  which  facilitate  the  action  of  the 


DIARRHEAS  OF  CHILDREN.  387 

essential  causes.  These  are,  especially,  dentition  and  the  extreme  heat  of 
summer.  The  effect  of  the  former  is  learned  in  the  experience  of  every 
mother,  while  the  extraordinary  frequency  of  infantile  diarrhea  in  summer 
attests  the  latter.  It  is  evident,  too,  that  constitutional  weakness  and  bad 
hygiene  must  also  co-operate  to  diminish  the  resisting  power  of  infants  to 
other  causes.  Hence  it  is  that  the  children  of  the  delicate,  the  poor,  and  the 
unclean  suffer  most. 

Morbid  Anatomy. —  This  seldom  exceeds  the  stage  of  catarrhal  swell- 
ing, already  described  when  treating  of  the  enteritis  of  adults. 

Symptoms. — No  symptoms  may  precede  the  diarrhea,  but  usually  there 
is  in  the  beginning  restlessness^  wdth  slight  fever,  which  seldom  becomes 
high.  Such  restlessness  may  be  due  to  nausea  or  to  colicky  pain.  The 
nausea  may  go  on  to  vomiting  or  not,  but  purging  soon  occurs.  Sudden 
onset  is  characteristic.  The  stools  are  at  first  copious  and  offensive,  often 
yeasty  and  sour,  and  generally  contain  particles  of  coagulated  milk  or  other 
undigested  food,  such  as  unripe  fruit,  if  the  child  is  old  enough  to  eat  it.  At 
first  infrequent,  they  become  more  numerous,  more  scanty,  acquire  sometimes 
a  green  color  and  sometimes  contain  mucus,  rarely  blood.  In  other  words 
the  condition  passes  over  into  enterocolitis.  There  may  be  but  three  or 
four  stools  or  there  may  be  twenty  or  more  in  the  twenty-four  hours. 

In  other  cases  fever  is  more  decided,  and  the  temperature  may  rise  rap- 
idly to  104°  F.  (40°  C.)  ;  there  are  great  thirst  and  scanty  urine.  Even  when 
there  is  no  fever  emaciation  is  rapid,  and  the  child  falls  away  amazingly  in 
a  few  days. 

Diagnosis. — The  sudden  onset  and  the  character  of  the  stools  are  dis- 
tinctive and  scarcely  mistakable.  The  small  amount  of  mucus  distinguishes 
them  from  those  of  ileo-colitis,  and  the  absence  of  serous  discharge  from 
those  of  cholera  infantum. 

Prognosis. — This,  among  the  better  classes,  is  commonly  favorable, 
but  among  the  weak,  puny,  and  half-starved  children  of  the  poor  large  num- 
bers perish,  especially  in  hot  weather.  The  disease  may  pass  over  into  the 
much  more  serious  affection  of  entero-colitis. 

Treatment. — The  principles  of  treatment  are  similar  to  those  of  enteritis 
in  adults.  A  primary  purge  is  commonly  indicated.  Calcined  magnesia  is 
very  suitable,  though  castor  oil  is  here  also  useful.  After  the  purge,  bismuth 
subnitrate  or  prepared  chalk,  in  doses  of  2  1-2  grains  (0.165  gm.)  for  a  child 
a  year  old,  with  1-2  grain  (0.033  S"^-)  of  salol  as  an  intestinal  antiseptic, 
may  be  given  ever}^  two  or  three  hours.  If  there  is  pain,  1-24  to  1-12  grain 
(0.0027  to  0.0054  gm.)  of  opium  may  be  added  each  time  or  every  other  dose, 
as  may  be  demanded  by  circumstances.  An  attempt  should  first  be  made  to 
relieve  pain  by  gentle  counterirritation,  as  by  weak  mustard  plasters  or  a 
plaster  of  mixed  spices,  wet  in  whisky  or  alcohol,  and  known  as  a  "  spice 
plaster,"  and  worn  continuously.  Deodorized  tincture  of  opium  or  paregoric 
may  be  substituted  for  the  whisky.  Astringents  are  seldom  necessary  in  chil- 
dren's diarrhea,  but  the  compound  tincture  of  kino,  which  contains  a  little 
opium,  is  an  efficient  remedy,  which  probably  owes  much  of  its  efficacy  to  the 
latter.  Chalk  mixture,  to  which  a  few  drops  of  paregoric  may  be  added,  is 
an  efficient  remedy.  The  pure  antiseptic  treatment  has  never  commended 
itself  to  me,  and  I  am  inclined  to  think  that  more  harm  than  good  has  been 
done  by  such  remedies  as  resorcin,  napthalin,  and  the  like,  which  are  often 
irritating. 

The  regulation  of  diet  is  of  the  utmost  importance.     It  is  better  to  give 


388  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  child  nothing  except  a  little  cold  water  or  barley-water  than  unsuitable 
food,  while  any  food  that  is  given  should  be  very  much  diluted,  and  should 
be  scanty  rather  than  overabundant.  Too  much  food  is  often  given.  Noth- 
ing is  better  than  peptonized  milk,  if  the  mother's  milk  or  that  of  a  wet- 
nurse  be  unobtainable.  Plain  fresh  cow's  milk  may  do  as  well.  All  of 
these  should  be  diluted  with  Vichy  water,  lime-water,  or  plain  water,  to  which 
a  little  brandy  mav  be  added.  As  long  as  casein  appears  in  the  stools  the 
milk  requires  further  dilution,  or  the  casein  may  be  removed  altogether  and 
the  whey  only  allowed.  Animal  broths,  however  dilute,  do  not  find  much 
favor  with  me,  though  occasionally  beef -juice  is  well  borne  when  milk  has 
not  been,  especially  in  children  two  or  more  years  old.  Albumen  water,  made 
by  mixing  the  albumen  of  one  or  two  eggs  with  a  pint  ( 1-2  liter)  of  sterilized 
water,  is  much  more  suitable. 

The  hygienic  surroundings  of  the  child  are  important.  Frequent  bath- 
ing ;  light,  cool  dressing  in  warm  weather ;  and  fresh  air  at  all  times  are  indis- 
pensable. The  patient  should  be  removed  from  city  air  to  the  country  or  sea- 
side, when  possible ;  and  when  this  is  not  possible,  frequent  excursions  should 
be  made  to  the  country  or  on  an  adjacent  river.  It  is  not  desirable  to  keep 
the  child  on  the  lap  any  more  than  is  necessary. 


Acute  Extero-colitis. 
Synoxyms. — Acute  Ilco-colitis:  Follicular  Enteritis;  Follicular  Dysentery. 

Definition, — An  inflammation  more  severe  than  dyspeptic  enteritis, 
chiefly  of  the  ileum  and  colon,  afifecting  especially  the  lymph  follicles. 

Etiology. — Entero-colitis  is  also  a  disease  of  the  hot  months  and  of 
teething.  It  is  met,  however,  in  the  cooler  seasons.  It  is  produced  by  the 
same  causes  as  dyspeptic  diarrhea.  It  is  more  frequent  between  the  ages 
of  six  and  eighteen  months, — second  summer, — and  is  not  infrequent  in  the 
third  and  fourth  years.  It  may  be  a  termination  of  dyspeptic  diarrhea  or  of 
cholera  infantum. 

Morbid  Anatomy. — The  morbid  changes  are  more  positive  than  in 
acute  dyspeptic  diarrhea,  and  are  found  chiefly  in  the  ileum  and  colon.  In 
the  first  stage  the  mucous  membrane  is  congested  and  swollen,  while  the 
solitary  follicles  and  Peyer's  patches  are  more  distinct.  The  epithelium 
is  exfoliated  in  places.  As  the  disease  continues  into  the  second  stage,  say 
after  the  first  week,  the  enlarged  follicles  and  Peyer's  patches  become  ulcer- 
ated. The  changes  may  end  here  or  may  become  more  extensive,  constitut- 
ing the  third  stage,  the  ulcers  enlarging  and  deepening  to  the  muscular 
coat,  with  the  separation  of  a  slough.  Or  there  may  be  a  diffuse  infiltration 
of  the  bowel  with  small  cells,  producing  a  decided  thickening  of  the  same, 
with  more  or  less  obliteration  of  its  distinctive  structure.  The  process  may 
be  so  intense  as  to  cause  coagulation-necrosis — false  membrane. 

Symptoms. — The  disease  may  begin  as  a  dyspeptic  diarrhea,  also  as  a 
cholera  infantum.  It  is  much  more  serious  than  dyspeptic  diarrhea,  as  evi- 
denced by  the  higher  fever,  which  rises  rapidly  to  104°  F.  (40°  C),  but  still 
remains  lower  than  in  cholera  infantum.  Vomiting  is  less  common  than  in 
dyspeptic  diarrhea  or  cholera  infantum.  There  are  decided  abdominal 
pain  and  a  tense,  szvollen  belly.  The  fecal  discharges,  which  are  at  first  pain- 
less, are  small  in  quantity  and  contain  much  mucus  and  even  a  little  blood. 


DIARRHEAS  OF  CHILDREN.  389 

They  vary  in  frequency  from  fifteen  to  thirty  in  the  twenty-four  hours,  and 
occur  more  frequently  during  the  day.  The  disease  may  abate  at  this  stage 
and  convalescence  be  established,  though  recovery  remains  slow.  Or  the 
symptoms  may  increase  in  severity,  the  fever  persist,  and  the  stools  he  pain- 
ful and  small,  consisting  mainly  of  mucus  and  blood.  Commonly  odorless, 
they  may  also  be  extremely  fetid.  The  urine  is  scanty,  of  high  specific  grav- 
ity, and  deposits  mixed  urates.  The  child  wastes  almost  to  a  skeleton,  the 
skin  becomes  loose  and  flabby,  and  the  "  old  man  "  appearance  is  assumed. 
Such  a  case  may  last  five  or  six  weeks,  terminating  fatally,  yet  may,  on  the 
other  hand,  get  well.  A  few  fatal  cases  are  much  more  rapid  in  their  course, 
being  ushered  in  with  convulsions  and  ending  in  from  forty-eight  hours  to 
five  or  six  days.  Relapses  after  convalescence  are  not  uncommon,  and 
should  be  guarded  against. 

Diagnosis. — Acute  entero-colitis  is  characterized  by  a  greater  severity 
than  dyspeptic  diarrhea,  by  the  high  fever,  the  large  amount  of  mucus  in 
the  stools,  the  greater  pain,  and  the  more  rapid  prostration.  From  cholera 
infantum  it  differs  in  its  lower  hyperpyrexia,  and  in  the  absence  of  vomiting, 
of  colliquative  diarrhea,  and  of  collapse. 

Prognosis. — This  is  more  unfavorable  than  in  acute  dyspeptic  diar- 
rhea; more  favorable  than  in  cholera  infantum.  Recovery  is  not  infrequent 
after  a  lengthy  illness  of  four  to  six  weeks,  while  the  severe  dysenteric 
form  is  apt  to  be  early  fatal.  Much  depends  upon  the  promptness  with 
which  treatment  is  instituted  and  the  ability  of  the  parents  to  carry  it  out, 
and  upon  the  previous  vigor  of  the  child,  its  hygiene,  and  its  food. 

Treatment. — The  general  hygienic  and  dietetic  treatment  of  acute 
entero-colitis  is  similar  to  that  of  acute  dyspeptic  diarrhea ;  the  medicinal 
treatment  is  somewhat  different.  Anodynes  are  more  imperatively  de- 
manded, because  there  is  greater  suffering,  and  depletion  may  be  needed 
in  the  beginning  by  salines,  though  good  judgment  is  required,  because  the 
child's  strength  must  be  husbanded.  Otherwise,  drugs  are  not  of  much  use, 
though  bismuth,  in  full  doses,  may  be  given  with  advantage. 

The  colon  may  be  flushed  with  a  one  per  cent,  cold  salt  solution,  or 
cold  water  or  pieces  of  ice  may  be  introduced  into  the  rectum,  which  may 
also  be  used  for  medication,  more  particularly  by  opium.  I  do  not  think 
the  large  rectal  enemas  recommended  in  the  chronic  colitis  of  adults  are 
to  be  advised  for  children.  If  used,  they  should  be  very  weak.  Solutions 
of  nitrate  of  silver,  one  grain  to  the  ounce  (0.066  gm.  to  30  c.  c),  and  tannic 
acid,  five  grains  to  the  ounce  (0.33  gm.  to  30  c.  c),  are  suitable.  The 
mouth  should  be  often  examined  and,  when  necessary,  the  coming  teeth 
scarified,  not  once  only,  but  as  often  as  necessary. 


Cholera  Ixfaxtum. 

Definition. — A  variety  of  acute  catarrhal  enteritis  of  intense  severity, 
corresponding  in  symptoms  and  course  to  cholera  morbus  in  the  adult,  but 
much  more  serious  in  termination. 

Etiology. — The  same  reasons  th'at  lead  us  to  expect  a  specific  cause  of 
cholera  morbus  would  suggest  one  also  for  cholera  infantum.  None  has, 
however,  been  found.  It  may  reasonably  be  ascribed  to  toxins  generated  in 
the  decomposition  and  fermentation  of  foods,  since  some  error  of  diet  is 
almost  always  the  apparent   exciting  cause.     There   are  also   predisposing 


390  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

causes,  of  which  hot  weather,  dentition,  or  both,  bad  hygiene,  the  previous 
presence  of  dyspeptic  diarrhea  or  entero-cohtis,  are  instances.  It  is  less  fre- 
quent than  either  of  the  last-named  affections,  including  only  a  small  propor- 
tion of  the  summer  complaints  of  children — according  to  Holt  not  more  than 
two  or  three  per  cent. 

Morbid  Anatomy. — There  is  little,  if  any,  deviation  from  the  normal 
appearance  in  the  affected  bowel. 

Symptoms. — These  consist  in  copious  serous  stools,  at  first  containing 
some  offensive  fecal  matter,  later  a  few  particles  of  greenish  matter ;  but  ulti- 
mately they  are  almost  aqueous,  being  ejected  also  with  great  force.  They 
contain  numerous  bacteria,  but  no  constant  organism  has  been  found.  There 
is  crampy  pain,  and  the  limbs  are  drawn  up  or  rigidly  extended.  There  is 
decided  fever,  more  than  in  either  of  the  two  other  forms,  the  temperature 
reaching  105°  F.  (40.5°  C.)  ;  the  pulse  is  frequent  and  feeble,  while  restless- 
ness is  a  characteristic  symptom.  The  temperature  should  be  taken  in  the 
rectum,  as  that  of  the  axilla  may  be  misleading.  Indeed,  the  skin  sometimes 
feels  cool  when  the  internal  temperature  is  high.  There  is  intense  thirst, 
and  the  child  eagerly  drinks  water.  The  purging  may  come  on  suddenly  or 
may  succeed  dyspeptic  diarrhea  or  ileo-colitis.  Simultaneously  there  is 
severe  and  obstinate  vomiting,  including  bile  at  first ;  but  later  the  vomited 
matter  is  also  serous.  The  tongue  is  coated  in  the  beginning,  but  later 
becomes  dry  and  red.  The  child  rapidly  loses  strength  and  as  rapidly 
emaciates.  The  restlessness  is  succeeded  by  apathy  and  indifference,  and  the 
condition  passes  into  collapse.  The  eyes  become  sunken,  the  fontanels 
depressed,  the  skin  gray  or  ashen  and  closely  applied  to  the  frame,  producing 
an  appearance  which,  once  seen,  is  rarely  forgotten.  Or  the  more  severe 
symptoms  may  subside,  and  a  condition  of  torpor  or  semicons\cionsness  may 
supervene.  The  head  is  retracted,  and  there  may  be  convulsions;  the  breath- 
ing is  interrupted  and  of  the  Cheyne-Stokes  type ;  the  pupils  are  irregular ; 
there  is  clutching  of  the  fingers — in  a  word,  the  "  hydrencephaloid  "  state,  so 
called  by  Marshall  Hall,  is  present.  These  "  brain  symptoms  "  have  often 
misled  the  inexperienced,  but  they  are  not  associated  with  changes  in  the 
brain  or  in  its  meninges.  They  may  be  due  to  the  toxins  developed  in  the 
intestine  by  bacteria. 

Diagnosis. — This  is  not  difficult.  The  serous  vomiting  and  purging, 
rapid  emaciation  and  prostration,  and  the  hyperpyrexia  are  significant, 
while  the  nervous  symptoms  described  as  succeeding  them  confirm  the  nature 
of  the  disease. 

Prognosis. — Unless  the  last-described  symptoms  supervene,  the  course 
is  rapid  to  a  fatal  termination  by  collapse  in  from  a  few  to  twenty-four  or 
forty-eight  hours.  If  the  hydrencephaloid  state  is  added,  the  disease 
may  be  prolonged  a  few  days  more.  Recovery  is  not  impossible,  and  begins 
with  abatement  of  the  more  serious  symptoms  within  the  first  twenty-four 
hours,  followed  by  tedious  convalescence.  Or  there  may  be  a  delusive 
improvement,  followed  by  a  return  of  the  choleraic  symptoms,  or  the  disease 
may  pass  into  entero-colitis. 

Treatment. — All  that  has  been  said  about  food  in  dyspeptic  diarrhea  and 
entero-colitis  applies  here,  but  the  opportunity  for  its  application  cannot, 
indeed,  be  availed  of  unless  convalescence  sets  in.  The  symptoms  must  be 
met  with  the  greatest  promptness  by  the  same  measures  described  in  the  treat- 
ment of  adults,  but  adapted  to  the  age  of  the  child.  Here,  too,  opiates  are  in- 
dispensable.    Even  morphin  may  be  used  hypodermically  with  great  caution. 


DIARRHEAS  OF  CHILDREN.  39! 

One  hundredth  of  a  grain  (0.00066  gm.)  is  about  the  proper  dose  for  a  child 
a  year  old,  and  it  may  be  associated  with  1-500  grain  (0.0001032  gm.)  of 
atropin.  This  may  be  repeated  in  an  hour  if  the  symptoms  do  not  subside, 
at  a  longer  interval  if  they  do.  Laudanum  or  deodorized  tincture  of  opium 
may  be  substituted  and  administered  by  the  rectum  in  doses  of  from  two  to 
four  drops  (0.133  to  0.264  gm.)  in  two  drams  of  starch-water.  Minute  doses 
of  Dover's  powder,  say  i-io  grain  (0.006  gm.),  may  be  given  in  combination 
with  bismuth  in  doses  of  two  grains  (0.12  gm.).  For  the  diarrhea  that  may 
continue  after  abatement  of  the  acute  symptoms  preparations  of  silver,  prefer- 
ably the  oxid,  are  sometimes  of  value.  They  may  be  combined  with  opium, 
the  dose  of  the  silver  being  1-12  grain  (0.0056  gm.),  of  the  opium  1-24  to  1-12 
grain  (0.00275  gm.  to  0.0056  gm.). 

The  hyperpyrexia  must  be  combated  by  hydrotherapy — the  bath  at 
80°  F.,  rapidly  reduced  to  70°  F.  (26.6°  to  21.1°  C.)  ;  or,  if  this  cannot  be 
done,  the  child  should  be  wrapped  in  sheets  wrung  out  in  cold  water.  Spong- 
ing is  a  feeble  substitute.     Hyperpyrexia  is  one  of  the  dangers. 

Stimulants  are  indicated,  but  the  difficulty  is  to  secure  their  retention, 
Brandy  is  the  best  form  of  stimulant,  though  iced  champagne  may  be  given 
in  small  doses  often  repeated,  while  the  prompt  rejection  of  liquids  should 
not  discourage  their  readministration.  Irrigation  of  the  large  bowel  may  be 
added,  using  a  flexible  catheter,  which  is  introduced  six  or  eight  inches  (2.3 
to  2.y  cm.).  A  pint  (0.5  liter)  will  suffice  for  a  child  six  months  old,  and 
a  quart  (i  liter)  for  one  of  two  years.  The  water  may  be  tepid,  or  cold  if 
the  temperature  is  high.  The  one  per  cent,  salt  solution  may  be  admin- 
istered by  enteroclysis,  and  even  by  hypodermoclysis  in  extreme  cases  of 
collapse.  The  hot  bath  should  be  substituted  for  the  cold  in  collapse,  and 
strychnin  may  be  administered  hypodermically  in  doses  of  i-ioo  grain 
(0.00066  gm.)  to  a  child  one  year  old. 

Should  convalescence  set  in  or  entero-colitis  supervene,  great  cau- 
tion in  the  giving  of  food  should  be  observed.  Only  peptonized  milk  should 
be  used,  substituted  occasionally  by  raw  beef -juice,  increased,  if  well  borne, 
a  teaspoonful  at  a  time ;  or  dilute  egg-albumen  may  be  tried  if  these  are  not 
retained. 


The  Celiac  Affection  in  Children. 
Synonyms. — Diarrhcca  alba;  Diarrhoea  chylosa. 

Definition, — A  form  of  intestinal  catarrh  of  children  one  to  five  years 
old,  of  insidious  onset,  and  characterized  by  copious,  offensive,  loose,  frothy 
stools,  resembling  oatmeal  gruel  in  color  and  consistence.  It  was  first 
described  by  Gee. 

Etiology. — This  is  unknown.  Ulceration  of  the  intestine  has  been 
found,  but  there  is  no  distinctive  morbid  anatomy. 

Symptoms. — The  symptoms,  in  addition  to  those  named,  are  progres- 
sive zvasting  and  weakness.  There  is  no  fever.  The  abdomen  is  distended 
as  by  flatus,  but  is  inelastic  and  doughy. 

Prognosis. — It  is  commonly  fatal.  It  has  been  likened  to  the  hill  diar- 
rhea of  the  tropics,  which  affects  adults. 

Treatment. — This  can  only  be  symptomatic. 


-392  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

PSEUDO-MEMBRAXOUS  ENTERITIS. 

Syxoxyms. — Croupous  Enteritis;  Diphtheritic  Enteritis. 

Definition. — A  rare  variety  of  intense  inflammation  affecting  either 
bowel,  and  characterized  by  the  formation  of  false  membrane. 

Etiology. — Pseudo-membranous  enteritis  occurs  in  connection  with 
such  infectious  diseases  as  pyemia,  pneumonia,  scarlet  fever,  and  even 
typhoid  fever;  also  from  the  toxic  effect  of  mineral  poisons,  such  as  lead, 
mercury,  and  arsenic,  and  during  the  cachexias  which  develop  toward  the 
close  of  cancer,  Bright's  disease,  cirrhosis  of  the  liver,  and  the  like,  as  a 
terminal  infection. 

Morbid  Anatomy. — The  false  membrane  present  varies  in  extent  and 
depth.  It  may  be  limited  so  as  simply  to  tip  the  villi  and  valvulse  conni- 
ventes  or  other  folds  with  a  grayish-}ellow  film,  or  the  coagulation-necrosis 
may  infiltrate  a  greater  depth  in  flake-like  patches,  or  it  may  invade  the 
follicles  and  solitary  glands,  which  may  suppurate.  To  the  false  membrane 
is  commonly  added  a  hyperemic  basis.-  The  deep-seated  diphtheritic  in- 
flammation found  in  diphtheritic  dysentery  is  elsewhere  described. 

Symptoms. — These  may  be  so  slight  as  to  be  unnoticeable.  At  other 
times  there  are  diarrhea  and  abdominal  pain,  but  nothing  distinctive. 

Treatment. — This  is  symptomatic,  and  that  of  the  attending  and  caus- 
ing disease. 


PHLEGMONOUS   ENTERITIS. 

This  is  a  rare  disease,  consisting  in  a  dift'use  suppurative  infiltration 
of  the  submucosa,  analogous  to  phlegmonous  inflammation  of  the  stomach. 
It  has  been  found  after  intussusception  and  strangulated  hernia,  and  may 
cause  symptoms  of  peritonitis  by  invasion  of  this  coat  of  the  bowel,  but 
there  are  no  symptoms  by  which  it  can  be  recognized  before  death.  It  has 
been  met  in  the  duodenum. 


HEMORRHAGIC  INFARCT  OF  THE  BOWEL. 

Definition. — Hemorrhagic  extravasation  in  the  wall  of  the  small  in- 
testine, due  to  embolism  or  thrombosis  of  one  or  other  of  the  mesenteric 
arteries. 

Etiology. — A  warty  vegetation  from  coexisting  valvular  heart  disease 
may  become  the  embolus,  or  the  latter  may  arise  from  the  clot  in  an  aneu- 
rysm of  the  aorta. 

Morbid  Anatomy. — There  are  congestion,  infiltration,  and  swelling  of 
the  jejunum  and  ileum,  and  the  superior  mesenteric  artery  will  generally  be 
found  plugged  with  a  clot,  which  may  be  preceded  by  an  embolus.  The 
mesentery  may  also  be  the  seat  of  congestion  and  infiltration. 

Symptoms. — There  may  be  sudden  nausea,  vomitins;,  faintness,  ab- 
dominal tympany,  and  pain.  There  may  be  symptoms  of  obstruction,  or 
diarrhea  with  blood-stained  stools. 


ULCERATION  OF  THE  BOWEL,  393 

Diagnosis. — The  condition  is  so  rare  that  infarction  is  not  apt  to  be 
thought  of.  But  should  there  be  valvular  heart  disease  or  aneurysm,  the 
sudden  occurrence  of  the  symptoms  mentioned  might  suggest  this  cause. 

Prognosis  and  Treatment. — The  prognosis  is  invariably  fatal  in  severe 
cases,  and  though  the  occlusion  of  a  small  vessel  may  be  followed  by  recov- 
ery, there  is  no  treatment  which  will  avail  further  than  to  abate  the  symp- 
toms. 


ULCERATION  OF  THE  BOWEL. 

What  is  Meant. — Apart  from  ulceration  symptomatic  of  typhoid  fever, 
dysentery,  tuberculosis,  and  chronic  enteritis,  we  are  not  often  called  upon 
to  recognize  this  lesion,  while  its  presence  is  often  unattended  with  any 
symptoms  whatever.  The  ulceration  of  typhoid  fever,  dysentery,  and  follicu- 
lar enteritis  requires  no  further  reference ;  nor  the  peptic  duodenal  ulcer 
which  was  considered  in  connection  with  gastric  ulcer ;  nor  tubercular  ulcera- 
tion secondary  to  tuberculosis  elsewhere,  which  may  be  said  to  be  probable 
whenever  such  tuberculosis  becomes  associated  with  obstinate  diarrhea,  un- 
controllable or  only  partly  controllable  by  medicines.  Such  probability  may 
be  confirmed  or  not  by  the  finding  of  bacilli  in  the  fecal  discharges,  to  which 
end  cultures  should  also  be  made.  At  the  same  time  it  is  to  be  remembered 
that  bacilli  found  may  have  been  swallowed  with  sputum,  a  source  more 
likely  if  the  patient  is  known  to  swallow  sputum  habitually. 

Primary  Tubercular  Ulcer. — Occasionally  tubercular  ulcers  occur 
primarily  or  without  preceding  symptoms  of  tuberculosis  elsewhere,  espe- 
cially in  children.  They  are  seldom,  if  ever,  below  the  ileum  and  appendix 
vermiformis,  yet  they  do  occur  in  the  rectum.  There  is  no  way  of  discover- 
ing them  during  life. 

In  the  first  place,  such  ulceration  is  hardly  suggested  unless  there  is 
some  discharge  from  the  rectum  of  the  nature  of  diarrhea,  or  pus,  with  or 
without  hemorrhage.  Given,  however,  such  symptoms,  with  tenderness  in 
the  region  of  the  ileum,  decided  fever,  pronounced  emaciation,  and  a  tuber- 
cular history,  the  feces  should  be  examined  for  tubercle  bacilli,  the  finding 
of  which  would  be  conclusive  in  the  absence  of  the  possibility  of  their  being 
swallowed.  On  the  other  hand,  their  absence  would  not  exclude  tuberculosis. 
The  sago-like  clumps  of  mucus,  formerly  considered  pathognomonic  of 
tubercular  ulceration,  are  no  longer  so  regarded,  since  they  are  found  in 
cases  where  autopsy  has  established  the  absence  of  any  ulceration  whatever. 
The  presence  of  enlarged  mesenteric  glands  palpable  through  the  abdominal 
walls  would  be  a  further  confirmation.  Especially  justified  would  be  the 
suspicion  if  to  the  diarrhea  the  symptoms  of  circumscribed  peritonitis — 
viz.,  tenderness,  impaired  percussion  resonance,  and  perhaps  slight  fever — 
are  added,  or  if  there  are  the  symptoms  of  general  peritonitis. 

A  rare,  but  acknowledged,  seat  of  the  tubercular  ulcer  is  the  appendix 
vermiformis,  a  rupture  of  which  might  cause  any  one  of  the  varieties  of 
perityphlitis  and  peritonitis  due  to '  perforation  in  appendicular  disease, 
including  post-peritoneal  abscess  invading  the  neighborhood  of  the  kidney 
and  producing  one  of  the  forms  of  perinephric  abscess.  A  similar  termi- 
nation may  follow  perforation  of  any  form  of  ulcer  of  the  bowel  suitably 
situated,  as  in  the  posterior  wall  of  the  ascending  and  transverse  parts  of 


394  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  duodenum,  and  ascending  and  descending  colon.  The  presence  of  tuber- 
cular ulcer  is  not  incompatible  with  cicatrization,  which  may  even  produce 
stenosis  of  the  bowel.  Tubercular  ulcer  of  the  rectum  may  be  recognized  by 
specular  examination. 

Syphilitic  Ulcer. — Syphilitic  ulceration  is  confined  almost  entirely  to 
the  rectum,  and  is  not  very  common  here.  Its  possible  presence  in  the  colon 
and  ileum  is  simply  to  be  remembered,  as  its  diagnosis  is  out  of  the  question. 
The  suspicion  of  its  occurrence  in  the  rectum  is  justified  under  circumstances 
of  rectal  discharge  of  blood  and  pus  not  due  to  carcinoma.  Syphilitic  ulcers 
arise  as  primary  sores  and  papules  or  from  breaking  down  of  gummy  tumors. 
They  are  characterized  by  their  serpiginous  outline,  an  indisposition  to  heal, 
and  the  presence  of  condylomata  about  the  anus — usually  the  broad,  but 
rarely  also  the  pointed  variety. 

Embolic  Ulcer  is  another  possible  variety  of  intestinal  ulcer,  though 
it  is  not  recognizable  before  autopsy.  Embolism  and  consequent  ulcer  may 
happen  when  valvular  heart  disease  exists  or  septic  pyemia,  and  it  is  possi- 
ble that  a  branch  of  an  intestinal  artery  may  become  the  seat  of  lodgment 
of  an  embolus  from  the  heart  or  from  some  septic  focus,  and  be  followed  by 
necrosis  and  solution  of  the  area  supplied  by  it. 

Treatment. — In  addition  to  the  general  treatment  of  tuberculosis,  the 
diarrhea  occasioned  by  the  ulceration  should  be  treated  by  the  usual  reme- 
dies, among  which  should  be  included  nitrate  of  silver  and  sulphate  of  copper 
with  opium. 

The  patient  with  syphilitic  ulceration  should  receive  the  specific  treat- 
ment of  syphilis,  while  the  ulcer,  if  accessible,  should  be  treated  by  local 
applications  of  silver  nitrate  in  solid  stick. 


APPENDICITIS. 

Synonyms. — Typhlitis;  Perityphlitis;  Paratyphlitis. 

Definition. — An  inflammation  of  the  vermiform  appendix,  catarrhal, 
ulcerative,  or  interstitial,  which  commonly  extends  to  the  structures  lying  in 
contact  with  it,  producing: 

1.  A  peritonitis  which  is  plastic  and  limited — appendicular  peritonitis, 
or  peri-appendicitis. 

2.  Circumscribed  suppuration  or  abscess — para-appendicitis,  or  peri- 
typhlitis. 

3.  Septic  and  general  peritonitis. 

Perforation  and  gangrene  are  often  intermediate  incidents. 

The  word  appendicitis,  which  is  now  by  almost  unanimous  consent 
applied  to  the  disease  under  consideration,  did  not  secure  the  appHcation 
without  a  struggle.  The  term  typhlitis,  so  long  employed,  was  adopted 
because  it  was  thought  that  the  disease  began  in  the  cecum,  or  typhlon. 
Modern  studies  go  to  show  that  true  appendicitis  almost  never  begins  in  the 
cecum,  but  that  in  essentially  all  cases  the  appendix  is  the  root  of  the  evil. 
Inflammation  and  perforation  of  the  cecum  are,  however,  possible  events, 
though  they  are  not  clinically  separable  from   appendicitis.     It  also  often 


APPENDICITIS.  395 

happens  that  one  of  the  earHest  symptoms  by  which  appendicitis  is  recog- 
nized is  that  of  inflammation  of  the  peritoneum  covering  the  appendix  and 
adjacent  cecum ;  but  the  existence  of  very  positive  disease  of  the  mucous 
membrane  of  the  appendix  has  been  demonstrated  over  and  over  again  when 
the  peritoneum  has  not  been  invaded.  It  is,  therefore,  hkely  that  the  process 
begins  in  the  appendicular  mucous  membrane  each  time.  The  term  appen- 
dicular peritonitis,  or  peri-appendicitis,  is  a  good  one  for  the  inflammation 
of  the  peritoneal  covering  of  the  appendix,  while  para-appendicitis  or  peri- 
typhlitis is  equally  suitable  for  the  more  extensive  peritonitis  about  the 
cecum,  and  the  term  perityphlitic  abscess  indicates  well  that  a  similar  in- 
flammation has  gone  on  to  pus  formation. 

Historical. — None  of  the  facts  bearing  on  the  nature  of  appendicitis  is  of  very  old 
date,  while  the  correct  notion  of  its  nature  may  be  said  to  have  been  quite  recently 
established.  The  first  recorded  case  of  perforation  of  the  vermiform  appendix  ap- 
pears to  have  been  by  Mestivier,  in  1759,  caused  by  a  large  pin  in  the  appendix; 
another  was  reported  by  J.  Parkinson,  an  English  phj^sician,  in  1812;  another  by 
Wegeler,  in  1813.  In  1S24  Louyer-Villermay  reported  a  case  of  fatal  peritonitis  which 
he  ascribed  to  perforation  of  the  appendix.  In  1827  Melier  reported  four 
cases — three  of  perforative  appendicitis  and  one  of  relapsing  appendicitis. 
Melier  even  suggested  the  possibility  of  curing  the  patient  by  operation, 
providing  the  diagnosis  could  be  sufficiently  established.  Other  isolated  cases 
of  fatal  inflammation  of  the  appendix  were  published  from  time  to  time,  but  the 
first  systematic  article  was  prepared  by  Husson  and  Dance  in  1827,  at  the  sug- 
gestion of  Dupuytren,  and  the  views  promulgated  by  them  were  apparently  those  of 
the  great  surgeon  himself,  since  they  are  the  same  as  those  he  published  six  years 
later  (1833)  in  his  "  Lectures  on  Clinical  Surgery."  He  treats  of  irritation  and  inflam- 
mation of  the  mucous  membrane  of  the  cecum,  extending  thence  to  the  retrocecal 
tissue  and  thence  rarely  to  the  peritoneum.  The  appendix  is  totally  ignored.  In 
1830  Goldbeck,  at  the  suggestion  of  Puchelt,  of  Heidelberg,  wrote  his  graduation 
thesis,  "  On  a  Peculiar  Inflammatory  Tumor  of  the  Right  Iliac  Region."  He  adopted 
the  views  of  the  French  authors  and  called  the  disease  peritj'phlitis.  He  also  recorded 
a  case  of  perforation  of  the  appendix  with  resulting  peritonitis.  He  says,  moreover, 
that  in  fatal  cases  of  perityphlitis  the  appendix  has  been  found  intact. 

In  1831  J.  M.  Ferrall  published  a  paper,  said  to  have  been  written  several  years 
earlier,  on  "  Phlegmonous  Tumors  in  the  Right  Iliac  Region,"  in  which  the  cecum  is 
also  held  to  be  the  primary  seat  of  the  phlegmon,  which  is  described  as  extending 
thence  to  the  connective  tissue  behind  it,  the  peritoneum  being  accorded  a  minor 
role. 

In  1834  James  Copland,  in  his  "  Dictionary  of  Practical  Medicine,"  describes  what 
is  now  known  as  perityphlitis  under  the  title  "Inflammation  of  the  Cecum."  He, 
moreover,  recognized  the  appendix  as  a  possible  primary  seat  of  disease  excited  by 
foreign  bodies  in  it  and  terminating  in  gangrene — a  great  advance  over  the  views  of 
Dupuytren.  John  Burne  came  still  nearer  the  truth  in  1837  and  again  in  1839. 
Though  he  wrote  on  "  Inflammation  of  the  Cecum,"  even  in  his  first  paper  he  speaks 
of  "  ulceration  of  the  appendix  "  set  up  by  foreign  bodies,  such  as  raisin  seeds,  cherry 
stones,  and  concretions,  of  possible  perforation  resulting  in  general  peritonitis  or  local 
peritonitis,  with  abscess.  In  his  second  paper  he  goes  further,  and  states  his  belief 
that  all  Dupuytren's  cases  were  due  to  disease  of  the  appendix.  He  introduced  the 
term  tuphlo-enteritis. 

In  1838  J.  F.  H.  Albers  retrograded  a  little.  Publishing  a  paper  on  inflammation 
of  the  cecum  and  introducing  the  term  typhlitis,  which  he  divides  into  acute,  chronic, 
and  stercoral  typhlitis  with  perityphlitis,  he  distinguished  the  latter  aifection  from 
typhlitis,  with  which  he  says  Puchelt  and  others  confounded  it.  But  while  recogniz- 
ing the  possibility  of  disease  starting  in  the  appendix  and  going  on  even  to  perforation 
he  regarded  the  phlegmon  of  the  right  iliac  fossa  as  more  frequently  due  to  disease  of 
the  cecum.  In  the  next  year  Grisolle,  appreciating  correctly  the  role  plaj^ed  b}^  per- 
foration of  the  appendix  in  causing  the  iliac  phlegmon  and  abscess,  opposed  the 
teaching  of  Albers  and  claimed  that  inflammation  of  the  cecum  would  not  cause  the 
grave  effects  ascribed  to  it,  since  dysenteric  and  other  well-recognized  forms  of  ulcer- 
ation of  the  same  structure  show  no  tendency  to  extend  into  the  neighboring  con- 
nective tissue.  Grisolle,  however,  as  thoyigh  under  the  thraldom  of  Dupuj-tren  and 
the  French  school,  still  assigned  an  important  role  to  the  cecum. 

From  this  time,  however,  and,  indeed,  from  the  date  of  Burne's  paper  m  1837  to 
the  present,  appendicitis  has  been  an  acknowledged  disease;  but  it  has  seenied 
almost  impossible,  even  to  this  day,  to  shake  off  the  idea  of  typhlitis  as  a  responsible 
factor  in  the  phenomena  of  appendicitis.  Louyer-Villermay  in  1840  reported  some 
cases  of  rapidly  fatal  inflammation  and  gangrene  of  the  appendix.     In  1843  A.  Voltz 


396 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


published  a  retrospective  paper  entitled  "  Ulceration  and  Perforation  of  the  Ap 
pendix"  occasioned  by  foreign  bodies.  He  concluded  that  the  appendix  was  the 
organ  at  fault  in  all  cases  previously  published,  and  apparently  for  the  first  time  the 
cecum  and  retrocecal  tissues  were  ignored. 

Simple  catarrh  of  the  appendix  was  first  recognized  by  Rokitansky  in  1843  in  his 
classic  work  on  "Pathological  Anatomy."  He  ascribes  it  to  the  irritation  of  fecal 
matter  and  to  concretions,  and  contrasts  it  with  the  more  intense  processes  of  gan- 
grene and  perforation.  Sucli  inflammation,  he  says,  maj^  become  chronic  or  go  on  to 
ulceration.  He  also  refers  to  the  benign  effect  of  inflammatory  adhesions  in  protect- 
ing against  general  peritonitis  in  the  event  of  subsequent  perforation.  He  still  ad- 
mitted the  existence  of  catarrhal  inflammation  of  the  cecum,  ulceration  and  perfor- 
ation of  the  latter,  with  inflammation  of  the  postcecal  tissue  as  a  consequence.  So  G. 
Lewis  in  1856  ascribed  tlie  less  serious  consequences — including,  however,  suppu- 
ration— to  typhlitis,  while  the  violent  and  fatal  cases,  he  said,  began  with  appendicitis, 
induced  always  by  concretions.  In  1858  C.  Wister  attached  further  importance  to  the 
part  of  the  appendix  in  producing  the  symptoms  in  question.  In  this  year,  too,  Op- 
polzer  suggested  the  name  paratyphlitis  for  that  form  of  iliac  phlegmon  which  was 
extraperitoneal:  /.  e.,  between  the  iliac  fascia  and  bone. 

Samuel  Wilks  was  one  of  those  who  appreciated  the  role  of  the  appendix.  Thus 
in  the  treatise  of  Wilks  and  Moxon  on  "  Pathological  Anatomy  "  in  1875,  he  says, 
referring  to  the  terms  cecitis,  typhlitis,  and  perityphlitis:  "  It  is  not  clear,  however, 
that  any  one  particular  form  of  disease  is  intended  by  those  who  make  use  of  these 
expressions.  The  cases  to  which  these  names  are  given  frequently  occur  clinically 
and  recover;  but  when  disease  in  the  same  region,  with  similar  characters,  proves 
fatal,  we  find  usually  some  prior  morbid  process  in  the  appendix  rather  than  in  the 
cecum  itself."  Also,  "the  suddenness  of  the  attack  of  cecitis  and  the  local  peri- 
tonitis following,  even  in  the  large  number  of  cases  which  recover,  all  point  to  the 
appendix  as  being  the  most  frequent  cause."  But  he  says  also:  "  inflammations  of  the 
cecum  itself  do  occur,  and  apparently  are  sometimes  caused  by  continuous  lodgment 
of  hard  feces  in  this  part  of  the  intestines.  Such  inflammations,  by  ulcerating  the 
mucous  membrane,  lead  to  perforation  and  local  peritonitis,  forming  fecal  abscesses 
which  may  discharge  inward,  but  we  believe  that  this  is  comparativel)^  rare."  Dr. 
Wilks'  most  recent  views  are  perhaps  best  expressed  by  C.  Hilton  Fagge,  who,  in  his 
"  Practice  of  Medicine,"  edition  of  1886,  says:  "  Dr.  Wilks  has  repeatedly  expressed  to 
me  the  opinion  that  in  both  '  typhlitis  and  perityphlitis '  the  disease  begins  in  the 
appendix,  and  that  variations  in  the  intensity  of  the  morbid  process  are  the  real  cause 
of  the  supposed  distinction  between  them.  And  so  far  as  I  can  learn,  all  the  evidence 
which  morbid  anatomy  affords  points  strongly  in  that  direction." 

C.  With,  of  Copenhagen,  was  apparently  the  first  to  deny  pointedly,  in  1880,  that 
peritonitis  ever  originates  in  typhlitis.  In  1883  William  Pepper  described  the  "  re- 
lapsing" form  of  appendicitis.  Reginald  H.  Fitz,  in  a  timely  and  exhaustive  paper 
read  before  the  Association  of  American  Physicians  in  1886,  admitted,  as  an  extreme 
rarity,  a  primary  perforating  inflammation  of  the  cecum  with  which  appendicitis 
vi\a.y  be  confounded.  In  a  second  paper  in  1888  he  concluded,  essentially,  that  the 
conditions  described  as  typhlitis,  perityphlitis,  paratyphlitis,  appendicular  peritonitis, 
and  perityphlitic  abscess  are  varieties  of  one  and  the  same  affection — appendicitis. 

The  text-books  published  prior  to  i8g2  treat  very  generally  of  typhlitis  as  an 
important  factor  in  producing  the  ultimate  phenomena  of  what  is  now  known  as  ap- 
pendicitis, unless  we  except  that  of  Dr.  Fagge,  already  quoted,  who,  while  he  uses 
the  word  typhlitis,  evidently  means  by  it  disease  of  the  appendix.  Ziegler,  in  his 
"  Pathological  Anatomy  "  (1885),  also  uses  the  word  typhlitis  for  appendicitis. 
William  Osier,  in  his  edition  of  1892,  says  that  the  terms  "  perityphlitis  and  para- 
typhlitis should  be  altogether  discarded,  as  the  cases  are,  with  rare  exceptions,  due 
to  disease  of  the  vermiform  appendix  ";  and  says  also  of  "  typhlitis,  or  inflammation 
of  the  cecum,"  that  it  is  "  a  doubtful  and  uncertain  malady,  the  pathology  of  which 
is  not  known,  but  which,  clinically,  is  still  recognized  by  authors."  In  his  edition  of 
1898  he  says  "  the  '  iliac  phlegmon'  was  thought  to  be  due  to  disease  of  the  cecum 
— typhlitis — and  of  the  peritoneum  covering  xt—pe^'ityphlitis;  but  we  know  now  that 
with  rare  exceptions  the  cecum  itself  is  not  affected,  and  even  the  condition  formerly'' 
described  as  stercoral  typhlitis  is  in  reality  appendicitis."  William  Pepper,  in  the 
"  Text-book  of  Medicine  by  American  Teachers"  (1894),  treats  of  typhlitis  as  an  af- 
fection very  much  less  common  than  formerly  supposed,  because  "the  majority  of 
cases  of  acute  disease  in  the  right  iliac  fossa  are  in  reality  appendicitis." 

Five  special  treatises  of  great  value  have  been  published  in  English: 
"  The  Pathology  of  the  Vermiform  Appendix,"  by  T.  N.  Kelynack,  of  Manchester, 
England,  in  1893;  "Appendicitis  and  Perityphlitis,"  by  C.  Talamon,  and  translated 
from  the  French  by  Richard  J.  H,  Berry,  of  Edinburgh,  in  1893;  "Appendicitis,"  by 
George  R.  Fowler,  of  New  York,  in  1894;  "  Diseases  of  the  Vermiform  Appendix,"  by 
Herbert  P.  Hawkins,  of  London,  in  1895;  and  "  A  Treatise  on  Appendicitis,"  by  John 
B.  Deaver,  of  Philadelphia,  in  1896.  Hawkins  summarizes  the  situation  in  the  follow- 
ing proposition,  to  the  confirmation  of  which  American  surgery  has  largely  con- 
tributed: "  In  fact,  it  will  be  generally  allowed  that  a  perforating  ulcer  of  the  cecum, 
though  it  does  certainly  occur,  is  of  so  rare  an  occurrence  that  it  may  be  disregarded  "; 


APPENDICITIS. 


397 


also,  "  There  is  ample  evidence  that  appendicular  disease  is,  at  any  rate,  of  frequent 
occurrence;  and  this  frequency,  moreover,  is  sufficiently  frequent  to  justify  us  in 
regarding  the  appendix  as  the  sole  cause  of  all  cases  of  perityphlitis,  mild  or  severe." 
As  historical  points  in  the  treatment  of  appendicitis  may  be  mentioned  the  sugges- 
tion of  early  operation  by  Willard  Parker  m  1867.  Grisolle  had  made  the  same  sugges- 
tion thirty  years  earlier,  and  doubtless,  as  stated  by  B.  Farquhar  Curtis,*  many  such  ab- 
scesses about  to  point  had  been  incised,  but  Parker  first  suggested  this  as  a  systematic 
treatment.  In  1881  Kraussold  advocated  early  operation  and  was  apparently  thie  first 
in  Germany  to  do  so,  but  made  no  reference  to  Parker.  In  1882  Noyes  reported  100 
■cases  treated  by  Parker's  method  of  which  90  had  been  done  in  the  United  States. 
In  1887  R.  F.  Weir,  of  New  York,  strongly  urged  the  early  operation,  without  waiting 
for  adhesions  between  the  pus  sac  about  the  appendix  and  the  abdominal  wall,  and 
even,  if  necessary,  to  open  the  general  peritoneal  cavity  in  order  to  reach  the  pus. 
At  "the  end  of  1887  Sands  recorded  the  first  successful  case  of  deliberate  laparotomy 
for  general  peritonitis  from  ordinary  perforation  of  the  appendix,  a  prior  case  by  Hall 
in  1886  being  rather  an  accidental  one.  In  18S8  Treves  reported  a  series  of  cases  of 
operation  for  chronic  appendicitis  of  the  relapsing  type.  In  18S9  Charles  McBurney 
advocated  even  earlier  operation  and  removal  of  the  appendix  before  perforation.  In 
addition  to  Parker,  Sands,  Weir,  and  McBurney,  Bull,  of  New  York.  Murphy  and 
Nicholas  Senn  of  Chicago,  Maurice  H.  Richardson,  of  Boston,  and  John  B.  Deaver, 
W.  W.  Keen,  and  Tliomas  G.  Morton,  of  Philadelphia,  were  important  coadjutors  in 
placing  the  operation  for  appendicitis  on  its  present  plane. 

Pathology  and  Morbid  Anatomy. — The  etiology  of  appendicitis  will 
be  more  easily  understood  if  its  morbid  anatomy  is  first  considered.  Mod- 
ern studies  establish  the  existence  of  three  degrees  or  stages  of  appendicitis : 

1.  Catarrhal  appendicitis. 

2.  Ulcerative  appendicitis. 

3.  Interstitial  or  parietal  appendicitis. 

1.  Catarrhal  Appendicitis. — Our  knowledge  of  this  is  based  upon  the 
systematic,  minute  study  of  cases  which  come  to  autopsy  froiti  other  causes 
as  well  as  from  operation.  In  the  first  or  acute  stage  there  is  a  shedding 
of  the  epithelium  of  the  mucous  membrane,  with  detachment,  partial 
destruction,  and  extrusion  of  the  follicles  of  Lieberkiihn,  and  some  cellular 
infiltration  of  the  retiform  tissue  at  their  base.  The  lumen  of  the  appendix 
contains  mucus,  leukocytes,  exfoliated  cells,  and  casts  more  or  less  perfect, 
of  the  crypts,  with  granular  debris  from  the  same  sources.  In  the  second 
stage  the  basement  membrane  is  broken  and  dislocated,  the  retiform  tissue 
more  closely  infiltrated  with  leukocytes,  and  the  internal  surface  ragged  and 
uneven.  In  the  third  or  still  more  advanced  degree  the  mucous  membrane 
is  thickened  by  infiltration  with  cells.  The  most  important  fact  as  to 
catarrhal  appendicitis  is  that  all  three  stages  offer  vulnerable  foci  for  the 
attacks  of  pathogenic  bacteria,  and  starting-points  of  an  infectious  peritonitis. 
On  the  other  hand,  by  the  union  of  the  opposing  surfaces,  obliteration  of  the 
lurnen  of  the  tube  may  take  place,  by  which  it  is  rendered  immune  against 
further  attacks.  A  natural  cure  has,  in  a  word,  been  effected.  The  oblit- 
eration may  be  partial,  producing  stricture,  beyond  which  a  cystic  distention 
of  the  tube  in  the  end  nearest  the  cecum  is  not  infrequent. 

2.  Ulcerative  Appendicitis. — In  this  stage  the  mucous  membrane  and 
submucous  tissue  are  destroyed  to  various  depths,  while  it  may  even  cul- 
minate in  perforation.  It  is  often  associated  with  a  concretion  or  a  foreign 
body.  The  latter  is  now  acknowledged  to  be  much  more  rare  than  was 
formerly  supposed.  The  error  was  a  natural  one,  owing  to  the  close  resem- 
blance of  fecal  concretions  to  seeds,  grains  of  wheat,  cherry  stones,  and 
even  date  stones,  as  the  result  of  a  gradual  molding  of  shape  and  loss  of 
water.  The  concretions  are  sometimes  also  the  seat  of  deposit  of  lime  salts. 
They  may  be  multiple  and  may  be  in  the  appendix  a  long  time  without 

*  "  Twentieth  Century  Practice  of  Medicine,  "  1896,  vol.  viii.  p.  434. 


398  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

producing  harmful  effect,  the  patient  dying  of  other  causes.  The  same  is 
true  of  foreign  bodies,  which  do,  of  course,  occur  and  include  the  objects 
already  mentioned.  Fecal  concretions  are  found  in  from  35  to  50  per  cent. 
of  cases;  foreign  bodies  in  a  much  smaller  number — say  7  to  12  per  cent. 

3.  Interstitial  or  Parietal  Appendicitis. — This  stage  may  succeed  upon 
either  of  the  two  stages  just  described,  but  occasionally  it  may  arise  de  novo 
by  infection  along  the  lymphatics.  In  the  former  event  it  starts  in  the  abraded 
or  ulcerated  surface  described ;  in  the  latter,  in  the  substance  of  the  appen- 
dix wall.  It  is  commonly  associated  with  necrosis  or  gangrene  of  the  wall, 
but  may  prove  fatal  before  the  necrosis  sets  in.  The  appearances  vary 
greatly.  They  may  be  limited  to  a  mere  point,  scarcely  visible,  and  between 
this  and  sphacelation  of  the  entire  organ  there  is  every  intermediate  degree. 
The  gangrenous  organ  is  usually  enlarged  and  distorted.  The  virulence 
of  the  appendicular  peritonitis  is,  however,  just  as  great  when  there  is  no 
necrosis.  The  peritonitis  which  ensues  on  perforation  of  the  appendix  is 
virulent,  resulting  from  the  invasion  of  the  peritoneum  by  myriads  of 
bacteria  in  the  fecal  matter  set  free  at  the  time  of  rupture  of  the  bowel. 

The  iiiimite  changes  in  interstitial  appendicitis  are  as  varied  as  the  mac- 
roscopic, but  Hawkins'  summary  of  three  more  distinctive  stages  or  degrees 
may  be  accepted  as  nearly  correct.  The  cases  which  succeed  on  the  catarrhal 
or  ulcerative  form  are,  of  course,  characterized  by  the  loss  of  tissue  corre- 
sponding to  the  extent  of  the  disease.  To  these  succeed  destructive  necrotic 
processes  in  the  deeper  structures  of  the  wall.  In  the  first  stage  of  the  latter 
the  inflammation  is  characterized  by  necrosis  of  the  muscular  coats ;  in  the 
second  by  suppuration  in  them ;  and  in  the  third  by  their  infiltration  with 
leukocytes  and  inflammatory  exudation.  The  first  is,  by  far,  the  most  com- 
mon. In  all  three  bacteria  are  found  in  the  mucous  and  muscular  coats, 
and  all  three  are  followed  alike  by  virulent  peritonitis. 

The  appendix  may  also  be  the  seat — indeed,  is  not  a  very  infrequent 
seat — of  tubercular  ulceration,  followed,  too,  by  perforation.  I  have  lately 
seen  a  remarkable  specimen  of  this  kind  in  which  no  symptoms  were  present 
before  death.  So,  too,  a  typhoid  idcer  may  form  in  the  appendix  and  perfo- 
rate, with  the  formation  of  a  tumor  mass  in  the  right  iliac  region.  Follicidar 
abscess  may  exist  and  occasion  the  usual  symptoms  of  appendicitis.  Actino- 
mycosis has  also  occurred  in  the  appendix,  with  the  formation  of  retrocecal 
abscess  and  metastatic  abscess  of  the  liver. 

Superadded  to  these  conditions  is  often  a  localized  or  general  peritonitis, 
the  development  of  which,  in  the  majority  of  cases,  constitutes  the  attack 
of  appendicitis.  In  lesser  degrees  of  the  peritonitis  (peri-appendicitis)  the 
adhesions  which  form  are  limited  to  the  appendix  and  adjacent  serous  tis- 
sues, limiting  the  inflammation  and  acting  as  a  barrier  against  general  peri- 
toneal infection.  In  higher  degrees  the  inflammation  attacks  the  tissues 
in  relation  to  the  appendix  (para-appendicitis),  and  forms  the  iliac  phlegmon 
or  tumor.  This  occupies  the  right  iliac  fossa  and  is  variously  constituted. 
It  may  consist  of  serous  and  cellular  exudation,  which  mats  together  coils  of 
small  intestine  and  the  cecum,  or  there  may  be  a  massive  accumulation  of  cells 
and  liquid  exudate,  constituting  abscess.  Even  the  latter,  as  well  as  the 
more  solid  exudate,  may  be  absorbed.  On  the  other  hand,  the  appendicular 
or  perityphlitic  abscess  may  rupture  into  the  peritoneum,  not  infrequently 
producing  fatal  general  peritonitis.  The  amount  of  pus  varies.  There  may 
be  a  dram  or  two  (4  to  8  c.  c),  or  a  pint  (a  half  liter)  or  more.  More  com- 
monly there  are  from  two  to  four  ounces  (60  to  120  c.  c).    The  pus  is  usually 


APPENDICITIS.  399 

thin  and  very  fetid;  at  times  it  is  thick,  yellow,  and  odorless.  It  may  be 
mixed  with  fecal  matter.  The  pus  may  have  escaped  into  the  bowel,  bladder, 
or  vagina,  or  externally  at  some  point  in  the  abdominal  wall, — as  the  navel 
or  groin,  as  in  a  case  of  my  own, — or  through  the  obturator  foramen  into 
the  hip  or  thigh.  The  iliac  muscle  may  be  destroyed  and  the  ilium  bared. 
The  abscess,  usually  in  the  iliac  region,  may  be  in  the  lumbar  region,  or 
perinephric,  in  the  true  pelvis,  or  under  the  liver.  These  very  diverse 
sites  are  commonly  determined  by  erratic  situations  of  the  appendix.  There 
may  be  secondary  abscesses  of  the  liver  by  pylephlebitis  or  portal  embolism. 
These  may  have  all  the  terminations  possible  to  hepatic  abscess. 

If  general  peritonitis  supervene,  there  are  added  the  usual  anatomical 
appearances  incident  to  this  condition — flakes  of  lymph  scattered  over  the 
intestines,  binding  the  latter  together,  with  pus-cells  in  varying  numbers  in 
the  flakes. 

Etiology. — Exciting  Causes. — All  three  stages  of  appendicitis  described 
are  probably  due  to  the  invasion  of  micro-organisms,  while  the  foreign  bodies, 
concretions,  and  other  agencies  to  be  mentioned  are  to  be  regarded  as  pre- 
disposing causes,  furnishing  the  conditions  favorable  to  the  operation  of  the 
pathogenic  bacteria. 

A  word  as  to  the  nature  of  the  organisms  which  are  responsible  for  the 
virulent  forms  at  least.  The  bacillus  coli  communis  is  a  bacterium  whose 
natural  habitat  is  the  colon  of  healthy  individuals,  cultures  of  which  from 
the  normal  colon  prove  harmless  when  injected.  Yet  cultures  of  this  same 
bacillus  taken  from  cases  of  virulent  appendicitis  produce  also  corresponding 
virulence ;  whence  it  may  be  inferred  that  in  some  way  virulence  is  engen- 
dered in  an  otherwise  harmless  bacillus.  There  is  good  reason  to  believe 
that  such  bacilli  may  pass  from  the  intestines  to  the  peritoneum  through  the 
lymph  spaces  in  an  intestinal  wall  which  is  simply  damaged,  as  well  as 
through  a  perforation.  Thus,  many  cases  of  so-called  idiopathic  peritonitis, 
or  peritonitis  in  which  macroscopic  examination  reveals  no  evident  lesion, 
may  still  be  due  to  the  bacteria  of  appendicitis  from  the  interior  of  the  tube. 
This  has  been  actually  demonstrated  in  some  cases,  and  it  is  not  unlikely 
that  it  will  be  found  true  of  all  such  cases  thoroughly  studied. 

While  in  most  instances  the  bacillus  coli  communis  has  been  found  in 
pure  cultures,  pyogenic  bacteria  have  been  found  associated  with  it.  The 
most  important  of  these  is  the  streptococcus  pyogenes;  after  this  the  staphylo- 
coccus pyogenes  aureus  and  the  proteus  vulgaris;  so  that  the  existence  of 
more  than  one  possibly  infecting  species  may  be  admitted.  The  bacilli  of 
typhoid  fever  and  influenza  are  possible  infective  agents  causing  appendicitis. 
The  same  is  true  of  the  infectious  agent  of  rheumatic  fever,  and  although 
I  have  never  met  a  case  of  appendicitis  traceable  to  rheumatic  fever  it  is 
quite  as  reasonable  to  believe  that  an  infectious  appendicitis  may  be  thus 
caused  as  an  infectious  endocarditis  and  pericarditis. 

Predisposing  Causes. — The  most  important  predisposing  cause  of 
appendicitis  is  the  appendix  itself.  An  organ  without  function,  and  therefore 
undeveloped  and  feebly  nourished,  is  correspondingly  feebly  resistant  to  all 
disease.  Its  anatomy  is  such  that  the  entrance  of  irritating  matters  is  easier 
than  their  exit,  while  inflammatory  products  are  not  easily  evacuated.  As 
predisposing  causes,  too,  must  be  considered  certain  influences  which  for- 
merly were  regarded  as  exciting  causes,  such  as  overeating,  especially  of 
unwholesome  and  indigestible  food,  acute  indigestion  from  any  cause,  in 
addition  to  the  foreign  bodies  and  concretions  already  mentioned.     It  can- 


400  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

not  be  said  that  the  precise  mode  of  operation  of  such  cause  is  certainly 
known.  It  may  be  that  a  hyperemia  or  deranged  circulation  thus  induced 
produces  a  condition  favorable  to  the  action  of  incessantly  present  bacteria. 
Similar  is  the  effect  of  fatigue,  cold,  and  traumatic  causes,  such  as  blows 
and  contusions. 

Appendicitis  is  a  disease  of  children  and  young  adults.  From  50  to 
55  per  cent,  of  cases  occur  under  the  age  of  twenty,  30  per  cent,  between 
twenty  and  thirty,  15  per  cent,  under  fifteen.  What  bearing  the  fact  that 
the  appendix  is  longer  in  children  and  young  adults  has  upon  this  can  only 
be  surmised.  Nearly  80  per  cent,  of  all  cases  occur  in  males.  It  has  been 
suggested  that  this  is  because  the  lumen  of  the  appendix  is  larger  in  males, 
and  therefore  more  liable  to  receive  fecal  or  foreign  matters.  Attacks  have 
occurred,  however,  in  the  first  year  of  life  and  as  late  as  the  seventy-sixth. 
More  cases  occur  in  summer  than  in  winter.  Occupation  has  no  effect  in 
exciting  it,  but  after  a  first  attack  recurring  attacks  of  appendicitis  are  more 
frequent  in  men  who  do  heavy  work,  such  as  porters  and  carriers,  or  men 
who  stand  on  their  feet  long  each  day. 

Symptoms. — Simple  catarrhal  appendicitis  is  often  unattended  by  any 
symptoms  whatever.  Indeed.  I  cannot  see  how  it  can  cause  any  recog- 
nizable symptoms  excepting  pain  and  tenderness.  ^lany  cases  of  ulcerative 
appendicitis  before  the  peritoneum  is  reached  in  the  invasion  are  character- 
ized by  a  like  absence  of  distinctive  symptoms.  Other  symptoms  more  or 
less  mild  and  vague  are  on  this  account  overlooked.  The  interstitial 
variety,  including,  as  it  does,  a  simultaneous  involvement  of  all  the  tissues, 
gives  rise  promptly  to  serious  symptom.s.  In  point  of  fact,  as  already  stated, 
appendicitis  is  known  to  be  present,  perhaps  in  a  majority  of  cases,  by  the 
symptoms  of  the  resulting  peritonitis,  local  or  general.  Though  in  most 
instances  the  first  attack  is  a  mild  one,  yet  no  one  knows  at  the  onset 
whether  this  is  going  to  be  the  case  or  not.  Furthermore,  it  is  often  im- 
possible to  say  when  suppuration  has  taken  place.  The  supervention  of 
general  peritonitis  is,  however,  usually  attended  by  unmistakable  signs. 

The  first  symptom  is  invariably  pain — sudden  pain.  Its  location  at 
first  is  not  constant :  it  may  be  anywhere  in  the  abdomen.  ]\Iost  frequently, 
perhaps,  it  is  in  the  neighborhood  of  the  umbilicus.  At  other  times  it  is  m 
the  epigastrium ;  at  others,  dift'use.  It  is  intermittent,  or  at  least  remittent. 
Usually,  within  the  first  twenty-four  hours,  it  settles  itself  in  the  right  iliac 
region,  where  it  remains.  It  may  then  be  mild  or  severe :  more  frequently 
it  is  moderately  severe.  Even  at  this  stage — end  of  twenty-four  hours — 
its  location  is  not  always  in  the  right  iliac  fossa.  It  has  even  settled  in  the 
left  iliac  fossa,  under  the  liver,  or  beneath  the  spleen,  anomalous  situations 
for  the  appendix.  This  pain  is  increased  by  coughing  or  taking  a  long 
breath,  or  by  turning  over  on  the  side. 

As  constant  as  pain  is  tenderness  in  the  right  iliac  region,  or  if  the 
appendix  happens  to  be  placed  in  one  of  the  unusual  situations  named,  it 
will  be  in  that  situation.  Rather  strong  pressure  may  at  times  be  necessar}' 
to  elicit  it,  but  usually  moderate  pressure  sulBces.  Its  extent  varies.  It 
m.ay  occupy  the  whole  lower  quadrant  of  the  abdomen,  or  may  extend  up 
to  the  costal  margin  and  around  into  the  flank,  but  the  seat  of  maximum 
tenderness  is  oftenest  a  point  known  as  AIcBurney's — a  point  at  the  inter- 
section of  a  line  drawn  from  the  anterior  superior  spinous  process  of  the 
ilium  to  the  umbilicus  and  another  along  the  right  edge  of  the  rectus  muscle. 
It  is  from  one  and  one-half  to  two  inches  from  the  anterior  superior  spinous 


APPENDICITIS.  401 

process  of  the  ilium.  The  patient  almost  invariably  assumes  the  dorsal 
decubitus,  often  with  the  right  leg  drawn  up,  because  of  the  relief  thus 
afforded. 

The  third  cardinal  symptom,  if  the  patient  comes  under  notice  suffi- 
ciently early,  is  rigidity  of  the  right  rectus  abdominis  muscle  and  other 
muscles  overlying  the  focus  of  inflammation.  This  may  be  associated  with 
a  slight  distention  of  the  entire  abdomen.  In  explanation  of  the  tenseness  it 
may  be  said  that  the  rectus  and  other  abdominal  muscles  receive  their  nerve 
supply  from  the  seven  lower  intercostal  nerves,  while  the  superior  mesenteric 
plexus  gets  its  splanchnic  branches  from  the  same  nerves.  This  primary 
tenseness,  after  two  or  three  days,  may  be  substituted  by  a  tumor.  The 
latter  varies  in  size  and  shape,  but  is  more  commonly  oval  and  about  as  large 
as  a  hen's  egg,  with  its  longer  axis  parallel  with  the  upper  part  of  Poupart's 
ligament.  It  may  be  much  larger,  occupying  also  the  whole  lower  left 
quadrant  and  extending  upward  and  backward  into  the  flank,  while  its  shape 
may  be  quadrilateral  or  triangular.  It  varies  in  consistence.  Its  composi- 
tion has  been  described  in  considering  the  morbid  anatomy  of  the  disease. 

There  is  usually  impairment  of  resonance  to  percussion  over  such  a 
tumor,  though  less  than  might  at  first  be  expected.  This  is  because  we  are 
really  percussing  over  hollow  organs,  though  matted  together  by  exudation. 
At  times,  However,  there  is  a  duller  note,  while  at  others,  it  may  be  natural. 
In  the  latter  event  the  tumor  is  small.  Indeed,  tumor  may  be  altogether 
absent,  but  this  can  never  be  said  of  tenderness. 

Vomiting  is  a  symptom  of  more  or  less  frequency.  It  is  commonly 
regarded  as  reflex  and  is  variously  severe.  The  matter  vomited  is  first  the 
gastric  contents,  with  the  evacuation  of  which  the  vomiting  usually  ceases, 
though  it  may  recur  in  the  event  of  perforation  or  rupture  of  the  abscess. 
If  the  symptom  is  more  prolonged,  the  vomited  matter  becomes  greenish. 
IMany  so-called  "  bilious  attacks  "  of  past  times  have  really  been  attacks  of 
appendicitis. 

Constipation  is  present  in  a  decided  majority  of  cases  from  the  begin- 
ning of  the  attack.  It  is  due  to  paralysis  of  the  bowel,  and  may  be  so  obsti- 
nate as  to  simulate  obstruction  of  the  bowel,  being  even  attended  at  times 
with  stercoraceous  vomiting.  Indeed,  appendicitis  has  often  been  con- 
founded with  obstruction.  On  the  other  hand,  there  may  be  diarrhea,  recur- 
ring with  each  successive  attack.  There  is  loss  of  appetite.  The  tongue 
at  first  may  be  natural,  but  later  becomes  more  or  less  coated,  and  in  advanced 
stages  dry. 

There  is  always  fez'er  at  the  outset,  the  temperature  102°,  103°  F. 
(38.9°,  39.4°  C),  and  even  104°  F.  (40°  C),  rarely  higher,  after  which  it 
gradually  falls,  reaching  the  normal  in  from  five  to  seven  days  in  favorable 
cases,  which  terminate  in  resolution.  The  pulse-rate  corresponds  with  the 
degree  of  fever,  but  its  force  and  volume  vary  with  the  patient's  strength. 
Should  suppuration  take  place,  the  temperature  continues  with  but  slight  fall, 
or  may  even  rise  higher  (see  Fig.  31).  Suppuration  may,  hozvever,  be 
unattended  with  fever. 

A  sudden  fall  of  temperature  does  not  always  mean  the  establishment  of 
convalescence.  Not  very  rarely  the^  event  has  a  widely  different  meaning. 
It  means  that,  instead  of  convalescence,  perforation  has  taken  place.  It  is 
extremely  important  that  this  fact  should  b'e  realized.  More  than  once  have 
I  known  the  physician  to  have  been  misled  by  it.  The  accompanying  tem- 
perature chart  illustrates  such  a  case  (Fig.  32).  Another  even  more 
26 


402 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


unusual  explanation  of  sudden  fall  of  temperature  is  the  rupture  of  a  small 
abscess  into  the  bowel.  Finally,  too  much  stress  cannot  be  laid  upon  the  fact 
that  there  may  be  gangrenous  appendicitis  in  the  presence  of  normal 
temperature. 

Leukocytosis  is  present  in  a  large  number  of  cases,  the  white  cells  often 
amounting  to  16,000  to  20,000.  It  is  an  unfavorable  symptom.  On  the 
other  hand,  the  absence  of  leukocytosis,  like  the  absence  of  fever,  should  not 
inspire  over-confidence,  as  a  lowering  blood  count  is  sometimes  evidence  that 
nature  has  given  up  the  struggle. 


I"     Details  of  Treutment 

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-Temperature  Chart  Showing  Temperature  Maintained  by  Abscess 
after  Partial  Decline. 


The  patient  was  first  seen  bv  Dr.  C.  F.  M.  Leidv  at  9  a.  m.  on  July  16,  the  first  day 
of  the  disease,  when  the  temperature  was  104=  F.  (40"  C).  It  continued  the  same 
at  I  p.  M.  the  same  day.  It  then  began  to  fall,  and  by  2  p.  m.  the  next  day  reached 
102"  F  (38.°  C).  By  4.45  p.  M.  of  the  fourth  day  it  had  fallen  as  low  as  100°  F. 
(37-7'  C.),  after  which  it  rose  and  fluctuated  to  about  102''  F.  (38.9"  C),  again  rose, 
reaching  103.2°  F.  (39.5°  C.)  at  10  a.  m.  on  the  seventh  day,  when  the  patient  was 
operated  on  by  the  late  Professor  John  Ashurst,  hi.  D.,  and  an  abscess  evacu- 
ated, after  which  the  case  proceded  to  convalescence. 


APPENDICITIS. 


403 


The  urine  is  scanty,  as  is  usual  in  fever,  and  quite  frequently  contains 
an  abnormal  quantity  of  indican.  It  is  rarely  albuminous,  unless  there  be 
high  fever,  when  there  may  be  the  small  albuminuria  characteristic  of  fever. 
There  are  often  irritable  bladder  and  frequent  micturition. 


Details  uf  Treatment 

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Fig.  32.— Temperature  Chart   Showing  Misleading  Fall  to  Normal,  Incident 
°  to  Perforation. 

The  expression  of  the  patient  varies  with  the  severity  of  the  symptoms, 
but  seldom  exhibits  the  anxiousness  characteristic  of  peritonitis,  unless  the 
latter  actually  is  present  in  consequence  of  perforation  or  rupture  of 
abscess. 

Is  there  any  surer  information  of  the  event  of  siippurafion  than  that  fur- 
nished by  the  temperature,  as  discussed?  Fluctuation  will,  of  course,  be 
thought  of,  but  this  is  rarely  obtainable  on  account  of  the  depth  and 
distribution  of  the  pus.  The  pus  may  come  to  the  surface  and  thus  be  recog- 
nized, but  not  often ;  and,  furthermore,  a  case  that  has  been  allowed  to  proceed 
to  this  degree  at  the  present  dav  has  not  been  properly  handled.     The  rigor 


404  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

and  sweat,  such  valuable  evidences  of  the  occurrence  of  suppuration  under 
other  circumstances,  are,  as  a  rule,  wanting  in  appendicitis.  Rapid  growth 
of  the  tumor  and  the  attainment  of  large  size  in  a  short  time  point  to  sup- 
puration, but  the  most  valuable  sign  is  the  pi'esejice  of  exquisite  tenderness 
over  the  focus  of  inflauunation.  Continued  high  temperature  is  significant, 
though  it  may  be  wanting.  Fully  formed  abscess  has  been  found  as  early 
as  the  third  day.  oNIore  commonly  six  to  eight  days  elapse  before  a  dimin- 
ished tenderness  and  'slight  decline  of  swelling  point  to  this  formation. 
Appendicitis  allowed  to  go  on  to  suppuration — /.  e.,  not  relieved  by  opera- 
tion— usually  terminates  by  rupture  of  the  abscess  into  the  peritoneum,  fol- 
lowed by  general  peritonitis  and  death.  The  event  is  variously  delayed  by 
the  extent  and  toughness  of  the  protective  adhesions  which  may  have  formed 
about  the  abscess,  A  few  abscesses  rupture  into  the  bowel,  thus  saving  the 
patient's  life.  Two  or  three  cases  in  a  hundred  are  thus  saved.  The  fecal 
fistula  incident  in  this  termination  usually  closes  eventually,  though  not 
always.  In  rare  instances  the  abscess,  especially  if  deeply  situated  in  the 
pelvis,  ruptures  into  the  bladder.  The  termination  in  these  cases  is  less 
favorable,  50  per  cent,  being  fatal.  A  few  also  break  through  the  groin,  and 
are  followed  by  recovery.  Lumbar  abscess  and  perinephric  abscess  must  be 
mentioned  as  possible  terminations,  also" infiltration  of  the  abdominal  walls 
and  tissues  of  the  thigh,  pylephlebitis,  and  hepatic  abscess. 

General  peritonitis  may  also  ensue  after  perforation  of  the  appendix. 
The  symptoms  of  the  resulting  general  peritonitis  are  those  characteristic  of 
this  disease  when  suddenly  induced  by  other  causes,  viz. : 

1.  Diffuse  pain,  as  contrasted  with  pain  localized  in  the  right  iliac 
region — pain  of  extreme  severity. 

2.  Generally  distended  and  tender  abdomen. 

3.  ^Moderate  fever,  succeeded  by  normal  or  subnormal  temperature, 
already  alluded  to  as  often  misleading  the  physician. 

4.  Rapid  and  feeble  pulse. 

5.  Dry  and  coated  tongue. 

6.  The  phenomena  of  collapse — i.  e.,  cold,  clammy  skin,  feeble  pulse, 
anxious  expression,  death. 

Complications  and  Sequelae. — The  most  important  complication  is 
obstruction  of  the  bowels,  by  w^hich  is  not  meant  the  obstinate  constipation 
so  often  met  as  an  early  symptom  of  appendicitis,  but  a  true  obstruction,  the 
direct  consequence  of  constriction  by  adhesions  developed  in  the  course  of 
the  peritonitis.  It  is  one  of  the  causes  of  death,  as  determined  by  autopsy, 
while  operation  frequently  discloses  conditions  which  could  easily  have  pro- 
duced obstruction. 

Other  complications  are  hepatic  abscess  from  pylephlebitis,  due  to 
thrombosis  and  even  embolism  of  branches  of  the  portal  vein ;  also  phlebitis 
of  the  right  iliac  vein.  In  abscess  of  the  liver  the  diaphragm  has  been  per- 
forated, producing  empyema  and  pyopericardium.  Pyemic  abscesses  else- 
where in  the  system,  including  the  brain  and  lungs,  have  also  been  found  in 
rare  instances.  Fecal,  vesical,  and  umbilical  fistulse  have  been  referred  to. 
Fatal  hemorrhage  has  also  resulted  from  necrosis  of  the  w^alls  of  the  iliac 
vessels.     Appendicitis  may  occur  in  a  hernial  sac. 

Recurring  and  Relapsing  Appendicitis. — Chronic  Appendicitis. — These 
terms  are  applied  to  cases  of  appendicitis  which  recur  after  a  first 
attack.  The  terms  are  sometimes  used  interchangeably,  but,  strictly  speak- 
ing, cases  are  recurring  which  repeat  themselves  at  considerable  intervals,  as 


APPENDICITIS.  405 

some  months  or  a  year  or  more ;  relapsing,  when  the  attacks  are  very  close — 
at  mtervals,  say,  of  one  or  two  weeks,  so  as  to  make  them  almost  continuous. 
In  the  former,  to  which  attention  was  first  called  by  William  Pepper  in 
1883,  it  is  reasonable  to  believe  that  the  patient  has  recovered  in  the  interval 
of  the  peri-appendicular  peritonitis,  while  the  appendicitis,  catarrhal  or  ulcer- 
ative, has  continued,  or  there  exists  a  cystic  appendix  as  an  exciting  cause. 
In  the  relapsing  form  it  seems  likely  that  there  has  not  been  complete 
recovery  in  the  interval.  Certain  it  is  that  one  attack  predisposes  to  another, 
so  that,  in  at  least  23  per  cent,  of  cases  observed,  according  to  Hawkins,  and 
44  per  cent,  according  to  Fitz,  it  is  found  that  there  have  been  previous 
attacks.  The  symptoms  of  a  recurrent  attack  are  the  same  as  those  of  a 
primary  one.  In  many  cases  the  interval  between  the  attacks  is  passed  in 
comparative  comfort ;  in  others,  there  is  no  small  amount  of  pain  or  discom- 
fort in  the  situation  of  the  appendix.  The  term  chronic  appendicitis  may 
also  be  applied  to  such  cases. 

Diagnosis. — The  diagnosis  of  many  cases  of  appendicitis  is  easy,  and 
becomes  more  so  as  experience  increases.  A  certain  number  of  cases  must 
be  carefully  weighed,  and  in  a  few  diagnosis  is  extremely  difficult.  Sudden 
pain,  becoming  localized,  tenderness,  and  rigidity  in  the  right  iliac  region 
are  three  symptoms,  which,  if  present,  point  almost  unmistakably  to  appendi- 
citis. A  "  lump  "  or  tumor  in  the  vicinity  of  McBurney's  point  is  less  fre- 
quently present,  though  it  is  often  found  in  many  cases,  and  greatly  aids  the 
diagnosis.  The  cases  difficult  of  diagnosis  are  those  in  which  these  symp- 
toms are  wanting  or  are  in  unusual  situations.  But,  in  truth,  these  symp- 
toms are  less  often  absent  than  has  been  supposed.  ]\Iore  frequently  they 
are  not  looked  for,  because  there  is  very  little  to  draw  attention  to  them.  A 
rule  should,  therefore,  be  made  to  examine  carefully  for  them  in  any  person 
subject  to  gastro-intestinal  attacks,  however  induced  and  however  manifested. 
It  is  certain  that  some  cases  of  so-called  catarrhal  enteritis  are  really  cases  of 
appendicitis. 

Differential  Diagnosis. — Intestinal  obstruction  is  a  condition  with  which 
appendicitis  has  sometimes  been  confounded.  The  special  symptoms  of  the 
various  causes  of  obstruction,  whether  those  of  fecal  impaction,  of  strangula- 
tion by  bands  or  twists,  by  intussusception,  or  by  tumor  or  foreign  body, 
should  be  recalled.  Especially  characteristic  of  obstruction  is  the  absence 
of  fever,  unless  the  patient  lives  long  enough  to  permit  peritonitis  to  be  set 
up.  The  pain  in  obstruction  is  more  intermittent  at  first,  and  though,  like 
that  of  appendicitis,  it  may  be  anywhere  in  the  abdomen,  it  is  not  likely  to 
localize  itseif  in  the  right  iliac  region.  The  constipation  is  more  complete 
in  obstruction,  and  even  the  passage  of  flatus  is  usually  absent.  The  vomit- 
ing, also,  is  more  severe  and  persistent,  and  is  more  likely  to  be  stercoraceous. 
There  is  more  general  distention  of  the  abdomen,  and  limited  tenderness  is 
less  easily  differentiated.  Intussusception  occurs  more  frequently  in  chil- 
dren younger  than  those  subject  to  appendicitis,  and  is  often  attended  with 
bloody  discharges,  which  seldom  occur  in  appendicitis,  while  a  tumor  may 
often  be  felt  on  examination  per  rectum.  Strangulation  by  bands  or  twists 
is  more  common  in  adults.  Malignant  growths  causing  obstruction  are 
usually  in  the  left  iliac  region,  although  cancer  of  the  cecum  is  to  be  remem- 
bered as  a  disease  of  the  right.  Its  slower  development  distinguishes  it 
from  appendicitis.     (See,  also.  Obstruction  of  the  Bowels.) 

Typhoid  fever  may  be  confounded  wnth  appendicitis,  and  I  have  more 
than  once  been  startled  in  the  course  of  typhoid  fever  by  the  thought  that 


4o6  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

I  might  be  dealing  with  an  appendicitis,  especially  when  there  have  been 
tympany  and  prolonged  tenderness  in  the  right  iliac  region ;  but  one  has,  as 
a  rule,  only  to  recall  the  mode  of  beginning  of  the  illness,  the  gradual  devel- 
epment  of  the  fever,  its  greater  intensity  and  peculiar  diurnal  variation,  the 
spots  at  the  eighth  day,  to  say  nothing  of  the  Widal  test,  to  be  reassured  in 
the  majority  of  instances.  I  recall  one  case  of  typhoid  fever  terminating  in 
perforation  in  which  was  simulated  very  closely  even  the  iliac  tumor  of 
appendicitis.  I  may  add  that  I  do  not  think  the  typical  spots  in  typhoid  fever 
are  ever  closely  approached  by  anything  similar  in  appendicitis,  though  the 
event  of  suppuration  is  said  to  be  sometimes  indicated  by  an  eruption.  On 
the  other  hand,  there  is  nothing  to  prevent  typhoid  fever  and  appendicitis 
from  accidentally  coinciding. 

A  question  which  one  w^ould  naturally  expect  to  give  rise  to  difficulty  is 
that  differentiating  between  appendicitis  and  the  pelvic  affections  of  zvonien 
when  on  the  right  side,  such  as  a  suppurating  ovarian  cyst  around  a  Fal- 
lopian tube,  or  a  pyosalpinx.  There  can  be  no  doubt  that  before  our  present 
accurate  knowledge  of  appendicitis  was  acquired,  numerous  mistakes  of 
diagnosis  were  made.*  Many  symptoms  are  identical,  but  usually  the  location 
of  the  original  pain  in  the  appendicitis  is  not  in  the  pelvic  cavity  or  in  close 
proximity  of  the  uterus,  even  though  it  be  not  at  McBurney's  point  or  the 
right  iliac  fossa.  The  appendicial  abscess  itself  is  usually  limited  to  the 
neighborhood  of  the  normal  appendix  and  cannot  be  recognized  per  vaginam, 
while  the  pelvic  abscess  can.  Should  the  appendix  rupture,  as  it  rarely  does, 
in  the  vagina,  the  pus  may  be  recognized  by  its  st-ercoraceous  odor.  It 
should  be  remembered  that  appendicitis  and  pregnancy  may  be  associated. 
The  onset  of  suppurating  ovarian  cyst  is  much  more  gradual,  and  the  pain 
more  constant  and  duller.  Pyosalpinx  is  in  more  intimate  relation  with  the 
uterus,  while  the  history  differs  from  that  of  appendicitis. 

Many  cases  of  acute  appendicitis  were  formerly  mistaken  for  bilious 
colic  and  acute  indigestion,  but  these  are  unaccompanied  by  tumor  or  tender- 
ness, while  the  vomiting  is  more  persistent  and  the  vomited  matter  differs. 
Enterocolitis  occasions  colicky  pains,  but  there  is  no  hardness  or  localization, 
while  there  is  diarrhea  with  mucous  stools.  It  will  be  remembered,  however, 
that  these  symptoms  sometimes  attend  appendicitis,  and  it  should  be  remem- 
bered, too,  that  gastro-enteritis  may  be  a  favoring  cause  of  infection  of  the 
appendix,  indeed  may  be  an  actual  cause  that  is  the  result  of  an  afferent 
wave  of  bacterial  invasion  from  an  irritated  intestinal  tract  as  suggested  by 
Dr.  Arthur  J.  Patek.f 

Ptomain  poisoning  or  food  infection  may  closely  simulate  the  symp- 
toms of  appendicitis,  by  abdominal  pain,  nausea  and  vomiting.  The  patient 
will,  however,  have  taken  food  of  the  kind  known  to  produce  such  illness, 
namely,  lobster,  sausage,  ham,  canned  meats,  cream  puffs,  old  ice  cream  and 
the  like. 

In  hepatic  colic  the  pain  is  higher  up.  in  the  region  of  the  gall-bladder, 
while  jaundice  is  almost  invariably  present,  and  sometimes  there  is  pain 
under  the  left  shoulder ;  there  is  no  fever.  In  nephritic  colic  the  pain  extends 
from  the  lumbar  region  into  the  groin  and  testicle.  A  floating  kidney  with 
twisted  ureter  is  movable,  as  contrasted  with  the  iliac  tumor  of  appendicitis ; 
there  is  sometimes  flattening  of  the  corresponding  lumbar  region,  while  sud- 

*  For  evidence  of  this,  see  an  excellent  paper  bv  the  late  Dr.  Paul  F.  Munde  entitled,  "  Perityph- 
litis and  Appendicitis  in  their  Relations  to  Obstetrics  and  Gynecology,"  published  in  "  Medical 
News,"  May  15,  iSqy. 

+  "  American  Medicine,"  April  i,  igo2. 


APPENDICITIS.  407 

den  relief  of  symptoms,  which  characterizes  the  untwist,  is  altogether  peculiar. 
The  presence  of  blood  in  the  urine  under  these  circumstances  is  confirmative 
of  renal  origin.  In  pyonephrosis  there  is  tenderness  in  the  region  of  the 
kidney,  as  well  as  pus  in  the  urine.  Perinephric  abscess  occasions  tenderness 
in  the  lumbar  region  while  the  pain  radiates  into  the  groin,  as  in  nephritic 
colic.  It  is  to  be  remembered  that  perinephric  abscess  may  be  occasioned  by 
suppurating  perityphlitis,  when  the  position  of  the  appendix  is  posterior  to 
the  cecum. 

Appendicular  colic,  or  neuralgia  of  the  right  iliac  fossa,  is  a  vague  con- 
dition of  pain  in  this  region,  which  has  been  ascribed  to  peristaltic  contraction 
of  the  appendix,  constituting  an  effort  to  expel  fecal  pellets,  but  of  which  no 
proof  is  afforded,  operation  in  several  cases  failing  to  discover  anything 
abnormal. 

I  think  it  sufficient  for  the  physician  to  diagnose  the  existence  of  appendi- 
citis without  attempting  to  point  out  the  particular  variety  of  appendicitis,  and 
while  I  do  not  deny  the  possibiHty  of  such  diagnosis  by  some,  I  have  known 
such  serious  errors  to  have  been  made  by  those  claiming  such  ability  that  I 
do  not  place  much  confidence  in  their  claims. 

Mention  should  be  made  of  carcinoma  of  the  cecum  or  appendix  as 
presenting  identical  symptoms  with  appendicitis.  It  has  occurred  to  me  to 
make  the  diagnosis  of  appendicitis  where  operation  showed  the  presence  of 
cancer  of  the  cecum.* 

Prognosis. — It  is  a  difficult  matter  to  consider  fairly  the  prognosis  of 
appendicitis,  or  rather  of  the  peri-appendicitis  growing  out  of  disease  of 
the  appendix.  For  if  we  separate  the  cases  which  do  not  go  on  to  sup- 
puration, recovery  is  apparently  the  rule.  Thus  out  of  190  cases  collected 
by  Hawkins,  none  died.  Again,  of  cases  treated  by  section  and  drainage 
after  suppuration  has  set  in,  fully  25  per  cent,  die ;  while  if  general  peri- 
tonitis supervene,  75  per  cent.  die.  Of  cases  operated  on  in  the  interval 
between  attacks,  scarcely  i  per  cent.  die. 

On  the  other  hand,  it  is  impossible  to  say  of  any  case,  however  mild, 
that  if  left  alone  it  will  not  terminate  in  suppuration,  while  a  large  niimber 
of  cases  still  perish  because  of  imperfect  diagnosis  and  delayed  operation. 
Again,  when  the  difficulties  of  an  accurate  diagnosis  in  the  mildest  cases  are 
considered,  it  is  not  unreasonable  to  conclude  that  many  cases  of  supposed 
recovery  were  really  not  cases  of  appendicitis. 

Treatment. — As  soon  as  the  diagnosis  of  appendicitis  is  established, — 
indeed,  pending  its  settlement, — a  competent  surgeon  should  be  associated 
with  the  physician,  for  the  reason  that  in  the  majority  of  cases  operative 
treatment  is  sooner  or  later  demanded,  while  the  hour  for  such  treatment 
is  best  settled  by  daily  conference.  The  course  of  cases  of  appendicitis  is 
often  very  delusive,  and  the  surgeon  who  operates  frequently  is  likely  to 
have  seen  more  cases  than  the  physician.  The  diagnosis  being  thoroughly 
established,  operative  treatment  should  be  deferred  only  long  enough  to 
determine  whether  symptoms  will  subside  under  rest.  If  they  do  not  sub- 
side, operate  at  once.  If  they  subside  in  a  degree  without  disappearing,  also 
operate.  If  they  subside  completely  in  twenty- four  to  forty-eight  hours,  and 
the  attack  is  a  first  one,  operatian  may  be  deferred  until  recurrence; 
then  operate  at  once,  or  after  subsidence  of  acute  symptoms,  as  may  seem 
best. 

*  See  also  a  paper  on  "  Primary  Cancer  of  the  Tip  of  the  Appendix,"  by  J.  Riddle  Goffe,  "  Medical 
Tlecord."  July  6,  igoi. 


408  DISEASES  OF  THE  DIGESTIVE  SYSTEM.    . 

It  must  be  admitted  that  it  is  not  always  easy  to  lay  down  a  rule 
as  to  when  operation  is  demanded,  for  it  is  not  only  that  we  must  know 
when  to  operate  to  save  life,  but  also  that  we  must  know  when  not  to  oper- 
ate in  cases  so  severe  that  operation  will  be  futile ;  it  is  due  the  operation 
that  it  should  be  saved  the  opprobrium  of  such  futility.  Certain  it  is,  too, 
that  in  cases  in  which  operation  is  of  no  avail  death  will  be  hastened  by  it, 
the  depressing  effect  of  etherization  co-operating  to  hasten  the  fatal  end. 
Much  difficulty  is,  however,  removed  when  we  decide  to  operate  zvifhoiit 
undue  haste  as  soon  as  the  diagnosis  is  established  in  all  cases,  except  when 
operation  will  evidently  be  futile.  I  say  without  undue  haste,  for  in  many 
cases  it  is  plain  that  a  few  days'  delay,  if  the  patient  is  kept  at  rest,  will 
make  no  difference  in  the  result ;  while,  if  the  inflammation  is  subsiding,  a 
stage  is  being  reached  in  which  operation  is  even  less  dangerous,  because 
the  united  experience  of  surgeons  goes  to  show  that  the  mortality  of  opera- 
tions between  attacks  is  practically  nil,  while  that  immediately  succeeding 
diagnosis  in  ordinary  cases  is  nearly  so.  There  can  be  no  doubt,  moreover, 
that  excision  of  the  appendix  after  a  first  attack  is  a  safer  procedure  than 
during  a  first  or  any  attack.  Even  when  suppuration  has  set  in  it  may  be 
safe  to  delay  operation  for  a  day  or  two  while  the  patient  is  held  quiescent. 

When,  on  the  other  hand,  shall  operation  be  omitted  because  it  must 
inevitably  be  followed  by  a  fatal  result?  In  all  cases  in  which  there  are 
diffuse  septic  peritonitis,  rapid  pulse,  leaky  skin,  constant  vomiting,  and  con- 
stipation, operation  is  generally  futile.  In  such  cases  saline  purgatives  and 
stimulants,  diffusible  and  cardiac,  are  indicated,  and  rarely,  though  rarely 
indeed,  recoveries  have  taken  place. 

Whatever  preparation  is  deemed  necessary  for  operation,  when  decided 
on,  must  be  directed  by  the  surgeon. 

Medicinal  Treatment. — Cases  must  occur,  however,  in  which,  from 
various  causes,  medicinal  treatment  is  necessary.  Operation  may  be  declined 
even  if  urgently  advised,  while  rarely  a  preparative  medicinal  treatment 
may  be  necessary  previous  to  operation. 

First  of  all,  absolute  rest  in  bed  must  be  insisted  upon  as  the  first  essen- 
tial condition  of  abatement  of  the  inflammation.  Many  a  fatal  case  would 
have  been  saved  had  this  injunction  been  carried  out. 

Next,  relief  of  pain  is  demanded.  For  this  purpose  opium  should  be 
avoided,  except  in  extreme  cases.  Only  when  relief  cannot  be  secured 
by  the  ice-bag,  by  hot  fomentations,  or  by  mild  counterirritants,  as . 
mustard  or  turpentine,  may  a  minimum  dose  of  morphin,  1-12  or  1-8  of  a 
grain  (0.005  or  0.008  gm.),  be  given  hypodermically.  The  objection  to 
opium  is  well  founded,  on  the  ground  that  it  masks  the  presence  of  important 
S3aTiptoms  which  should  be  open  to  observation.  In  cases  where  operation 
is  from  any  cause  out  of  the  question,  counterirritation  by  repeated  blistering 
may  be  practiced,  and  excellent  results  were  reported  under  the  older  treat- 
ment before  operation  became  common.  Of  other  remedies  for  the  relief 
of  pain,  ice  is  to  be  preferred  to  all  others,  especially  if  there  is  fever.  Only- 
after  the  temperature  has  been  reduced  to  the  normal  does  it  sometimes  be- 
come abnormally  low,  and  then  moist  or  dry  heat  may  be  better  borne. 

The  question  of  the  propriety  of  giving  an  aperient  is  a  nice  one,  and 
must  depend,  for  the  most  part,  on  the  circumstances  and  the  good  judg- 
ment of  those  in  attendance.  The  result  mav  be  verv  happy  or  mischievous. 
Cases  may  be  so  advanced  or  severe  that  a  purgative  may  cause  perforation 
or  rupture  of  an  abscess,  but  in  ordinary  cases  or  in  those  of  moderate- 


INTESTINAL  OBSTRUCTION.  409 

severity  an  aperient  may  be  useful  to  clear  up  a  diagnosis,  while  it  relieves 
pressure,  depletes  the  blood-vessels,  and  diminishes  the  danger  of  peritonitis. 
On  the  other  hand,  purgatives  should  not  be  aggressive  and  drastics  should 
not  be  used.  Perhaps  a  safe  rule  would  be,  "If  there  is  doubt,  do  not 
purge."  The  best  aperient  is  castor  oil,  followed,  if  necessary,  by  salines, 
and  of  these  Rochelle  salts  or  the  solution  of  citrate  of  magnesium  is  recom- 
mended. If  the  stomach  is  sensitive,  calomel  in  divided  doses,  triturated 
with  sugar  of  milk,  is  the  best  drug.  When  there  is  reason  to  believe  that 
suppuration  has  set  in,  no  purgative  should  be  given,  and,  as  a  rule,  opera- 
tion should  be  prompt  toward  evacuating  the  pus  and  removing  the  appendix 
at  the  same  time.  In  severe  cases  even  enemas  should  be  avoided,  as  tend- 
ing to  favor  perforation  and  rupture. 

Nourishment  should  be  purely  liquid,  and  of  liquid,  milk  is  the  best, 
though  animal  broths  are  not  contra-indicated.  It  should  not  be  an  object 
to  force  food ;  indeed,  only  the  minimum  sufficient  should  be  permitted. 


INTESTINAL  OBSTRUCTION.* 

Definition. — The  words  intestinal  obstruction  explain  themselves. 
Obstruction  to  the  descent  of  fecal  matter  is  the  fundamental  idea,  but  the 
absence  of  bowel  movements  is  not  an  essential  symptom.  For  in  the  course 
of  our  studies  it  will  be  found  that  in  intussusception,  for  example,  frequent 
loose  bowel  movements  occur,  and  that  in  fecal  obstruction  they  may  be 
present  throughout  the  whole  course  of  the  disease,  while  in  other  forms 
of  obstruction  they  are  not  infrequent  at  the  beginning.  Intestinal 
obstruction  is  further  divided  into  acute  and  chronic,  according  to  the 
rate  of  development  of  its  symptoms,  the  same  causes  at  times  producing 
acute,  and  at  others  chronic  forms. 

Acute  obstruction  is  produced  by  strangulation,  intussusception,  foreign 
bodies,  twists  and  knots,  strictures,  and  morbid  growths. 

Chronic  obstruction  is  produced  also  by  strictures,  morbid  growths,  and 
fecal  impaction.     Intussusception  may  sometimes  cause  chronic  obstruction. 

I.  Internal  Strangulation. 
Synonyms. — Constriction  of  the  Bozvel;  Hernia  zvithin  the  Abdomen. 

Definition. — By  internal  strangulation  is  meant  stricture  of  the  bowel 
by  inflammatory  bands  or  adhesions,  by  vitelline  remains,  omental  or  mesen- 
teric slits,  adherent  appendix,  and  the  like. 

Occurrence. — This  is  probably  the  most  frequent  cause  of  acute  intes- 
tinal obstruction,  though  intussusception  closely  approaches  it  in  frequency. 
Thus,  Reginald  H.  Fitz,  in  America,  found  it  in  35  per  cent,  of  295  cases 
of  obstruction,  as  against  32  per  cent,  of  intussusception ;  Duchaussoy,  in 
France,  in  54  per  cent,  of  347  cases,  as  against  39  per  cent,  of  intussuscep- 
tion ;  while  Leichtenstern,  in  Germany/ found  it  in  35  per  cent,  of  1134  cases, 
as  against  39  per  cent,  of  intussusception ;  and  Brinton,  in  England,  found 

*  Reginald  H.  Fitz's  able  paper  in  the  "  Transactions  of  the  Con.^ress  of  American  Physicians 
and  Surg-eons,"  i88g.  Leichtenstern's  article  in  Ziemssen's  "  Cj'clopsedia  of  Practical  jMedicine,''  and 
Frederick  Treves'  book  on  "Intestinal  Obstruction,"  1884,  are'important  modern  papers  to  which  I 
am  indebted  for  much  of  the  matter  in  this  section. 


4IO  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

it  in  33  per  cent,  of  481  cases,  as  contrasted  with  54  per  cent,  of  intussus- 
ception. The  percentages  of  Leichtenstern,  Brinton,  and  Fitz  are  astonish- 
ingly close,  and  cannot  therefore  be  far  astray. 

Etiology. — The  causes  of  strangulation  have  been  carefully  worked 
out  by  Fitz  in  his  loi  cases,  collected  from  reports  since  1880.  Of  these 
in  84  the  strangulation  was  caused  by  hands  and  cords,  of  which  63  were 
simple  inflammatory  bands  or  adhesions  and  21  were  vitelline  remains,  repre- 
sented by  Meckel's  diverticulum,*  or  by  the  persistent  remains  of  vitelline 
blood-vessels.  Meckel's  diverticulum  is  usually  attached  by  these  remains 
to  some  part  of  the  abdominal  wall  near  the  navel  or  to  the  mesentery,  or 
it  may  be  adherent  because  of  peritonitis.  The  persistent  vitelline  vessels 
may  themselves  be  the  strangulating  cord  in  the  absence  of  Meckel's  diver- 
ticulum. Of  the  remaining  strangulations  6  were  due  to  adherent  appendix, 
6  to  mesenteric  and  omental  slits,  3  to  peritoneal  pouches  and  openings,  i  to 
adherent  Fallopian  tube,  and  i  to  pedunculated  tumor.  To  these  must  be 
added  diaphragmatic  hernia.  This  was  the  cause  of  strangulation  in  ten  per 
cent,  of  Leichtenstern's  cases,  but  Fitz  found  none  reported  between  1880 
and  1888.  I  reported  two  cases  of  diaphragmatic  hernia  in  i893,f  both  of 
some  standing,  the  immediate  cause  of^  death  being  acute  strangulation. 

The  seat  of  the  strangulation  is  in  the  small  bowel  in  a  decided  majority 
of  cases — nearly  90  per  cent.  In  83  per  cent,  the  strangulated  part  lay  in 
the  lower  abdomen,  and  in  67  per  cent,  in  the  right  iliac  fossa.  Seventy  per 
cent,  of  cases  occur  in  males,  and  at  least  40  per  cent,  between  the  ages  of 
fifteen  and  twenty,  the  causes  in  these  being  inflammatory  adhesions  twice 
as  often  as  vitelline  remains.  Strangulation  in  early  youth  is  relatively  un- 
common, and  when  it  does  occur,  it  is  usuallv  caused  bv  vitelline  remains. 


II.  Intussusception — Invagination. 

Definition. — In  this  condition  one  part  of  the  bowel  has  slipped  into 
another,  always  from  above  downward,  and  may  readily  be  illustrated  by 
slipping  one  part  of  a  coat  sleeve  into  another. 

The  external  or  receiving  portion,  known  as  the  intussuscipiens,  has  its 
mucous  surface  in  contact  with  the  mucous  surface  of  the  middle  or  inter- 
mediate portion,  whose  peritoneal  surface  is  in  contact  with  the  peritoneal 
surface  of  the  internal  or  returning  portion,  while  the  two  mucous  surfaces  of 
the  returning  portion  are  apposed.  The  internal  and  middle  parts  are  called 
the  intussiisceptnm.  The  resultant  is  a  cylindrical  tumor  which  varies  from 
half  an  inch  to  a  foot  or  more  in  length. 

The  annexed  diagram  gives  a  very  good  idea  of  the  different  parts  of 
the  tumor.  Intussusceptions  may  occur  in  any  part  of  the  bowel  from  the 
duodenum  to  the  rectum,  and  are  named  in  accordance  with  the  part  of  the 
bowel  involved :  viz.,  in  the  order  of  frequency,  ilea-cecal,  of  the  ileum  and 
cecum  into  the  colon,  carrying  the  ileo-cecal  valve  with  it ;  enteric,  of  the 
small  intestine  into  itself ;  colic,  of  the  colon  within  itself  in  any  portion  of  its 
course,  most  frequent  of  the  descending  colon  into  the  sigmoid  flexure; 
rectal,  of  the  rectum  into  itself ;  colico-rectal,  of  the  colon  into  the  rectum ; 

*  Meckel's  diverticulum,  a  remnant  of  the  omphalo  mesenteric  duct,  throug-h  which,  in  the  early 
embryo,  the  intestine  communicates  with  the  yolk  sac,  is  a  fing-er-like  projection  from  the  ileum, 
usually  within  eighteen  inches  of  the  ileo-cecal  valve.  The  length  of  this  tube  is  on  an  average 
three  inches,  while  it  has  attained  at  times  a  length  of  ten  inches. 

t  "  Transactions  of  the  Association  of  .American  Physicians,"  1893. 


INTESTINAL  OBSTRUCTION. 


411 


and  ileo-colic,  of  the  small  intestine  into  the  cecum  or  colon  through  the 
ileo-cecal  valve.  According  to  Leichtenstern,  52  per  cent,  only  are  ileo- 
cecal and  ileo-colic,  30  per  cent,  are  enteric,  and  18  per  cent,  rectal  and 
colico-rectal. 

It  will  be  remembered  that  intussusception  is  almost,  if  not  quite,  as 
frequent  a  cause  of  obstruction  as  strangulation,  under  which  the  percent- 
ages were  given. 


-■g—cvj 


Fig.    33. — Vertical  and  Transverse  Sections  of  an   Intussusception, 
I,  the  Sheath,  or  Intussuscipiens;   2,  the   Entering-,  or  inner  layer;  3,  the  Returning 

or  middle   layer. 

Etiology. — Diarrhea  and  habitual  constipation  are  probable  exciting 
causes,  having  preceded  in  13  and  12  cases  respectively  out  of  51.  Other 
possible  causes  are  so  infrequent  as  to  be  unworthy  of  mention.  Experi- 
ments with  faradism  would  seem  to  show,  however,  that  spasm  plays  a 
more  important  role  than  relaxation. 

As  to  distribution,  two-thirds  are  found  in  males  and  one-third  in 
females.  It  is  especially  an  accident  of  the  young,  occurring  in  34  per  cent, 
under  one  year  and  56  per  cent,  under  ten  years. 

Intussusception  of  the  dying  should  be  mentioned,  in  passing,  as  a  form 
of  intussusception  which  often  takes  place  a  short  time  before  death,  more 
frequently  in  children,  and  is  probably  caused  by  certain  irregular  peristaltic 
movements  toward  the  end  of  life.     It  produces  no  symptoms  during  life. 

III.  Twists  and  Knots — Volvulus. 

The  majority  of  cases  are  axial  twists, — i.  e.,  the  bowel  is  twisted  on  its 
mesenteric  axis, — this  being  the  case  in  40  out  of  Fitz's  42  cases,  two  only 
being  knots.  Eighty-seven  per  cent,  of  cases  occur  in  the  large  intestine, 
the  remainder  in  the  small  intestine,  one-half  are  in  the  neighborhood  of  the 
sigmoid  flexure,  and  nearly  one-third  in  the  ileo-cecal  and  cecal  region. 

It  is  more  frequent  in  males  in  the  proportion  of  two  to  one.  Most 
cases  occur  between  the  ages  of  thirty  and  forty.  It  is  a  disease  of  the  old 
rather  than  the  young. 

'  f 
IV.  Obstruction  by  Abnormal  Contents  or  Foreign  Bodies. 


The  majority  of  these  are  gall-stones — 23  cases  out  of  44  of  obstruction 
by  foreign  bodies  collected  by  R.  H.  Fitz ;   19  were  fecal  impactions  and 


412  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

two  enteroliths.  Obstruction  by  gall-stones  appears  to  be  three  times  as 
common  in  females  as  in  males.  They  enter  the  bowel  usually  by  ulcerating 
through  the  gall-bladder,  commonly  into  the  small  intestine,  more  rarely  into 
the  colon. 

The  seat  of  obstruction  by  gall-stones  is  most  frequently  the  ileo- 
cecal region;  after  this,  lodgments  are  in  the  small  intestine,  with  diminish- 
ing frequency  as  we  ascend.  The  ages  are  pretty  uniformly  distributed  from 
eight  to  eighty.  One  of  the  enteroliths  was  made  up  of  shellac,  found  in 
a  man  who  had  been  in  the  habit  of  drinking  alcoholic  solution  of  shellac. 
Usually,  enteroliths  are  made  up  of  triple  phosphate  of  lime  and  magnesia, 
about  a  nucleus  which  may  be  a  mass  of  hair  or  other  foreign  body.  Cour- 
voisier  collected  131  cases,  in  70  of  which  the  stone  was  spontaneously  passed 
per  anum.  Some  were  very  large.  In  six  they  were  found  in  diverticula  or 
in  the  appendix. 

In  a  few  instances  obstruction  is  caused  by  substances  introduced  by 
the  mouth,  but  the  objects  thus  introduced,  as  pennies,  buttons,  pins,  fruit- 
stones,  and  the  like,  are,  as  a  rule,  promptly  expelled  with  the  stools.  In 
the  George  B.  Wood  Museum  of  the  University  of  Pennsylvania  is  a  plaster 
cast  showing  obstruction  of  the  intestine  toward  its  cecal  end  by  plum- 
stones,  followed  by  inflammation  and  abscess.  A  coil  of  lumbricoid  worms 
has  caused  obstruction,  as  has  the  accumulation  of  certain  medicines,  such 
as  magnesia  and  bismuth. 


V.  Strictures  and  Morbid  Growths. 

A  comparatively  small  number  of  obstructions  occur  from  these 
causes.  They  are  always  found  in  adults,  four-fifths  after  the  age  of  forty, 
and  are  apparently  twice  as  common  in  women  as  in  men.  By  far  the  largest 
number  is  met  in  the  large  intestine  and  lower  abdomen,  the  majority  being 
in  the  left  iliac  fossa. 

Strictures  may  be  (i)  Congenital,  illustrated  by  imperforate  anus  or 
defective  union  between  the  pylorus  and  duodenum. 

(2)  Cicatricial,  from  healed  ulcers.  Tubercular  ulcers  in  their  healing 
have  produced  decided  and  fatal  obstruction,  especially  in  the  rectum.  Syphi- 
lis is  also  thought  to  produce  stricture  in  the  same  locality. 

Of  morbid  growths,  the  most  frequent  is  the  cylindric-celled  epithelioma, 
which  may  form  a  ring  in  the  vicinity  of  the  sigmoid  flexure,  where  colloid 
cancer  is  also  met.  Any  of  the  varieties  of  benign  tumors  may  produce 
obstruction,  while  inflammatory  processes  external  to  the  bowel,  especially 
in  the  pelvis,  may  cause  obstruction  by  pressure  from  without. 


VI.  Fecal  Obstruction. 

Synonym. — Ileus  paralyticus  vel  nervosus. 

Occurrence. — Fecal  obstruction  occurred  19  times  in  Fitz's  42  cases. 
It  is  more  frequent  in  females  and  in  adults,  especially  in  the  aged.  It 
occurs  more  frequently  in  the  large  intestine,  and  in  the  lower  part  rather 
than  the  upper.     The  fecal  tumors  found  in  appendicitis  are  now  regarded 


INTESTINAL  OBSTRUCTION. 


413 


as  the  result  of  the  inflamed  appendix,  rather  than  the  cause  of  the  cecal 
inflammation. 

Ileus  paralyticus  may  affect  both  the  small  and  large  intestines,  but  is 
more  common  in  the  latter,  especially  in  the  cecum,  where  the  pressure  is 
concentrated  from  above  and  below.  A  local  peritonitis  may  also  be  devel- 
oped about  the  paralyzed  and  distended  intestine.  Mention  is  made  under 
Chronic  Constipation  of  the  enormous  masses  of  fecal  matter  thus  accu- 
mulated. The  wall  of  the  intestine  above  the  accumulation  may  also  be 
hypertrophied  because  of  the  propulsive  efforts  of  the  muscular  coat. 

Etiology,— Fecal  impaction  is  favored  by  constipation  and  its  causes, 
although  a  tendency  to  fecal  obstruction  is  sometimes  congenital.  Nervous 
influence  is  not  to  be  ignored ;  the  tendency  to  constipation  is  seen  in  the 
chronic  insane,  in  the  hysterical  and  hypochondriacal,  and  in  affections  of  the 
spinal  cord.  Chronic  enteritis  and  chronic  peritonitis  favor  it;  so  may  ana- 
tomical peculiarities  of  the  colon.  These  causes  weaken  the  muscular  coat 
which  moves  the  contents  of  the  bowel  onward,  resulting  ultimately  in  an 
absolute  paralysis  of  a  segment  of  the  bowel,  arrest  of  motion  of  contents,  and 
finally  obstruction.  The  plug  of  fecal  matter  grows  harder  and  larger,  and 
compresses  and  stenoses  the  adjacent  bowel,  resisting  any  further  onward 
movement,  and  increasing  the  impediment  to  the  restoration  of  a  natural 
condition,  culminating,  finally,  in  paralysis  and  stretching  of  the  muscular 
fibers.  The  so-called  "  stercoral  ulcer  "  of  the  cecum,  on  which  the  older 
writers  laid  much  stress,  and  which  was  ascribed  partly  to  gangrene,  due  to 
pressure,  and  partly  to  the  irritating  effect  of  impacted  fecal  matter,  is  to-day 
regarded  as  extremely  rare. 

Symptoms  of  Obstruction. — As  most  of  the  important  symptoms  are 
common  to  the  different  causes  of  obstruction,  I  will  first  consider  them  from 
the  general  standpoint,  emphasizing  any  special  relation  which  a  given 
symptom  may  bear  to  a  special  cause.  In  addition  to  the  usual  absence  of 
Trowel  movement  there  is : 

First,  abdominal  pain.  This  is  the  most  constant  of  all  symptoms, 
Ibeing  present  in  a  decided  majority  of  cases  of  obstruction  from  whatever 
cause.  The  pain  is  one  of  the  earliest  symptoms  in  every  form  of  acute 
obstruction.  It  is  usually  sudden  and  very  severe,  and  may  be  intermittent 
or  constant  with  exacerbations.  It  may  occur  in  any  part  of  the  abdomen, 
regardless  of  cause,  though  most  frequent  in  the  neighborhood  of  the  umbili- 
cus, so  that  its  location  is  of  no  diagnostic  value. 

Nausea  and  vomiting  are  almost  as  frequent.  The  vomitus  at  the  onset 
consists  of  the  food  last  taken,  but  soon  becomes  bilious,  yellow,  and  finally 
fecal.  Vomiting  is  relatively  infrequent  in  strangulation  and  intussusception, 
while  it  is  relatively  frequent  in  volvulus,  stricture,  and  tumor.  The  vom- 
itus is  especially  apt  to  become  fecal  when  caused  by  strangulation — usually 
from  the  third  to  the  fifth  day. 

Tympany  is  next  in  frequency.  It  is  a  symptom  of  later  occurrence 
than  pain  and  vomiting,  presenting  itself  usually  from  the  second  to  the 
sixth  day.  It  varies  greatly  in  degree,  increasing  as  a  rule  with  the  dura- 
tion of  the  obstruction  and  being  sometimes  enormous.  It  is  of  least  im- 
portance in  obstruction  by  intussusception,  and  most  marked  in  volvulus. 
Tt  is  sometimes,  but  not  always,  accompanied  by  tenderness. 

Inability  to  pass  flatus  is  as  constant  as  the  absence  of  bowel  move- 
ment. 

Tenesmus  is  a  frequent  symptom  when  there  is  obstruction  in  the  large 


414  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

bowel,  as  in  15  per  cent,  of  cases  of  volvulus  and  55  per  cent,  of  acute  intus- 
susception.    Fecal  vomiting  succeeds  in  some  cases. 

Tumor,  under  which  are  included  circumscribed  visible  intestinal  coils 
as  well  as  swelling  characterized  by  absolute  dullness,  is  a  rare  symptom 
except  in  intussusception,  when  it  is  characteristic,  having  been  present  in 
69  per  cent,  of  Fitz's  cases,  more  particularly  when  in  the  large  intestine, 
where  it  is  also  sometimes  associated  with  a  relaxed  sphincter.  The  tumor 
of  intussusception  is  more  frequently  found  in  the  left  iliac  region  in  the 
descending  part  of  the  large  bowel,  because  the  invagination  extends  in  that 
direction  and  often  does  not  form  an  appreciable  tumor  till  that  part  of  the 
bowel  is  reached.  Tumor  occurs  sometimes  in  obstruction  by  foreign  bodies. 
In  strictures,  morbid  growths,  and  invagination  it  may  be  recognized  by 
rectal  examination.  Tumors  with  dullness  on  percussion  are  not  seen  in 
twist,  though  visible  coils  are  sometimes  present. 

Fever  is  even  less  frequent  than  tumor — in  fact,  its  absence  is  rather 
characteristic,  especially  in  the  beginning.  Records  of  elevated  temperature 
are,  however,  found  in  from  22  per  cent,  to  28  per  cent,  of  all  cases,  the 
maximum  record  being  102°  F.   (38.9°  C). 

Hiccough  is  an  occasional  symptom,  and  appears  to  be  more  frequent  in 
volvulus.     Jaundice  is  often  found  in  obstruction  by  gall-stones. 

The  urine  has  been  irregularly  studied  in  acute  obstruction.  It  is  not 
infrequently  spoken  of  as  scanty  and  containing  an  increased  amount  of  in- 
dican,  especially  in  obstruction  in  the  small  intestine,  not,  it  is  said,  of  the 
large.  Albumin  is  rarely  present.  It  is  to  be  remembered  that  peritonitis 
causes  an  increased  indican  reaction. 

Tumultuous  peristalsis  is  not  infrequent  above  the  seat  of  obstruc- 
tion. 

Intussusception  especially  adds  bloody  stools  and  tenesmus,  which  are 
important  in  the  diagnosis,  the  former  occurring  in  three-fifths  of  the  cases, 
the  latter  in  55  per  cent.  It  may  occur  early  or  late.  Blood-stained  stools 
also  occur  in  connection  with  cancer  of  the  lower  bowel. 

Volvulus  and  obstruction  by  gall-stones  add  local  peritonitis,  caused,  in 
the  latter  case,  rather  by  the  destructive  results  incident  to  the  passage  of 
the  stone  into  the  bowel  from  the  common  duct. 

The  same  train  of  symptoms  may  succeed  stricture  and  tumors,  to  be 
followed  at  times  by  partial  relief,  which  is  again  succeeded  by  similar 
symptoms  leading  to  ultimate  total  obstruction  and  death.  Such  symptoms 
will,  of  course,  be  associated  with  the  anemic  dyscrasia  and  emaciation 
which  belong  to  the  causing'- diseases,  and  which  more  frequently  lead  to 
death  without  obstruction  than  with  it.  Meteorism  in  the  right  inguinal 
region  is  said  to  be  more  or  less  characteristic  of  obstruction  by  Meckel's 
diverticulum. 

Collapse  is  the  terminal  symptom  in  fatal  cases,  due  to  the  profound 
impression  on  the  nervous  system,  and  presents  the  lowered  temperature, 
leaking  skin,  and  feeble  pulse  characteristic  of  collapse  from  other  causes. 
Cases  are  reported  in  which  operation  during  collapse  was  followed  by  re- 
covery. 

In  chronic  obstruction  due  to  fecal  impaction,  more  rarely  to  stricture, 
cancerous  disease,  or  foreign  bodies,  these  symptoms  are  less  marked  and 
succeed  each  other  more  slowly.  In  fecal  impaction,  what  appears  to  be 
simple  constipation  at  first  is  succeeded  by  permanent  retention,  which  may 
last  for  weeks  without  causing  inconvenience.    Examination  per  rectum  will 


INTESTINAL  OBSTRUCTION.  415 

often  disclose  this  tube  filled  with  hard  fecal  matter  which  may  be  cleaned 
out  with  the  finger  or  a  spoon-handle.  There  may  even  be  diarrhea,  due  to 
irritation  of  the  bowel  above  the  impaction,  when  the  catarrhal  secretion  may 
channel  out  the  mass  and  carry  a  portion  with  it.  Gradually,  however,  the 
impaction  becomes  impregnable  to  all  remedies,  natural  and  artificial,  the 
abdomen  swells,  there  are  fullness  and  weight  within,  and  pain  in  the  genitals 
or  thigh  from  pressure  on  the  sacrolumbar  nerves ;  the  appetite  fails,  the 
tongue  is  coated,  and  the  breath  offensive ;  sometimes  a  condition  of  lethargy 
and  indifference  supervenes  along  with  great  weakness,  and  the  patient  dies 
of  exhaustion.  At  any  time,  on  the  other  hand,  may  follow  with  suddenness 
the  train  of  symptoms  already  described — pain,  tympany,  nausea  and  vom- 
iting, ultimately  of  fecal  matter,  with  collapse  and  death. 

In  many  cases  of  impaction  sooner  or  later,  a  fecal  tumor  presents  itself 
— a  tumor  formed  by  the  mass  of  retained  feces,  chiefly  in  the  right  iliac 
fossa,  the  region  of  the  cecum,  corresponding  to  the  outer  half  of  Poupart's 
ligament.  It  is  sometimes  hard,  at  others  soft  and  yielding,  and  sometimes 
tender  and  painful,  probably  because  of  a  mild  local  peritonitis.  In  the  as- 
cending colon  the  tumor  is  soft,  and  in  the  hepatic  flexure  it  may  give  rise 
to  the  notion  of  an  enlarged  liver.  It  may  move  in  the  more  loosely  attached 
parts  of  the  colon,  and  may  drag  the  transverse  colon  down  toward  the 
pubis.  In  the  descending  colon  and  sigmoid  flexure  it  is  usually  harder, 
and  may  be  subdivided  into  scybala.  It  is,  of  course,  easier  of  detection  in 
persons  with  thin  abdominal  walls,  and  may  be  obscured  by  flatulent  dis- 
tention. When  recognized,  it  is  of  great  diagnostic  value.  Such  tumors 
have  been  mistaken  for  tumors  of  the  stomach,  liver,  spleen,  and  kidneys, 
and  for  pregnancy. 

Diagnosis. — The  importance  of  early  and  correct  diagnosis  is  intensified 
at  the  present  day  by  the  fact  that  operative  interference  promises  by  far 
the  best  results,  while  to  be  effectual  it  must  be  early.  The  diagnosis  has 
three  principal  objects:  first,  the  existence  of  obstruction  per  se ;  second,  its 
seat,  and  third,  its  cause.  The  first  is  by  far  the  most  important,  as 
operation  is  indicated  in  one  variety  or  situation  almost  as  much  as  in 
another. 

First,  as  to  the  presence  of  obstruction  in  general,  the  absence  of  bowel 
movements,  the  presence  of  abdominal  pain  and  tympany  are  suggestive 
symptoms.  As  to  differential  diagnosis,  it  has  happened  that  a  case  of 
intense  enteritis  has  presented  all  the  symptoms  of  obstruction.  Fever  is 
commonly  present  in  such  enteritis,  while  it  is  absent  in  chronic  obstruction, 
at  least  at  first.     Such  a  cause  of  error  is,  however,  rare. 

Acute  poisoning  associated  with  vomiting,  such  as  is  caused  by 
poisonous  mushrooms,  biliary,  renal,  and  intestinal  colic,  the  pain  caused 
by  twisting  of  the  ureter  in  a  movable  kidney,  all  present  symptoms  more 
or  less  like  those  of  obstruction ;  but  the  combination  of  signs  necessary  to 
the  picture  of  obstruction  is  still  wanting. 

Much  more  common  is  the  mistaking  of  appendicitis  for  obstruction. 
In  this  there  are  pain,  vomiting,  and  constipation,  as  well  as  tumor  in  the 
neighborhood  of  the  cecum,  but  the  differentiation  between  these  two  con- 
ditions was  considered  when  treating  of  acute  appendicitis.  Peritonitis 
itself  presents  symptoms  common  to  it  knd  obstruction,  including  abdominal 
pain,  distention,  constipation,  and  collapse,  with  increase  of  indican.  But 
the  presence  of  fever,  the  absence  of  tumor  and  of  fecal  vomiting,  point  to 
peritonitis. 


41 6  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

The  symptoms  of  licniia  are  also  those  of  intestinal  obstruction,  and  in 
all  cases  careful  search  should  be  made  for  a  concealed  hernia.  Such  hernise 
have  been  found  in  the  external  ring  and  in  the  obturator  foramen  at  autopsy 
by  William  Osier,  who  has  also  met  a  case  of  acute  hemorrhagic  pancre- 
atitis presenting  the  symptoms  of  acute  obstruction. 

Second,  as  to  the  seat  of  obstruction.  This  is  more  difficult  to  determine. 
Unfortunately,  the  situation  of  the  pain  gives  little  information,  since  it  is 
almost  always  in  the  vicinity  of  the  navel,  wherever  the  actual  seat  of  ob- 
struction may  be.  In  other  cases  the  pain  is  diffuse.  Rarely,  it  may  be  at 
the  seat  of  obstruction.  Though  fecal  vomiting  is  much  more  frequent  in 
obstruction  of  the  small  intestine  than  of  the  large,  it  still  occurs  in  one-eighth 
of  all  cases  of  the  latter. 

When  a  tumor  is  present,  it  gives  valuable  information,  being  com- 
monly at  the  seat  of  obstruction.  Active  peristalsis  limited  to  one  part  of 
the  bowels  indicates  that  the  obstruction  is  below  it. 

Having  excluded  hernia  by  a  careful  examination  for  a  seat  of  strangu- 
lation, examination  per  rectum  should  be  made,  also  per  z'aginam.  By 
either  method  a  tumor  may  sometimes  be  recognized.  Especially  is  this 
true  of  a  tumor  caused  by  intussusception.  A  stricture  may  also  be  detected 
by  digital  examination  of  the  rectum,  as  may  obstruction  by  foreign 
bodies. 

On  the  other  hand,  the  rectum  may  be  totally  empty  of  feces  and  con- 
tinue so,  whence  it  is  probable  that  the  obstruction  is  in  the  small  intes- 
tine or  high  up  in  the  large.  The  position  and  size  of  the  uterus  and 
ovaries  may  also  be  ascertained  by  rectal  examination.  The  rectum  can  be 
more  thoroughly  explored  by  suitable  specula  in  the  knee-elbow  position, 
but  rectal  exploration  by  the  entire  hand  has  not  been  followed  by  the 
results  anticipated.  The  hard  rectal  tube  has  produced  perforation,  while 
the  flexible  tube  so  coils  itself  up  as  to  be  valueless  in  diagnosis.  Some- 
times, if  the  distended  intestine  is  filled  with  hard  fecal  matter,  it  can  be  felt 
as  an  uneven  mass  in  the  course  of  the  bowel. 

Moderate  distention  in  the  upper  part  of  the  abdomen,  with  flatness 
below  and  in  the  sides,  rapid  collapse  and  oliguria,  point  to  obstruction  in 
the  duodenum  and  jejunum.  Such  distention  is  temporarily  diminished  by 
vomiting,  but  is  uninfluenced  by  fecal  discharges  secured  by  enemas.  Nor 
is  the  vomiting  always  fecal  in  duodenal  and  jejunal  obstruction ;  when  the 
obstruction  is  in  the  ileum  and  cecum  the  distention  is  more  central,  the 
region  of  the  colon  being  flatter  until  covered  in  by  the  extending  tympany, 
and  the  vomiting  is  more  likely  to  be  fecal. 

When  obstruction  is  seated  in  the  colon  tympanitic  distention  is 
greatest,  yet  the  difiference  between  it  and  that  of  obstruction  in  the  ileum 
is  not  so  great  as  to  possess  much  diagnostic  value.  If  in  the  lower  colon, 
there  may  be  tenesmus  and  discharge  of  blood  and  mucus.  Measuring  the 
capacity  of  the  large  bowel  by  air,  gas,  or  water  has  been  recommended  as 
an  aid  to  diagnosis.  Reliable  observation  goes  to  show  that  these  substances 
may  be  made  to  pass  the  ileo-cecal  valve.  Water  recommends  itself  so  far 
above  the  others  that  it  alone  will  be  considered.  Moreover,  the  difficulty 
in  passing  water  through  the  ileo-cecal  valve  is  so  great  that  it  is  practically 
applicable  only  in  case  of  the  large  intestine.  The  capacity  of  the  large 
intestine  of  adults  is  about  six  quarts,  or  about  as  many  liters.  That  of 
infants  appears  to  be  widely  different  in  children  of  the  same  age.  Thus, 
in  measurements  by  Dr.  Muir,  the  capacity  of  the  colon  of  a  boy  five  months 


INTESTINAL  OBSTRUCTION.  417 

old  was  found  to  be  but  ten  ounces  (300  c.c),  while,  in  a  girl  of  seven 
months,  it  was  thirty  ounces  (900  c.  c).  If  the  method  is  employed 
at  all  for  diagnosis,  it  should  be  early,  before  the  nutrition  of  the  bowel  has 
suffered,  since  rupture  has  taken  place  under  light  pressure.  The  patient, 
etherized,  should  be  inverted  or  placed  on  his  right  side,  and  precaution 
taken  to  keep  the  fluid  from  returning.  Close  pressure  of  the  buttocks 
generally  suffices.  The  fluid  is  most  conveniently  introduced  by  the  fountain 
syringe,  by  which  pressure  can  be  varied,  but  the  reservoir  should  not  be 
more  than  2  1-2  feet  (0.75  m.)  above  the  body  of  the  child.  Various  diffi- 
culties, more  or  less  well  founded,  are  suggested,  such  as  resistance  by 
voluntary  muscles  during  life,  valve-like  obstruction,  which  permits  ascent 
of  fluid,  but  not  descent,  and  unequal  dilatation.  However,  the  method 
should  not  be  overlooked,  and  it  is  more  than  likely  that  much  will  be 
learned  from  future  opportunity.  Thus,  since  a  case  of  obstruction  at  the 
sigmoid  flexure,  cited  by  Treves,  permitted  the  injection  of  three  pints  of 
fluid  (1.4  liters),  it  is  evident  that  only  in  the  event  of  the  injection  of  a 
larger  amount  can  the  gut  be  considered  open  at  this  point.  Treves  claims, 
too,  that  the  entrance  of  fluid  in  the  cecum  may  be  recognized  by  aus- 
cultation. Under  favorable  circumstances — as,  for  example,  with 
empty  colon,  a  trained  ear,  and  skillful  technique — this  seems  quite 
possible. 

Third,  the  presence  of  obstruction  being  recognized,  the  nature  of  the 
obstructing  cause  may  sometimes  be  determined  with  a  degree  of  probability. 
First  to  be 'considered  is  the  relative  frequency  of  the  different  morbid  states. 
Adopting  Fitz's  figures,  strangulation  and  intussusception  together  make 
up  70  per  cent,  of  all  cases,  the  two  being  nearly  equal.  After  that  come 
volvulus  with  15  per  cent.,  gall-stones  with  8  per  cent.,  and  stricture  or 
tumor  6  per  cent., — that  is,  the  twists  about  equal  obstruction  from  gall- 
stones and  tumor  and  stricture  together. 

Again,  if  the  obstruction  be  found  in  the  large  intestine,  it  is  more  likely 
to  be  intussusception,  twist,  or  stricture  and  tumor,  since  of  the  obstructions 
in  the  large  bowel  51  per  cent,  are  intussusception,  30  per  cent,  twists,  and 
12  per  cent,  stricture  and  tumor.  If  in  the  small  intestine,  it  is  most  likely 
strangulation  or  gall-stone  obstruction,  since  72  per  cent,  of  obstructions 
in  the  small  intestine  are  strangulations  and  14  per  cent,  gall-stones, 
leaving  8  per  cent,  only  for  intussusception,  5  per  cent,  for  twists,  and  i 
per  cent,  for  stricture  and  tumor.  If  the  attack  has  been  preceded  by  one 
of  jaundice  or  by  other  liver  symptoms,  as  hepatic  colic,  it  is  almost  certain 
to  be  gall-stone,  especially  if  the  patient  be  over  fifty  years  old. 

If  the  patient  is  under  thirty,  particularly  if  a  child,  it  is  more  likely 
to  be  intussusception  than  twist,  while  if  there  are  palpable  abdominal 
tumor,  bloody  stools,  and  rectal  tenesmus,  the  case  is  almost  sure  to  be  in- 
tussusception, rendered  still  more  likely  if  the  rectum  has  a  large  capacity 
for  water,  since  the  intussusception  is  found  near  the  cecum  in  75  per  cent., 
while  twist  is  found  near  the  sigmoid  flexure  in  50  per  cent.  Of  all  forms, 
intussusception  presents  the  clearest  clinical  picture  and  is  most  easily  rec- 
ognized. 

Tzvist,  cancer,  and  stricture  are  more  apt  to  be  below  the  sigmoid,  and 
the  last  two  may  sometimes  be  felt  by  the  finger.  In  point  of  fact,  twist  in 
the  large  bowel  is  not  often  recognized.  It  is  a  disease  of  the  adult,  rarely 
occurring  under  forty ;  vomiting  is  less  early  and  less  severe  than  in  stran- 
gulation by  bands.     Pain  is  often  severe  in  twist.     Some  degree  of  local 

27 


41 8  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

peritonitis  almost  invariably  results,  causing  rigidity  of  the  abdomen,  while 
meteorism  appears  early  and  is  extreme,  the  distended  intestine  often  dis- 
placing the  solid  viscera. 

If  there  is  a  history  of  previous  peritonitis,  strangtdation  becomes  more 
likely,  since  such  inflammation  precedes  in  68  per  cent.,  while  there  is  also 
a  history  of  previous  attacks  in  12  per  cent.  The  pain  in  strangulation  is 
early,  sudden,  and  severe,  and  the  same  may  be  said  of  vomiting.  It  be- 
comes stercoraceous  in  60  per  cent.,  while  the  vomiting  affords  no  relief. 
There  is  little  or  no  distention  unless  peritonitis  supervene.  There  is  great 
prostration,  and  no  tenesmus  or  discharge  of  blood.  The  average  duration 
is  about  five  days.  The  presence  of  diaphragmatic  hernia  as  a  cause  of 
internal  strangulation  must  not  be  overlooked ;  it  is  almost  always  the  result 
of  severe  injuries.  The  half  of  the  thorax  containing  the  viscera  is  distended 
and  tympanitic  on  percussion,  while  breathing  movement  is  restricted,  the 
breath-sounds  are  feeble,  the  vocal  fremitus  and  vocal  resonance  diminished 
or  absent — signs  shared  with  pneumothorax.  The  pitch  and  intensity  of 
the  percussion  note  vary  also  with  the  degree  of  distention  and  the  position. 
of  the  viscera  invading  the  thorax,  while  there  may  be  metallic  tinkling  of 
fluid  in  the  intestine,  due  to  peristalsis. 

Obstruction  by  Meckel's  divert iciilnm  is  said  to  be  indicated  by  meteor- 
ism in  the  right  inguinal  region. 

Fecal  obstruction  is  recognized  by  the  symptoms  already  described 
under  chronic  obstruction,  and  such  recognition  is  not  very  difficult, 
especially  if  the  fecal  tumor  is  found.  Sometimes,  however,  on  account  of 
its  insidiousness,  fecal  obstruction  is  overlooked  when  presenting  only  the 
more  chronic  symptoms,  and  the  patient  dies  of  supposedly  unknown  cause 
when  accurate  and  careful  study  would  have  led  to  its  discovery. 

Prognosis. — In  fecal  tumors  alone,  of  all  the  causes  of  obstruction  con- 
sidered, is  the  prognosis  favorable  if  the  condition  is  recognized  sufficiently 
early,  while  a  considerable  latitude  of  duration  may  also  be  allowed. 

Treatment. — In  intussusception  and  fecal  impaction  alone  is  it  worth 
while  to  consider  anything  but  operative  treatment. 

Treatment  of  Intussusception. — It  is  usual  to  attempt  to  reduce  an  intus- 
susception by  inflation  or  irrigation.  The  latter  is  preferable  in  the  colic 
variety,  because  pressure  can  be  more  accurately  graduated,  but  it  is  con- 
sidered of  little  or  no  value  in  the  enteric  form.  For  the  latter  Nicholas 
Senn  considers  that  better  results  may  be  obtained  by  inflation  with  a  gas 
like  hydrogen,  which  he  finds  passes  through  the  ileo-cecal  valve  under  a 
much  lower  pressure  than  a  ftuid.  On  the  other  hand,  D'Arcy  Power  recom- 
mends that  the  abdomen  be  opened  at  once  when  this  condition  is  suspected. 
If  irrigation  is  decided  upon,  the  fluid — salt  solution  at  100°  F.  (37.8°  C.)  — 
is  best  allowed  to  pass  into  the  large  intestine  slowly  by  its  own  weight 
through  a  long  tube  carried  high  up,  the  reservoir  being  raised  not  more  than 
2  1-2  feet  (0.75  meter)  above  the  etherized  patient.  A  higher  level  than  this 
for  the  reservoir  may  result  in  rupture  of  the  bowel,  while  the  bowel  may  also 
kink  if  the  fluid  be  allovv^ed  to  enter  too  rapidly.  Some  place  the  patient 
head  downward  over  the  back  of  an  inverted  chair,  suitably  covered  with  a 
bolster  and  quilts.  Others  hold  that  inversion  is  unnecessary.  The  nozzle 
should  be  closely  fitted  to  the  anus,  accomplished  by  simply  compressing  the 
buttocks.  One  hand  should  be  kept  flat  on  the  abdomen,  while  variations 
of  pressure  should  be  avoided.  It  is  said  that  in  this  way  water  may  not  only 
be  passed  from  the  colon  through  the  ileo-cecal  valve  into  the  small  intestine, 


INTESTINAL  OBSTRUCTION.  419 

but  also  through  the  pylorus  into  the  stomach,  thence  into  the  esophagus,  and 
out  at  the  mouth.  If  success  is  not  attained  in  forty-eight  hours,  it  is  not 
likely  to  follow,  and  laparotomy  should  be  done.  The  extent  or  size  of  the 
intussusception  furnishes  no  reason  against  the  use  of  the  treatment.  It  has 
been  found  effectual  in  33  out  of  44  cases  of  suspected  or  probable  intussus- 
ception collected  by  Fitz,  and  therefore  merits  a  trial.  Unfortunately,  there 
is  always  a  tendency  to  recurrence  after  the  reduction  of  an  intussusception 
by  this  method.  Should  the  recurrence  persist,  laparotomy  should  be  done 
without  much  delay,  especially  in  view  of  the  fact  that  the  operation  is  so 
much  better  borne  early  in  the  disease,  before  the  strength  of  the  patient  is 
exhausted.  Rarely  should  more  than  forty-eight  hours  be  allowed  to  elapse 
without  operative  interference  in  cases  of  acute  obstruction  from  any  cause 
except  fecal  impaction. 

What  else  may  be  done  early  and  without  risk  to  the  patient?  Above 
all,  give  7io  aperients.  To  relieve  the  excessive  vomiting  after  the  simpler 
remedies  have  been  tried,  the  stomach  may  be  zuaslied  out  as  suggested  by 
Kussmaul  and  described  on  page  348.  This  is  at  once  a  harmless  measure  and 
may  be  efficient  for  the  purpose  intended.  It  may  be  done  three  or  four  times 
a  day.  It  may  be  expected  to  be  of  service  in  the  vomiting  of  any  variety  of 
obstruction.  Opium  may  be  administered  hypodermically  to  allay  the  intense 
pain,  and  may  also  relieve  the  vomiting.  Or  it  may  be  given  with  a  view 
to  cure,  which  there  is  reason  to  believe  it  has  accomplished  in  cases  of  intus- 
susception and  even  strangulation.  Opium  may,  on  the  other  hand,  be  harm- 
ful, by  obscuring  diagnosis  and  producing  an  appearance  of  relief,  while  the 
local  condition  of  the  bowel  is  really  growing  worse. 

The  nourishment  of  the  cases  demands  careful  thought.  It  is  irrational 
to  continue  the  administration  of  nutriment  by  the  mouth  when  it  is  rapidly 
rejected.  If  the  obstruction  is  in  the  small  bowel  the  rectum  should  be  the 
only  route  employed,  while  ice  should  be  administered  freely  by  the  mouth. 
On  the  other  hand,  when  the  obstruction  is  in  the  colon,  when  tenesmus  and 
diarrhea  are  symptoms,  and  v%^hen  vomiting  is  a  less  prominent  symptom, 
small  amounts  of  liquid  nourishment  may  be  introduced  by  the  mouth. 

Treatment  of  Fecal  Tumor. — The  situation  is  altered  when  a  diagnosis 
of  fecal  tumor  has  been  correctly  made.  Here  nothing  is  so  efficient  as 
repeated  large  injections  of  warm  water,  high  up  and  retained  for  from  ten 
to  fifteen  minutes  if  the  patient  can  retain  them,  as  he  should  be  encouraged 
to  do.  Good  results  are  sometimes  obtained  from  the  coincident  use  of  small 
doses  of  calomel,  1-8  to  1-5  grain  (0.008  to  0.013  gm.),  given  hourly.  If 
the  fecal  impaction  is  low  enough  down  in  the  rectum,  in  most  cases  the  fin- 
ger or  some  mechanical  appliance,  as  a  spoon-handle,  can  be  used  to 
loosen  it. 

It  is  in  this  form,  too,  that  electricity,  massage,  and  metallic  mercury,  as 
used  by  the  older  practitioners,  are  sometimes  useful.  Electricity  is  vari- 
ously used,  but  the  most  efficient  application  is  the  recto-abdominal,  in  which 
one  electrode  of  a  faradic  machine  is  placed  in  the  rectum,  the  other  over 
the  abdomen.  The  use  of  metallic  mercury  has  been  revived  by  M.  Matignon 
in  fecal  impaction  with  apparently  good  results,  the  dose  being  1.5  to  9  ounces 
(50  to  280  gm.).  It  probably  acts  by  insinuating  itself  in  a  state  of  minute 
subdivision  through  the  fecal  tumor  and  between  it  and  the  bowel,  loosening 
and  breaking  up  the  mass  so  as  to  restore  the  natural  passage.  It  is  of  no 
use  when  there  is  strangulation,  intussusception,  or  volvulus. 

In  stenosis  of  the  gut,  inflammatory  or  otherwise,  the  treatment  recom- 


420  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

mended  for  fecal  impaction  may  oftentimes  be  used,  with  the  eft'ect  of  remov- 
ing the  obstruction  so  far  as  due  to  the  delay  of  fecal  matter  at  the  narrowed 
point.     Sooner  or  later  operative  interference  becomes  necessary. 

Tix'ist,  strangulation  by  hands  and  obstruction  by  gall-stones  can  only  be 
relieved  by  operation,  and  a  surgeon  should  be  associated  in  the  treatment 
from  the  outset. 

For  treatment  of  cancer  of  the  bon'cl  see  section  on  that  affection. 


COXSTIPATION. 
Syxoxym. — Costiveness. 

Definition. — Unnatural  retardation  or  delay  in  the  natural  evacuation 
of  the  bov.-els. 

Though  there  may  be  some  exceptions,  an  evacuation  of  the  bowels  once 
in  twenty-four  hours  seems  to  be  nature's  law  in  the  case  of  the  adult  human 
being,  and  any  prolongation  of  this  interval  may  be  said  to  constitute  costive- 
ness. A  popular  application  of  the  term  is  also,  however,  to  a  condition  in 
which,  though  there  may  not  be  infrequency  of  stools,  the  dejecta  are  dryer 
and  harder  than  natural  and  are  discharged  with  more  or  less  difficulty  and 
pain.  The  physician  should  appreciate  this,  otherwise  misunderstanding 
may  arise  as  to  the  exact  meaning  of  the  patient.  Constipation  is  also  some- 
thing different  from  retention  due  to  obstruction  by  various  causes.  The  in- 
terval between  bowel  movements  in  constipation  varies  greatly,  ranging  be- 
tween a  couple  of  days  and  weeks.  Alany  constipated  persons  have  no  de- 
jections unless  aperient  medicine  is  taken. 

Morbid  Anatomy. — There  are  no  morbid  changes  characteristic  of 
constipation.  Dilatation  of  the  colon  in  various  degrees  is  present,  some- 
times enormous,  as  shown  in  Fig.  34.  and  there  may  be  found  the  remnants 
of  inflammatory  or  other  local  lesions  which  may  be  responsible  for  the 
obstruction.  The  large  accumulations  of  fecal  matter  found  in  these  cases 
are  known  as  coprostasis. 

Etiology. —  The  immediate  causes  of  constipation  are: 

1.  Atony  of  the  colon,  whence  results  a  slow  peristalsis.  Perhaps  the 
most  common  cause  of  atony  is  a  habit,  engendered  through  indifference  or 
necessity,  of  disregarding  nature's  call  for  relief.  Repeated  disregard  of 
such  call  results  sooner  or  later  in  disappearance  of  inclination.  .Sedentary 
habits  co-operate  to  produce  such  disinclination.  Atony  may  also  be  the 
result  of  disease  of  the  bowel  and  of  general  disease  causing  debility,  such  as 
anemia,  chlorosis,  and  protracted  illness,  like  typhoid  fever. 

2.  A  deficiency  of  the  natural  stimuli  to  peristalsis  afforded  by  various 
secretions,  especially  the  bile. 

3.  A  loss  of  muscular  power  in  the  abdominal  walls  from  overdisten- 
tion  or  obesity. 

4.  Improper  food.  The  foods  which  most  stimulate  peristalsis  are  vege- 
tables, especially  those  with  an  insoluble  residue,  such  as  is  afforded  by  the 
outer  coatings  of  grain.  Foods  of  an  opposite  kind  are  represented  by  milk 
and  the  farinacea. 

5.  Finally,  stricture  and  displaced  organs, — such  as  the  uterus, — tumors. 


CONSTIPATION.  421 

and  foreign  bodies  impinging  on  the  bowel  and  delaying  the  descent  of  the 
feces,  become  causes. 

Among  consequences  of  fecal  impaction  are  hemorrhoids,  which  result 
from  pressure  on  the  hemorrhoidal  veins. 

Treatment. — Every  case  of  constipation  should  be  carefully  studied  with 
a  view  to  determining  its  cause,  and  if  such  cause  is  found,  it  should,  of 
course,  be  removed  when  possible.  If  such  cause  is  not  found,  the  first 
injunction  in  the  management  of  constipation  is  the  observance  of  regularity 
in  going  to  stool  at  a  fixed  hour  of  the  day,  whether  inclination  prompts  or 
not.  The  usual  hour  for  this  purpose  is  immediately  after  breakfast,  though 
it  matters  not  much  when  it  is,  so  that  it  is  regularly  observed.  Especially 
harmful  is  it  to  disregard  any  inclination  which  may  appear  at  this  time,  or, 
indeed,  at  any  time.  Next  is  the  use  of  food  of  the  kind  referred  to  under 
the  head  of  etiology,  such  as  fresh  green  vegetables  of  all  kinds  and  succulent 
fruits. 

Of  breads,  the  so-called  "  brown  "  or  bran  bread,  or  gluten  bread,  is 
to  be  preferred.  With  such  food  should  be  conjoined  massage  of  the 
abdomen  or  compression,  either  by  the  patient  himself  or  by  another.  A 
very  excellent  daily  practice  is  to  flex  the  body  forward  and  as  far  as  possible 
backward,  a  number  of  times  while  in  the  standing  position.  This  has  the 
efifect  of  compressing  the  bowels  and  stimulating  peristalsis,  and  is  one  of  the 
most  useful  aids.  It  should  be  practiced  once  or  twice  a  day :  if  once,  in  the 
morning  on  rising ;  if  twice,  at  bedtime  also.  Rising  to  a  sitting  posture 
while  lying  on  the  back  with  the  feet  fixed  is  another  exercise  helpful  in  the 
correction  of  constipation ;  so  is  twisting  of  the  body  while  standing.  Daily 
exercise,  including  horseback  riding,  golf,  and  tennis,  has  an  important  influ- 
ence in  correcting  constipation.  I  have  known  dancing  also  to  be  serviceable. 
The  free  use  of  plain  water  is  sometimes  sufficient  to  overcome  the  milder 
cases.  Thus,  a  glass  of  water  may  be  taken  before  breakfast  and  another  at 
bedtime. 

Last  of  all  should  aperients  be  employed.  Unfortunately,  these  are 
often  necessary.  The  simplest  and  least  irritating  should  be  employed.  A 
simple  tonic  pill  composed  of  1-3  to  1-2  grain  (0.022  to  0.033  g™-)  of  the 
extract  of  nux  vomica  and  1-12  to  1-8  grain  (0.005  to  0.008  gm.)  of  the 
extract  of  belladonna,  three  times  a  day,  and  kept  up  for  some  time  in  con- 
nection with  the  dietetic  measures  alluded  to,  is  often  sufficient. 

But  of  atcual  aperients,  the  natural  mineral  waters  are  deserving  fav- 
orites, especially  Friedrichshalle,  Apenta,  Hunyadi  Janos,  and  Carlsbad, 
and,  when  less  active  waters  are  required,  the  American  Saratoga  waters. 
The  Saratoga  waters  are  saline  waters  which  present  quite  a  range  of  pro- 
portion in  their  constituents,  chiefly  sodium  chlorid,  at  the  various  springs. 
The  waters  of  the  Bedford  Springs,  of  Bedford,  Pa.,  are  also  very  efficient, 
stimulating,  as  does  the  Saratoga  water,  the  secretion  of  bile.  The  doses 
of  all  of  these  waters  vary  so  much  with  circumstances  that  it  is  impossible 
to  indicate  them  with  definiteness.  The  minimum  dose  of  the  foreign  aperient 
waters  mentioned  is  two  fluid  ounces  (60  c.  c),  increased  to  eight  fluid  ounces 
(240  c.  c).  Less  than  the  latter  quantity  of  the  American  waters  is  seldom 
used  at  a  dose. 

Of  drugs,  cascara  sagrada  has  become  deservedly  popular.  The  best 
preparation  is  the  fluid  extract,  as  its  dose  can  be  readily  regulated.  From. 
10  to  30  minims  (0.6  to  2  c.  c.)  may  be  given  after  the  evening  meal,  and  if 
this  should  prove  insufficient,  the  same  dose  after  the  midday  meal  is  to  be 


422  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

preferred  before  increasing  the  evening  dose.  The  soHd  extract  is,  however, 
also  efficient,  and  a  grain  or  two  (0.066  to  0.13  gm.)  more  may  be  added  to 
the  laxative  pill  already  mentioned,  or,  if  a  more  active  aperient  is  desired, 
as  many  grains  of  extract  of  colocynth  may  be  substituted. 

An  old  favorite,  a  pill  composed  of  extracts  of  aloes,  nux  vomica,  and 
belladonna,  in  varying  proportions,  to  be  taken  at  bedtime,  has  been  largely 
substituted  of  late  by  another  made  by  the  manufacturers  and  pharmacists, 
of  aloin  1-5  grain  (0.013  gm.),  strychnin  1-60  grain  (o.ooii  gm.),  and  bella- 
donna 1-8  grain  (0.008  gm.),  of  which  one  or  two  are  a  dose.  To  such  a 
pill  podophyllin,  in  doses  of  1-4  to  1-2  grain  (0.0165  to  0.033  gm.),  may  be 
added  with  advantage,  or  blue  mass  in  doses  of  1-2  grain  to  2  grains  (0.033  to 
0.132  gm.),  or  rhubarb  one  to  two  grains  (0.066  to  0.013).  The  bella- 
donna may  be  substituted  by  the  extract  of  hyoscyamus,  of  which  one  to  two 
grains  (0.066  to  0.132  gm.)  may  be  given.  The  compound  licorice  powder 
in  which  senna  and  sulphur  are  the  active  ingredients  is  a  favorite  aperient 
with  some,  but  is  bulky,  and  has  a  tendency  to  cause  griping.  The  dose  is 
a  dram  (3.8  gm.)  or  more. 

A  glycerin  suppository  or  1-2  dram  (2  c.  c.)  of  glycerin  injected  has 
become  a  favorite  means  of  securing  an  evacuation.  It  should  be  remem- 
bered as  a  possible  remedy,  but  it  acts  by  irritating  the  lower  bowel  and  soon 
loses  its  effect.  The  enema  of  plain  water,  one  to  two  pints  (500  to  1000 
c.  c),  though  less  convenient,  is  to  be  preferred,  and  some  persons  use  it 
regularly.  None  of  these  measures  is  curative.  They  simply  empty  the 
bowel  at  the  time,  and  systematic  efifort  should  be  made  to  reduce  them 
gradually,  while  the  hygienic  treatment  is  kept  up. 

Among  the  more  unusual  remedies  recommended  for  chronic  constipa- 
tion is  creasote,  one  drop  daily,  increasing  one  drop  a  day  until  the  result  is 
obtained. 

It  sometimes  happens  that  an  impacted  fecal  mass  becomes  channeled, 
and  fecal  matter  may  descend  from  above  through  it,  anl  thus  lead  to  the 
belief  that  normal  passages  are  being  secured.  The  physician  should  not  be 
slow  to  explore  the  rectum  with  the  finger,  and  by  means  of  it  or  the  handle 
of  a  spoon  clear  out  the  mass.  This  is  often  absolutely  necessary  before  an 
evacuation  can  be  secured. 

Treatment  of  the  Constipation  of  Infants. — I  prefer  to  overcome  this, 
when  possible,  by  simple  small  enemas  repeated  until  an  effect  is  produced, 
and  carried  out  at  a  fixed  hour  each  day,  preferably  in  the  evening.  The 
child  is  best  held  on  the  motli^r's  lap,  properly  protected  by  a  mackintosh  and 
a  small  quantity,  say  two  ounces  (60  c.  c),  of  tepid  water  is  thrown  into  the 
rectum.  If  it  returns  unchanged,  after  a  few  minutes'  delay  another 
syringeful  is  thrown  in,  and  if  necessary,  another.  Ultimately,  a  fecal 
discharge  is  usually  thus  obtained.  I  lay  stress  also  on  the  regularity  of 
this  performance.  It  may  be  necessary  to  add  a  little  soap  to  the  hot 
water.  Sometimes  slight  titillation  of  the  anus  by  twisted  pieces  of  paper 
answers  every  purpose.  At  the  same  time,  the  belly  of  the  child  should  be 
massaged  by  the  mother.  Small  suppositories  of  soap  or  of  glycerin  may  be 
used  if  the  measures  mentioned  are  inefficient.  For  simple  constipation  in 
infants  it  is  preferable  to  administer  nothing  by  the  mouth  if  it  can  be  dis- 
pensed with. 

Dilatation  of  the  Colon. — This  is  one  of  the  consequences  of  chronic 
constipation,  though  it  may  also  occur  as  an  acute  condition,  the  result  of 


CONSTIPATION. 


423 


sudden  obstmction,  as  by  a  twist  in  the  meso-colon.  It  may  '"volve  the 
whole  colon,  but  the  vicinity  of  the  sigmoid  flexure  ,s  ,  s  usual  seat.  Two 
classes  of  cases  of  idiopathic  dilatation  are  met.-first,  that  of  adult  males 
eeneraUy  over  fifty  years  of  age ;  second,  that  of  children  in  whom  abdominal 
fymptoms  have  been  present  more  or  less  since  birth.     In  the  former  >t  .s 


Fig  34 -Giant  Congenital  Wlatation  of  Human  Colon. 
The  more  distended  end  is  the  sigmoid  fl^^'^jl'.e  narrow  part  ^^^^tJ^^J'^f' 

were  dried  preparations. 

thought  that  the  overloaded  sigmoid  dependent  into  ''■«  P'^!™^''"'!,''™^^. 
itself  becomes  occluded  and  responsible  for  ddatat.on.     The  form  met  m  ch.l 


424  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

dren  is  usually  congenital  and  involves  the  lower  portion  of  the  colon,  which 
is  also  hypertrophied.  The  congenital  form  becomes  the  direct  cause  of 
chronic  constipation  or  coprostasis,  which  in  turn  increases  the  dilatation. 
Such  is  a  remarkable  specimen  in  the  museum  of  the  University  of  Pennsyl- 
vania, secvired  by  the  late  Henry  F.  Formad  *  in  the  course  of  his  work  as 
coroner's  physician.  Two  and  a  half  pailfuls  of  feces,  weighing  40  pounds 
(20  kilograms),  were  removed  at  autopsy. 

Symptoms. — They  are  the  same  as  those  of  obstinate  constipation 
extending  over  weeks,  in  addition  to  enormous  distention  and  tympany  of  the 
abdomen.  Physical  examination  in  extreme  cases  recognizes  dislocation  of 
the  adjacent  abdominal  and  thoracic  viscera,  especially  the  liver,  spleen,  heart,, 
and  lungs. 

Treatment. — The  treatment  is  that  of  the  resulting  constipation,  which,, 
in  cases  of  this  kind,  is  by  enemas  carried  high  up  into  the  bowel,  together 
with  remedies  which  stimulate  secretion  into  the  upper  bowel,  of  which  calo- 
mel is  one  of  the  best.  It  should  be  given  in  doses  of  not  less  than  1-4  grain 
(0.016  gm.)  hourly,  until  an  effect  is  produced  in  association  with  that  of  the 
enemas.  Dilatation  probably  results,  at  times,  from  the  gradual  accumula- 
tion of  fecal  matter,  while  frequent  small  discharges  are  being  obtained  wdiich 
do  not  clear  out  the  bowel.  Hence  the  rectum  should  unhesitatingly  be 
explored  by  the  finger  in  doubtful  cases.  Complete  evacuation  of  the  bowels 
is  sometimes  extremely  difficult,  but  if  the  exact  state  of  affairs  is  appreciated, 
perseverance  will  ultimately  conquer.  Operation  with  exsection  of  large 
portions  of  the  bowel  has  been  done  with  excellent  results. 


NERVOUS    AFFECTIONS    OF   THE    BOWEL. 

The  bowel,  like  the  stomach,  is  subject  to  deranged  nervous  influence, 
which  manifests  itself  in : 

I.  Increased  or  diminished  contractility  of  the  muscular  coat. 

II.  Increased  or  diminished  sensibility  of  the  bowel. 

III.  Increased  or  diminished  secretory  function. 

I.  Derangements  of  Motion. — These  are  manifested  by  diarrhea,  by 
constipation,  and  by  cramp. 

I.  Increased  motor  activity  producing  nervous  diarrhea  occurs  in  adults 
and  children,  the  result  of  increased  peristalsis  due  to  pure  nervous  influ- 
ence. It  implies  a  hyperexcitability  of  the  nerves  regulating  peristalsis,  caus- 
ing them  to  respond  to  stimuli  to  which  they  are  otherwise  indifferent,  such 
stimuli  including  the  simple  mechanical  and  chemical  irritation  of  the  natural 
intestinal  contents.  Hence  we  find  nervous  diarrhea  in  nervous,  hysterical^ 
and  neurasthenic  persons.  In  these  persons,  too,  psychical  influences,  such 
as  fright,  depression,  and  even  joy,  cause  diarrhea.  The  attacks  of  diarrhea 
which  occur  in  tabetic  persons  have  a  similar  origin  through  central  nervous 
influence.  Still  more  does  such  an  excitability  of  the  nervous  system  respond 
to  unnatural  irritation,  such  as  that  of  teething  in  infants,  producing  diarrhea, 
which  may  be  quite  independent  of  irritating  food,  though  the  latter  may 
co-operate. 


*  "  Transactions  of  the  Pathological  Society  of  Philadelphia,"  vol.  xvi.,  1891-93,  p.  23.     Dr.  Formad 
gives  in  his  paper  a  summary  of  other  cases  reported. 


NERVOUS  AFFECTIONS  OF  THE  BOWEL.  425 

There  is  no  morbid  change,  and  the  bowel  movements  are  generally 
watery  and  without  blood  or  mucus.  They  vary  greatly  in  frequency, — from 
two  to  twenty  or  more  daily, — occur  suddenly,  and  disappear  often  as  sud- 
denly as  they  come.     They  may  last  for  several  days. 

2.  Decreased  motor  activity  producing  constipation,  the  result  of  altered 
nervous  influence,  is  even  more  common  than  diarrhea. 

In  this  condition,  strictly  speaking,  the  muscular  coat  has  lost  its 
impressibility  to  stimuli  ordinarily  sufficient  to  excite  the  automatic  actions 
which  result  in  bowel  movements,  and  peristalsis  is  at  a  standstill.  Associa- 
ated  with  such  condition  is  often  an  atony  of  the  muscular  coat,  which  per- 
mits gaseous  overdistention  and  tympany.  It  is  scarcely  possible  to  separate 
such  phenomena  from  those  of  impaired  nervous  sensibility  of  the  bowel,  to 
the  paragraphs  on  which  the  reader  is  referred. 

3.  Nervous  cramp,  or  excessive  contraction  of  the  intestinal  muscles,  is 
so  intimately  associated  with  pain  that  it  will  be  considered  in  connection 
with  deranged  sensibility. 

II.  Derangements  of  Sensibility. — i.  Enteralgia. — Sensory  neuroses 
of  the  bowel  are  mostly  in  the  direction  of  increased  irritation  of  sensory 
nerves  derived  from  the  splanchnics,  which  contain  the  sensory  as  well  as  the 
inhibitory  and  vasomotor  nerves  to  the  bowel.  Such  irritation  implies 
increased  irritability  of  these  nerves  or  the  presence  of  unusual  irritants.  The 
pain  thus  induced,  unassociated  with  organic  lesion,  is  known  as  enteralgia 
or  neuralgia  of  the  bowels. 

Associated  with  exaggerated  contraction  of  the  muscular  coat  it  is  known 
as  colic,  though  the  terms  enteralgia  and  colic  are  also  interchangeably  used. 
Characteristic  of  enteralgia -are  its  suddenness  of  occurrence  and,  to  a  less 
degree,  the  suddenness  of  its  cessation.  It  is  often  associated  with  crampy 
contraction  of  the  abdominal  walls,  when  the  pain  is  augmented. 

Etiology  of  Enteralgia. — Among  the  causes  which  excite  pain  are  such 
foreign  bodies  as  indigestible  articles  of  food,  intestinal  worms,  fecal  masses, 
overdistention  with  gases,  and  the  like.  The  effect  of  the  latter  is  attested 
by  the  relief  which  attends  the  discharge  of  gas.  The  operation  of  reflex 
causes  must  also  be  admitted.  Such  may  be  the  mode  of  action  of  cold  and 
of  lead  intoxication,  which  produces  the  well-known  lead  colic.  Such  is, 
possibly,  gouty  enteralgia,  or  the  enteralgia  succeeding  an  attack  of  gout. 
The  enteralgia  associated  with  certain  nervous  diseases,  such  as  occurs  in 
the  painful  enteric  crises  of  locomotor  ataxia,  is  probably  the  direct  result  of 
alteration  in  the  sensitive  nerves  themselves.  It  may  be,  too,  that  the  action 
of  lead  in  producing  lead  colic  is  thus  direct.  The  hysterical  and  hypochon- 
driacal and  the  anemic  are  subject  to  colic  through  increased  sensitiveness  of 
nerves. 

Diagnosis. — The  pain  existing  in  enteralgia  is  diffuse  and  throughout 
the  abdomen.  Enteralgia  is  to  be  distinguished  from  enteric  pain  due  to 
organic  disease.  Most  important  are  the  inflammatory  and  ulcerative  states 
associated  with  enteritis,  typhoid  fever,  peritonitis,  appendicitis,  and  intesti- 
nal obstruction.  The  diagnosis  is  usually  not  difficult.  There  is,  first  of  all, 
the  absence  of  fever ;  second,  the  history  of  the  ingestion  of  irritating  foods, 
or  some  one  of  the  causes  named.  Very  important  is  the  point  that  colicky 
pain  is  relieved  by  pressure,  while  pressure  increases  pain  in  all  of  the  affec- 
tions named.  Most  difficult  becomes  the  diagnosis  in  those  cases  in  which 
there  is  coincident  flatulence,  as  is  sometimes  the  case  in  typhoid  fever,  when 
the  question  to  be  answered  is.  Is  this  colic,  or  is  it  the  tenderness  which  comes 


426  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  peritonitis?  Undoubtedly  in  some  instances  both  are  present,  and  one 
condition  reacts  upon  the  other. 

The  diagnosis  from  appendicitis  has  been  considered  in  treating  of  the 
latter.  Intestinal  obstruction  offers  further  similarity  in  the  absence  of  fever, 
but  the  severity  of  the  symptoms  in  obstruction  is  on  the  whole  greater,  their 
duration  is  longer,  while  constipation  and  vomiting  are  superadded.  Rheu- 
matism of  the  abdominal  muscles  sometimes  resembles  enteralgia  very  closely. 
In  this,  however,  there  is  commonly  exquisite  tenderness,  while  the  pain  is 
superficial  and  more  continuous.  Nervous  dermalgia,  or  hyperesthesia  of 
the  abdominal  wall,  has  similar  features  and  is  common  in  hysterical  women. 
Sometimes  this  is  associated  with  hysterical  colic,  but  even  here,  while  the 
skin  itself  is  sensitive,  deep-seated  pressure  does  not  bring  out  incerased 
pain. 

Biliary  colic  and  nephritic  colic  also  resemble  enteralgia,  and  may  at 
first  be  mistaken  for  it,  but  careful  examination  should  soon  discover  the 
points  peculiar  to  each,  such  as  localized  tenderness  and  jaundice  in  the 
former  and  the  course  of  the  pain  into  the  groin  and  testicle  and  thigh  in  the 
latter.  Uterine  colic  may  also  be  confounded,  but  the  pain  is  distinctly  local- 
ized in  the  region  of  the  uterus  and  is  apt  to  be  associated  with  menstruation 
or  to  precede  it. 

It  is  important,  also,  if  possible,  to  discover  the  form  of  enteralgia  or  its 
special  cause,  whether  due  to  indigestion,  to  reflex  causes,  to  constipation, 
to  lead,  to  hysteria,  or  to  central  nervous  causes.  This  is  to  be  arrived  at  by 
close  attention  to  .the  history  and  associated  symptoms. 

2.  Neiiralgia  of  the  Rectum. — Some  special  symptoms  characterize  the 
sensory  neuroses  of  the  rectum  which  demand  separate  allusion.  The  nerves 
of  the  hemorrhoidal  plexus  are  thus  concerned.  An  uncomfortable  aching 
sensation  in  the  lower  bowel  and  lower  abdomen,  extending  at  times  to  the 
sacrum,  perineum,  and  genitalia,  is  the  principal  symptom.  With  this 
is  associated  an  irresistible  desire  to  go  to  stool,  which  is,  however,  fruit- 
less. 

As  a  reflex  sensory  neurosis  of  the  rectal  nerves  may  be  considered  a 
peculiar  sensation  of  exhaustion  and  disposition  to  faint  after  a  movement  of 
the  bowels,  complained  of  by  some  persons.  Wilhelm  v.  Leube  also  calls 
attention  to  an  "  intestinal  vertigo,"  excited  during  the  passage  of  feces 
through  the  anus,  and  capable  of  being  excited,  too,  by  introducing  the  finger 
into  the  rectum. 

The  sensorv  neuroses  of  the  rectum  are  more  common  in  nervous  women 
and  in  the  subjects  of  hemorrhoids,  while  tabetic  patients  are  apt  to  suffer 
from  the  same  symptoms. 

3.  Diminished  Sensibility. — This  is  manifested  for  the  most  part  only  in 
delayed  peristalsis.  It  has  been  said  that  constipation  is  one  of  its  most  con- 
stant results.  In  the  case  of  the  rectum,  it  is  well  known  how,  in  health,  we 
are  informed  of  a  desire  to  go  to  stool.  Paralysis  of  these  nerves  results  in 
anesthesia,  which  is  followed  by  the  absence  of  this  desire.  The  effect  must 
be  an  accumulation  of  feces  in  the  rectum,  which  may  still  be  evacuated  if 
volition  and  the  motor  nerve  route  are  intact,  but  which  demands  artificial 
removal  if  these  are  in  abeyance.  It  is  a  constant  symptom  in  those  affec- 
tions of  the  spinal  cord  associated  with  paralysis.  To  higher  degrees  is 
added  the  loss  of  the  limited  reflex  control,  and  if  there  be  also  loss  of  the 
voluntary  control  over  the  sphincter  ani,  an  involuntary  stillicidium  of  liquid 
contents  of  the  bowel  results,  though  the  solids  go  on  accumulating  unless 


NERVOUS  AFFECTIONS  OF  THE  BOWEL.  427 

artificially  removed.  Thus  is  explained  the  constipation  of  the  hysterical 
and  neurasthenic. 

The  constipation  associated  with  the  passive  congestion  of  heart  and 
liver  disease  is  the  result  of  a  similar  lethargy  of  the  nerves  distributed  to 
the  muscular  coat  of  the  bowel.  Here,  too,  we  may  infer  an  exhaustion  of 
nervous  excitability  by  overstimulation,  if,  as  is  suggested,  normal  peristalsis 
is  excited  by  the  stimulus  of  the  carbonic  acid  of  the  venous  blood,  as  well  as 
by  the  food  present  in  the  intestinal  tube.  On  the  other  hand,  a  food  may  be 
too- bland  and  unirritating  to  excite  the  normal  peristalsis.  Hence  it  is  that 
constipation  attends  the  use  of  milk  and  the  farinacea. 

The  effect  of  paralysis  of  the  voluntary  muscles  controlling  the  external 
sphincter  ani  results  in  inability  to  retain  the  fecal  contents,  whence  involun- 
tary evacuations  take  place,  a  frequent  symptom  in  disease  of  the  brain. 
Under  such  circumstances  the  control  of  the  bowels  is  given  over  altogether 
to  the  reflex  nervous  center  in  the  spinal  cord,  and  man  is  reduced  to  the  con- 
dition of  the  infant  and  the  lower  animals,  in  which  defecation  is  a  purely 
reflex  act.  Oversensitiveness  or  overstimulation  of  the  sphincter  would 
result  in  a  spasmodic  and  painful  contraction,  which  is,  however,  a  very  rare 
and  anomalous  condition. 

III.  Secretion  Neuroses. — It  is  difficult  to  separate  the  consideration 
of  the  secretion  neuroses  of  the  bowel  from  that  of  the  sensory  and  motor 
neuroses.  Yet  it  is  well  known  that  secretion  into  the  bowel  may  be  in- 
fluenced quite  independently  of  peristaltic  motion,  perhaps  through  the  vaso- 
motor nerves.  Thus,  while  it  is  more  than  likely  that  the  saline  aperients 
produce  their  effect  in  response  to  the  physical  laws  of  osmosis,  the  secretion 
into  the  bowel  which  follows  the  hypodermic  injection  of  pilocarpin  cannot  be 
explained  upon  any  other  ground  than  that  of  vasomotor  nervous  influence. 
Mention  has  already  been  made  of  the  responsibility  of  the  nervous  system  in 
producing  the  mucous  discharges  and  casts  referred  to  in  discussing  chronic 
enteritis. 

Treatment  of  Neuroses  of  the  Bowel. — This  follows  easily  upon  a  cor- 
rect diagnosis,  which  is  indispensable.  The  primary  point  of  attack  is  that 
of  the  nervous  condition  at  fault.  The  removal  of  the  causes  of  irritation 
should  be  coincident  with  measures  directed  to  the  relief  of  pain.  If  irritat- 
ing ingesta  are  present,  an  emetic  should  be  given.  In  children  the  gums 
should  often  be  examined,  and  lanced  when  swollen  and  tender. .  If  there  is 
constipation,  the  bowels  should  be  opened.  If  there  is  hysteria,  a  nervous 
sedative  is  indicated.  In  enteralgia  the  promptest  means  of  relief  is  a  hypo- 
dermic injection  of  morphin  of  1-4  grain  (0.0165  gm.)  to  an  adult.  Less 
may  suffice,  but  if  the  pain  is  extreme,  it  is  not  worth  while  to  temporize  with 
smaller  doses.  On  the  other  hand,  it  is  not  safe  to  give  more  at  a  single  injec- 
tion. Should  this  dose  be  ineffectual,  associated  with  the  local  measures  to 
be  described,  it  may  be  repeated  in  half  an  hour.  The  combination  of 
atropin  1-150  grain  (0.00044  grn-)»  with  the  morphin  will  increase  its 
efficiency. 

Of  local  measures,  massage  is  probably  the  most  efficient  for  constipa- 
tion and  enteralgia.  It  has  been  mentioned  that  relief  of  the  pain  by 
pressure  is  characteristic  of  enteralgia.'  Especially  happy  results  may,  there- 
fore, be  expected  from  massage,  an  expectation  that  is  realized  in  practice. 
Counterirritation  to  the  abdomen  by  mustard  or  turpentine  stupes  may  be 
used  as  an  adjuvant  to  treatment  in  lieu  of  massage. 

In  milder  forms  of  enteralsfia,  aromatics  and  carminatives,  alone  or  in 


428  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

combination  with  morphin,  have  always  had  a  justified  reputation.  Some  of 
these  have  been  mentioned  in  considering  the  treatment  of  cholera  and  cholera 
morbus.     An  especially  elegant  and  efficient  preparation  is: 

I^     Spiritus  ammon,  aromat. "] 

Tinct.  card.  comp.  !  t  ••  ca         \ 

Spiritus  chloroformi  (^^ 3iJ(»c.c.; 

Spiritus  vin.  gall.  J 

M.  et.  Sig. — Teaspoonful  every  half  hour  or  fifteen  minutes, 
in  cracked  ice  or  hot  water  until  relieved. 

Its  efficiency  is  increased  by  adding  a  few  drops  of  deodorized  tincture  of 
opium  to  each  dose. 


CARCINOMA  OF  THE  BOWEL. 

All  parts  of  the  bowel  are  subject  to  carcinoma,  which  occurs  in  grow- 
ing frequency  as  the  gut  is  descended.  Thus,  of  all  cases  of  bowel  cancer, 
barely  5  per  cent,  are  found  in  the  small  intestine,  15  per  cent,  in  the  cecum 
and  colon,  while  80  per  cent,  are  met  in  the  rectum. 

In  the  small  intestine,  in  the  neighborhood  of  the  orifice  of  the  bile-duct, 
we  meet  most  frequently  the  cylinder-celled  epithelioma  or  adeno-carcinoma. 

In  the  large  intestine  there  is : 

1.  Cylinder-celled  epithelioma,  the  most  common  form  of  cancer,  in  the 
cecum  and  sigmoid  flexure. 

2.  Colloid  cancer 

3.  Scirrhus 

4.  Soft  cancer  ^  in  the  rectum. 

5.  Squamous  epithelioma  just  above  the  anus    I 

6.  Sarcoma,  including  the  melanotic  variety       j 

Benign  tumors  of  the  bowel,  which  may  present  symptoms  similar  to 
those  of  malignant  tumors  or  no  symptoms  at  all,  include  mucous  polypi  and 
fibromata,  more  rarely  lipoma,  myoma,  angioma,  and  lymphoma. 

Symptoms. — There  are  no  symptoms  distinctive  of  cancer  of  the  bowel. 
The  most  constant  local  effect  is  more  or  less  obstruction  of  the  bowel,  and 
we  have  already  seen  in  our  study  of  obstruction  how  far  it  is  contributed  to 
by  cancer.  There  are,  howeyer,  other  symptoms  which,  added  to  those  of 
obstruction,  aid  in  the  diagnosis.  Particularly  is  this  true  in  the  case  of 
the  rectum. 

The  symptoms  of  obstruction  met  with  in  cancer  of  the  bowel,  already 
considered  in  treating  of  obstruction,  include,  especially,  constipation,  pain, 
tumor,  anorexia,  nausea,  and,  more  rarely,  vomiting.  The  added  symptoms 
are  cachexia  and  altered  fecal  discharges,  which  may  include  pus,  blood,  and, 
in  few  instances,  fragments  of  cancerous  tissue.  Of  the  symptoms  of 
obstruction  named  tum,or  alone  demands  further  consideration,  being  the 
most  important  of  all  the  symptoms  of  cancer.  In  fact,  without  it  a  certain 
diagnosis  is  scarcely  possible.  On  the  other  hand,  given  a  case  of  obstruc- 
tion, the  presence  of  tumor  points  more  to  cancer  than  to  any  other  cause 
except  intussusception  and  fecal  impaction.  As  contrasted  with  intussus- 
ception, the  tumor  of  cancer  is  of  long  duration  and  found  in  adults ;  as  with 
impaction,   it  is  tender  and   movable,   usuallv  harder  and   more   irregular. 


CARCINOMA  OF  THE  BOWEL.  429 

While  the  tumor  may  give  a  dull  note  to  light  percussion,  to  a  hard  stroke  it 
is  tympanitic.  It  may  pulsate  also  if  it  lie  over  one  of  the  large  blood-vessels. 
Fecal  tumors  never  do  this.  The  difficulty  of  distinguishing  from  a  fecal 
tumor  is  increased  when  a  fecal  mass  is  added  to  the  cancerous  tumor,  but 
some  of  it  may  be  cleared  up  by  the  use  of  purgatives  and  injections. 

Cachexia,  added  to  other  signs  of  chronic  obstruction,  points  to  cancer. 
Change  in  the  shape  of  the  formed  feces,  especially  a  band-like  flattening,  is 
much  spoken  of.  It  may  be  produced  by  any  cause  which  protrudes  into 
the  lumen  of  the  large  bowel,  characterizes  rather  disease  of  the  lower  part, 
and,  to  be  of  value  in  diagnosis,  it  must  be  constant.  The  more  or  less  con- 
stant presence  of  sanious  pus,  particularly  of  fetid  character,  is  important 
evidence  in  favor  of  cancer. 

Diagnosis. — Carcinoma  of  the  duodenum  is  not  easily  distinguished 
from  tumor  of  the  pylorus;  indeed,  it  is  sometimes  impossible  to  separate 
them.  Both  are  movable  tumors.  With  pyloric  tumor  are  associated  symp- 
toms of  obstruction  and  dilatation  of  the  stomach.  More  rarely  cancer  of  the 
duodenum  has  the  same  effect.  The  presence  of  jaundice  points  to  cancer  of 
the  duodenum,  as  does  also  the  continued  natural  acidity  of  the  gastric  con- 
tents removed  after  a  test-meal,  but  neither  of  these  symptoms  is  pathog- 
nomonic of  duodenal  cancer.  In  cancer  of  the  stomach  dyspeptic  symptoms 
occur  earlier  and  are  more  serious.  Carcinoma  of  the  duodenum  may  ter- 
minate suddenly  by  fatal  hemorrhage.  Cancer  of  the  head  of  the  pancreas 
also  produces  jaundice,  but  the  tumor  arising  from  it  is  fixed  and  immovable, 
and  much  more  deep-seated  than  tumors  of  any  portion  of  the  bowel,  being 
behind  the  pylorus  and  the  transverse  colon,  between  the  left  sternal  border 
and  parasternal  line. 

With  the  other  abdominal  tumors  intestinal  cancer  is  not  likely  to  be 
confounded.  The  floating  kidney  is  movable,  but  when  sufficiently  so  to  be 
compared  in  this  respect  with  a  cancerous  tumor,  is  more  movable,  and  may 
be  generally  returned  to  its  natural  seat.  The  kidney  shape  may  not  infre- 
quently be  recognized.  Compression  of  the  kidney  often  produces  a  peculiar 
sickening  pain.  The  presence  of  nerv^ous  symptoms  is  especially  character- 
istic of  floating  kidney,  but  there  is  no  cachexia.  A  movable  spleen  is  even 
less  likely  to  be  confounded,  for  similar  reasons.  It  is,  moreover,  less  sensi- 
tive. A  laced-off  lobe  of  the  liver,  often  quite  movable,  can  generally  be 
traced  to  its  normal  attachment. 

An  actual  tumor  of  the  kidney,  being  behind  the  peritoneum,  pushes  the 
bowel  and  the  ascending  or  descending  colon  before  it,  and  must  attain  con- 
siderable size  before  it  shows  itself  to  the  usual  examination  from  the  front. 
Such  tumor  very  rarely  compresses  the  bowel  so  as  to  produce  symptoms  of 
obstruction.  The  same  may  be  said  of  tumors  of  postperitoneal  lymphatic 
glands.  An  ovarian  tumor  is  characterized  by  its  deep-seated  origin,  its 
ascending  development,  and  its  relation  to  the  uterus,  as  determined  by  joint 
vaginal  and  abdominal  examination. 

A  circumscribed  peritoneal  exudate  might  be  mistaken  for  a  cancer  of 
the  bowel,  but  the  history  of  its  development,  its  flat  percussion  note,  and  the 
presence  of  some  temperature,  which  characterizes  it,  are  wanting  in  cancer 
of  the  bowel. 

Cancer  of  the  bowel  is  not  likely  to  be  mistaken  for  appendicitis,  the 
acuteness  of  symptoms  marking  the  grave  form  of  the  latter,  while  the 
absence  of  serious  constitutional  and  cachectic  symptoms  is  characteristic  of 
the  more  chronic  form  of  appendicitis. 


430  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

Chronic  infiauiviatory  tlu€kcning  of  the  bowel  may,  however,  be  a  seri- 
ous stumbhng-block.  Especiahy  apt  to  occur  about  the  sigmoid  flexure,  it 
produces  also  obstructive  symptoms,  and  careful  and  prolonged  study  may  be 
necessary  to  the  making  of  a  correct  diagnosis.  Cachexia  remains  absent  in 
simple  inflammatory  stenosis  for  a  longer  time  at  least  than  cancer. 

Diagnosis  of  the  Pari  of  Bowel  Involved. — As  to  the  part  of  the  bowel 
involved,  once  assured  that  the  tumor  is  of  the  bowel,  some  indication  of  its 
more  exact  location  may  be  obtained  by  noting  its  position,  which,  if  in  the 
right  abdominal  region,  suggests  the  duodenum ;  in  the  vicinity  of  the  um- 
bilicus, the  transverse  colon ;  in  the  right  iliac  fossa,  the  cecum,  and  in  the 
left,  the  sigmoid  flexure.  It  should  be  remembered,  however,  that  serious 
dislocation  of  the  tumor  from  its  natural  site  may  occur  as  the  result  of  in- 
flammatory adhesions  formed  w^hile  the  tumor  is  temporarily  in  a  position 
remote  from  its  natural  site.  Often,  too,  a  cancer  of  the  sigmoid  flexure 
gives  no  indication  of  its  presence  to  abdominal  examination.  Distention 
of  the  bowel  with  water  or  gas  and  the  application  of  the  principles  laid 
down  from  this  standpoint,  when  treating  of  obstruction,  may  be  availed  of 
in  settling  this  cjuestion  (see  p.  418).  Allusion  has  been  made  to  the 
presence  of  jaundice  as  characteristic  of  duodenal  cancer;  also  to  the  retained 
natural  acidity  of  the  gastric  contents  "removed  after  a  test-meal  as  com- 
pared with  gastric  cancer. 

Cancer  of  the  rectum  exhibits  a  somewhat  special  train  of  symptoms. 
The  rectum  is  subject  to  the  same  forms  of  cancer  as  the  pylorus,  and  in 
somewhat  the  same  order  of  frequency,  the  columnar-celled  epithelioma  being 
most  common. 

The  early  symptoms  of  cancer  of  the  rectum  are  those  of  irritation,  in- 
cluding pain,  tenesmus,  the  discharge  of  mucus  and  blood,  and,  probably, 
most  cases  of  carcinoma  of  the  rectum  are  mistaken  at  first  for  dysentery. 
In  the  cases  of  colloid  cancer,  the  colloid  material  may  be  discharged  from  the 
bowel  and  reasonably  mistaken  for  mucus.  Fortunate  is  the  clinician  if  it 
occurs  to  him  to  make  an  early  examination  of  the  rectum  by  the  finger ;  for 
generally  the  disease  can  be  felt,  either  as  an  ulcerated  mass  infiltrating  the 
wall  of  the  bowel,  thus  intruding  upon  the  lumen,  or  as  one  or  more  nodular 
growths  under  the  mucous  membrane  and  adherent  to  it.  If  ulceration  has 
occurred,  bloody  and  mucoid  matter,  characterized  by  extreme  and  persistent 
fetor,  is  apt  to  adhere  to  the  finger.  Von  Leube  especially  calls  attention  to 
hemorrhoids  as  a  symptom  of  cancer  of  the  rectum,  and  says  they  are  sel- 
dom absent,  because  of  the  resistance  opposed  to  the  return  of  the  venous 
blood.  He  claims  he  has  discovered  rectal  cancer  in  examination  suggested 
by  hemorrhoids  when  no  other  symptoms  were  present.  So,  too,  the  pres- 
ence of  secondary  cancer  of  the  liver  should  suggest  examination  of  the 
rectum,  since  marked  instances  of  the  former  have  been  found  associated 
v^ith  cancer  of  the  rectum,  otherwise  latent. 

Almost  all  morbid  growths  affecting  the  rectum  are  cancerous.  Polypi, 
mucous  and  fibromatous,  occasionally  found  in  children,  produce  dysenteric 
symptoms,  including  bloody  discharges,  while  they  may  project  from  the 
rectum  during  stool.  Lipomata  and  other  histioid  tumors  have  been  found 
at  autopsy  without  having  caused  symptoms. 

Prognosis  and  Treatment  of  Cancer  of  the  Bowel. — The  prognosis 
of  cancer  of  the  bowel  is  always  unfavorable.  Occasionally  operative  pro- 
cedures have  prolonged  the  life  of  the  patient  at  the  expense  of  an  artificial 
anus  in  the  lumbar  or  abdominal  region,  while  resection  has  even  been  made 


HEMORRHOIDS.  431 

with  some  degree  of  success.     Especially  happy  have  been  the  results  in 
some  cases  of  exsection  of  the  rectum. 

The  propriety  of  operation  should,  therefore,  always  be  considered. 
Should  it  be  decided  against,  the  patient  must  be  nourished  by  easily  assimi- 
lable foods,  such  as  peptonoids  and  peptonized  milk,  by  the  mouth  or  bowel, 
as  circumstances  may  determine.  A  regular  and  sufficient  evacuation  of  the 
bowels  should  be  carefully  looked  after,  lest  impaction  add  its  inconve- 
niences to  the  others  present. 


HEMORRHOIDS. 

Synonym. — Piles. 

This  troublesome  affection  lies  on  the  border-line  between  medicine  and 
surgery,  and  is,  therefore,  as  appropriately  considered  from  the  standpoint 
of  the  physician  as  from  that  of  the  surgeon. 

Definition. — A  hemorrhoid  is  a  mass  of  varicose  or  dilated  and  sac- 
culated veins  at  the  anus  and  lower  rectum,  the  central  situation  being  almost 
always  the  muco-cutaneous  surface  which  joins  these  two  structures.  From 
this  edge  one  or  more  piles  may  protrude  externally  or  internally,  constitut- 
ing external  or  internal  piles,  the  former  protruding  outside  the  gut,  the 
latter  within  the  sphincter. 

Piles  are  called  "  open  "  or  "  bleeding  "  as  they  give  rise  to  hemorrhage, 
and  "  blind  "  when  they  do  not  bleed. 

Morbid  Anatomy. — The  external  pile  constitutes  a  little  circum- 
scribed tumor.  Commonly  there  is  more  than  one  of  these,  whence  the 
common  use  of  the  plural,  "  piles,"  or  "  hemiorrhoids."  They  may  be  so 
numerous  as  to  form  a  more  or  less  complete  circle  around  the  anus.  Within 
the  sphincter  the  individual  or  tumor-like  shape  is  more  usually  maintained, 
and  the  pile  may  be  more  elongated.  The  color  varies  from  dark  red  to 
purple,  the  surface  is  smooth  or  lobulated,  and  the  consistence  is  variously 
soft,  hard,  or  elastic,  corresponding  to  the  degree  of  vascular  turges- 
cence. 

On  section  the  pile  is  found  to  be  a  mass  of  loculi  filled  with  blood  and 
separated  by  areolar  tissue.  These  cells  are  produced  by  the  sacculated 
and  dilated  veins  referred  to.  After  lasting  for  some  time  the  structure 
becomes  altered.  The  walls  of  the  veins  are  thickened,  the  intervening  con- 
nective tissue  becomes  firmer,  and  the  whole  pile  grows  harder,  and  appears 
more  or  less  shriveled. 

Etiology. — Piles  are  favored  by  the  anatomical  structure  and  relations 
of  the  seat  at  which  they  occur,  more  particularly  the  arrangement  of  the 
so-called  hemorrhoidal  plexus  of  the  lower  rectum.  In  health  the  plexus 
forms  a -.rich,  tortuous  network  lying  between  the  muscular  layer  and  the 
muco-cutaneous  surface,  and  is  subject  to  pressure  by  masses  of  fecal  mat- 
ter accumulated  in  the  rectum  and  by  straining  at  stool.  The  blood  from  the 
hemorrhoidal  veins  is  discharged  partly  into  the  portal  system  and  partly 
into  the  general  venous  system:  the  :former  through  the  superior  hemor- 
rhoidal and  the  inferior  mesenteric  veins,  and  the  latter  by  the  middle  hemor- 
rhoidal and  the  internal  iliac  veins.  The  plexus  is  therefore  between  the 
portal  and  general   venous   systems,  but  more   closely  connected  with  the 


432  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

former.  Hence  obstructions  to  either  the  portal  circulation  or  cardiac  cir- 
culation, however  induced,  tend  to  engorge  these  veins,  and  become  a  pre- 
disposing or  even  sufficient  cause  of  piles. 

After  the  predisposing  causes  described,  the  most  common  cause  of 
hemorrhoids  is  constipation  and  the  accumulation  of  large  quantities  of  fecal 
matter  in  the  rectum.  Hence  it  is  that  persons  whose  bowels  do  not  act 
daily  are  very  apt  to  be  troubled  with  piles,  and  as  women  suffer  much  in 
this  way,  it  is  they  who  are  most  frequently  victims.  On  the  other  hand, 
women  suffer  less  than  they  would  but  for  the  relief  afforded  to  congestions 
in  this  neighborhood  by  their  monthly  flow,  so  that  it  is  not  until  after  the 
menopause  that  they  become  most  liable.  Hence  it  is  that  hemorrhoids  are 
more  common  in  men  up  to  the  age  of  from  forty-five  to  fifty,  and  that  after 
this  age  more  cases  occur  among  women.  The  diseases  in  the  abdominal 
cavity  peculiar  to  women  often  produce  hemorrhoids  through  the  pressure 
thev  exert  on,  and  the  resistance  they  present  to,  the  return  of  the  blood 
from  the  hemorrhoidal  plexus.  Such  are  uterine  enlargements  and  fibroid 
tumors  of  the  uterus,  ovarian  tumors — in  a  word,  any  morbid  growths  which 
may  invade  the  pelvic  organs  and  become  large  enough  to  exert  pressure. 
The  pregnant  uterus  is  another  frequent  cause  of  hemorrhoids  in  women, 
and  thus  hemorrhoids  sometimes  become  one  of  the  most  distressing  com- 
plications of  the  puerperal  state. 

Symptoms. — External  Hemorrhoids. — The  first  evidence  usually 
afforded  of  the  presence  of  a  hemorrhoid  is  a  tender,  painful  lump,  about 
as  large  as  a  pea,  which  makes  its  appearance  just  outside  the  sphincter  ani, 
sometimes  quite  suddenly,  more  frequently  requiring  two  or  three  days  to 
attain  its  full  development.  This  little  tumor  may  pass  away  in  the  course 
of  two  or  three  days  without  treatment,  or  it  may  grow  to  larger  size.  If  it 
disappears,  it  may  never  reappear,  but  more  frequently  it  recurs — it  may  be 
not  for  months.  In  other  cases  the  recurrence  becomes  more  frequent,  the 
condition  lasts  longer,  and  the  inconvenience  is  correspondingly  greater, 
especially  during  and  succeeding  defecation.  The  size  of  these  tumors  also 
varies,  although  they  begin  generally  as  described.  The  tendency  is  to 
enlargement  with  each  recurrence,  until  they  form  a  mass  which  more  or 
less  fills  the  anal  region.  The  degree  of  hardness  and  pain  also  varies. 
Often  the  pain  is  excruciating  and  throbbing,  and  the  patient  will  frequently 
compare  the  condition  to  that  of  a  boil.  In  such  cases  it  is  impossible  to 
sit  because  of  the  pain,  and  defecation  is  torture.  If  partially  relieved,  the 
swelling  may  diminish,  and  with  it  the  pain  and  tenderness,  leaving  a  fleshy 
mass  smaller  than  the  original  pile,  which  may  be  permanent  unless  removed 
by  operation.  This  fleshy  mass  may  at  any  time  become  engorged  again  into 
a  painful  swelling,  with  the  characteristics  already  described.  More  rarely, 
instead  of  the  shriveling,  suppuration  may  take  place,  and  the  pile  is  thus 
cured  after  weeks  of  suffering ;  or  the  circulation  may  be  so  interfered  with 
that  the  hemorrhoid  becomes  sphacelated  and  ulcerates  off. 

In  addition  to  the  local  symptoms  named,  there  may  be  a  sense  of  heat 
and  fullness  and  itching  about  the  anus.  Occasionally,  hemorrhoids  bleed 
freely,  affording  relief  to  the  suffering,  and  d:>  no  harm,  if  the  bleed- 
ing is  moderate.  At  times  the  bleeding  recurs,  constituting  "  bleeding 
piles." 

Internal  Hemorrhoids. — When  the  pile  is  entirely  within  the  sphincter 
ani,  it  is  called  "  internal."  The  sensation  produced  by  piles  in  this  situa- 
tion varies  also  with  their  size,  the  rectum  being  sometimes  quite  filled  with 


HEMORRHOIDS.  433 

them,  causing  a  sense  of  fullness  and  an  inclination  to  expel  the  mass,  like 
that  excited  by  the  presence  of  feces  in  the  rectum.  Along  with  this  there 
is  often  considerable  secretion  of  mucus.  The  same  anal  sensations  pre- 
viously described  as  characteristic  of  external  piles  may  be  present,  and,  in 
addition,  a  dull,  aching  pain,  extending  beyond  the  anal  region  to  that  of  the 
sacrum  and  sacro-iliac  juncture.  These  hemorrhoids  are  also  subject  to 
bleeding,  which  will  sometimes  relieve  them,  and  from  them  especially  arise 
copious  hemorrhages,  producing  at  times  great  prostration. 

Diagnosis. — The  diagnosis  of  hemorrhoids  is  usually  most  easy.  It 
is  very  common  for  the  lait}:,  however,  to  mistake  a  variety  of  conditions, 
including  simple  pruritus,  eczema  with  and  without  pruritus,  prolapsus  ani, 
polypus  of  the  rectum,  condylomata  about  the  anus,  and  even  fistula:  in 
ano,  for  hemorrhoids,  and  absurd  mistakes  are  sometimes  made  simply  be- 
cause the  physician,  from  unfounded  delicacy  or  other  cause,  does  not  make 
an  ocular  examination.  The  distinction  from  prolapsus  ani  may  be  briefly 
referred  to.  In  prolapsus  there  is  a  smooth,  symmetrical,  complete  annular 
■proturberance,  more  prominent  than  hemorrhoids  and,  as  a  rule,  less  painful. 
It  is  also  usually  more  easily  reduced.  The  polypus  is  recognized  by  its 
pedunculated  attachment,  and  the  condyloma  by  its  w^art-like  appearance 
and  its  light  color  as  compared  with  the  red  of  hemorrhoids. 

Prognosis. — This  is  usually  favorable,  particularly  if  treatnient  be 
instituted  early,  and  it  is  most  frequently  in  consequence  of  neglect  of  treat- 
ment that  the  tumors  go  on  from  bad  to  worse,  and  that  operation  is  ulti- 
mately required  for  their  successful  cure.  Reference  has  been  made  to  the 
free  hemorrhage  which  sometimes  occurs,  even  causing  the  patient  to  faint 
from  loss  of  blood ;  yet,  I  never  knew  death  to  result. 

Treatment. — Apart  from  the  prophylaxis  furnished  by  attention  to  the 
bowels,  this  is  further  secured  by  absolute  cleanliness.  Advantage  should 
be  taken  of  the  daily  bath  to  wash  the  anal  region  thoroughly  with  water 
and  soap.  All  irritating  particles  are  thus  removed,  and  any  tendency  to 
hyperemia  is  kept  subdued.  The  first  condition  necessary  to  successful 
treatment  is  to  remove,  if  possible,  the  predisposing  causes,  as  constituted 
by  diseases  of  the  heart  or  liver,  or  by  pelvic  tumors,  including  uterine  en- 
largement, and  to  favor  the  return  of  the  blood  from  these  parts.  Consti- 
pation being  the  immediate  cause  of  the  vast  majority  of  cases  of  hemor- 
rhoids, it  should  be  corrected,  and  every  efifort  should  be  made  to  secure  free 
and  easy  movements  of  the  bowels  daily.  Fortunately,  the  same  treatment 
which  relieves  the  constipation  tends  also  to  relieve  the  portal  engorgement 
so  often  the  cause  of  the  hemorrhoids.  Hence,  mercurial  purges  are  espe- 
cially indicated,  and  among  these  blue  mass  is  the  best.  It  may  be  combined 
with  compound  extract  of  colocynth,  from  2  to  5  grains  (0.132  to  0.33  gm.) 
of  each,  with  1-4  grain  (0.0165  gm.)  of  extract  of  belladonna,  and  may  be 
given  nightly  in  the  smaller  dose,  and  two  or  three  times  a  week,  if  the  larger, 
followed  by  a  saline  in  the  morning,  until  the  acute  stage  is  passed.  Senna, 
sulphur,  and  cream  of  tartar  or  compound  jalap  powder  have  long  been 
favorite  remedies.  They  may  be  given  in  various  combinations.  An  excel- 
lent aperient  to  be  used  in  this  way  is  equal  parts  of  precipitated  sulphur  and 
bitartrate  of  potassium,  made  into  an  electuary  with  syrup,  of  which  mixture 
two  teaspoonfuls  may  be  taken  nigl7tly.  Another  combination  is  pow^dered 
jalap  and  bitartrate  of  potassium,  each  half  an  ounce :  confection  of  senna 
an  ounce,  made  into  an  electuary  with  simple  syrup  or  syrup  of  orange,  of 
which  half  a  teaspoonful  m.ay  be  given  nightly  or  two  or  three  times  a  day, 
28 


434  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

as  found  necessary.  The  natural  aperient  waters — Apenta  water,  Hunyadi 
water,  Rubinat  water,  Carlsbad  water,  the  Saratoga  waters,  and  others  of  this 
class — may  be  substituted  or  added  in  the  morning  on  an  empty  stomach. 

After  this  the  medicinal  treatment  consists  largely  in  the  application  of 
astringent  ointments,  of  which  equal  parts  of  ointment  of  galls  and  ointment 
of  belladonna,  the  favorite.  Simultaneously  with  the  application  of  this 
the  pile  should  be  patiently  reduced  and  returned  within  the  sphincter,  the 
ointment  being  used  in  the  manipulation,  as  well  as  subsequently  applied 
and  properly  retained  by  dressing.  In  certain  cases  in  which  the  inflamma- 
tion is  very  decided  nothing  can  be  acomplisRed  until  cold  applications,  such 
as  ice-water  or  ice  itself,  are  made  to  the  part  and  retained  there.  Satisfac- 
tory results  from  this  treatment  are  greatly  favored  by  the  patient  going 
to  bed ;  indeed,  it  is  scarcely  possible  to  carry  it  out  otherwise,  and  some 
such  treatment  as  this  is  sometimes  necessary  to  force  the  patient  to  bed. 
The  application  of  cold  is  often  efficiently  made  by  a  stream  of  water  played 
upon  the  part  for  fifteen  minutes  or  more,  using  a  bidet  or  rubber  hose  at- 
tachment to  a  spigot.  If  the  inflammation  has  been  reduced  and  the  astrin- 
gent ointment  is  insufficient,  I  have  frequently  obtained  good  results  by 
applications  of  Monsel's  solution  of  persulphate  of  iron,  applied  with  a  brush, 
once  or  twice  daily.  By  this  means,  used  conjointly  with  the  astringent 
ointment,  I  have  seen  large  and  painful  hemorrhoids  dwindle  away  in  the 
course  of  a  few  days.  In  all  instances  where  these  applications  are  made  to 
external  hemorrhoids  suitable  measures  should  be  used  to  protect  the  linen 
from  soiling.  Too  much  stress  cannot  be  laid  upon  the  return  of  the  hemor- 
rhoid within  the  anus  and  pressing  or  "  seaming  "  it  down  with  the  finger 
each  time  it  comes  out. 

D.  W.  Sam-ways  recommends  the  application  of  collodion  to  external 
hemorrhoids.  The  hardening  of  the  collodion  supports  the  pile  and  stimu- 
lates it  to  contraction.  It  is  directed  to  be  dropped  on  a  few  fibers  of  cotton 
wool  which  are  spread  over  the  pile  each  morning  after  defecation. 

The  medical  treatment  of  internal  hemorrhoids  is  not  essentially  differ- 
ent from  that  for  external  hemorrhoids.  The  suffering  in  this  form  is  not 
usually  so  great,  though  hemorrhage  appears  to  be  more  frequent  from  this 
kind  of  pile  than  from  the  external  form. 

Failing  by  the  above  described  efforts  to  cure,  recourse  must  be  had 
to  operation,  which  will  carry  us  into  the  field  of  surgery,  to  the  text-books  on 
which  the  reader  is  referred  for  suitable  operative  methods. 


ABNORMALITIES  OF  THE  LIVER.  435 


DISEASES  OF  THE  LIVER. 

ABXORMx\LITIES  IX  THE     SHAPE  AND  POSITIOX  OF 

THE  LIVER. 

Altered  Shape. — The  only  abnormality  in  the  shape  of  the  liver 
requiring  special  mention  is  the  "  laced-o£f  "  or  "  corset  "  liver.  In  this  the 
right  lobe  is  divided  by  a  transverse  furrow,  more  or  less  deep,  into  two 
Tiearly  equal  parts.  In  extreme  cases  the  connecting  furrow  is  a  mere  fibrous 
band,  and  the  liver  can  be  folded  on  itself ;  in  others  it  contains  more  or  less 
liver  parenchyma.  It  is  usually  caused  by  the  pressure  of  a  tight  waist- 
band or  corset,  and  accordingly  is  more  frequent  in  women,  but  it  is  met 
also  in  men. 

It  seldom  gives  rise  to  any  symptoms,  but  sometimes  leads  to  confusion 
in  diagnosis,  being  especialh'  frequently  mistaken  for  a  movable  kidney  or 
an  abdominal  tumor,  for  the  inferior  portion  may  extend  as  low  as  the 
crest  of  the  ilium.  This  confusion  is  increased  if,  as  occasionally  happens, 
a  loop  of  intestine  lies  in  the  furrow  and  gives  a  tympanitic  note  on  percus- 
sion ;  whence  the  inference  that  the  lower  portion  is  a  separate  organ.  Skill- 
ful palpation  is  a  valuable  means  for  determining  the  true  nature  of  such  a 
condition.  The  edge  of  the  liver  should  be  followed  around  from  the  epi- 
gastrium into  the  right  lumbar  and  iliac  regions.  If  the  continuity  with 
the  supposed  tumor  is  uninterrupted,  the  latter  must  be  a  portion  of  liver 
laced  off.  It  is  not  unlikely  that  such  a  condition  may  occasion  symptoms 
of  dragging  and  weight,  with  the  nervous  strain  frequently  incident  to  them, 
like  that  which  is  so  characteristic  of  floating  kidney.  The  corset-liver  is 
said  to  be  one  of  the  favoring  causes  of  cholelithiasis,  by  reason  of  its  inter- 
ference with  the  natural  onward  movement  of  the  bile. 

Abnormality  of  Position. — The  liver  in  cases  of  transposed  viscera  is 
found  on  the  left  side.  ^lore  frequently  it  is  simply  turned  downward  or 
upward,  anteverted  or  retroverted  as  it  may  be  on  its  transverse  axis,  chiefly 
as  a  consequence  of  tight  lacing  in  women.  It  may  be  pushed  upward  above 
its  normal  site  by  ascitic  fluid  or  abdominal  tumors,  and  downward  by  pleu- 
ritic effusion  on  the  right  side  or  by  emphysema  of  the  right  lung. 

The  floating  Ik'er  is  by  far  the  most  interesting  of  these  conditions. 
When  it  occurs,  the  natural  site  of  the  liver  is  vacant,  especially  when  the 
patient  is  in  the  upright  position,  occupied  usually  by  hollow  viscera,  or, 
in  rare  instances,  by  morbid  growths.  The  condition  of  such  movableness 
is  a  long  suspensory  ligament  and  a  coronary  ligament  so  stretched  as  to 
form  a  sort  of  mesohepar,  which  permits  the  liver  to  fall  out  of  its  normal 
position.  It  occurs  usually  in  women  past  middle  life,  with  loose  abdominal 
walls,  and  is  favored  by  tight  lacing.  It  has  been  met  with  in  men.  It  is 
sometimes  responsible  for  the  condition  known  as  the  pendent  belly.  It  is 
a  rare  condition. 

The  organ  itself  is  usually  easily  recognized  as  a  large,  hard,  but 
movable  tumor,  below  its  normal  place,  and  having  also  the  shape  and  size 
of  the  liver,  while  the  normal  site  is  tympanitic  on  percussion  or  occupied 
by  organs  which  do  not  give  the  sarrte  outline  on  percussion.  The  suspen- 
sory ligament  may  also  be  felt.  The  organ  may  generally  be  restored  to  its 
normal  position  when  the  patient  is  recumbent. 

The  same  dragging  symptoms  mentioned  as  characteristic  of  the  con- 


436  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

stricted  liver,  with  the  usual  contingent  of  nervous  symptoms  which  succeed 
upon  it  and  the  movable  kidney,  may  be  present  here. 

Treatment. — The  treatment  for  both  of  -these  conditions — the  con- 
stricted and  the  displaced  liver — must  consist  in  some  instrumental  means 
by  which  the  organ  or  constricted  portion  can  be  held  in  position. 


Diseases    of  the   Bile   Passages   and    Gall-bladder. 

JAUNDICE  OR  ICTERUS. 

Definition. — Jaundice  is  not  a  disease,  but  a  symptom,  consisting  in 
a  yellowish  discoloration  of  the  skin  and  other  tissues  by  coloring-matters 
derived,  in  some  cases,  directly  from  the  bile,  and  in  others  directly  from 
the  blood.  The  shades  of  coloring  range  from  a  very  pale,  scarcely  ap- 
preciable, yellow  to  a  brown  olive  hue.  It  is  a  symptom  present  in  so  many 
different  diseases  of  the  liver,  and  so  associated  with  other  symptoms  more 
or  less  constant  that  its  separate  consideration  is  justified. 

Etiology. — xA.s  intimated,  its  immediate  cause  is  a  deposit  of  pigment 
in  the  skin,  which,  in  the  majority  of  cases,  is,  reabsorbed  bile  pigment.  In 
other  instances  the  pigment  represents  the  coloring-matter  from  disinte- 
grated red  blood  discs,  disintegration  so  rapid  that  the  liver,  spleen,  and 
kidneys,  all  combined,  are  unable  to  eliminate  the  hematin.  It  has  also  been 
claimed  that  jaundice  may  be  due  to  suppressed  secretion,  the  result  of 
extensive  destruction  of  liver  cells,  but  this  has  been  rendered  very  unlikely 
by  the  experiments  of  Stein,  who  found  that  jaundice  did  not  occur  when 
the  entire  blood  supply  of  the  pigeon's  liver  was  cut  off.  The  jaundice  due 
to  bile  absorption  has  received  the  name  hepatogenous  jaundice,  because  of 
its  purer  hepatic  origin ;  the  second  form  is  called  hematogenous,  because 
disintegrated  blood  is  its  direct  source. 

Reabsorption  of  bile  takes  place  when  there  is  obstruction  to  its  onward 
movement,  such  as  results,  for  example,  from  impaction  of  a  gall-stone  in  the 
hepatic  duct  or  common  bile-duct;  from  closure  of  the  duodenal  end  of  the 
common  bile-duct  by  inflamed  and  swollen  intestinal  mucous  membrane ; 
from  complete  or  partial  obliteration  of  the  duct  by  adhesive  inflammation ; 
and  from  pressure  from  without  by  morbid  growths.  These  growths  may 
be  enlarged  glands  in  the  fissure  of  the  liver,  or  tumor  in  the  gall-bladder, 
in  the  liver  itself,  in  the  pancreas,  and  in  the  stomach,  and  especially  cancer 
of  the  pylorus  and  duodenum.  More  rarely  tumors  of  the  kidney  or  omen- 
tum, abdominal  aneurysm  of  the  celiac  axis  or  aorta,  or  enlargement  of  the 
uterus  may  occasion  obstruction.  So  may  fecal  accumulation.  The  morbid 
states  in  the  liver  which  may  produce  jaundice  are  cancer,  abscess,  hydatid 
cysts,  and  cicatrices,  all  of  which  will  be  referred  to  again.  It  is  reasonable 
to  suppose  that  the  bile  is  absorbed  from  the  overdistended  biliary  vessels 
by  the  adjacent  capillary  vessels  of  either  portal  or  hepatic  vein  system 
facilitated  by  pressure.  Reduced  pressure  in  the  blood-vessels  of  the  liver, 
as  contrasted  with  that  in  the  biliary  vessels  and  ducts,  also  favors  reabsorp- 
tion of  bile  from  the  latter.  Such  explanation  is  speculative,  but  thus  have 
been  explained  those  interesting  cases  of  jaundice  brought  about  by  emo- 
tion. Those  who  have  read  the  charming  story  of  "  Put  Yourself  in  His 
Place,"  by  Charles  Reade,  will  recall  the  case  of  Henry  Little,  whose  attack 
of  jaundice  is  described  with  the  skill  of  an  expert  physician. 


JAUNDICE  OR  ICTERUS.  437 

It  should  be  mentioned,  also,  that  the  hematogenous  form  of  jaundice 
has  recently  been  denied  by  Stadelmann,  who  holds  that  all  jaundice  is  hepa- 
togenous in  origin,  and  that  the  needed  condition  of  obstruction  is  secured 
in  the  so-called  hematogenous  form  by  a  plugging  of  the  smaller  bile-ducts 
by  viscid  bile  or  catarrhal  secretion,  or  by  compression  of  these  ducts  by 
swollen  adjacent  liver  cells,  or  by  leukocytic  infiltration  of  the  interstitial 
tissue.  I  do  not  as  yet  feel  justified  in  discarding  the  heretofore  accepted 
classification. 

Associated  Symptoms. — i.  Of  Hepatogenous  or  Obstructive  Jaun- 
dice.— This  is  the  usual  form  of  jaundice.  All  ages  are  subject  to  it.  In 
addition  to  the  discoloration  described  there  is  often  an  annoying  itching 
of  the  skin,  due  to  irritation  of  the  deposited  bile  pigment.  Further  evidence 
of  the  irritation  thus  caused  is  seen  in  occasional  eruptions,  such  as  urticaria, 
lichen,  and  even  furuncles.  A  bright  yellow  discoloration  of  the  sclerotic 
coat  of  the  eye  is  as  constant  as  the  staining  of  the  skin,  while  the  mucous 
membranes  are  often  similarly  tinged. 

After  the  skin,  the  urine  exhibits  the  most  conspicuous  alteration,  even 
in  mild  cases.  Indeed,  "  bilious  urine  "  is  sometimes  the  first  symptom. 
The  color  may  be  slightly  yellow  or  deep  brown,  like  that  of  porter.  The 
presence  of  bile  pigment  in  the  urine  is  readily  shown  by  Gmelin's  nitrous 
acid  test,  though  ordinary  nitric  acid  answers  nearly  as  well.  A  few  drops 
of  the  urine  and  half  as  many  of  the  acid  are  placed  on  a  porcelain  plate  and 
gradually  allowed  to  approach  and  fuse,  when  a  brilliant  play  of  colors 
appears,  in  which  green,  yellow,  red,  and  violet  are  most  easily  recognized. 
The  reaction  is  due  to  the  oxidation  of  the  bilirubin  by  the  acid.  The  dem- 
onstration of  the  biliary  acids  by  Pettenkofifer's  test  with  cane-sugar  and 
sulphuric  acid  is  impossible  unless  the  bile  acids  be  first  separated  by  a 
tedious  process.  One  of  the  most  reliable  ways  of  recognizing  bile  in  the 
urine  is  by  the  stained  cellular  elements  which  it  contains.  Under  no  other 
circumstances  are  the  bright  yellow-stained  cells  found,  and  they  are  even 
met  with  when  the  quantity  of  coloring-matter  is  insufficient  to  react  by 
Gmelin's  test.  In  a  few  cases  the  bilirubin  reaction  is  not  obtainable,  when 
the  urine  contains  in  increased  amount  its  normal  coloring-matters,  urobilin 
or  hydrobilirubin — i.  e.,  reduced  bilirubin. 

Of  the  remaining  secretions,  the  perspiration  is  often  stained,  the  milk 
rarely,  the  tears,  saliva,  and  mucus  not  at  all.  There  is  sometimes  a  bitter 
taste  in  the  mouth,  showing  an  elimination  of  some  constituent  of  the  bile 
by  the  buccal  glands,  probably  the  salivary. 

On  the  other  hand,  the  feces  are  devoid  of  biliary  coloring-matter,  and 
their  pale-gray  or  pipe-clay  color  has  long  been  significant  of  the  absence 
of  bile.  For  the  same  reason  the  bowels  are  usually  constipated  and  the 
discharges  pasty,  ill-smelling,  and  acid.  Occasionally  there  is  diarrhea, 
which  may  be  caused  by  the  irritating  effect  of  the  feces  disposed  to  rapid 
decomposition,  because  of  the  absence  of  their  natural  antiseptic  ingredient. 
For  the  same  reason,  too,  the  absorption  of  fats  is  hindered.  There  may 
be  other  signs  of  gastro-intestinal  derangement,  such  as  loss  of  appetite, 
nausea,  fetid  breath,  and  fullness  in  the  epigastrium  after  eating.  Gastro- 
intestinal hemorrhages  have  been  noticed  in  grave  cases.  In  cases  of 
long  standing  there  may  be  albumimiria  as  well,  with  bile-stained  tube- 
casts. 

Very  characteristic  of  simple  obstructive  jaundice  is  a  sloiv  pulse,  which 
may  be  as  infrequent  as  50,  40,  or  30.     It  must  be  due  to  some  stimulating 


438  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

effect  on  the  inhibitory  action  of  the  pneumogastric  nerve.  The  breathing 
rate,  on  the  other  hand,  is  normal. 

The  chief  subjective  symptom  of  jaundice  is  depression  of  spirits,  w^hich 
may  even  amount  to  melanchoHa.  Irritability  is  also  prominent.  Headache 
and  vertigo  are  frequent.  Vision  is  variously  affected :  to  some,  objects 
appear  yellow ;  some  see  better  by  obscure  light — nyctalopia ;  to  others,  the 
approach  of  darkness  is  associated  with  more  than  usually  difficult  vision — 
hemeralopia.  Grave  nervous  symptoms,  rarely  manifested,  are  sudden  coma, 
acute  delirium,  and  convulsions.  These  usually  supervene  in  cases  of  long 
standing,  and  are  attended  by  fever,  rapid  pulse,  and  dry  tongue — the  symp- 
toms, in  a  word,  of  the  typhoid  state.  The  term  cholemia  is  applied  to  the 
sum  of  these  symptoms,  and  the  condition  is  regarded  as  due  to  the  presence 
in  the  blood  of  the  constituents  of  bile,  of  which  cholesterin  is  the  most 
important ;  whence  also  the  name  cholesteremia. 

The  liver  is  more  or  less  altered,  in  accordance  with  the  disease  which 
may  be  present  in  it  and  responsible  for  the  jaundice.  These  changes  will 
be  considered  in  treating  of  the  diseases  in  which  jaundice  is  a  conspicuous 
symptom.  It  may  also  be  bile-stained,  as  are  other  internal  organs,  especially 
the  kidneys. 

The  duration  of  this  form  of  jaundice  depends  upon  the  disease  which 
is  responsible  for  it,  and  it  may  be  a  few  days  or  many  months.  In  chronic 
cases  remission  and  exacerbations  occur,  but  the  longer  the  duration,  the 
more  likely  is  there  to  be  some  organic  change  in  the  liver. 

2.  Of  Hematogenous  Jaundice. — The  symptoms  of  this  form  are  those 
of  the  diseases  which  are  responsible  for  the  hemolysis — ^viz.,  acute  yellow 
atrophy,  phosphorus-poisoning,  yellow  fever,  bilious  fever,  typhoid,  typhus, 
and  relapsing  fevers,  pyemia,  pernicious  anemia,  snake  poison,  chloroform, 
and  other  poisons.  In  all  of  these  there  is  some  toxic  agent  working  de- 
struction of  the  blood.  It  should  be  added  that  in  this  form  of  jaundice 
the  stools  are  not  clay-colored.  The  urine  also  is  less  bile-stained,  though 
the  true  urinary  pigments,  notably  urobilin,  are  often  very  much  increased. 

Diagnosis. — One  of  the  most  frequent  errors  of  the  inexperienced,  and 
a  constant  one  of  the  laity,  is  to  mistake  for  jaundice  a  dirty,  yellowish 
discoloration  of  the  skin,  known  as  sallowness,  which  is  symptomatic  of 
general  ill  health,  especially  of  uterine  disease  in  women  and  of  malarial 
poisoning.  It  is  probably  an  anemia,  and  may  be  distinguished  from  jaun- 
dice by  the  fact  that  it  is  not  associated  with  staining  of  the  conjunctiva  and 
secretions.  It  is,  moreover,  not  a  yellow,  but  a  dirty  brown.  One  needs 
only  to  have  his  attention  aroused  to  avoid  error. 

Much  more  closely  does  the  discoloration  of  the  skin  in  Addison's  dis- 
ease resemble  that  of  some  cases  of  jaundice.  In  the  former  there  is  no 
discoloration  of  the  sclerotic  coat  nor  of  the  urine,  while  the  feces  remain 
natural.  In  Addison's  disease  the  exposed  portion  of  the  body  and  its 
flexures  are  more  deeply  stained. 

The  purpose  of  diagnosis  includes  the  discovery  of  the  cause  and  seat 
of  obstruction.  In  the  first  place,  most  cases  of  acute  jaundice  are  due  to 
catarrhal  inflammation  of  the  common  bile-duct.  If  associated  with  fever, 
it  may  be  assumed  that  the  smaller  ducts  are  involved.  After  this,  obstruc- 
tion by  gall-stones  causes  many  cases ;  then  follow  hypertrophic  cirrhosis 
and  the  various  malignant  diseases  of  the  liver,  hydatid  disease,  abscess, 
pressure  by  enlarged  glands  in  the  fissure  of  the  liver,  and  others  mentioned 
on  page  436. 


SIMPLE  CATARRHAL  JAUNDICE.  439 

Prognosis. — This  depends  on  the  cause  of  producing  it.  Ordinary 
catarrhal  jaundice  invariably  is  recovered  from  in  from  two  to  six  weeks, 
and  jaundice  from  impacted  calculus  usually  sooner  or  later.  When  due  to 
other  causes,  its  duration  depends  on  them.  In  the  hematogenous  form 
the  duration  is  brief,  because  the  termination  of  the  disease  causing  it  is 
usually  early  and  fatal. 

Treatment. — The  treatment  of  both  forms  of  jaundice  must  be  directed 
to  the  conditions  causing  it,  and  will  be  appropriately  considered  in  discuss- 
ing them. 

Icterus  Neonatorum. 

Synonym. — Jaundice  of  the  New-horn. 

Jaundice  occurs  in  new-born  children  in  a  simple  and  harmless  form, 
with  symptoms  comparable  to  obstructive  jaundice,  and  in  a  grave  form 
comparable  to  hematogenous  jaundice.  The  first  is  probably  a  form  of 
obstructive  jaundice  due  to  like  causes,  though  it  has  been  assigned  a 
hematogenous  origin.  It  is  much  the  more  frequent,  and  disappears  in  from 
a  few  days  to  several  weeks.    The  grave  form  is  usually  fatal. 

A  patulous  ductus  venosus  has  been  suggested  as  an  avenue  through 
which  the  portal  blood  which  contains  bile  enters  the  circulation. 

The  grave  form  has  been  found  associated  with  absence  of  the  hepatic 
duct  or  common  duct,  with  congenital  syphilitic  hepatitis,  and  with  septic 
phlebitis  of  the  umbilical  vein. 

Treatment. — The  simple  form  of  jaundice  of  new-born  infants  demands 
no  treatment.  In  the  graver  forms  treatment  is  of  no  avail  unless  the  condi- 
tion be  traceable  to  syphilis,  when  it  demands  the  treatment  of  that  disease 
in  its  tertiary  form. 

Simple   Catarrhal  Jaundice. 
Synonyms. — Diiodeno-cholangitis ;  InHammation  of  the  Common  Bile-duct. 

Definition. — The  term  catarrhal  jaundice  is  applied  to  jaundice  due  to 
any  inflammation  of  the  common  duct  not  the  result  of  impacted  gall-stone. 

Etiology. — The  most  frequent  cause  of  such  inflammation  is  the  ex- 
tension of  a  gastro-duodenitis  into  the  common  duct.  To  the  same  cause 
is  ascribed  the  jaundice  sometimes  occurring  with  passive  congestion  of  the 
liver  due  to  mitral  valvular  heart  disease,  also  that  found  in  association 
with  the  infectious  diseases,  especially  pneumonia,  or  with  mental  emotion. 
Catarrhal  jaundice  may  also  be  epidemic.  The  jaundice  in  hypertrophic 
cirrhosis  is  probably  likewise  due  to  cholangitis. 

Morbid  Anatomy. — Opportunities  of  studying  postmortem  conditions 
after  catarrhal  jaundice  are  not  often  afforded,  but  when  they  occur,  the 
duodenal  end  of  the  duct — the  pars  intestinalis — has  been  mostly  involved. 
In  it  the  mucous  membrane  is  swollen,  while  its  orifice  and  the  diverticulum 
of  Vater  may  be  filled  with  mucus.  The  inflammation  may  extend  up  into 
the  cystic  duct,  and  even  higher,  into  the  hepatic  duct  and  branches.  Sup- 
puration does  not  take  place  in  this  form  of  cholangitis. 

Symptoms. — Excepting  the  jaundice,  there  may  be  no  symptoms. 
There  is  no  pain,  but  there  may  be  tenderness,  due  to  gastro-intestinal 
derangement  rather  than  to  the  hepatic  state,  though  this  may  cause  it, 
while  such  derangement  may  also  lead  to  general  malaise,  loss  of  appe- 


440  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

tite,  coated  tongue,  fetid  hrcxith,  nausea,  z'omiting,  a  sense  of  fullness,, 
constipation,  or  irregular  action  of  the  bowels.  There  may  also  be 
slight  fever,  particularly  if  the  smaller  biliary  passages  are  involved. 
If  the  gall-bladder  is  distended  and  can  be  felt  at  the  edge  of  the 
liver,  there  is  probably  obstruction  of  the  common  duct,  and  if  there  are 
pain  and  tenderness,  the  obstructive  agent  is  probably  a  gall-stone. 
The  paler  the  feces,  the  more  complete  must  be  the  obstruction,  and  the 
more  likely  is  it  to  be  in  the  common  duct,  for,  with  obstruction  of 
the  cystic  duct,  there  may  still  be  a  discharge  of  bile  into  the  intestine; 
also  with  obstruction  of  the  hepatic  duct  until  the  gall-bladder  is  empty, 
which,  however,  soon  happens.  Obstruction  of  the  hepatic  duct  is  unas- 
sociated  with  distention  of  the  gall-bladder,  while  there  will  be  jaundice. 
Obstruction  of  the  cystic  duct  may  still  be  associated  with  distention  of  the 
gall-bladder,  either  through  transudation  or  pus-formation,  but  there  may 
be  no  jaundice,  and  the  feces  may  remain  colored.  If  the  jaundice  is  chronic 
or  permanent,  we  must  look  for  some  organic  change  in  the  liver  or  external 
permanent  cause  of  obstruction  outside  of  its  condition.  In  the  hematog- 
enous form  the  jaundice  is  usually  so  plainly  secondary  to  other  symptoms 
that  there  is  little  difficulty  in  recognizing  its  cause. 

Diagnosis. — The  presence  of  jaundice  without  pain  or  other  symptoms 
points  almost  invariably  to  catarrhal  jaundice.  The  same  diagnosis  is  justi- 
fied by  the  presence  of  the  symptoms  of  gastro-intestinal  catarrh,  of  asso- 
ciated mitral  disease,  or  of  any  of  the  infectious  diseases. 

Prognosis, — Unless  associated  with  infectious  diseases  or  with  hyper- 
trophic cirrhosis,  the  prognosis  of  catarrhal  jaundice  is  favorable.  In  the 
diseases  referred  to  the  danger  is  not  from  the  jaundice,  but  from  the  diseases 
with  which  it  is  associated. 

Treatment. — The  treatment  of  catarrhal  jaundice  resolves  itself  into 
two  parts :  first,  that  for  the  catarrhal  state ;  second,  that  demanded  by  the 
absence  of  bile  in  the  small  intestine. 

For  the  catarrhal  inflammation,  either  of  the  duodenum  adjacent  to 
the  duct  or  of  the  duct  itself,  local  depletion  is  indicated.  This  is  accom- 
plished by  the  use  of  saline  aperients  and  the  natural  mineral  waters  which 
act  similarly — i.  e.,  produce  watery  stools.  Of  the  former,  Rochelle  salts, 
Epsom  salts,  or  the  solution  of  the  citrate  of  magnesium  are  representative; 
while  the  Saratoga,  Hunyadi  Janos,  Friedrichshalle,  or  Rubinat  and  Carls- 
bad waters  represent  the  latter.  These  should  be  taken  daily  in  aperient 
doses.  In  this  country  the  Saratoga  mineral  waters,  particularly  those  of 
the  Hathorn  Spring,  are  especially  valuable,  and  no  better  course  can  be 
pursued  by  those  who  can  afford  it  than  to  spend  some  weeks  at  Saratoga. 
The  Bedford  Springs  waters,  near  Bedford,  Pa.,  are  also  useful,  but  not 
nearly  so  efficient  as  the  Saratoga  waters.  Of  foreign  waters,  those  of 
Carlsbad  are  especially  valuable,  and  in  Europe  these  springs  may  be  resorted 
to.  Their  use  may  also  be  associated  between  meals  with  that  of  the  alkaline 
mineral  waters,  of  \vhich  those  of  Vichy  and  Vals  are  the  type.  These  waters 
are  largely  employed  in  this  country,  and  may  be  availed  of  at  home.  There 
is  no  indication  for  the  use  of  calomel,  which  is  so  often  prescribed,  as  it  is 
not  reasonable  to  believe  the  secretion  of  the  bile  can  be  so  stimulated  by  it 
as  to  force  onward  any  obstruction,  whether  by  calculus  or  swollen  mucous 
membrane,  until  the  latter  is  depleted.  After  the  flow  into  the  intestine  is 
resumed,  calomel  may  be  given  to  stimulate  it  further.  Podophyllin  and 
colocynth  may  be  used  for  the  same  purpose.     Sodium  salicvlate  has  also  a 


CHOLELITHIASIS.  441 

reputation  to  this  end.     Irrigation  of  the  large  bowel  with  cold  water  has 
been  recommended  as  a  means  of  stimulating  the  descent  of  the  stone. 

The  second  indication  should  be  met  by  the  use  of  such  food  as  does  not 
require  the  bile  to  facilitate  its  digestion  or  absorption  or  to  prevent  its  decom- 
position. Fats  and  oils  should,  therefore,  be  avoided;  hence  skimmed  milk, 
animal  broths,  and  egg-albumen,  with  an  abundance  of  liquids,  are  indicated. 
The  liquids  may  be  some  one  or  more  of  the  mineral  waters  previously  named, 
or,  in  their  absence,  plain  water.  Warm  bathing  is  especially  indicated,  as  it 
causes  elimination  by  the  skin  and  relieves  the  itching.  Lotions  of  carbolic 
.acid  and  glycerin  are  also  useful  to  this  end. 

CHOLELITHIASIS. 

Synonyms. — Hepatic  calculus ;  Biliary  calculus. 

Etiology. — Since  the  great  bulk  of  the  gall-stone  is  cholesterin,  an  evi- 
dent condition  of  its  formation  is  a  precipitation  of  this  substance  from  the 
bile,  of  which  it  is  the  chief  constituent.  The  thicker  the  bile,  the  more 
likely  it  is  to  throw  down  sediment.  Moreover,  recent  studies,  espe- 
cially by  Naunyn,  have  shown  that  micro-organisms  play  an  important 
part  in  the  production  of  gall-stones,  primarily  by  exciting  a  catarrhal  inflam- 
mation which  modifies  the  chemical  composition  of  the  bile  and  favors  the 
precipitation  of  cholesterin  and  of  lime  salts,  in  combination  with  epithelial 
debris  and  bacteria.  Tlie  typhoid  fever  bacillus  is  an  especially  frequent 
cause  of  inflammation  of  the  gall  bladder.  Naunyn  also  showed  that  choles- 
terin and  lime  salts  are  a  secretion  of  the  mucous  membrane  of  the  gall- 
bladder and  bile-ducts,  and  that  it  is  a  function  which  is  especially  active 
when  the  mucosa  is  in  a  state  of  inflammation.  If,  as  is  supposed,  the  cholate 
salts  of  sodium  hold  cholesterin  in  solution,  it  is  plain  that  their  decomposi- 
tion or  destruction  may  cause  precipitation,  which  may  also  be  further  fav- 
ored by  micro-organisms. 

Occurrence. — Gall-stones  have  been  met  in  infants  and  in  the  new-born, 
but  practically  are  found  in  adults  only,  while  their  tendency  to  form  appears 
to  increase  from  the  age  of  thirty  upward.  Most  patients  who  consult  us  for 
the  effects  of  gall-stones  are  over  forty  and  under  fifty.  Cholelithiasis  is 
also  very  much  more  frequent  in  women  than  in  men ;  according  to  Naunyn, 
four  times  as  frequent,  and  especially  so  in  women  who  have  borne  children 
or  have  had  abdominal  tumors.  He  says  that  90  per  cent,  of  women  who 
have  gall-stones  have  borne  children. 

Naunyn  says,  too,  that  25  per  cent,  of  all  women  wdio  die  have  calculi 
in  the  gall-bladder.  Lack  of  exercise,  sedentary  habits,  and  tight  lacing  are 
held  partly  responsible  for  this,  and  with  some  reason,  since  all  of  these 
conditions  are  calculated  to  impede  the  movement  of  bile.  Cholelithiasis  has 
been  found  associated  with  the  habit  of  free  eating  of  starchy  and  saccharine 
foods  and  in  stout  persons ;  yet  I  recall  striking  cases  among  the  lean  also. 
The  movable  liver  and  the  movable  right  kidney  are  likewise  said  to  pre- 
dispose to  cholelithiasis.  Constipation  and  a  tendency  to  depression  of  spirits 
are  apt  to  be  associated,  probably  as  effects  rather  than  causes. 

Morbid  Anatomy, — The  gall-s1,one  itself  is  a  brown  object,  nearly 
spherical,  oval  or  faceted,  and  even  polygonal  in  shape,  usually  the  size  of  a 
pea,  or  as  small  as  a  millet-seed,  producing  in  aggregation  "  gall  sand."  The 
faceted  shape  is  produced  by  close  packing  of  a  large  number  of  stones  in  a 


442  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

gall-bladder,  as  frequently  happens.  More  rarely  the  stone  is  irregular — 
mulberry-shaped.  In  addition  to  cholesterin,  which  makes  up  from  70  to  80 
per  cent,  of  most  stones,  they  contain  in  various  but  still  small  amounts  bile 
pigment,  calcic  carbonate,  and  organic  matter.  A  few  are  made  up  almost 
entirely  of  bilirubin  and  lime.  On  section,  the  stone  exhibits  either  a  con- 
centric or  homogeneous  appearance,  with  or  without  a  nucleus  of  bile  pigment 
or  organic  matter,  and  very  rarely  of  some  foreign  body.     The  cholesterin 


COMMON) 
BILE    DUCT\ 


Fig.  35. — The  Cystic  Duct  in  Section,  with  Part  of  the  Gall-bladder  and  Hepatic 
and  Common  Bile-duct. — {Testiit). 

stones  are  almost  completely  soluble  in  etherized  alcohol,  whence  beautiful 
crystals  of  cholesterin  may  be  obtained  after  evaporation. 

In  addition  to  their  enormous  accumulation  in  the  gall-bladder,  where 
they  may  be  counted  sometimes  by  hundreds,  they  are  found  anywhere  in  the 
biliary  tract  between  the  duodenal  end  of  the  common  duct  and  the  ultimate 
ramification  of  the  bile  vessels.  Outside  of  the  gall-bladder  the  cystic  duct 
and  the  common  duct  are  naturally  the  situations  in  which  lodgment  most 
frequently  occurs.  If  in  the  common  duct,  it  is  usually  at  the  orifice  of  the 
papilla  in  the  diverticulum  of  Vater,  and  from  the  duodenal  side  the  stone 
feels  as  though  it  were  directly  under  the  mucous  membrane.  Two  or  even 
more  stones  may  be  found  in  the  duct.  The  common  duct  under  these  cir- 
cumstances may  attain  a  diameter  of  an  inch  (2.5  cm.)  or  more.  Permanent 
obstruction  of  the  cystic  duct  causes  dilatation  of  the  gall-bladder — hydrops 
veskcE  fellece.  Such  dilatation  may  be  enormous,  filling  the  entire  abdominal 
cavity,  and  has  been  mistaken  for  ovarian  tumor ;  usually  it  is  more  moderate, 
but  the  contents  frequently  amount  to  a  pint  (500  c.  c.)  or  more.  The  con- 
tents are  a  colorless,  viscid,  or  watery  fluid,  more  or  less  albuminous,  and 
neutral  or  alkaline  in  reaction ;  the  greater  the  dilatation,  the  more  aqueous 
and  unlike  bile  do  its  contents  become.  In  any  situation  the  stone  may  pro- 
duce ulceration  and  even  suppuration,  with  perforation  into  the  peritoneal 
cavity  or  adjacent  organs,  the  duodenum,  stomach,  transverse  colon,  right 
renal  pelvis,  ureter,  through  the  diaphragm  into  a  bronchus,  and  into  the 
abdominal  wall. 

The  various  situations  in  which  gall-stones  are  lodged  may  be  easily 
learned  from  the  accompanying  Figure  35. 


CHOLELITHIASIS.  443 

Acute   Impaction. 
Synonym. — Biliary  Colic. 

Symptoms. — The  characteristic  symptom  of  impacted  gal]  stones  is 
biliary  colic,  but  biliary  colic  is  by  no  means  always  present  in  every  case  of 
cholelithiasis.  The  gall-bladder  is  often  found  full  of  calculi  without  the  sug- 
gestion  of  a  symptom.  Small  stones  even  pass  into  the  duodenum  without 
-producing  symptoms.  Commonly,  however,  they  lodge  while  in  this  transit, 
and  give  rise  to  attacks  of  pain  which  are  known  as  biliary  colic.  This  pain 
is  usually  sudden,  very  severe,  often  excruciating,  and  the  patient  writhes  in 
agony  and  sometimes  faints  in  consequence.  It  is  usually  referred  to  the 
epigastrium,  whence  it  radiates  in  all  directions  over  the  abdomen  and  at 
times  into  the  right  shoulder  and  arm.  As  a  rule,  however,  it  is  localized  on 
the  right  side,  under  the  liver.  It  is  a  sharp  and  cutting  pain.  There  is 
always  tenderness  in  this  region,  which  varies  in  degree.  It  is  sometimes  as- 
sociated with  a  more  or  less  rigid  state  of  the  abdominal  muscles  of  that  side. 
The  duration  of  the  pain  is  that  of  the  lodgment  of  the  stone,  and  it  may  be 
from  a  few  hours  to  weeks,  ceasing  rather  suddenly  when  the  stone  is  dis- 
charged into  the  bowel.  There  may,  however,  be  remissions.  Nausea  and 
vomiting  are  almost  invariable  symptoms  of  biliary  colic.  They  often  bring 
temporary  relief  through  the  resulting  relaxation.  Fever  is  soon  added  to 
the  pain,  while  a  chill  is  not  infrequent.  The  temperature  is  usually  102°  F. 
to  103°  F.  (38.8°  C.  to  39.5°  C).  It  may  be  intermittent,  but  such  intermis- 
sion is  more  apt  to  be  associated  with  prolonged  obstruction,  constituting 
with  a  chill  a  part  of  the  symptoms  of  so-called  hepatic  fever,  to  be  next  con- 
sidered. Gall-stone  crepitus  may  sometimes  be  detected  when  the  gall- 
bladder is  packed  with  calculi. 

If  the  attack  last  long  enough,  jaundice  almost  always  supervenes, 
whence  we  infer,  too,  that  the  stone  is  likely  to  be  in  the  common  duct,  hav- 
ing probably  started  in  the  cystic  duct.  Three  or  four  days  may  elapse 
between  the  beginning  of  obstruction  and  the  supervention  of  jaundice,  the 
degree  of  which  increases  with  the  completeness  and  duration  of  obstruction. 
The  entrance  of  the  stone  into  the  common  duct  may  be  attended  by  one  of 
the  remissions  alluded  to,  though  the  jaundice  grows  even  deeper  on  account 
of  the  more  thorough  obstruction  to  the  'descent  of  the  bile. 

The  liver  is  sometimes  slightly  enlarged,  as  determined  by  percussion. 
A  rare  symptom  is  collapse  with  fatal  syncope,  due  to  perforation  at  the  seat 
of  lodgment,  with  consequent  peritonitis  and  shock. 

Diagnosis. — This  is  commonly  easy.  While  the  pain  may  be  more  or 
less  diffuse,  it  is  for  the  most  part  localized  in  the  right  lower  thoracic  and 
upper  abdominal  regions,  and  the  tenderness  is  always  there,  while,  if  jaun- 
dice and  biliary  urine  are  present,  all  doubt  is  removed.  Nephritic  colic  and 
biliary  colic  are  confounded  with  surprising  and  unjustified  frequency.  In 
the  former  condition  the  pain  starts  in  the  lumbar  region  and  radiates  down- 
ward into  the  groin,  the  testicle,  and  the  inside  of  the  thigh.  Such  error  is 
fortified  by  the  fact  that  bilious  urine  is  too  often  confounded  with 
bloody  urine.  It  should  be  necessary  only  to  mention  this  to  guard  against 
error. 

Cholelithiasis  has  been  mistaken  for  acute  pleurisy  in  the  vicinity  of  the 
gall-bladder  and  the  reverse  mistake  has  been  made.     The  friction  rale  of 


444  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

pleurisy  should  preclude  an  error,  but  the  friction  rale  may  not  be  present  at 
the  particular  stage. 

Our  growing  knowledge  of  appendicitis  has  led  to  the  discovery  that  the 
pain  characteristic  of  this  disease  is  sometimes  localized  in  the  right  hypo- 
chondrium,  where,  indeed,  the  appendix  has  been  found  at  operation.  Jaun- 
dice and  bile-stained  urine  do  not,  however,  attend  appendicitis.  Gastralgia 
has  been  confounded  with  biliary  colic,  but  attention  to  the  symptoms 
described  when  treating  that  afifection  should  prevent  mistake.  The  term 
hepatic  neuralgia  has  been  applied  to  an  apparently  causeless  pain,  sometimes 
felt  in  the  neighborhood  of  the  liver,  but  it  is  less  severe  than  biliary  colic 
and  unaccompanied  by  any  of  the  other  symptoms.  This  is  allied  to  pseudo- 
biliary  colic  which  is  to  be  remembered  as  a  possible  event  in  nervous  women. 
Both  are  characterized  by  the  absence  of  jaundice. 

It  is  very  important,  immediately  after  an  attack  of  supposed  biliary 
colic,  to  search  for  a  stone  in  the  fecal  discharges.  For  this  purpose  the 
mass  should  be  placed  on  a  sieve,  and  water  passed  over  it  until  all  soluble 
parts  are  run  out.  Such  examination  should  be  kept  up  for  several  days 
after  the  attack,  for  the  stone  is  not  always  passed  immediately. 

Prognosis. — The  termination  of  an  ordinary  attack  of  biliary  colic  is,  in 
the  vast  majority  of  instances,  favorable.  It  is  only  in  the  rare  cases,  where 
perforation  takes  place,  that  a  fatal  ending  follows.  Surgery  of  the  gall- 
bladder has  come  to  be  an  important  division  of  surgery,  and  many  lives  have 
been  saved  by  operations  before  and  after  perforation.  The  surgeon  should, 
therefore,  be  promptly  sent  for.  More  frequently  the  escape  of  the  stone  is 
long  delayed,  producing  the  symptoms  of  chronic  impaction,  to  be  next 
described. 

Chronic  Impacted  Gall-stone. 

Symptoms. — These  vary  somewhat  with  the  seat  of  the  impaction  and 
its  duration.     From  this  standpoint  they  may  be  divided  into  certain  groups : 

1.  Syuiptouis  Due  to  Chronic  Calculous  Obstruction  of  the  Cystic  Duct. 
— In  addition  to  more  or  less  of  the  symptoms  detailed  under  acute  impaction, 
the  immediate  result  of  such  obstruction  is  dilatation  of  the  gall-bladder,  or 
hydrops  vesica  fellecr,  already  referred  to.  Contrary  to  what  might  be 
expected,  dilatation  is  more  frequently  caused  by  obstruction  of  the  cystic, 
than  of  the  common  duct.  The  source  of  the  accumulation  is  not,  however, 
the  bile,  which,  as  might  be  expected,  cannot  get  into  the  gall-bladder 
through  the  obstructed  duct  any  more  than  it  can  get  out  of  it.  It  is  the 
products  of  inflammation  of  the  mucosa,  added  to  the  bile  previously  present, 
which  cause  the  dilatation.  The  occasional  enormous  dilatation  has  more 
than  once  been  mistaken  for  ovarian  disease,  an  error  the  more  excusable 
when  we  remember  that  jaundice  is  often  absent.  More  frequently  the  dila- 
tation is  moderate,  and  can  be  felt  below  the  edge  of  the  liver  as  a  round  or 
ovoid  elastic  tumor,  in  which  fluctuation  may  sometimes  be  obtained. 

2.  Symptoms  Due  to  Chronic  Calculous  Obstruction  of  the  Common 
Dti'Ct. — If  the  common  duct  is  obstructed,  dilatation  of  the  gall-bladder  does 
not  necessarily  follow,  and  if  it  does  occur,  the  dilatation  is  moderate.  Such 
obstruction  is  commonly  associated  with  cholangitis,  catarrhal  or  suppura- 
tive, (a)  In  simple  chronic  catarrhal  cholangitis  the  common  duct  is  dilated ; 
at  times  also  the  branches  of  the  hepatic  duct  extending  into  the  liver.  This 
condition  has  been  especially  studied  by  Charcot  and  Murchison  abroad  and 
William  Osier  in  this  country.     It  may  be  intermittent  or  remittent.     Very 


CHOLELITHIASIS.  445 

interesting  among  the  causes  "of  intermittent  obstruction  is  the  movable  or 
ball-valve  stone  in  the  diverticulum  of  Vater. 

Chronic  catarrhal  cholangitis,  in  addition  to  the  persistent  jaundice  and 
paroxysmal  pain,  is  characterized  by  ague-like  attacks,  consisting  of  chills, 
fever,  and  sweats.  These  occur  at  surprisingly  regular  intervals,  resembling 
in  this  respect  the  quotidian,  tertian,  and  quartan  spells  of  intermittent  fever, 
with  which  the  condition  has  been  confounded.  They  may  occur  for  weeks 
at  a  time  and  then  remit.  Pain  is  commonly  associated  with  the  ague-like 
spells,  but  is  not  always  present.  The  chills  may  be  extremely  severe,  the 
sweats  also,  and  the  fever  correspondingly  high,  the  temperature  sometimes 
reaching  105°  F.  (40.5°  C).  The  jaundice  usually  deepens  after  an  attack. 
There  may  be  nausea  and  vomiting.  The  duration  may  be  indefinite  from  a 
few  months  to  years,  and  the  patient  may  yet  recover ;  or  he  may  perish, 
although  the  exhaustion  is  extremely  slow  and  the  effect  on  the  general  health 
barely  appreciable  from  week  to  week.  The  fever  is  probably  irritative, 
although  it  has  been  ascribed  to  the  omnipresent  organism — hacterium  coli 
commune.  There  is  sometimes  slight  enlargement  of  the  liver,  appreciable 
to  physical  examination,  and  in  long-protracted  cases  some  fibroid  induration 
may  be  expected  to  take  place.  The  stools  are  sometimes  bile-stained,  at 
others  not.     There  is  occasionally  enlargement  of  the  spleen. 

The  following  are  Naunyn's  distinguishing  signs  of  stone  in  the  common 
duct:  "(i)  The  continuous  or  occasional  presence  of  bile  in  the  feces;  (2) 
distinct  varitions  in  the  intensity  of  the  jaundice;  (3)  normal  size  or  only 
slight  enlargement  of  the  liver;  (4)  absence  of  distention  of  the  gall-bladder; 
('5)  enlargement  of  the  spleen;  (6)  absence  of  ascites;  (7)  presence  oi 
febrile  disturbance,  and  (8)  duration  of  the  jaundice  for  more  than  a  year." 

Osier  *  has  formulated  the  following  symptom-group  for  the  ball-valve 
stone  commonly  found  in  the  diverticulum  of  Vater,  but  occasionally  also  in 
the  common  duct  itself:  "  (a)  Ague-like  paroxysms,  chills,  fever,  and  sweat- 
ing— the  hepatic  intermittent  fever  of  Charcot;  {h)  jaundice  of  varying 
intensity,  which  persists  for  months  or  even  years,  and  deepens  after  each 
paroxysm;  (c)  at  the  time  of  the  paroxysm  pains  in  the  region  of  the  liver, 
with  gastric  disturbance.  These  symptoms  may  continue  intermittently  for 
three  or  four  years  without  the  development  of  suppurative  cholangitis.  An 
important  diagnostic  sign  of  obstruction  of  the  common  duct  by  stone  is  the 
absence  of  dilatation  of  the  gall-bladder — Courvoisier's  rule.  It  would 
appear  somewhat  unaccountable  that  obstruction  by  other  causes  is  more 
frequently  followed  by  dilatation  of  the  gall-bladder  than  obstruction  by  cal- 
culus. Thus,  Ecklin  found  that  of  172  cases  of  obstruction  of  the  common 
duct  by  calculus,  the  gall-bladder  was  contracted  in  no,  normal  in  34,  and 
dilated  in  28.  Of  139  cases  of  occlusion  of  the  common  duct  from  other 
causes  the  gall-bladder  was  contracted  in  9,  normal  in  9,  and  dilated  in  121. 

(h)  Suppurative  cholangitis  is  marked  symptomatically  by  a  fever  which 
is  more  of  the  septic  type,  with  remissions  rather  th?n  intermissions.  The 
jaundice  is  less  marked,  the  liver  is  tender  and  enlarged,  the  duration  of  the 
disease  shorter,  and  termination  fatal.  The  inflammation  involves  more  or 
less  the  ducts  of  the  liver,  whence  it  may  extend  into  the  liver  substance 
or  gall-bladder,  causing  abscess  of  the  liver  and  empyema  of  the  gall-bladder. 

Other  Remote  Results  of  Gail-stone  Impaction. — Rarer  terminations 
of   impacted   gall-stones   are   the   various    forms    and    situations    of   biliar>' 

*  See  paper  by  Osier  on  "  Fever  of  Hepatic  Orig-in.  Particularly  Intermittent  Pyrexias  Associated 
■with  Gallstone,""  Johns  Hopkins  Hospital  Reports,"  vol.  ii.,  No.  i,  1890. 


446  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

fistulas,  mentioned  when  treating  of  the  morbid  anatomy.  Some  more 
detailed  reference  to  these  fistulae  should  be  made.  Much  has  been 
added  to  our  knowledge  of  the  subject  by  the  industry  of  Prof.  L.  G. 
Courvoisier  of  Basle.*  Courvoisier  collected  499  cases  of  ulcerative  perfora- 
tion of  the  biliary  passages  of  which  70  occurred  directly  into  the  peritoneum, 
while  in  49  cases  there  was  encapsulated  abscess,  and  in  3  there  was  retro- 
peritoneal perforation.  Between  the  biliary  passages  themselves  were  8 
cases:  this  perforation  was  found  directlyfrom  the  gall-bladder  into  the  sub- 
stance of  the  liver  (4  cases)  ;  into  the  hepatic  duct  (2  cases),  into  a  divertic- 
ulum of  the  common  duct  (i  case),  or  between  the  intestinal  and  hepatic 
parts  of  the  common  duct  ( i  case).  Perforation  between  the  biliary  passages 
and  portal  vein  was  found  in  5  cases,  if  the  celebrated  case  of  Ignatius  Loyola, 
about  which  Courvoisier  expresses  some  doubt,  be  included.  Openings 
between  the  biliary  passages  and  gastro-intestinal  canal  are  not  uncommon 
(137  cases)  ;  most  frequently  between  the  bile  passages  and  duodenum,  of 
which  there  were  83  cases,  of  which  "/t,  were  between  the  gall-bladder  and 
the  duodenum,  while  10  were  between  the  common  duct  and  duodenum.  From 
the  biliary  passages  into  the  stomach  there  were  13  perforations;  into  the 
jejunum  one,  ileum  one,  colon  39.  As  might  be  expected,  perforation  takes 
place  most  frequently  from  the  intestinal  part  of  the  duct,  the  stone  first  lodg- 
ing in  the  diverticulum  of  \'ater.  Perforation  into  the  urinary  passages  was 
found  in  7  cases  and  into  the  pleura  and  lungs  in  24  cases.  To  these  last  J.  E. 
Graham  t  added  10  cases  of  broncho-biliary  fistula.  Finally,  there  may  be 
fistulous  communication  between  the  biliary  passages  and  the  external  integ- 
umient,  Courvoisier  having  collected  196  cases,  in  49  of  which  the  communica- 
tion was  in  the  right  hypochondrium,  36  at  the  border  of  the  ribs,  49  at  the 
navel  or  in  its  vicinity,  17  in  the  right  mesogastrium,  10  in  the  right  iliac 
region,  and  6  in  the  epigastrium.  Very  interesting  in  this  connection  is  the 
fact  that  out  of  169  cases  in  which  the  sex  was  noted,  126  were  women  and 
43  men.  Among  other  remote  results  are  septic  cholecystitis,  associated 
with  high  fever,  intense  prostration,  and  death  from  fatal  peritonitis ; 
empyema  of  the  gall-bladder,  already  alluded  to  as  a  result  of  suppurative 
cholangitis ;  the  latter  is  commonly  associated  with  gall-stones.  Calcification 
of  the  gall-bladder  is  a  frequent  termination  of  purulent  inflammation.  It  is 
present  in  two  forms :  first,  as  a  simple  incrustation  of  the  mucosa  with  lime 
salts,  and.  second,  as  a  true  infiltration  of  the  whole  thickness  of  the  wall. 

Atrophy  of  the  gall-bladder  is  not  infrequent  and  may  succeed  on  hydrops 
vesiccs  fellecc.  I  have  seen  many  gall-bladders  which  did  not  hold  more  than 
a  dram  (4  c.  c.)  or  two  of  bil^,  and  sometimes  there  is  a  mere  remnant  left 
in  the  shape  of  a  fibroid  mass ;  at  other  times  the  shrunken  bladder  closely 
embraces  a  gall-stone  of  large  size.  Gall-stones  are  occasionally  found  in 
diverticula  of  the  gall-bladder.  Suppurative  phlebitis  and  abscess  of  the 
liver  may  also  be  due  to  gall-stone,  causing  a  puriform  thrombus  in  an 
adjacent  branch  of  the  portal  vein. 

In  other  instances  the  gall-stone  is  of  such  size  as  to  obstruct  the  bowel 
when  discharged  into  it.  although  it  may  have  passed  through  the  natural 
channel,  as  evidenced  by  dilatation  of  the  common  duct.  But  for  the  most 
part  such  discharge  is  by  ulceration  into  the  intestinal  tract.  This  subject 
has  been  sufficiently  considered  when  treating  of  obstruction  of  the  bowels. 

Diagnosis  and  Prognosis. — There  may  be  some  difficulty  at  first  in  the 

*  Casuistisch-Statistische  Beitrage  zur  Patholoerieund  Chirurgie  der  Gallenwege,  Leipzig,  i8qo. 
t  Transactions  of  the  Association  of  American  Phj-sicians,  vol.  xii.,  1897. 


CHOLELITHIASIS.  447 

diagnosis  of  hepatic  fever,  but  the  persistent  jaundice,  the  ague-Hke  parox- 
ysms of  chills,  fever,  sweats,  and  pain  are  a  combination  of  symptoms  belong- 
ing to  no  other  condition.  A  cancer  of  the  gall-bladder,  which  will  form  a 
tumor  in  the  same  locality,  is  much  more  tender ;  it  is  harder  and  more  uneven, 
and  jaundice  is  invariably  associated  with  it,  while  the  patient  is  much  more 
seriously  ill  and  declines  more  rapidly.  There  should  be  no  confusion  with 
a  movable  kidney,  which  furnishes  a  different  physical  condition.  An  aspira- 
tor needle  may  be  used  to  confirm  the  diagnosis.  The  suppurative  form  is 
characterized  by  the  more  continuous  fever  and  the  more  serious  aspect  of  the 
septic  state,  its  shorter  course,  and  its  ultimate  fatal  termination.  The 
catarrhal  form  is  less  serious  and  quite  often  terminates  favorably. 

Treatment  of  Impacted  Gall-stone  and  its  Complications. — The  first 
indication  is  the  relief  of  pain.  This  is  best  accomplished  by  the  hypodermic 
injection  of  morphin,  the  action  of  which  is  favored  by  combination  with 
atropin.  Scarcely  less  than  1-4  grain  (0.0165  gm.)  with  1-150  grain  (0.0005 
gm.)  of  atropin  suffices,  and  this  must  often  be  repeated.  The  use  of  ano- 
dynes must  be  kept  up  as  long  as  needed.  The  atropin  favors  the  relaxation 
needed  to  release  the  calculus.  The  severest  cases  may  require  the  inhalation 
of  a  few  drops  of  chloroform  pending  the  action  of  the  morphin. 

Whether  anything  else  can  be  done  toward  releasing  the  stone  is 
not  established.  The  nausea  and  vomiting,  which  are  so  often  symptoms, 
sometimes  relieve  the  pain  by  the  relaxation  they  produce,  such  relaxation 
being  at  times  sufficient  to  favor  the  onward  movement  of  the  stone.  Anes- 
thesia by  ether  or  chloroform  may  act  similarly,  and  the  inhalation  above  sug- 
gested while  waiting  for  the  morphin  to  act  favors  such  relaxation.  Hot 
baths  or  fomentations  applied  to  the  region  of  the  liver  may  also  be  similarly 
effective. 

Some  solvent  for  the  stone  is  constantly  inquired  after.  Ether,  turpen- 
tine, and  sweet  oil,  although  lauded  for  this  purpose,  have  been  tried  and 
found  wanting.  Durande's  remedy  consists  of  turpentine  one  part,  ether 
four  parts ;  dose,  fifteen  drops  three  times  a  day.     It  is  useless. 

To  relieve  the  itching  caused  by  the  deposit  of  pigment  in  the  skin,  which 
is  sometimes  very  annoying  in  chronic  cases,  the  hot  pack  on  alternate  days 
or  even  every  day  is  serviceable.  A  very  efficient  local  application  for  this 
purpose  is  a  mixture  of  7  1-2  minims  (0.5  gm.)  of  carbolic  acid,  two  fluid 
dramas  (8  c.  c.)  of  glycerin,  and  six  fluid  drams  (24  c.  c.)  of  water.  It  should 
be  applied  with  a  sponge  and  allowed  to  dry  on  the  skin. 

The  free  use  of  alkaline  mineral  waters  does  seem  to  favor  the  dislodg- 
ment  of  the  stone,  especially  if  the  authorities  at  Carlsbad  are  to  be  relied  on, 
who  claim  the  discharge  of  immense  numbers  of  biliary  calculi  under  the  use 
of  Carlsbad  water.  Certainly  no  harm  can  attend  its  use,  and  when  within 
the  power  of  the  patient  to  get  it,  it  may  be  freely  taken.  The  same  is 
claimed  by  the  physicians  at  Vichy  for  the  Vichy  waters — true  alkaline  waters. 
In  this  country,  however,  the  Saratoga  waters  may  be  used  instead.  These 
waters  are  saline  and  not  alkaline  waters,  but  they  seem  to  fulfill  much 
the  same  indications.  Those  containing  the  largest  proportion  of  alkaline 
carbonate  are  to  be  preferred.  The  waters  of  Vals — also  true  alkaline  waters 
— are  recommended  for  the  same  purpose. 

Surgical  procedures  have  of  late  been  availed  of  even  with  a  view  to 
exploration,  and  if  done  by  competent  surgeons  with  due  antiseptic  precau- 
tions, cannot  be  regarded  as  more  dangerous  than  most  abdominal  sections. 
The  curative  measure  first  suggested  by  Marion  Sims  consists  in  removing 


448  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  impacted  stone  and  emptying  the  gall-bladder  of  others.  At  the  present 
dav  the  gall-bladder  itself  is  being  successfully  removed.  Under  operative 
procedure  is  included  aspiration  of  the  dilated  gall-bladder,  which  is  justified 
in  the  event  of  a  positive  diagnosis,  though  it  has  been  followed  by  a  fatal 
result.  A  carefully  conducted  exploratory  section  is  little  more  dangerous, 
but,  on  the  other  hand,  should  not  be  done  until  the  case  has  assumed  some 
chronicity.  Nothing  is  gained  at  the  present  day  by  exploratory  puncture, 
but  it  is  interesting  to  know  that  it  was  done  by  the  elder  William  Pepper  in 
1857,  and  by  Roberts  Bartholow  in  1878. 

The  preventive  treatment  is  important,  and  although  an  attack  of  biliary 
colic  very  commonly  does  not  take  place  until  a  number  of  stones  have 
accumulated  in  the  gall-bladder,  so  that  the  descent  of  one  is  apt  to  be  fol- 
lowed bv  that  of  another,  prophylaxis  should  still  be  availed  of.  To  this  end 
diet  is  important.  The  patient  should  eat  sparingly  of  hydrocarbons  and  car- 
bohydrates, omitting  every  form  of  fat.  alcohol,  sugar,  and  starch.  Meat, 
cheese,  and  glutens,  on  the  other  hand,  are  allowable. 

The  alkaline  and  saline  mineral  waters  are  more  especially  indicated 
between  the  attacks  than  during  them,  and  their  more  or  less  continued  use 
is  advisable,  especially  in  the  morning,  when  their  efficiency  is  also  increased 
by  their  being  taken  hot.  The  sodium  salts  have  considerable  reputation  for 
their  efficiency  in  preventing  the  concentration  of  bile  and  formation  of  gall- 
stones, having  been  long  ago  recommended  by  Prout.  The  phosphate  is 
the  modern  favorite,  in  dram  doses  in  the  morning,  or  more  frequently,  but 
the  sulphate  is  more  constant  and  more  potent  in  its  results,  and  little,  if  any, 
m.ore  unpleasant.  The  sodium  salicylate  has  a  similar  reputation,  and  may 
be  used  when  no  eiTect  on  the  bowels  is  desired.  By  either  of  the  former  or 
by  the  aperient  mineral  waters  a  daily  action  of  the  bowels  should  be  secured, 
while  a  proper  hygiene  of  the  body,  in  which  daily  exercise,  bathing,  and 
friction  play  a  conspicuous  part,  is  to  be  constantly  maintained. 

I  have  been  in  the  habit  of  placing  my  patients,  between  attacks,  on  the 
succinate  of  sodium,  in  doses  of  five  grains  ( 0.32  gm. )  three  times  a  day, 
and  it  has  so  happened  that  I  have  seldom  met  a  recurrence  in  one  of  these 
cases,  although  many  of  them  passed  out  of  my  observation  and  may  have  had 
attacks  without  my  knowledge. 


ACUTE   IXFECTIOUS   CHOLECYSTITIS. 
Syxoxym. — Acute  inflainination  of  the  gall-bladder. 

Definition. — Inflammation  of  the  gall-bladder  due  to  infection  by  patho- 
genic bacteria. 

Etiology. — The  most  frequent  predisposing  condition  which  leads  to 
infection  of  the  gall-bladder  is  probably  biliary  calculus,  the  stone  being 
lodged  either  in  the  gall-bladder  or  some  one  of  the  biliary  ducts,  the  vulner- 
ability of  the  mucous  membrane  of  the  gall-bladder  being  thus  increased. 
But  any  obstructive  cause,  such  as  inflammatory  adhesion,  or  even  inflam- 
mator}-  swelling  of  the  mucous  membrane  of  the  cystic  duct,  may  be  such 
cause — facilitating  bacterial  infection.  Adhesive  inflammation  between 
the  gall-bladder  and  intestines,  however  induced,  is  a  rare  cause,  the  process 
extending  inwards  through  the  peritoneum.  Lithiasis  is  not.  however, 
necessary  to  produce  infection.     Pathogenic  bacilli  may  act  independently 


ACUTE  INFECTIOUS  CHOLECYSTITIS.  449 

of  predisposing  cause.  Indeed,  gall-stones  themselves  are  a  result  of  bac- 
terial invasion.  The  infecting  bacterium  may  be  any  one  of  the  pathogenic 
bacteria  infesting  the  small  intestine,  but  recent  observations  have  shown 
the  bacillus  of  typhoid  fever  and  the  colon  bacillus  to  be  probably  the  most 
frequent,  although  the  pneumococcus,  staphylococcus,  and  streptococcus  have 
also  been  found  to  be  the  infecting  agents. 

Morbid  Anatomy. — This  varies  with  the  virulence  of  the  inflammation. 

In  the  severer  cases  there  is  distention  of  the  gall-bladder  with  mucus,  muco- 

pus,  or  pus ;  at  times  its  contents  may  be  hemorrhagic.     Perforation  and 

^^angrene  have  been  the  first  indications   of  the  presence   of   the  disease. 

There  may  be  adhesion  between  the  gall-bladder  and  colon  or  omentum. 

Symptoms. — The  most  invariable  symptom  is  pain,  which  is  commonly 
sudden  and  sometimes  paroxysmal.  It  is  situated  to  the  right  of  the  median 
line  at  the  border  of  the  thorax ;  is  attended  by  fever,  sometimes  preceded  by 
chills  and  followed  by  sweats.  So  many  abdominal  conditions,  however, 
cause  pain  that  it  alone  is  not  distinctive.  Tenderness,  less  circumscribed 
than  might  be  expected,  is  invariably  present.  Jaundice  is  not  a  frequent 
symptom,  never  unless  the  infection  involves  the  hepatic  duct  or  common 
duct.  Vomiting,  on  the  other  hand,  is  very  common  and  often  severe.  It, 
too,  may  be  paroxysmal.  Certain  cases  are  fulminating,  and  it  may  be 
impossible  to  get  the  surgeon  soon  enough  to  avert  perforation  and  a  fatal 
termination.  On  the  other  hand,  many  mild  cases  occur,  like  one  seen  with 
Dr.  Thomas  Potter,  of  Germantown,  succeeding  a  relapse  of  typhoid  fever 
after  a  normal  temperature  had  been  maintained  for  several  days.  After 
recovery  from  this  relapse,  there  occurred  suddenly  a  chill,  sharp  pain  in  the 
region  of  the  gall-bladder,  and  rise  of  temperature.  These  symptoms  sub- 
sided in  four  or  five  days,  to  be  followed  by  another  attack  in  which,  instead 
of  a  chill,  there  was  simply  chilliness  and  with  pain  and  fever  less  marked ; 
again,  after  a  couple  of  days,  a  return  of  pain  with  sudden  rise  of  temperature 
"but  no  chill,  again  disappearing  in  a  few  days.  The  distended  gall-bladder 
may  sometimes  be  felt.  The  pulse  is  sometimes  very  slow,  as  in  a  case 
reported  by  the  late  Frederick  A=  Packard,  where  the  rate  fell  to  48,  and 
another  seen  with  Dr.  Markley,  of  Camden,  N.  J.,  in  which  it  fell  to  40.  It 
is  seldom  over  100.  In  Dr.  Packard's  case  there  was  no  fever,  in  that  of 
Dr.  Markley  the  temperature  rose  to  103°  F.  (39.4°  C). 

Symptoms  may  arise  from  adhesions  with  adjacent  organs,  chiefly  pain, 
tut  sometimes  also  a  dragging  sensation.  These  are  commonly  part  of  a 
chronic  condition.  Constipation  is  also  a  symptom  to  be  expected.  In  fact, 
some  cases  have  been  treated  for  obstruction  of  the  bowel,  for  appendicitis, 
and  more  rarely  for  pancreatitis. 

Diagnosis. — Since  attention  has  been  directed  to  the  subject,  the  diag- 
nosis in  many  cases  has  become  easy.  In  others  it  still  remains  difficult  or 
impossible.  Given  a  case  of  typhoid  fever  in  which,  especially  during  con- 
valescence, a  chill,  fever,  and  sweat  make  their  appearance  and  there  is  pain 
in  the  region  of  the  gall-bladder,  we  may  infer  reasonably  the  presence  of 
cholecystitis.  The  same  inference  may  be  made  if  these  symptoms  occur 
in  a  case  of  chronic  cholelithiasis.  The  presence  of  an  actual  tumor  at  the 
seat  of  the  gall-bladder  is  even  more  confirmatory,  but  in  my  experience 
it  is  not  often  easy  to  recognize  a  distended  gall-bladder  through  the  abdomi- 
nal wall  unless  it  be  of  considerable  size.  Circumscribed  tenderness  is  more 
frequent.  The  severity  of  the  attack  cannot  always  be  inferred  from  the 
early  symptoms,  but  as  there  are  a  good  many  mild  cases,  a  diagnosis  of 

29 


450  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

cholecystitis  need  not  necessarily  cause  alarm.  It  should  be  remembered 
that  jaundice  is  not  a  frequent  symptom,  indeed,  it  is  a  rare  symptom. 

As  to  differential  diagnosis,  the  conditions  with  which  it  has  been  con- 
founded are  appendicitis,  especially  when  the  appendix  happens  to  be  under 
the  liver,  as  it  not  very  rarely  is,  pancreatitis,  localized  peritonitis,  pyone- 
phrosis and  inflammatory  thickening  about  the  pyloric  orifice  of  the  stomach 
and  the  duodenum.  In  the  absence  of  the  predisposing  conditions  referred 
to,  these  lesions  are  sometimes  difficult  to  differentiate.  Disease  of  the  head 
of  the  pancreas  is  much  more  frequently  associated  with  jaundice  than  is 
cholec3'stitis.  If  a  tumor  is  present  in  pancreatitis,  it  is  fixed  and  immovable. 
It  is  not  usually  movable  in  cholecystitis.  An  exploratory  operation  should 
not  be  long  delayed  as  perforation  of  the  gall-bladder  may  precipitate  a  fatal 
issue.  In  cases  like  three  narrated  by  Maurice  H.  Richardson,*  in  none  of 
which  was  there  history  suggesting  gall-stones  and  where  the  symptoms, 
including  pain,  vomiting,  fever,  and  tenderness  over  the  appendix,  were  so 
suggestive  that  an  incision  was  made  in  that  quarter,  a  diagnosis  of  chole- 
cystitis is  impossible.  It  is  difficult  to  see  how  anything  but  appendicitis 
could  be  expected  in  such  cases. 

Prognosis. — This  depends,  of  course,  upon  the  severity  of  the  case  and 
the  promptness  of  operative  interference.  There  appear  to  be  a  good  many 
mild  cases  which  seemingly  do  not  go  beyond  catarrhal  inflammation. 

Treatment. — There  is  really  no  medical  treatment  except  the  symp- 
tomatic, and  the  patient  recovers  through  inherent  tendencies,  or  his  life  is 
saved  by  operation  and  drainage.  In  gangrenous  cases  even  operation  fails 
to  save  some,  but  all  cases  demanding  operation  have  the  chances  of  recovery 
increased  by  promptness.  Richardson  says  that  acute  cholecystitis  de- 
mands interference  even  more  strongly  than  appendicitis.  Counter-irritation 
by  mustard  or  hot  fomentations  may  be  applied  to  the  region  of  the  gall- 
bladder to  relieve  pain.  Nausea  and  vomiting  are  among  the  most  difficult 
symptoms  to  relieve.  It  is  a  reflected  nausea  like  that  of  appendicitis.  Local 
applications  of  ice,  or  at  times  the  opposite  treatment  by  heat,  pieces  of  ice 
swallowed,  champagne,  cold  effervescing  waters  may  all  be  tried.  The 
blister  applied  to  relieve  pain  may  also  check  the  nausea  and  vomiting. 
Calomel  in  hourly  doses  of  i-io  gr.  (.0066  gm.)  to  1-5  gr.  (.0132  gm.),  ap- 
plied dry  on  the  tongue,  should  be  given  in  connection  with  other  remedies. 


CANCER  OF  THE  GALL-BLADDER. 

Etiology  and  Morbid  Anatomy. — Though  rare,  this  affection  has 
excited  much  interest  and  has  been  thoroughly  studied,  with  widely  different 
results  in  some  points.  Thus,  John  H.  Musser,  in  a  study  of  100  cases, 
found  it  three  times  as  frequent  in  women  as  in  men,  while  Courvoisier, 
in  a  study  of  an  equal  number,  found  it  five  times  as  frequent  among 
men. 

It  is  usually  primary,  when  it  commonly  begins  in  the  fundus.  At 
other  times  it  occurs  by  contiguous  invasion,  either  from  the  liver  or  adja- 
cent abdominal  organs.  Cancer  may  also  extend  from  the  gall-bladder  to 
adjacent  parts.  The  primary  form  is  associated  in  at  least  87  per  cent,  of  all 
cases  with  biliary  calculi,  and  there  has  been  much  discussion  as  to  which 

*  "  Acute  Inflammation  of  the  Gall-bladder,"  "  Am.  Jour.  Med.  Sci.,"  June,  1898. 


AFFECTIOXS  OF  THE  BILE  DUCTS.  451 

is  primary,  the  gall-stone  or  the  cancer.  Zenker  and  others  regard  the 
cancer  as  secondary,  starting  in  the  ulcerative  and  cicatricial  tissue  caused 
by  the  stones,  as  is  thought  to  be  the  case  in  some  instances  of  cancer  of  the 
stomach.  This,  too,  may  account  for  the  greater  frequency  of  the  disease 
in  women,  if  such  is  the  case,  since  women  are  much  more  commonly  the 
subjects  of  gall-stone.  It  seems  reasonable  to  regard  the  biliary  calculi  as 
secondary  to  the  cancerous  disease  which  may  produce  changes  in  the 
composition  of  the  bile,  and  I  am  inclined  to  agree  with  ]\Iusser  that  the 
gall-stones  are  only  a  possible  exciting  cause  of  the  cancer. 

A  more  or  less  hard,  solid,  irregular,  and  fixed  mass  is  the  form  assumed 
by  the  cancer. 

Symptoms. — Jaundice  is  absent  so  long  as  the  disease  is  limited  to 
the  gall-bladder,  but  as  soon  as  the  biliary  duct  or  the  common  duct  is 
involved  it  ensues,  so  that  jaundice  is  present  in  69  per  cent.,  gradually 
increasing  in  intensity.  There  is  great  tenderness,  with  pai)i;  vomiting, 
sometimes  of  blood,  bloody  stools,  and  dropsy,  at  times  succeeded  by  the 
cancerous  cachexia.  But  none  of  these  is  distinctive,  being  found  in  cancer 
of  the  pylorus,  duodenum,  and  transverse  colon.  The  presence  of  a  hard, 
uneven,  and  tender  tumor  in  the  neighborhood  of  the  gall-bladder,  and 
which  moves  with  the  liver  in  respiration,  confirms  the  suspicion.  This 
has,  in  fact,  been  found  in  about  69  per  cent.  If  the  disease  is  seated  in 
the  cystic  duct,  the  enlargement  of  the  gall-bladder  is  comparable  to  that  due 
to  obstruction  in  that  duct  from  other  causes,  and  may  be  marked. 

Diagnosis. — This  is  sometimes  difficult.  Pain  and  tenderness  are  more 
marked  than  in  most  other  affections  of  the  liver,  except  cholecystitis.  Fever 
and  rigors  are  exceptional  and  point  rather  to  infectious  disease  of  the  gall- 
bladder or  ducts. 

Treatment. — The  treatment  can  only  be  palliative. 


AFFECTIOXS  OF  THE  BILE  DUCTS. 

Carcinoma  of  the  Biliary  Passages. 

Cancer  of  the  bile-ducts  may  be  primary  or  secondary.  In  either  event 
the  first  symptom  is  usually  jaundice,  which  grows  deeper  and  deeper  until 
the  skin  may  assume  an  almost  bronze-like  hue.  A  cachexia  rapidly  de- 
velops. There  are  pain  and  tenderness  and  moderate  enlargement,  but  noth- 
ing more  destructive  than  the  progressive  jaundice,  which  never  grows  better. 
The  disease  often  escapes  recognition  until  an  autopsy  reveals  it.  Cancer 
may  invade  the  bile-ducts  from  the  gall-bladder  and  possibly  from  primary 
or  secondary  cancers  in  the  parenchyma  of  the  organ.  The  relation  of  the 
morbid  growth  to  gall-stones  in  its  vicinity  is  governed  by  the  same  laws 
as  that  between  gall-stones  and  cancer  of  the  bladder.  The  discussion  need 
not,  therefore,  to  be  repeated  here. 

Stenosis  of  the  Biliary  Ducts. 

Stenosis,  or  more  or  less  incomplete  occlusion  of  the  common  duct,  may 
be  due  to  inflammatory  adhesion  or  to  compression  from  without.  Some- 
times it  follows  the  ulceration  attending  the  passage  of  a  gall-stone.     Exter- 


452  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

nal  pressure  may  be  produced  by  morbid  growths  and  other  causes  alluded 
to  on  p.  436.     Notably,  cancer  of  the  pancreas  is  one. 

Cicatricial  contraction  the  result  of  perihepatitis,  syphilitic  disease,  per- 
forating duodenal  ulcer,  and  cholelithiasis  should  also  be  mentioned  as  a 
cause  of  external  compression  of  biliary  passages,  to  be  recognized,  if  at  all, 
by  aid  of  the  associated  symptoms  of  the  disease  causing  it.  In  the  first 
there  may  be  a  peritoneal  friction  in  the  neighborhood  of  the  liver,  audible 
and  palpable. 

Parasites. 

Parasites  may  enter  the  larger  biliary  passages  and  produce  obstruction. 
Such  are  echinococci  which  may  enter  the  ducts  primarily  in  the  larval 
state  and  develop  there  the  hydatid  cyst  with  resulting  obstruction ;  or, 
as  is  more  frequent,  the  sac  perforates  or  compresses  a  duct  in  the  course 
of  its  growth.  The  other  symptoms  of  echinococcus  disease  are  added  to 
those  of  obstruction  thus  produced,  or  the  cysts  may  appear  in  the  stools, 
vomited  matter,  or  expectoration.  Cases  are  reported  in  which  the  distoma 
hepaticmn  has  been  found  lodged  in  the  hepatic  duct,  and  round  zvornis 
in  the  common  and  hepatic  ducts.  A  remarkable  specimen,  containing  a 
number  of  lumbricoids  lodged  in  these  ducts,  is  in  the  Wistar  and  Horner 
Museum  of  the  University  of  Pennsylvania.  The  symptoms  of  these  last 
conditions  would  be  undistinguishable  from  hepatic  obstruction  from  other 
causes. 


DISEASES  OF  THE  BLOOD-VESSELS  OF  THE  LIVER. 

Hyperemia. 
Passive  Hyperemia — Red  Atrophy. 

The  hyperemia  of  the  liver  which  is  of  chief  clinical  importance  is 
passive  hyperemia. 

Etiology, — It  is  always  due  to  obstruction  to  the  movement  of  the 
blood  towards  or  through  the  heart.  Valvular  heart  disease  is  the  most 
frequent  cause,  though  diseases  of  the  lungs,  such  as  emphysema  or  cirrho- 
sis, intrathoracic  growths,  diseases  of  the  pleura,  compression  of  the  vena 
cava,  or  other  cause  resisting  the  movement  of  the  blood  through  the  organ 
are  all  competent  to  produce  passive  hyperemia  of  the  liver. 

Morbid  Anatomy. — The  appearances  of  the  organ  after  death  are  deter- 
mined by  the  duration  of  the  congestion.  If  it  has  been  of  short  duration,  the 
h'ver  rapidly  assumes  its  natural  size  and  appearance  after  death.  Even  in 
long-continued  passive  congestion  the  liver  after  death  becomes  very  much 
smaller  than  during  life,  by  reason  of  the  emptying  of  the  blood-vessels, 
which  rapidly  succeeds  death.  In  other  respects,  however,  after  prolonged 
hyperemia  it  presents  decided  changes.  It  is  dark  in  color,  and  the  vessels 
still  contain  an  excess  of  blood,  but  the  /nfralobular  vein — i.  e..  the  central 
vein  of  each  lobule — and  its  adjacent  capillaries  contain  most  blood,  con- 
trasting stronsrly  with  the  peripheral  or  z';;f^;'lobular  vessel  and  its  adjacent 
capillaries.  There  is  thus  produced  in  one  way  that  alternation  of  dark  and 
light  tint  which  constitutes  the  nutmeg  liver  and  which  is  particularly  con- 


DISEASES  OF  BLOOD-VESSELS  OF  LIVER.  453 

spicuous  on  section.  It  becomes  even  more  marked  at  a  later  stage,  when 
the  organ,  in  its  ultimate  atrophy,  becomes  reduced  in  size,  constituting  the 
so-called  red  or  cyanotic  atrophy  of  the  liver, — the  atrophied  nutmeg  liver, — 
the  histology  of  which  exhibits  a  destruction  of  the  cells  and  capillaries  in 
the  center  of  each  lobule  and  a  deposit  of  dark  pigment  in  their  places.  In 
the  liver  thus  atrophied  the  blood-vessels  also  share  in  the  destruction,  and 
short  cuts  are  established  between  the  branches  of  the  portal  vein  and  he- 
patic vein,  while  the  latter  may  also  become  dilated.  The  exterior  of  the 
liver  is  smooth,  and  the  organ  dififers  in  this  respect  from  the  cirrhotic 
liver,  though  there  is  sometimes  a  slight  overgrowth  of  the  interlobular 
connective  tissue. 

Symptoms. — The  liver  at  first  is  enlarged  and  tender — sometimes  very 
much  enlarged  and  exquisitely  tender.  The  lower  border,  as  determined 
by  percussion,  may  be  as  low  as  the  umbilicus  and  even  lower.  It  may  be 
the  seat  of  pulsation,  due  to  regurgitation  of  blood  into  it  from  the  right 
heart.  This  pulsation  is  to  be  distinguished  from  a  motion  communicated 
to  the  liver  by  the  action  of  the  heart.  In  the  true  pulsation  the  whole 
liver  seems  to  dilate,  and  does  dilate  as  the  blood  flows  back  into  it,  as  con- 
trasted with  the  downward  movement  communicated  by  the  heart.  Very 
characteristic  of  this  enlargement  is  the  changing  size  of  the  organ  pari 
passu  with  the  degree  of  congestion,  whether  spontaneous  or  the  result  of 
treatment. 

Ascites  is  also  a  symptom.  It  does  not  occur,  however,  until  a  marked 
degree  of  passive  hyperemia  or  secondary  contraction  is  attained.  The 
ascites  is  partly  the  result  of  the  general  stagnation  always  present,  and 
partly  of  the  congestion  of  the  portal  system  due  to  the  backing  of  the 
blood  of  the  hepatic  vein  into  it.  laundice  is  another  rather  rare  symptom. 
It  is  due  to  the  compression  exerted  on  the  fane  interlobular  gall-ducts  by 
the  overdistended  interlobular  capillaries,  thus  producing  an  obstructive 
jaundice. 

Scanty  urine  of  high  specific  gravity  is  also  a  symptom,  while  hyper- 
emia zvith  enlargement  of  the  spleen  and  hyperemia  of  the  mucous  mem- 
brane of  the  stomach  are  constant,  as  a  result  of  the  same  cause. 

Treatment. — The  treatment  of  passive  hyperemia  is  the  treatment  of 
the  condition  causing  it.  Most  frequently  the  cause  is  heart  disease,  and 
when  the  latter  is  amenable  to  digitalis  or  other  heart  tonics,  the  passive 
hyperemia  disappears  with  the  restoration  of  compensation.  Simultane- 
ously the  urine  is  increased,  and  the  general  dropsy,  ascites,  and  hydro- 
thorax  disappear.  Such  treatment  is  aided  also  by  depletion  from  the  por- 
tal side  by  purgatives.  Blue  mass  is  the  type  of  these,  but  colocynth,  ela- 
terium,  and  compound  jalap  powder,  or  the  simple  salts,  are  also  efficient. 
It  sometimes  happens  that  the  general  dropsy  in  these  cases  is  dispersed 
by  treatment,  but  the  ascites  remains,  in  which  event  we  must  suppose  the 
simple  passive  congestion  to  be  combined  with  some  degree  of  atrophy, 
when  the  dropsy  is  more  likely  to  remain.  Treatment  should  now  be  sup- 
plemented by  hydragogue  cathartics,  or,  still  better  by  tapping,  followed 
by  dry  diet  and  the  hydragogues.  A  dram  (4  gm.)  or  more  of  compound 
jalap  powder  may  be  given  each  morning  fasting,  or  elaterium,  1-6  grain 
(o.oi  gm.)  every  three  hours,  until 'the  bowels  are  moved. 

It  was  suggested  by  George  Harley  to  deplete  the  liver  under  these 
circumstances,  and  it  has  been  put  into  practice  by  East  Indian  physicians, 
it  is  said,  with  good  results. 


454  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Active  Hypcrcniia. 

Definition. — This  is  a  much  less  important  condition  than  passive 
hyperemia,  and.  indeed,  is  rarely  recognized.  A  physiological  hyperemia 
of  the  liver  takes  place  after  each  meal,  which  may  be  exaggerated  and 
even  continuous  in  those  who  overeat  and  overdrink  habitually.  Such 
hyperemia  may  lead  to  structural  change,  consisting  ultimately  in  intersti- 
tial growth.  Like  this,  also,  is  the  hyperemia  which  is  associated  with 
diabetes  mellitus,  and  which  is  the  associated  condition  of  many  glycosurias, 
whether  experimental  or  the  result  of  disease  affecting  the  diabetic  center. 
Such  is  a  vicarious  hyperemia  said  to  take  place  during  suppressed  men- 
struation and  after  cutting  off  a  hemorrhoidal  flux. 

Active  hyperemia  does  not,  however,  present  any  symptoms  referable 
to  it,  unless  it  be  that  the  dull  ache  and  full  feeling  sometimes  felt  in  the 
right  hypochondrium  be  caused  by  such  condition. 

Treatment. — The  treatment  of  fluxion  to  the  liver  must  consist  of 
measures  which  tend  to  diminish  this,  mainly  the  substitution  of  a  scanty 
for  an  overabundant  diet,  simple  and  easily-digested  foods,  dilute  milk,  and 
thin  broths,  and  the  avoidance  of  fats,  alcohol,  apd  sugar. 

Thrombosis   axd    Embolism. 

The  portal  vein  is  the  seat  of  thrombosis  and  of  inflammation,  consti- 
tuting pylethrombosis  and  pylephlebitis.  The  hepatic  artery  also  becomes 
rarely  the  seat  of  aneurysms. 

Pylethrombosis. 

Thrombosis  takes  place  in  the  smaller  branches  of  the  portal  vein, 
which  are  constantly  being  obliterated  in  the  course  of  cirrhosis  of  the  liver. 
Larger  branches  are  sometimes  invaded  by  cancer,  or  a  gall-stone  may  be 
admitted  into  one  of  them  by  ulceration,  or  the  lodgment  of  a  parasite  may 
be  the  focus  about  which  a  coagulum  may  form,  while  thrombosis  may  also 
be  favored  by  the  pressure  incident  to  the  encroachment  of  a  neighboring 
tumor. 

Symptoms. — These  include  those  to  be  detailed  when  treating  of 
cirrhosis — viz.,  ascites,  hyperemia  in  the  parts  behind  the  obstructed  vessel, 
with  this  dift'erence.  that  the  symptoms  appear  more  or  less  suddenly  and 
severely.  It  is  mainly  by  the  suddenness  and  intensity  of  the  symptoms 
that  we  are  led  to  suspect  thrombosis,  especially  if  it  be  associated  with 
any  of  the  previously-named  conditions  capable  of  producing  it.  In  such 
an  event  the  symptoms  would  come  about  in  the  course  of  a  few  days, 
instead  of  weeks  and  months.  A  caput  mediiscc  thus  rapidly  produced 
would  mean  that  the  thrombus  had  formed,  not  in  the  portal  vein  itself,  but 
more  peripherally,  causing  the  para-iimbilical  veins  to  be  filled  from  the 
peripheral  branches.  These  come  oft'  the  portal  vein  in  the  suspensory 
ligament,  and  pass  out  to  the  neighborhood  of  the  navel  by  two  branches 
communicating  with  the  epigastric  and  internal  mammary  vein. 

When  pylethrombosis  occurs,  it  sometimes  happens  that  a  complete 
collateral    circulation    is    established,    the    thrombus    undergoing   the    usual 


FATTY  LIVER. 


455 


changes,  while  the  portal  vein  may  be  ultimately  converted  into  a  fibrous 
cord.  Osier  reports  such  a  case,  in  which  compensation  finally  failed,  and 
the  usual  symptoms,  including  hematemesis,  supervened,  and  the  patient 
died. 

Pylephlebitis. 

Mild  grades  of  pylephlebitis  probably  succeed  the  thrombosis  referred 
to,  but  they  are  of  no  consequence  unless  the  thrombus  is  septic.  Hemor- 
.  rhagic  infarct  does  not  usually  succeed  the  lodgment  of  an  embolus  in 
a  branch  of  the  portal  vein,  because  of  the  free  anastomosis  of  its  branches 
with  those  of  the  hepatic  artery,  by  which  the  lobular  capillaries  are 
supplied.  It  does,  however,  sometimes  occur.  Here  again  the  results 
are  not  serious,  so  long  as  the  embolus  is  not  septic.  Much  more 
serious  is  suppurative  phlebitis,  the  result  of  septic  embolism,  or  throm- 
bosis arising  from  an  inflammatory  focus  somewhere  in  the  portal  area, 
as  in  the  bowel  dysentery,  or  in  the  territory  of  the  umbilical  vein 
of  the  new-born  child.  Pylephlebitis  is  one  of  the  causes  of  abscess  of  the 
liver.  It  is  associated  with  the  usual  signs  of  septic  infection — viz.,  chills, 
remittent  fever,  and  sweats,  while  the  symptoms  which  point  to  the  liver 
are  pain  in  that  neighborhood,  jaundice  in  most  cases,  and  the  signs  of 
portal  vein  obstruction  more  or  less  pronounced.  Suppurative  peritonitis  is 
also  sometimes  added.  Such  phlebitis  does  not  always  proceed  to  the  degree 
of  abscess  formation  before  death  supervenes.  The  symptoms  of  abscess 
will  be  considered,  when  treating  of  that  subject,  when,  too,  attention  will 
be  called  to  the  diagnosis  between  it  and  suppurative  phlebitis,  so  far  as  it 
can  be  made  out. 

Other  Changes  in  the  Hepatic  Artery  and  Vein. 

The  artery  is  sometimes  dilated  in  cirrhosis  of  the  liver ;  it  may  be  the 
seat  of  endarteritis  and  sclerosis.  Aneurysm  of  the  artery  is  a  rare  condi- 
tion. The  symptom  is  a  pulsating  tumor,  which  may  be  the  seat  of  a  mur- 
mur. In  the  cases  reported  there  have  been  hematemesis,  bloody  stools,  jaun- 
dice from  compression  of  the  biliary  ducts,  and  pain  in  the  neighborhood  of 
the  liver  due  to  compression  of  adjacent  nerves. 

The  hepatic  vein  is  subject  to  dilatation,  alluded  to  in  treating  of 
passive  h}'peremia ;  to  stenosis,  and  to  thrombosis  extending  backward 
from  the  right  auricle. 

FATTY  LIVER. 

Definition. — The  term  fatty  liver  is  applied  to  a  condition  in  which 
the  cells  of  the  liver  are  more  or  less  completely  converted  into  fat.  This 
is  accomplished,  however,  by  two  distinct  processes.  In  one  there  is  an 
infiltration  of  the  liver  cells  with  fat  drops,  which  simply  push  aside  the 
protoplasm  and  cause  its  ultimate  disappearance  by  interfering  with  its 
nutrition.  In  the  other  there  is  a  disintegration  or  metamorphosis  of  the 
protoplasm  of  the  cell  into  various  products,  of  which  one  is  oil.  In  the 
former,  fatty  infiltration,  the  cell  maintains  its  integrity,  being  simply  filled 
with  the  fat  drops ;  in  the  latter  the  cell  disintegrates  and  leaves  a  residue 
of  which  fat  is  the  chief  representative.  It  should  be  mentioned  that  some 
use  the  term  "  fatty  liver  "  as  synonymous  with  "  fatty  metamorphosis." 


456  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Fatty   Infiltration. 

Etiology. — Abnormal  fatty  infiltration  occurs  in  two  ways. 

1.  In  case  of  overingestion  of  fat-producing  substances,  resulting  in 
obesity,  of  which  it  is  a  part,  and  as  the  result  of  which  the  liver  becomes  a 
storehouse  for  fat.  Excessive  consumption  of  alcohol  is  attended  by  fatty 
infiltration,  because  more  carbohydrate  is  introduced  than  can  be  burned  up. 
It  is,  therefore,  stored  in  the  liver  cells. 

2.  In  a  series  of  cachectic  states,  in  which  oxidation  is  interfered  with 
and  the  fat  which  is  ingested  is  not  oxidized,  but  accumulates  in  the  liver. 
Such  a  condition  is  pulmonary  tuberculosis,  which  is  the  most  common 
cause  of  fat-infiltrated  liver,  except  alcoholism. 

Morbid  Anatomy. — The  liver  of  fatty  infiltration  is  uniformly  large, 
soft,  and  smooth.  Its  appearance  varies  somewhat  at  different  stages. 
Since  the  infiltration  begins  at  the  periphery  of  the  lobule,  we  have,  in  the 
first  stage,  a  simple  distinctiveness  of  the  line  of  demarcation  between  the 
adjacent  acini.  In  the  second  stage  this  has  become  more  marked,  contrast- 
ing strongly  with  the  darker  color  of  the  center  of  the  lobule,  and  producing 
one  form  of  nutmeg  liver — as  contrasted  with  the  liver  of  red  atrophy, 
already  described  in  treating  of  passive  congestion.  In  the  third  stage  the 
entire  acinus  is  infiltrated,  and  the  whole  organ  assumes  a  uniform  yellow 
or  brownish-yellow  appearance,  from  complete  fatty  infiltration  of  the  cells. 
The  organ  is  also  anemic.  In  this  last  stage  it  is  that  we  have  the  macro- 
scopic changes  complete — the  softness,  the  broadened  edges,  and  increase 
in  size,  with,'  however,  a  decided  reduction  in  specific  gravity,  so  that  the 
whole  organ  floats  when  placed  in  water. 

Symptoms. — Outside  the  physical  condition,  determined  by  palpation 
and  percussion,  and  the  causing  disease  or  state,  there  are  no  distinctive 
symptoms.  There  is  no  jaundice,  and  the  bile-forming  function  of  the 
liver  seems  little  interfered  with,  though  the  stools  are  pale.  There  is  no 
obstruction  to  the  portal  circulation,  and,  therefore,  no  abdominal  dropsy. 
Percussion  recognizes  enlargement  of  the  liver,  which  is,  however,  moderate 
compared  with  that  of  amyloid  liver  and  cancer,  extending,  as  it  does,  but 
a  short  distance  below  the  normal  site,  where  its  edge  can  be  felt  even 
through  abdominal  walls  of  some  thickness.  There  is  no  enlargement  of  the 
spleen. 

Diagnosis. —  It  becomes  necessary  to  differentiate  the  enlarged  fatty 
liver  from  the  amyloid  liver,  which  is  harder  and  larger  and  associated  with 
enlarged  spleen  and  albuminuria.  With  the  hyperemic  enlargement  of  the 
first  stage  of  cirrhosis  it  is  not  likely  to  be  confounded.  Such  enlargement 
would  be  trifling,  accompanied  by  tenderness,  and  sooner  or  later  succeeded 
by  contraction,  while  the  fatty  liver  continues  to  enlarge.  From  the  enlarge- 
ment due  to  the  cloudy  swelling  characteristic  of  the  infectious  diseases, 
typhoid  and  typhus,  it  is  distinguished  by  the  absence  of  fever  and  other 
symptoms  of  these  diseases. 

Prognosis. — This  depends  upon  that  of  the  causing  disease.  The 
liver  of  fatty  infiltration  can  be  completely  restored  to  its  natural  condition 
with  the  removal  of  the  cause. 

Treatment. — The  treatment  is  that  of  the  disease  causing  it. 


THE  AMYLOID  LIVER.  457 


Fatty   Metamorphosis. 

Definition. — This  is  a  much  more  serious  condition,  in  which  the  cell 
protoplasm  is  directly  converted  into  fat,  or  rather,  perhaps,  into  a  number 
of  products  of  which  fat  is  one,  while  the  cell  undergoes  disintegration.  It 
is  the  effect  of  some  poison,  w'hich  has  its  type  in  phosphorus-poisoning 
and  in  the  cause,  whatever  it  may  be,  of  acute  yellow  atrophy  of  the  liver. 

Morbid  Anatomy. — The  liver,  instead  of  enlarging,  undergoes  rapid 
reduction  in  size,  or  at  least,  if  there  is  enlargement,  it  is  of  such  short 
duration  that  it  is  never  recognized.  The  appearance  and  condition  of  the 
liver,  to  be  described  under  acute  yellow  atrophy,  are  those  of  the  liver 
which  is  the  seat  of  rapidly  progressing  fatty  metamorphosis. 

Symptoms. — They  are  those  of  the  diseases  causing  it,  and  wall  be 
described  under  Acute  Yellow  Atrophy. 

The  prognosis  is  fatal  and  treatment  is  unavailing. 


THE  AMYLOID  LIVER. 
Syxoxyms. — Lardaceous  Liver;  Waxy  Liver;  Albuminoid  Liver. 

Definition. — In  the  amyloid  liver  there  is  an  infiltration,  in  various 
degrees,  of  all  the  tissues  of  the  organ  by  the  so-called  amyloid  substance. 
The  blood-vessel  walls  are  the  first  affected,  and  by  preference  those  of  the 
intermediate  area  of  the  lobule — i.  e.,  that  supplied  by  the  hepatic  artery, 
then  the  central  or  hepatic  vein  zone,  and  finally  the  peripheral  or  portal 
zone.  The  infiltration  begins  in  the  smaller  arteries,  then  invades  the  cells 
and  capillaries,  and  in  extreme  cases  pervades  all  the  liver  tissue,  including 
connective  tissue. 

Etiology. — The  most  usual  cause  of  amyloid  liver  is  prolonged  sup- 
puration, especially  in  connection  with  tubercular  disease  of  the  bones. 
Hence  it  is  found  in  children  who  have  had  hip  disease.  For  the  same 
reason  it  is  found  associated,  though  less  frequently  than  might  be  expected, 
with  prolonged  tuberculosis  of  the  lungs.  Syphilis  is  one  of  the  recognized 
causes,  whence  it  may  arise  as  a  tertiary  manifestation  or  as  the  result  of 
bone  disease  incident  to  it.  Rickets  likewise  produces  some  cases,  and  it  is 
also  associated,  though  rarely,  with  leukemia,  the  cancerous  cachexia,  and 
the  infectious  diseases. 

Morbid  Anatomy. — The  liver  is  much  enlarged,  reaching  sometimes 
enormous  dimensions,  scarcely  exceeded  by  the  largest  cancers.  Its 
appearance  is  waxy  or  bacony,  especially  in  thin  sections.  This  appear- 
ance is  partly  due  to  the  anemic  state  of  the  blood-vessels,  whose  lumen 
is  encroached  upon  by  the  infiltrated  walls.  The  amyloid  parts  strike  a 
mahogany-red  color  with  weak  solutions  of  iodin.  In  addition  to  the 
change  in  size  and  translucency,  the  amyloid  liver  is  hard  and  smooth, 
its  border  usually,  though  not  always,  rounded,  and  its  fissure  exaggerated. 
In  certain  syphilitic  forms  its  surface  is  beset  with  nodules.  Instead  of 
being  general,  the  amyloid  change  is  sometimes  circumscribed,  when  it 
may  be  associated  with  red  atrophy.  '  It  is  occasionally  combined  with  fatty 
infiltration. 

Symptoms. — Bevond  the  enlaro;c}nent.  which  is  usually  manifest,  the 
organ  extending  sometimes  as  low  as  the  umbilicus,  and,  in  addition  to  the 


458  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

symptoms  of  its  causing  state,  there  are  none  peculiar  to  the  amyloid  liver. 
There  is  no  pain,  unless  it  be  the  result  of  an  associated  syphilitic  hepatitis, 
but  there  may  be  a  dragging  scnsatioji,  induced  by  the  weight  of  the  organ. 
There  is  no  jaundice,  though  the  stools  may  be  light-hued,  because  the 
secretion  of  bile  is  diminished.  There  is  no  ascites,  except  in  extreme  cases, 
when  it  is  a  consequence  of  the  general  hydremia,  and  not  of  obstruction 
in  the  portal  circulation.  It  is  usually  associated  with  amyloid  spleen,  which 
is  enlarged,  and  with  the  amyloid  kidney,  which  secretes  albuminous  urine. 

Diagnosis. — This  is  usually  easy.  The  large,  smooth,  hard  organ, 
the  history  of  the  presence  of  the  causing  disease,  the  absence  of  jaundice 
and  of  dropsy,  the  association  of  enlarged  spleen  and  albuminuria,  admit  of 
scarcely  any  other  interpretation.  It  is  to  be  remembered,  however,  that 
amyloid  spleen  is  not  invariably  present,  and,  when  present,  may  be  over- 
shadowed and  compressed  by  the  large  liver.  The  enlarged  liver  of  leuke- 
mia, the  result  of  white-cell  infiltration,  is  not  likely  to  be  confounded, 
because  the  other  symptoms  of  this  afifection  are  so  evident.  The  nodular 
amyloid  liver,  due  to  syphilis,  must  be  remembered  as  a  possibility,  and 
will  be  referred  to  again  in  considering  the  diagnosis  of  cancer  of  the  liver. 

Prognosis  and  Treatment. — They  are  those  of  the  causing  disease. 
I  have  never  seen  an  amyloid  liver  reduced  ,to  the  normal  size,  yet  the 
absence  of  symptoms  growing  out  of  moderate  degrees  of  it  makes  practical 
recovery  not  impossible. 


■    CIRRHOSIS   OF   THE   LIVER. 

Synonyms. — Chronic  Interstitial  Hepatitis;  Gin  Liver;  Granular  Liver; 

Hob-nail  Liver. 

Definition. — Cirrhosis  of  the  liver  is  a  disease  characterized  by  an  over- 
growth of  connective  tissue  with  more  or  less  destruction  of  the  paren- 
chyma of  the  organ,  commonly  attended  by  a  harder  consistence,  sometimes 
by  a  reduction  of  size,  at  others  by  enlarg-ement,  and  at  others  by  no  changes 
in  this  respect.  Too  much  stress  has,  perhaps,  been  laid  in  the  past  on 
shrinking  of  the  organ  as  a  necessary  feature  of  the  disease. 

Etiology  and  Pathology. — Alcoholism  is  the  commonly  recognized 
cause  of  cirrhosis  of  the  liver,  though  by  no  means  all  alcoholics,  even  the 
most  confirmed,  have  cirrhosis.  Indeed,  a  large  number  of  drunkards, 
watched  to  their  death  and  examined  with  special  reference  to  this  subject, 
have  been  found  to  have  normal  livers  at  the  autopsy.  Hence,  some  expe- 
rienced observers,  notably  Francis  E.  Anstie  and,  later,  Henry  F.  Formad, 
were  disposed  to  deny  that  the  abuse  of  alcohol  ever  produces  cirrhosis. 
Even  W.  H.  Dickinson's  observations,  which  were  made  with  the  definite 
purpose  of  settling  the  question,  were  not  so  conclusive  as  might  have  been 
expected.  Thus,  he  noted  in  149  autopsies  upon  persons  connected  with  the 
liquor  traffic,  22.  or  only  14.75  per  cent.,  had  cirrhosis ;  while  out  of  149 
otherwise  engaged.  8,  or  51-2  per  cent.,  were  thus  affected.  On  the  other 
hand,  the  studies  of  the  late  R.  Palmer  Howard,*  of  Montreal,  noted  below, 
seem  to  reaffirm  the  long  acknowledged  dictum.  The  large  fatty  liver  is 
probably  as  frequent  a  consequence  of  alcoholism  as  is  cirrhosis. 

*  R.  Palmer  Howard,  "Transactions  of  the  Association  of  American  Physicians,"  vol.  ii.,  1887. 


CIRRHOSIS  OF  THE  LIVER,  459 

Long-continued  malarial  intoxication  and  congenital  syphilis  are  con- 
sidered causes  of  cirrhosis.  Syphilis  produces,  however,  quite  a  special 
form  of  interstitial  hepatitis.  In  his  able  study  of  that  very  interesting  class 
of  cases,  cirrhosis  in  children,  Dr.  Howard  found  11  per  cent,  due  to  syph- 
ilis, chiefly  hereditary,  while  alcohol  was  still  responsible  in  15.8  per  cent., 
even  in  children.  Passive  congestion  due  to  heart  disease  or  pulmonary 
obstruction  causes  some  cases,  but  red  atrophy  is  the  more  usual  form 
associated  with  valvular  heart  disease.  This  cause  I  consider  more  fre- 
quent than  is  commonly  supposed.  Other  causes  mentioned  are  stimulating 
diet  and  irritation  of  the  gall-ducts  by  such  agencies  as  obstructing  calculus. 
Finally,  a  certain  number  of  cases  of  cirrhosis  are  altogether  inexplicable. 

It  has  heretofore  been  thought  that  most  of  the  causes  act  through 
the  blood  of  the  portal  vein,  irritating  the  connective  tissue  of  Glisson's 
capsule,  which  accompanies  everywhere  the  branches  of  that  vessel,  causing 
first  a  hyperemia,  and  then  a  hyperplasia  of  connective-tissue  cells.  Thus, 
the  first  stage  of  the  disease  would  be  one  of  enlargement,  accompanied 
often  by  tenderness.  Subsequently,  it  was  supposed,  this  embryonic  con- 
nective tissue  undergoes  organization  and  contraction,  gradually  compressing 
the  cells  within  its  grasp  and  ultimately  destroying  immense  numbers  of 
them;  that  the  reduction  in  size  so  often  present  goes  pari  passu  with  a 
hardening  of  the  organ,  which  is  also  a  conspicuous  feature  of  advanced 
degrees  of  the  disease.  But  while  cases  are  met  with  representing  both 
ends,  so  to  speak,  of  the  process,  the  initial  stage  of  enlargement  and  tender- 
ness, and  the  terminal  one  of  smallness  and  hardness,  few  can  attest  that 
they  have  had  the  opportunity  of  tracing  the  one  stage  into  the  other  in 
the  same  patient,  though  the  celebrated  Dr.  Bright,  as  far  back  as  1827, 
claimed  to  have  traced  cirrhosis  from  the  incipient  enlargement  to  the 
smallness  of  the  later  stage.  I  myself  have  seen  reduction  of  size  succeed 
on  enlargement,  but  I  have  never  seen  the  contracted  small  liver  result. 

]Much  more  reasonable  appears  Weigert's  conclusion,  based  on  experi- 
ment, that  the  death  of  the  cells  is  primary  and  the  overgrowth  of  con- 
nective tissue  secondary.  Acknowledging  that  the  majority  of  causes  which 
produce  the  disease,  such  as  alcohol,  for  example,  operate  through  the  portal 
circulation,  it  is  only  reasonable  that  the  cells  whose  business  it  is  to  elimi- 
nate the  poison  should  receive  the  first  sting  and  perish  in  consequence,  and 
that  their  place  should  be  supplied  by  a  reactive  overgrowth  of  connective 
tissue,  as  Weigert  has  shown.  We  may  also  admit  a  reactive  contracting 
effect  of  the  new  connective  tissue  on  remaining  cells,  producing  thus  the 
death  of  a  greater  number. 

T.  G.  Adami's  studies  "  On  the  Bactericidal  Functions  of  the  Liver 
and  the  Etiology  of  Progressive  Hepatic  Cirrhosis "  *  tend  to  support 
this  view.  In  all  the  cells  of  the  liver  in  most  instances  Dr.  Adami  finds 
a  few  dead  bacteria,  but  in  certain  cases  of  cirrhosis,  of  which  he  had 
examined  more  than  twenty  livers,  he  found  large  numbers  of  a  living 
bacillus  which  he  regards  as  one  of  the  many  varieties  of  the  colon  bacillus. 

But  poisons  do  not  enter  the  liver  by  the  portal  vein  alone.  Irritants 
may  enter  by  the  systemic  circulation  (the  hepatic  artery),  and  passively  by 
the  hepatic  vein  and  bile-ducts  when  obstruction  occurs  in  either  of  these 
sets  of  vessels.  Cirrhosis  of  the  liver  may  result  from  any  one  of  these 
four  anatomical  sources,  and  it  may  be  that  each  one  of  these  may  place 

*  Read  before  the  British  Med.  Assoc,  at  its  meeting  in  Edinburgh,  and  published  in  the  "  British 
Medical  Jour.,"  October  22,  1898. 


46o  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

a  more  or  less  special  stamp  on  the  form  originating  from  it,  at  least  at 
the  beginning  of  the  process. 

Though  occurring  in  children,  cirrhosis  of  the  liver  is  still  a  com- 
paratively uncommon  disease  among  them,  being  rarely  met  before  the  age 
of  thirty-five.     It  is  also  a  disease  of  men,  rather  than  of  women. 

Morbid  Anatomy. — At  least  two  well-defined  varieties  of  interstitial 
hepatitis  are  met,  known  as  atrophic  and  hypertrophic  cirrhosis. 

(a)  Of  Atrophic  Cirrhosis. — In  addition  to  the  hardness  and  reduced 
size  of  the  liver,  which  may  fall  from  its  normal  weight  of  four  or  five 
pounds  (1.8  to  2.2  kilograms)  to  two  pounds  (0.9  kilogram)  or  less,  the 
surface  of  the  organ  is  rough  and  uneven.  In  the  formation  of  these 
inequalities  circlets  of  parenchyma  are  replaced  by  connective  tissue,  within 
which  the  parenchyma  remains  intact  and  appears  raised.  According  as 
the  elevations  vary  in  size  the  liver  is  described  as  a  granular  liver,  a  hoh- 
nailed  liver,  or  a  lobular  liver.  If  the  cells  are  fatty,  as  is  sometimes  the 
case,  they  are  yellow ;  at  other  times  they  are  natural  in  hue ;  at  others, 
paler.  It  was  on  the  color  of  these  nodules  that  Laennec  based  the  name  of 
cirrhosis,  from  the  Greek  uippo?,  reddish-yellow,  or  tawny.  In  some  in- 
stances the  cirrhotic  liver  is  quite  smooth,  showing  a  uniform  distribution  of 
the  connective  tissue  through  the  parenchyma  of  the  organ,  appreciable  only 
in  thin  sections  examined  by  the  microscope.  As  the  process  extends  it 
involves  branches  of  the  portal  vein  itself  in  its  destruction,  and  even  bile- 
ducts  are  obliterated.  Amyloid  and  fatty  infiltration  may  be  associated  with 
cirrhosis.  Indeed,  the  atrophic  liver  is  very  commonly  associated  with 
fatty  infiltration,  which  enlarges  the  liver  to  a  degree  which  may  overbalance 
the  contraction.  The  new  connective  tissue,  on  the  other  hand,  is  richly 
supplied  with  blood-vessels  from  the  hepatic  artery,  and  Rindfleisch  has 
suggested  that  the  bile  is  secreted  from  this  blood,  rather  than  that  of  the 
portal  vein. 

(h)  Of  Hypertrophic  Cirrhosis — Elephantiasis  of  the  Liver. — The 
French  clinicians,  headed  by  Charcot  and  Henoch,  have  studied  this  form 
most  thoroughly.  The  liver  is  enlarged,  and  it  is  not  unlikely  that  what  has 
been  characterized  as  the  first  stage  of  atrophic  cirrhosis  has  sometimes 
been  represented  by  this  form  of  disease.  An  important  difference  between 
the  two  forms  is  that,  while  in  both  there  is  an  overgrowth  of  connective 
tissue,  in  hypertrophic  cirrhosis  the  newly-formed  tissue  exhibits  little  dis- 
position to  contraction.  Nor  is  there  any  compression  of  the  branches  of 
the  portal  vein.  On  the  other  hand,  there  is  obstruction  of  the  biliar}' 
channels,  producing  the  jaundice  which  is  so  characteristic  a  symptom, 
whence  the  French  investigators  would  have  the  disease  begin  as  an  inflam- 
mation of  these  passages — a  cholangitis — and  call  it  "cirrhosc  hypcrtro- 
phique  avec  ictere."  It  is  claimed  also  by  Henoch  that  there  is  a  new  forma- 
tion of  biliary  capillaries.  Others  hold  that  this  absence  of  contraction  in  the 
connective  tissue  is  exaggerated ;  that  while  it  is  much  less  marked  than  in 
atrophic  cirrhosis,  it  does  occur  sooner  or  later  if  the  patient  lives  long 
enough.  It  is  said  to  be  further  characteristic  of  the  development  of  con- 
nective tissue  in  hypertrophic  cirrhosis  that  it  is  more  active  zi'ithiit  the 
lobules.  However  this  may  be,  the  liver,  thus  enlarged,  may  weigh  from 
eight  to  ten  pounds  (3.6  to  4.5  kilograms).  Its  color  is  greenish-yellow  or 
green. 

Biliary  Cirrhosis. — This  term  is  used  bv  some  as  synonymous  with 
hypertrophic  cirrhosis;  but  the  French   clinicians  also  describe   a  liver  of 


CIRRHOSIS  OF  THE  LIVER.  461 

increased  size,  in  which  the  enlargement  is  ascribed  to  an  overgrowth  of 
interstitial  connective  tissue,  an  overgrowth  which  replaces  gaps  in  the 
parenchyma  destroyed  through  the  toxic  effect  of  bile  retained  in  the  ducts. 
This  is  followed  by  a  deposit  of  pigment  granules  in  the  interlobular  con- 
nective tissue  and  within  the  acini  themselves.  It  is,  therefore,  "  secondary  " 
to  obstruction  of  the  gall-ducts  by  any  prolonged  cause,  as  a  gall-stone,  tumor, 
or  the  like.  In  such  case  the  liver  is  larger  and  harder.  This  reasoning  seems 
to  be  sustained  by  experiment,  since  ligation  of  the  common  bile-duct  in  ani- 
mals has  been  followed  by  such  cirrhosis.  I  cannot,  however,  see  any  essen- 
tial difference  in  the  etiology  and  motive  of  these  two  forms. 

The  spleen  is  found  enlarged  in  most  cases  of  cirrhosis  of  the  liver  of 
any  variety  which  come  to  autopsy. 

Symptoms. —  (a)  Of  Atrophic  Cirrhosis. — It  must  be  admitted  that 
cirrhosis  of  the  liver  sometimes  fails  to  give  rise  to  any  symptoms.  The 
early  subjective  symptoms  of  this  affection  are  rather  the  result  of  secondary 
conditions  caused  by  it.  Among  these  are,  pre-eminently,  those  of  chronic 
gastric  catarrh,  anorexia,  nausea,  sense  of  distention,  and  resulting  discom- 
fort. The  gastric  catarrh  is  the  consequence  of  chronic  passive  hyperemia, 
due  to  obstructed  movement  of  the  portal  blood  through  the  liver.  As  a 
result  of  the  hyperemia  the  mucous  membrane  of  the  stomach  is  more  or 
less  constantly  covered  with  mucus,  which  excites  nausea  and  interferes  with 
secretion  of  gastric  juice.  A  similar  condition  exists  in  the  small  intestine, 
causing  constipation,  which  is  increased  by  the  deficient  biliary  secretion. 
This  is  further  shown  by  the  paleness  of  the  stools.  The  well-known  com- 
forting effect  of  the  early  morning  "  dram  "  upon  the  inebriate  may  be  due  to 
some  action  of  the  alcohol  upon  this  mucus.  The  disease  is  usually  afrebile. 
Occasionally  there  is  slight  fever  with  temperature  of  100°  to  102°  F.  (37.7° 
to  38.8°  C). 

The  remaining  symptoms  are  also  mainly  the  result  of  the  ligature-like 
effect  of  the  connective  tissue  on  the  portal  vessels.  Nasal  hemorrhage,  often 
very  obstinate,  is  one  of  these.  So  are  gastric  and  intestinal  and,' more  rarely, 
esophageal  hemorrhages,  these  hemorrhages  being  often  enormous  and 
alarming,  but  really  beneficial,  by  removing  the  gastro-intestinal  congestion. 
I  have,  however,  had  two  cases  of  fatal  hemorrhage  thus  caused. 
Either  one  of  these  forms  of  hemorrhage  may  be  the  very  first  symptom  to 
attract  attention.  Uterine  flooding  also  sometimes  occurs,  and  even  hema- 
turia. Similarly  caused  is  the  abdominal  dropsy,  which  is  often  enormous. 
Four  gallons  (15  liters)  and  more  are  not  infrequently  removed  at  one  tap- 
ping, and  sometimes  the  fluid,  from  its  weight,  bursts  through  the  feeble 
barrier  at  the  abdominal  ring,  distending  the  tunica  vaginalis.  The  navel  is 
■often  pushed  out  by  the  enormous  distention. 

The  surface  of  the  upper  abdomen  and  lower  thorax,  anteriorly,  is 
marked  by  overdistended  veins.  This  is  directly  due  to  the  backing  of  the 
blood  into  these  veins,  rendered  possible  by  the  anastomotic  communication 
"between  the  portal  and  caval  circulations.  Such  anastomosis  between  the 
rudimentary  veins  in  the  round  ligament  (branches  of  the  portal  vein)  and 
the  epigastric  and  mammary  veins  leads  to  enlargement  of  the  superficial 
branches  of  the  latter,  and  in  extreme  cases  to  the  formation  of  a  caput 
medusce  about  the  navel.  Communication  between  the  superior  hemorrhoidal 
vein  (a  branch  of  the  portal  vein)  and  the  middle  and  inferior  hemorrhoidal, 
and  through  them  with  the  hypogastric  veins  and  vena  cava,  produces  hemor- 
rhoids, a  characteristic  symptom  of  cirrhosis.     Anastomosis  between   the 


462  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

superior  gastric  vein  (a  branch  of  the  portal)  and  the  inferior  esophageal, 
whose  blood  goes  to  the  cava  through  the  az}gos  and  hemiazygos,  causes  a 
varicose  condition  of  the  veins  of  the  lower  end  of  the  esophagus  which  has 
resulted  in  fatal  hemorrhage.  The  overfilling  of  the  esophageal  and  azygos 
veins  also  obstructs  the  movement  of  the  blood  through  the  intercostal  and 
pleural  vessels  of  the  right  side,  causing  right-sided  hydrothorax.  These 
dilatations,  which  have  been  characterized  as  "  attempts  at  compensation," 
are  to  be  distinguished  from  the  more  diffuse  dilatations  of  the  abdominal 
veins  seen  in  the  flanks,  which  are  due  to  the  pressure  on  the  cava  of  extreme 
abdominal  dropsy,  preventing  the  return  of  the  blood  of  the  lower  extremi- 
ties to  these  veins.  Edema  of  the  legs  is,  however,  much  more  uncommon 
than  abdominal  dropsy,  and,  when  present,  depends  upon  the  further  pressure 
exercised  by  the  enormous  accumulation  of  fluid  in  the  abdominal  sac  upon 
the  returning  blood  of  the  lower  extremities. 

Jaundice  is  a  symptom  in  atrophic  cirrhosis,  though  the  constrict- 
ing effect  of  the  interstitial  tissue  upon  the  gall-ducts  would  lead  us  to 
expect  it  to  be  more  frequent.  It  may  be  because  comparatively  little  bile  is 
secreted.  Fagge  *  reports  34  cases  of  jaundice  out  of  130  examined  in  the 
postmortem  room  of  Guy's  Hospital,  rather  more  than  might  be  expected. 
A  sallowness  of  complexion  is  also  sometimes  present,  while  a  ruddiness  of 
face  is  not  uncommon. 

Physical  examination  by  palpation  and  percussion  discovers  a  dimin- 
ished area  of  hepatic  dullness  in  atrophic  cirrhosis.  On  the  other  hand, 
splenic  dullness  is  often  enlarged,  the  latter  because  of  resisted  return  of  its 
blood  through  the  liver,  though  the  same  cause  which  operates  in  producing 
cirrhosis  may  also  co-operate  to  produce  splenic  enlargement  if  it  be  systemic 
in  origin.  According  to  Frerichs,  the  spleen  is  enlarged  in  about  one-half  of 
the  cases ;  some  even  say  in  three-fourths.  In  alcoholic  cirrhosis  especially 
enlarged  spleen  is  considered  evidence  of  an  advanced  stage  of  the  disease. 
It  is  often  impossible  to  outline  either  liver  or  spleen  because  of  the  extreme 
abdominal  distention,  and  tapping  must  first  be  resorted  to  before  physical 
exploration  is  satisfactory. 

The  urine  in  atrophic  cirrhosis  of  the  liver  is  generally  scanty,  of  high 
specific  gravity,  highly  colored,  and  often  loaded  with  urates,  which  subside 
on  standing,  forming  a  bulky  sediment.  The  proportion  of  urea  is  often 
diminished,  a  natural  result  of  the  deranged  function  of  the  liver,  to  which 
modern  physiology  assigns  an  important  role  in  urea  formation.  The  urine 
also  contains  at  times  bile  pigment,  but  less  frequently  than  in  hypertrophic 
cirrhosis.     Blood  is  also  sometimes  found  in  the  urine. 

Drozvsiness  and  coma  and  even  delirium  are  sometimes  terminal  symp- 
toms, especially  in  cases  where  there  is  jaundice,  but  also  where  there  is 
ascites  without  jaundice.     They  have  been  ascribed  to  cholesteremia. 

(&)  Symptoms  of  Hypertrophic  Cirrhosis. — The  symptoms  which  dis- 
tinguish this  form  from  the  atrophic  variety  are : 

1.  The  jaundice,  which  begins  with  the  first  vague  symptoms  of  the  dis- 
ease and  gradually  deepens  as  the  disease  progresses.  The  explanations  sug- 
gested of  this  feature  of  the  disease,  as  contrasted  v,'ith  its  absence  in  atrophic 
cirrhosis,  cannot  be  said  to  be  altogether  satisfactory.  It  is  simply  true  that 
in  some  way  there  is  produced  obstruction  in  the  biliary  vessels,  perhaps  by 
a  cholangitis. 

2.  The  absence  of  hyperemia  of  the  stomach  and  bowels,  of  hemor- 

*  "Practice  of  Medicine,"  1886,  vol.  ii.  p.  306. 


CIRRHOSIS  OF  THE  LIVER.  463 

rhoids,  enlargement  of  the  spleen,  and  pre-eminently  of  ascites ;  or  the  pres- 
ence at  least  of  only  mild  degrees  of  these  symptoms. 

3.  The  presence  of  tenderness  in  the  liver,  in  addition  to  its  evident 
enlargement  and  smoothness. 

4.  Certain  differences  in  the  urine  in  the  two  forms. 

It  is  a  well-recognized  fact  that  when  there  is  jaundice  the  urine  is  also 
jaundiced.  In  atrophic  cirrhosis  jaundice  is  more  infrequent,  and  when 
present,  say  in  about  one-fourth  the  cases,  it  is  very  slight.  The  same  is  true 
to  a  less  degree  of  the  urine,  for  while  the  latter  is  scanty  and  highly  colored, 
it  less  frequently  contains  bile  pigment.  In  hypertrophic  cirrhosis,  on  the 
other  hand,  bile-stained  urine  is  more  common.  Blood  is  never  found  in  the 
urine  of  hypertrophic  cirrhosis,  while  in  atrophic  cirrhosis  it  sometimes  is 
in  advanced  stages,  as  is  also  albumin.  In  atrophic  cirrhosis  the  urea  is 
diminished;  in  hypertrophic,  it  is  normal  in  quantity.  In  hypertrophic 
cirrhosis  the  feces  are  sometimes  devoid  of  bile ;  at  times,  not. 

Rosenstein  has  made  a  study  of  the  blood  in  hypertrophic  cirrhosis,  and 
has  found  the  red  corpuscles  diminished  one-half  and  the  leukocytes  relatively 
increased.  He  also  found  it  to  coincide  in  certain  cases  with  the  hemorrhagic 
diathesis.  Alcohol  is  said  to  be  even  a  more  important  factor  in  causing 
hypertrophic  than  atrophic  cirrhosis. 

The  course  of  hypertrophic  cirrhosis  is  usually  more  rapid  than  that  of 
the  atrophic.  It  may  be  put  down  at  one  or  two  years,  yet  in  some  cases  it  is 
very  short.  Osier  mentions  a  case  which  proved  fatal  in  ten  days ;  another 
in  three  weeks.  It  may  be  questioned  whether  these  were  not  cases  of  acute 
yellow  atrophy.  All  cases  terminate  more  or  less  acutely.  Delirium  sets  in, 
the  tongue  becomes  dry,  the  pulse  rapid,  and  the  temperature  rises  from 
102°  F.  to  104°  F.  (38.9°  C.  to  40°  C). 

Diagnosis. —  (a)  Of  Atrophic  Cirrhosis. — The  diagnosis  of  cirrhosis  of 
the  liver  is  not  usually  difficult.  If  one  is  satisfied  that  there  is  a  reduction 
in  the  size  of  the  organ,  and  there  are  associated  with  this  no  symptoms  of 
acute  disease  and  no  history  of  starvation,  we  may  infer  scarcely  anything 
else  but  cirrhosis ;  and  if  to  this  is  added  ascites,  without  dropsy  elsewhere, 
the  diagnosis  is  absolute. 

Tubercular  peritonitis,  with  its  liquid  effusion,  has  been  mistaken  for 
cirrhosis,  and  the  wasting  which  attends  advanced  stages  of  the  former 
affection  closely  resembles  that  in  the  latter,  but  the  abdominal  tenderness  in 
peritonitis  is  characteristic,  there  is  fever,  and  the  effusion  is  never  very 
large.     The  tuberculin  test  should  be  applied  in  all  doubtful  cases. 

(b)  Of  Hypertrophic  Cirrhosis. — Hypertrophic  cirrhosis  is  to  be  distin- 
guished from  cancer  of  the  liver,  amyloid  liver,  multilocular  echinococcus 
disease,  and  the  liver  of  obstructive  jaundice.  In  cancer  there  is  no  splenic 
enlargement,  ascites  is  more  frequent,  the  liver  is  more  uneven,  and  the  patient 
is  older,  while  in  hypertrophic  cirrhosis  we  have  also  the  history  of  alcoholism. 

In  amyloid  liver  there  is  also  splenic  enlargement,  but  there  is  no  pain, 
no  jaundice,  and  we  have  the  etiological  history  peculiar  to  amyloid  disease. 

Multilocular  hydatid  disease  in  the  liver  may  present  almost  identical 
symptoms,  including  jaundice  and  splenic  tumor,  but  in  addition  there  are 
the  nodules  on  its  surface  which  soften  with  time. 

The  liver  which  is  associated  with  chronic  biliary  obstruction  and  sec- 
ondary cirrhosis,  while  somewhat  enlarged,  is  not  nearly  so  much  so  as  in 
hypertrophic  cirrhosis.  Hepatic  colic  has  been  present  at  some  time  in  the 
course  of  the  disease.     It  is  also  hard,  and  accompanied  by  marked  jaundice 


464  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

and  other  evidence  of  hepatic  obstruction.  Its  course,  while  slow,  is  more 
rapid  as  a  rule  than  that  of  hypertrophic  cirrhosis,  while  the  liver  also  after 
a  time  diminishes  in  size. 

Prognosis. — The  prognosis  of  cirrhosis  of  the  liver  is  unfavorable  if 
restoration  of  the  normal  organ  be  the  object.  A  liver  once  the  seat  of  inter- 
stitial hepatitis  can  probably  never  resume  its  normal  histologv.  Yet  the  liver 
has  a  good  deal  of  elasticity  of  function,  and  if  the  cause  of  the  condition, 
supposing  it  to  be  alcoholism,  is  removed  and  the  contraction  be  not  too  far 
advanced,  the  patient  may  be  restored  to  comparative  health.  Generally, 
however,  the  course  of  cirrhosis  is  from  bad  to  worse,  although  it  mav  be  a 
slow  course,  and  the  patient  finally  dies  of  exhaustion  and  cholemia. 

It  only  rarely  happens  that  death,  is  caused  by  the  copious  hemorrhages 
from  the  stomach  and  bowels  which  sometimes  occur.  I  have  already 
referred  to  two  cases  in  my  practice.  On  the  other  hand,  thev  frequently 
relieve  the  portal  congestion,  thus  giving  to  the  patient  a  new  lease  of  life. 
He  may  live  many  years  in  comparative  comfort. 

Treatment. — The  treatment  of  cirrhosis  of  the  liver  resolves  itself  into 
two  parts — first,  the  relief  of  the  symptoms,  and,  second,  the  restoration  of 
the  organ  to  its  normal  state. 

Toward  the  first  result  the  removal  of  the  cause  is  indispensable.  The 
alcoholic  must  stop  drinking.  This,  after  some  temporary  inconvenience,  of 
itself  brings  alleviation.  But  the  effect  of  gastric  congestion  remains  in 
part,  and  sufficiently  to  cause  want  of  appetite,  nausea,  unpleasant  taste  in 
the  mouth,  and  a  general  disgust  of  one's  self  and  everyone  else.  The 
mucous  membrane  of  the  stomach  is  swollen,  and  probably  bathed  with 
mucus.  The  latter  can  be  removed  by  free  drinking  of  alkaline  mineral 
waters  before  meals,  such  as  those  of  Vichy,  Vals,  and  Carlsbad,  the  effect 
of  all  of  which  is  increased  when  hot.  Here,  too,  as  in  gastric  catarrh, — it  is 
really  gastric  catarrh  we  are  treating, — the  hot-water  treatment  is  often 
highly  useful  by  ridding  the  stomach  of  mucus.  A  tumblerful,  as  hot  as  it 
can  be  borne,  is  taken  slowly  before  breakfast,  or  before  each  meal.  Its 
effect  is  often  highly  beneficial.  I  know  no  additional  explanation  of  its 
action  unless  it  be  that  it  may  likewise  stimulate  the  secretion  of  gastric  juice. 
Lavage  also  relieves  this  condition  and  its  consequent  symptoms. 

The  congestion  which  is  responsible  for  this  secretion  must  be  removed. 
This  is  best  done  by  the  saline  and  mercurial  purgatives.  Five  to  ten  grains 
of  blue  mass  at  bedtime,  followed  by  a  dose  of  sulphate  of  magnesium  in  the 
morning  or  of  Hunyadi  or  Friedrichshalle  water,  will  deplete  the  engorged 
veins  and  relieve  the  symptoms  for  the  time  being.  The  mineral  waters  of 
Saratoga  in  this  country,  some  of  which  are  also  purgative,  are  very  useful 
for  the  same  purpose.  A  course  at  Saratoga  is  greatly  appreciated  by  the 
confirmed  free  drinker,  and  he  is  always  better  for  some  time  after  it.  The 
hot  saline  and  sulphur  waters  at  Greenwood,  Colo.,  are  similar  in  their  effects. 

Finally,  foods  which  make  the  least  demand  upon  the  stomach  are  to 
be  used.  Fatty  matters  are  especially  contra-indicated.  In  advanced  stages 
milk  and  \'ichy,  peptonized  milk,  and  beef  peptonoids  may  be  assimilated 
when  other  foods  cannot  be  managed  by  the  feeble  digestion,  but  even  these 
are  absorbed  with  difficulty  as  long  as  the  mucous  membrane  of  the  bowels 
is  much  congested. 

The  abdominal  effusion  is  combated  by  the  purgatives  alluded  to,  and 
diuretics  may  be  added ;  of  these  'the  acetate  of  potassium  seems  more  effi- 
cient than  the  bicarbonates  and  citrates  where  dropsy  is  due  to  hepatic  affec- 


SUPPURATIVE  HEPATITIS.  465 

tions.  Perhaps  this  is  because  in  large  doses  it  has  also  some  laxative  effect. 
Theobromin  is  often  an  efficient  diuretic  in  these  cases,  especially  when  the 
heart  is  in  good  condition.  When  the  abdominal  eft'usion  becomes  large,  it 
must  be  removed  by  tapping,  although  the  reaccumulation  may  be  very  rapid 
and  it  may  have  to  be  repeated  many  times.  Recently  operation  has  been 
suggested  for  permanent  cure  of  abdominal  effusion  due  to  this  cause. 

Can  anything  be  done  to  remove  the  growth  of  the  connective  tissue  and 
promote  the  redevelopment  of  the  destroyed  parenchyma?  Presumably,  if 
the  former  could  be  accomplished,  the  latter  may  take  place,  for  there  is 
evidence  to  show  that  the  liver  structure  may  be  reproduced.  Theoretically, 
iodid  of  potassium  is  a  remedy  which  should  melt  away  the  overgrown  con- 
nective tissue.  Practically,  it  is  extremely  doubtful  whether  it  does.  I  have 
never  seen  such  effect,  nor  can  I  point  to  any  reliable  observations  that  affirm 
it.  There  may  be,  however,  and  to  such  an  end  it  is  right  to  use  the  drug 
in  small  doses,  which,  to  produce  any  effect,  should  be  long  continued.  It  is 
also  a  diuretic.  There  is  reason  to  believe  that  the  iodid  is  more  efficient 
when  taken  freely  diluted  and  on  an  empty  stomach  than  in  larger  doses  after 
meals.  Thus  administered,  three  to  ten  grains  (0.2  to  0.66  gm.)  may  be 
regarded  as  a  sufficient  dose. 


SUPPURATIVE  HEPATITIS. 
Synonym. — Abscess  of  the  Liver. 

Etiology. — The  vast  majority  of  abscesses  of  the  liver,  some  would  say 
all  of  them,  are  traceable  to  causes  which,  in  one  way  or  another,  are  associ- 
ated with  microbic  origin.  Even  traumatic  abscess,  which  is  of  admitted 
occurrence,  is  ascribed  to  an  associated  infectious  agent.  The  possibility  of 
abscess  excited  by  simple  chemical,  as  contrasted  with  bacterial  cause  should 
at  least  be  mentioned.  Most  abscesses  of  the  liver  arise  by  infection  from  the 
portal  area.  These  are  thrombotic,  embolic,  or  amebic.  The  thrombotic 
are  caused  by  infectious  thrombus,  which,  starting  in  the  venules  of  an  area 
drained  by  the  portal  vein,  extends  thence  to  the  branches  of  the  portal  vein 
in  the  liver,  where  it  gives  rise  to  a  suppurative  pylephlebitis.  Such  an  area 
is  the  colon  when  the  seat  of  dysentery,  the  rectum  by  its  hemorrhoidal 
veins,  or  the  neck  of  the  bladder.  More  frequently  a  fragment  of  such 
thrombus  lodges  in  a  branch  of  the  portal  vein  and  starts  an  abscess,  consti- 
tuting the  embolic  origin.  Or  the  oiiieba  coli,  which  is  the  cause  of  amebic 
dysentery,  is  transferred  from  its  primary  seat  in  the  intestine  into  the  liver. 
A  similar  mode  of  origin  of  abscess  is  by  an  umbilical  phlebitis  in  the  new- 
born infant. 

Abscesses  of  the  liver  may  also  be  caused  by  infectious  emboli  arising  in 
the  left  heart,  the  pulmonic  or  systemic  circulation,  reaching  the  liver  via  the 
hepatic  artery.  These  emboli  mostly  originate  in  the  lungs  or  left  heart,  but 
may  arise  beyond,  the  condition  being  that  they  are  small  enough  to  pass 
through  the  capillaries  of  the  pulmonary  artery.  Such  would  be  the  abscesses 
caused  by  injuries  to  the  scalp  or  to  bones  of  the  skull,  or  from  seats  of 
osteomyelitis  elsewhere,  all  of  whicb  are  acknowledged  to  be  rare  causes  of 
abscess  of  the  liver.  Septic  emboli,  producing  abscess  of  the  liver,  may  arise 
from  the  left  heart  in  cases  of  ulcerative  endocarditis.  These  are  among  the 
rare  causes  of  abscess  of  the  liver.     Even  a  non-infectious  embolus  may 

30 


466  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

excite  an  abscess  if  brought  into  association  with  pyogenic  organisms  enter- 
ing the  Hver  in  another  way.  Such  organisms  may  enter  the  Hver  through 
the  common  duct  from  the  ahmentary  canal.  This  is  probably  the  route  of 
the  organism  causing  suppurative  cholangitis,  and  of  that  causing  the  abscess 
often  associated  with  hydatid  cyst  of  the  liver.  Finally,  regurgitant  embolism 
of  the  hepatic  vein  is  a  possible  cause  of  hepatic  abscess.  In  the  vast 
majority  of  cases,  however,  abscess  of  the  liver  is  preceded  by  dysentery, 
whence  arises  an  infectious  thrombus,  an  embolus,  or  an  ameba  coli. 

Morbid  Anatomy. — The  right  lobe  of  the  liver  in  its  thickest  part  is  the 
most  frequent  seat  of  abscess — in  two-thirds  of  all  cases.  The  abscess  varies 
in  size  from  that  of  a  mere  point  to  that  of  a  child's  head,  the  whole  right  lobe 
being  sometimes  converted  into  one  abscess  cavity.  It  may  be  single  or 
multiple.  Rarely,  the  abscesses  intercommunicate.  The  liver  is,  of  course, 
proportionately  enlarged.  Notwithstanding  ibis,  the  external  appearance  of 
the  organ  may  not  be  changed.  On  the  other  hand,  if  the  abscess  is  near 
the  surface,  there  may  be  a  prominence  under  which  fluctuation  may  be  recog- 
nized, or  the  liver  may  become  adherent  to  the  abdominal  wall  or  adjacent 
viscera.  The  abscess  cavity,  if  of  any  size,  is  usually  ragged,  and  not  sharply 
defined  from  the  surrounding  hyperemic  liver  tissue.  Such  hyperemia  may 
involve  two  or  three  rows  of  acini.  In  chronic  cases,  however,  there  may  be 
a  tolerably  firm  pyogenic  membrane. 

The  contents  of  the  abscess  may  be  pus,  or  a  puriform  fluid  consisting  of 
the  granular  debris  of  cells,  oil  drops,  a  few  leukocytes,  cholesterin  and  other 
fat  crystals,  and  numerous  crystals  of  bilirubin.  The  ameba  coli  has  been 
found  among  the  contents  of  the  abscess,  but  recognizable  liver  cells  are 
rarely  found.  Occasionally  the  pus  may  become  inspissated,  caseous,  or  even 
calcified  or  encysted.  Should  the  abscess  accompany  hydatid  disease,  echin- 
ococcus  booklets  may  be  found.  The  contents  of  such  abscesses  is  generally 
a  true  pus.  Any  form  of  abscess  may  perforate  the  diaphragm  and  lung, 
producing  interstitial  emphysema;  or  the  pus  with  echinococcus  booklets 
may  be  expectorated ;  or  the  abscess  may  burrow  into  the  peritoneum,  setting 
up  fatal  peritonitis,  or  into  the  pericardium,  causing  fatal  pericarditis ;  into 
any  adjacent  hollow  organs  or  into  the  abdominal  wall,  discharging  exter- 
nally by  fistulous  openings. 

The  thrombotic  and  embolic  forms  of  abscess  always  begin  as  a  phlebitis, 
which  rapidly  invades  the  adjacent  tissue.  Contrary  to  what  is  usual  in 
embolism  elsewhere,  the  lodgment  of  an  embolus  in  the  liver  is  not  followed 
by  hemorrhagic  infarct. 

Symptoms. — There  may  be  latent  liver  abscess,  even  when  the  abscess  is 
of  considerable  size,  though  this  is  a  very  rare  event.  Abscess  of  the  liver 
is  generally  associated  with  pain  in  the  hepatic  region,  with  fever,  very  often 
with  chills,  szveats,  and  sometimes  with  jaundice.  The  pain  is  almost  invari- 
ably accompanied  with  tenderness.  It  may  be  deep  or  superficial,  and  in  the 
latter  event  it  may  be  sharp  and  cutting,  because  involving  the  peritoneum. 
The  characteristic  shoulder  pain  of  hepatic  disease  may  also  be  present. 

Fever  is,  perhaps,  the  most  invariable  symptom,  and  in  no  other  affection 
of  the  liver  does  it  rise  so  high.  Indeed,  except  acute  yellow  atrophy  and 
the  so-called  hepatic  fever,  there  are  no  other  diseases  of  the  liver  associated 
with  fever.  In  the  former  it  is  of  comparatively  short  duration,  and  in  the 
latter  it  is  moderate.  The  temperature  reached  in  abscess  is  very  high, — 
104°  to  105°  F.  (40°  to  40.5°  C), — and  may  be  preceded  by  chills  of  cor- 
responding severity,  while  the  fever,  in  turn,  is  succeeded  by  sweats,  profuse 


SUPPURATIVE  HEPATITIS.  467 

and  exhausting.  Jaundice  is  not  usually  present,  but  may  be,  when  it  varies 
in  intensity.  When  perforation  takes  place  into  the  pleural  sac,  it  is  likely 
also  to  perforate  the  lung,  when  there  succeeds  an  anchovy-sauce-like 
expectoration  of  purulent  matter  quite  characteristic.  In  this  the  ameba  coli 
may  be  present. 

Physical  examination  easily  recognizes  an  enlargement  of  the  organ 
upward  in  the  mammary  and  midaxillary  regions  rather  than  downward,  as 
is  usual  with  other  diseases  of  the  liver.  Yet  the  liver  is  by  no  means  always 
enlarged,  even  if  there  be  multiple  abscesses.  The  enlargement  is  due  not 
merely  to  the  presence  of  pus,  but  is  also  contributed  to  by  the  hyperemia 
and  the  swelling  of  cells.  The  lung  being  thus  encroached  upon,  the  move- 
ment of  the  liver  consequent  on  respiration  is  less  marked  than  in  health. 
The  hepatic  region  is  at  first  unyielding  to  palpation,  but  ultimately  fluctuation 
may  be  recognized,  while  a  doughy  or  edematous  condition  of  the  abdominal 
wall  is  sometimes  present  and  quite  characteristic. 

Diagnosis. — This  may  be  difficult  at  first,  but  as  time  passes  doubts 
clear  up.  Intermittent  fever  very  naturally  is  first  thought  of  in  many 
instances,  but  it  will  not  be  long  before  this  disease  can  be  eliminated. 
There  is  no  enlargement  of  the  spleen,  no  history  of  malarial  exposure,  no 
malarial  organism  is  found  in  the  blood,  and,  above  all,  antiperiodic  thera- 
peutics, so  efficient  in  malarial  disease,  fails  of  its  purpose.  In  the  absence 
of  malaria  and  in  the  presence  of  the  causes  usually  responsible  for  abscess 
of  the  liver  there  is  little  else  left  to  mistake  for  it.  A  pleuritic  effusion  on  the 
right  side  gives  dullness  on  percussion  in  the  same  locality,  but  along  with 
this  are  the  diminished  fremitus  and  diminished  vocal  resonance  character- 
istic of  fluid  in  the  pleural  sac,  while  there  may  also  be  the  bronchial  breath- 
ing brought  on  by  compressed  lung.  A  suppurating  cchinococcus  cyst  may 
give  rise  to  similar  symptoms,  but  in  view  of  its  rarity  in  this  country,  is 
scarcely  likely  to  be  recognized  until  aspiration  discovers  the  elements  char- 
acteristic of  it.  The  needle  should  be  tried  early  if  abscess  be  suspected,  yet 
it  is  evident  that  in  so  large  an  organ  an  abscess  of  moderate  size  may  easily 
elude  it. 

Hepatic  intermittent  fever,  due  to  chronically  impacted  calculus, 
resembles  abscess  by  its  fever,  chills,  and  sweats,  and  by  tenderness  over  the 
liver,  but  the  history  of  hepatic  colic  is  present,  jaundice  is  more  marked  and 
obstinate,  and  the  condition  is  evidently  not  so  serious. 

Prognosis. — This  is  generally  unfavorable.  Even  in  cases  where  the 
abscess  happens  to  point  to  the  surface  and  is  properly  opened,  death  usually 
superv^enes  after  long  and  tedious  illness,  say  in  six  weeks  to  three  months, 
and,  where  surgical  interference  is  not  possible,  death  is  even  more  speedy. 
Cases  do,  however,  recover,  not  so  much  by  the  aid  of  the  physician  as 
through  nature's  irresistible  tendency.  It  is  said  that  with  surgical  inter- 
ference 30  per  cent,  recover,  and  where  this  is  impossible  20  per  cent,  still 
survive,  but  this  has  not  been  my  experience.  The  hydatid  abscess  is  more 
apt  to  terminate  favorably  if  opened  than  is  the  infectious  abscess. 

Treatment. — This  is  palliative  and  supporting,  except  in  those  cases 
where  surgical  interference  is  possible.  The  usual  measures  to  relieve  pain, 
nourishing  and  easily  assimilable  food,  quinin,  iron,  and  stimulants  are 
indicated. 


468  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


PERIHEPATITIS. 

Definition. — An  inflammation  of  the  peritoneal  covering  of  the  Uver. 

Etiology. — Perihepatitis  occurs  in  a  circumscribed  area — (i)  as  the 
resuh  of  extension  by  continuity  from  some  one  of  the  various  diseases  of 
the  Hver,  such  as  abscess  or  hydatid  cyst;  (2)  as  a  part  of  a  general  peri- 
tonitis, and  (3)  rarely  by  the  spread  of  a  pleurisy  through  the  diaphragm; 
(4)  it  may  also  be  caused  by  direct  violence,  as  by  a  blow,  or  be  the  result 
of  a  perforation  of  an  ulcer  of  the  stomach  or  duodenum  or  gall-bladder. 

Morbid  Anatomy. — In  the  more  acute  forms  there  is  a  fibrinous  or 
puriform  product  with  more  or  less  adhesion.  These  adhesions  may  lace  off 
areas  between  the  liver  and  the  diaphragm  which  may  be  filled  with  pus, 
sometimes  large  quantities,  constituting  subphrenic  abscess,  or  if  there  be 
perforation  of  the  diaphragm,  subphrenic  pyopneumothorax,  more  common 
over  the  right  lobe.  In  the  more  chronic  form  the  capsule  of  ihe  liver  is 
thickened,  especially  near  the  portal  fissure,  and  adhesions  may  take  place 
with  adjacent  organs,  as  the  diaphragm,  stomach,  colon,  or  abdominal  wall. 
The  organ  may  be  shrunken  and  lobulated,  and  the  portal  or  hepatic  vein 
and  bile-ducts  may  be  stenosed.  The  capsule  of  the  liver  is  often  found  thick- 
ened at  autopsies  when  no  symptoms  were  present  during  life  to  indicate  it. 

Symptoms. — The  pain  and  tenderness  which,  naturally,  are  attached  to 
this  condition,  while  often  exceedingly  severe,  like  those  of  peritonitis  from 
other  cause,  are  not  distinctive  of  it.  Xor  is  the  jaundice  resulting  from 
compression  of  the  bile-ducts ;  nor  the  symptoms  of  portal  engorgement  due 
to  compression  of  the  portal  vein  by  the  inflammatory  products.  Physical 
examination  sometimes  gives  more  definite  results.  Thus,  a  friction  rub 
may  sometimes  be  heard  in  the  mammillary  line  from  the  seventh  rib  down- 
w-ard,  and  in  the  axillary  line  from  the  ninth  rib  downward ;  also  sometimes 
in  the  epigastrium.  It  is,  however,  of  short  duration.  If  there  is  a  puru- 
lent collection,  fever  is  likely  to  be  present,  while  the  right  hypochondrium 
may  be  distended  and  the  intercostal  spaces  motionless.  The  dullness  on 
percussion  may  extend  as  high  as  the  angle  of  the  scapula,  and  all  the  signs 
of  a  pleuritic  effusion  may  be  present.  On  the  other  hand,  the  lower  border 
of  the  liver  may  be  much  lowered — as  far  down  as  the  navel. 

The  course  of  perihepatitis  may  be  acute,  or  it  may  be  much  prolonged, 
when  all  the  symptoms  of  chronic  suppurative  processes  are  added — fever, 
high  temperature,  sweats,  fistulous  communications  with  other  organs, 
including  the  lungs,  intestines,  and  abdominal  wall. 

Diagnosis. — This  lies  chiefly  between  that  form  of  the  condition  under 
consideration,  attended  with  pus  accumulation  between  the  liver  and  dia- 
phragm, and  an  empyema  or  pneumothorax.  The  physical  signs  and  later 
symptoms  are  very  similar,  and  it  is  chiefly  in  the  initial  symptoms  that  the 
two  conditions  differ,  the  one  beginning  with  cough  and  pleuritic  pain  asso- 
ciated with  cardiac  displacement ;  the  other  with  symptoms  more  abdominal 
in  situation.  The  liver  in  pleuritic  effusion  and  empyema  is  never  so  much 
pushed  dov.-n  as  in  the  hepatic  disease.  Aspiration  may  also  be  availed  of  in 
diagnosis.  The  trocar  is  to  be  introduced  in  the  midaxillary  line  in  the 
seventh  or  eighth  interspace.  It  was  pointed  out  by  Pfuhl  that  in  subphrenic 
abscess  the  spurting  occurs  with  inspiration  or  as  the  diaphragm  moves  down- 
ward, and  in  empyema  with  expiration  as  the  diaphragm  moves  upward. 
The  atrophic  results  of  perihepatitis  are  rarely  recognized  before  death. 


ACUTE  YELLOW  ATROPHY  OF  THE  LIVER.  469 

Prognosis.— This  is  grave  in  the  severer  forms  terminating  in  suppura- 
tion. A  protracted  illness,  with  gradual  exhaustion  of  the  patient's  strength, 
is  prone  to  occur,  which  skillful  surgical  measures  may  nevertheless  turn  to 
recovery.     Milder  attacks  terminate  favorably  in  a  few  days. 

Treatment. — Treatment  in  the  early  stage  must  consist  of  measures 
to  relieve  pain,  local  and  general.  Counterirritation  by  cupping  operates  to 
check  the  disease  and  also  shorten  the  attack.  Sinapisms  and  fomentations 
contribute  in  a  less  degree  to  the  same  end.  If  suppuration  occur,  the  coun- 
sel and  aid  of  a  surgeon  should  be  early  sought,  as  it  is  by  his  efforts  that  a 
cure  becomes  possible. 

Glissonian  Cirrhosis. — This  is  a  term  applied  to  a  form  of  peri- 
hepatitis in  which  the  capsule  is  thickened,  assuming  a  semicartilaginous 
appearance.  It  is  associated  with  reduction  in  size  and  some  degree  of  inter- 
stitial overgrowth  and  distortion.  The  capsule  may  attain  a  thickness  of 
from  4-10  to  6-10  of  an  inch  (i  to  1.5  cm.). 


ACUTE  YELLOW  ATROPHY  OF  THE  LIVER. 

Synonyms. — Icterus  gravis;  Acute  Parenchymatous  Hepatitis;  Malignant 

Jaundice. 

Definition. —  A  rapidly  destructive  disease  of  the  liver,  resulting  in  fatty 
degeneration  and  atrophy  of  the  organ,  associated  with  toxic  symptoms  and 
death. 

Etiology. — This  remarkable  and  fortunately  rare  disease  is  probably 
due  to  the  action  of  some  virulent  poison,  autogenetic  perhaps,  but  whose 
nature  is  as  yet  undiscovered.  Pregnancy  is  one  of  the  conditions  acknowl- 
edged to  produce  it,  and  more  cases  occur  among  women  than  men.  It 
occurs  in  the  second  half  of  pregnancy.  It  has  occurred  in  the  course  of  the 
infectious  diseases,  and  the  usual  microbic  origin  has  been  held  responsible 
for  it,  as  have  been  alcoholism  and  mental  excitement.  Bacteria  have  been 
found  in  the  organ  after  death.     Beyond  this  we  know  nothing  of  its  cause. 

Pathology  and  Morbid  Anatomy. — The  destructive  process  in  the  liver 
is  almost  identical  with  that  of  phosphorus-poisoning,  and  consists  essen- 
tially in  a  very  rapid  destruction  of  liver-cells.  Opinions  are  divided  as  to 
whether  this  is  the  result  of  an  acute  inflammatory  process,  or  whether  the 
cells  are  destroyed  by  some  solvent  action.  Frerichs  and  Demme  held  the 
view  that  it  is  an  acute  parenchymatous  inflammation,  of  which  the  chief 
seat  is  the  peripheral  zone  of  the  lobule,  whose  swelling  causes  obstruction 
in  the  biliary  capillaries  and  the  reabsorption  of  bile.  Henoch  and  von 
Dusch  consider  retention  of  bile  the  starting-point,  and  that  the  liver  cells  are 
dissolved  by  this  retained  bile.  Munk  regarded  all  cases  as  the  result  of 
phosphorus-poisoning. 

The  liver  at  necropsy  is  found  very  much  reduced  in  size,  often  to  half 
and  even  quarter  its  normal  volume.  This  may  take  place  in  three  or  four 
days,  and  even  less.  A  stage  of  primary  enlargement  is  said  to  be  sometimes 
present,  but  Is  never  seen  at  autopsy.  The  organ  is  flattened,  flabby,  and  can 
be  folded  over  on  itself,  and  the  usual  lobular  markings  are  either  very  indis- 
tinct or  altogether  absent.  The  capsule  is  loose  and  wrinkled,  and  the  organ 
is  of  a  dirty  yellow  color. 


470  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

On  section,  the  surface  is  either  uniformly  yellow  or  it  exhibits  an  alter- 
nation of  yellow  and  red.  The  yellow  appears,  for  the  most  part,  in  islets, 
which  are  surrounded  by  the  red.  The  yellow  represents  an  earlier  stage  of 
the  disease.  It  is  soft  and  spongy,  and  rises  cushion-like  above  the  surface. 
The  red  is  tougher,  more  leathery,  and  sinks  below  the  level  of  the  cut  surface. 
When  the  organ  is  uniformly  yellow,  this  later  stage,  represented  by  the  red, 
has  not  been  reached  before  death. 

Histologically,  the  ycllozc  areas  exhibit  softening  and  apparent  solution  of 
the  cell  network,  very  few  liver  cells  remaining  which  retain  their  own  con- 
tour. Instead  are  found  disintegrating  cells  wath  fat  drops  of  all  sizes,  the 
cells  being  in  places  still  united  by  their  connecting  substance  so  as  to  main- 
tain the  original  network.  Sometimes  crystals  of  bilirubin,  leucin,  and 
tyrosin  are  met  with.  The  red  areas  consist  of  a  loose  connective  tissue 
whose  meshes  contain  fat  drops  and  biliary  coloring-matter,  representing  the 
softened  liver  parenchyma  bereft  of  its  cells.  In  places  there  may  be  seen  a 
slight  degree  of  cell  infiltration  of  the  interstitial  tissue,  in  others  irregular 
branching  bands  and  apparently  blind-ending  tubes  of  cells  resembling  biliary 
epithelium.  These,  Waldeyer  says,  are  the  result  of  an  attempt  at  repair. 
The  atrophy  usually  takes  place  more  rapidly  in  the  left  lobe. 

The  skin  and  organs  are  generally  intensely  bile-stained.  There  may 
be  small  extravasations  of  blood  in  various  parts.  The  spleen  is  enlarged 
and  hyperplastic,  the  renal  epithelium  and  heart  muscle  are  fatty,  while  the 
serous  cavities  contain  more  than  the  normal  amount  of  fluid. 

Symptoms. — There  are  no  symptoms  distinctive  of  the  beginning  of 
acute  yellow  atrophy.  For  several  days  there  may  be  signs  of  gastro-intes- 
tinal  catarrh,  promptly  followed  by  jaundice.  The  former  include  headache, 
malaise,  loss  of  appetite,  nausea,  vomiting,  eructations,  and  epigastric  discom- 
fort. Then  there  suddenly  supervene  serious  symptoms — delirium,  abdom- 
inal pain,  convulsions,  local  or  general  drozvsiness,  and  coma.  Sometimes 
the  symptoms  of  this  stage  are  delayed — in  extreme  cases  as  long  as  three 
weeks. 

The  liver  rapidly  diminishes  in  sise.  Three  or  four  days  may  see  its 
disappearance  to  percussion  and  palpation,  favored  by  further  obscuration 
by  distended  air-holding  viscera.  W.  von  Leube  calls  attention  to  a  symp- 
tom elicited  by  palpation  which  he  thinks  may  be  of  diagnostic  value — a 
more  or  less  permanent  "  pitting  "  to  pressure  in  the  epigastric  region.  He 
ascribes  this  to  an  impression  made  upon  the  relaxed  liver,  to  which  the 
abdominal  wall  fits  itself.  The  spleen,  on  the  other  hand,  is  enlarged,  the 
jaundice  is  intense,  the  vomiting  obstinate,  while  there  may  be  epistaxis, 
hematemesis,  hematuria,  nienorrhagia,  and  hemorrhagic  extravasations, 
while  the  stools  are  devoid  of  bile.  The  pregnant  woman  aborts.  There 
is  little  fever,  and  in  the  worst  stage  there  is  but  moderate  rise  of  tempera- 
ture— rarely  above  ioi°  F.  (38.2°  C).  The  pulse,  at  first  infrequent,  in- 
creases toward  the  end  to  120  or  more. 

The  ichanges  in  the  urine  are  very  characteristic  and  have  been  thor- 
oughly studied.  It  is  deeply  bile-stained,  is  concentrated,  the  specific 
gravity  often  reaching  1030.  It  is  slightly  albuminous,  and  may  contain 
the  bile  acids,  bile-stained  fatty  casts,  and  bile-stained  renal  epithelium. 
The  quantity  of  urea  is  diminished,  even  totally  absent.  The  characteristic 
feature  is  the  presence  of  leucin  spheres  and  tyrosin  needles  in  most  cases. 
These  crystals  may  appear  without  treatment  of  the  urine  or  they  may  come 
down  after  slight  concentration.     In  addition  are  found  also  aromatic  oxy- 


MORBID  GROWTHS  OF  THE  LIVER.  471 

acids,  especially  oxymandelic  acid,  all  representing  products  of  albumin  dis- 
integration. 

Diagnosis, — The  symptoms  of  acute  yellow  atrophy  in  the  first  stage 
do  not  admit  of  a  diagnosis.  This  is  the  more  true  because  there  is  no 
symptom,  even  atrophy,  which  may  not  be  wanting.  Thus,  cases  have 
perished  from  hemorrhage  before  the  disease  was  recognized  or  before 
jaundice  appeared  in  the  rapidly  terminating  cases.  In  the  second  stage, 
on  the  other  hand,  the  symptoms  are  so  distinctive  that  it  seems  almost 
impossible  for  one  familiar  with  them  to  fail  to  recognize  them.  It  is, 
however,  so  rare  a  disease  in  this  country  that  the  opportunity  does  not 
often  present  itself ;  hence  it  is  sometimes  overlooked  because  not  sus- 
pected, the  more  excusably  because  grave  nervous  symptoms  may  occur 
even  in  catarrhal  jaundice  and  in  the  infectious  diseases — as,  for  example, 
in  pneumonia,  where  jaundice  is  sometimes  a  symptom.  Acute  phosphorus- 
poisoning  so  closely  resembles  acute  yellow  atrophy  that  the  diagnosis 
depends  largely  upon  the  possible  recognition  of  the  cause.  There  are, 
however,  some  differences.  The  reduction  in  size  of  the  liver  is  not  so 
rapid,  the  nervous  symptoms  are  not  so  grave,  and  leucin  and  tyrosin  are 
not  usually  found  in  the  urine  of  phosphorus-poisoning.  Hypertrophic 
cirrhosis  also  sometimes  resembles  acute  yellow  atrophy  clinically,  but  the 
enlarged  liver  is  the  distinctive  feature  of  the  former. 

Prognosis. — This  is  so  unfavorable  that  recovery  may  be  said  to  imply 
an  error  of  diagnosis. 

Treatment. — There  is  no  curative  treatment.  Symptoms  should  be 
relieved  by  the  usual  palliatives.  Headache  should  be  relieved  by  phenacetin 
and  acetanilid,  rather  than  morphin.     An  ice-bag  may  give  great  relief. 


MORBID  GROWTHS  OF  THE  LIVER. 

The  only  morbid  growths  of  the  liver  which  are  of  clinical  importance 
are  cancer  and  sarcoma.  An  angioma  is  an  interesting  new  formation  of 
small  size,  which  presents  no  recognizable  symptoms  before  death.  It  is 
composed  of  vascular  tissue  and  is  distinctly  capsulated.  The  large  sizes 
may  be  as  large  as  a  walnut,  more  rarely  still  larger.  Some  pathologists 
describe  an  adenoma,  which  others  class  among  the  cancers  as  a  trabecular 
variety.  Myoma  is  another  form  of  histioid  tumor  rarely  found  in  the  liver. 
Cysts,  represented  by  the  dilatation  cyst  and  the  hydatid  cyst,  are  of  occa- 
sional occurrence. 

Carcinoma  of  the  Liver. 

Etiology. — Cancer  of  the  liver  is  a  comparatively  common  disease ; 
of  internal  organs,  next  in  frequency  to  that  of  the  uterus  and  stomach.  It 
is,  moreover,  in  the  vast  majority  of  cases  secondary — in  full  three-fourths 
of  cases,  and  of  these  two-thirds  are  secondary  to  primary  cancer  of  the 
portal  area,  one-third  to  primary  cancer  elsewhere.  The  stomach  Is, 
naturally,  the  most  frequent  primary  focus.  Cancer  of  the  liver  is  most 
common  in  male  adults  between  the  fortieth  and  sixtieth  year,  yet  it  does 
occur  occasionally  in  children. 

Morbid  Anatomy. — There  are  two  chief  forms  in  which  cancer  of  the 
liver  presents  itself — the  nodular  and  the  massive.  Rare  forms  are  radiating, 
colloid,  and  cancer  with  cirrhosis. 


472  DISEASES  OF  THE  DIGESTIVE  SYSTEiM. 

1.  In  the  nodular  form  nodules  of  various  sizes  are  scattered  through- 
out the  organ.  The  nodules  vary  in  diameter  from  one-fifth  of  an  inch  to 
two  inches  (0.5  cm.  to  5  cm.)  or  more.  They  are  usually  opaque,  white, 
or  yellowish-white,  and  may  be  very  numerous.  The  superficial  nodules 
project  above  the  surface,  and  ma}-  even  be  felt  through  the  abdominal  wall 
in  the  emaciated  subject,  giving  rise  to  the  oft-described  ''  bosselated  "  feel. 
These  superficial  nodules  are  often  umbilicated,  because  of  the  disintegration 
and  absorption  of  the  older  central  cells,  leaving  a  residue  of  connective 
tissue  and  partially-obliterated  blood-vessels.  The  umbilication  is  confined 
to  the  superficial  nodules,  which  also  received  the  name  of  Farre's  tubercles. 
This  variety  of  nodular  cancer  may  be  both  primary  and  secondary.  The 
nodules  usually  reach  a  larger  size  in  the  secondary,  and  are  apt  to  be  more 
numerous. 

2.  The  uiassiz'e  form,  in  w'hich  there  is  one  large  cancerous  mass, 
greatly  increasing  the  bulk  of  the  organ.  It  is  grayish-white  in  color,  and 
may  reach  four  or  six  inches  (10  or  15  cm.)  in  diameter.  This  form  is 
primary. 

3.  The  radiating  form,  usually  pigmented,  in  which  the  nodules  may 
also  be  multiple,  but  smaller  and  less  numerous  than  in  ti.e  nodular  form. 
It  is  a  form  of  secondary  cancer. 

4.  A  colloid  form,  rare  and  only  secondary. 

5.  A  rare  form  is  cancer  zvith  cirrhosis,  in  which  the  liver  is  but 
slightly  enlarged,  weighing  4.5  to  6.5  pounds  {circa  2  or  3  kilograms),  and 
presents  a  greenish-yellow  appearance,  studded  over  with  small  white 
nodules  not  unlike  those  of  the  hob-nail  liver,  the  same  appearing  in  large 
numbers  when  the  organ  is  cut. 

All  varieties  of  cancer  are  subject  to  degeneration,  but  the  secondary 
forms  more  rapidly.  The  change  is  a  fatty  metamorphosis  of  the  cells, 
associated  sometimes  with  rupture  of  blood-vessels  and  large  extravasations 
of  blood,  which  may  even  burst  into  the  peritoneum  and  gall-bladder. 
There  may  be  occasional  suppuration  around  the  nodule. 

As  to  the  histological  origin  of  cancer,  the  primary  forms  start  in  the 
liver  cells;  they  are  true  epitheliomata,  the  capillary  network  forming  the 
primary  stroma,  to  which  an  independent  growth  of  stroma  is  subsequently 
added.  The  secondary  forms  are  embolic  in  origin,  chiefly  through  the 
branches  of  the  portal  vein,  but  possibly  by  the  hepatic  artery,  with  or 
without  intermediate  involvement  of  the  lung,  the  first  new  cancer  cell 
being  an  infected  cell  of  the  capillary  wall,  whence  the  parenchymal  liver 
cells  are  in  turn  afifected.  Tfie  stamp  of  the  pigmented  radiating  cancer 
is,  perhaps,  thus  derived,  and  illustrates  this  mode  of  invasion.  The  second- 
ary forms  repeat  the  type  of  the  primary  varieties.  The  cells  are  mainly 
epithelioid,  but  may  be  polygonal  and  even  cylindrical.  They  exhibit  va- 
rious grades  of  fatty  degeneration. 

The  liver  is  variously  enlarged  by  these  dififerent  forms  of  cancer,  the 
maximum  product  being  the  largest  produced  by  any  disease  of  the  liver 
(see  Fig.  36). 

Sarcoma. — Of  the  remaining  morbid  growths  of  the  liver,  sarcoma 
alone  demands  a  few  words.  It  is  almost  invariably  secondary,  very  few 
cases  of  primary  sarcoma  of  the  liver  having  ever  been  found.  Secondary 
sarcoma  of  the  liver  includes  melanosarcoma,  lymphosarcoma,  and  myxo- 
sarcoma. The  melanosarcoma  is  the  most  frequent  and  interesting.  It  is 
always  secondary  and  usually  multiple,  though  a  diffusely  infiltrated  variety; 


MORBID  GROWTHS  OF  THE  LIVER. 


473 


exists,  giving  the  liver  on  section  a  granitic  appearance.  Melanotic  sarcoma 
of  the  orbit  often  precedes  it,  and  it  is  sometimes  a  part  of  a  general  melan- 
otic distribution  over  the  body,  including  the  skin.  Sarcoma  of  the  liver  is 
said  to  be  never  associated  zvith  ascites. 

Symptoms. — Very  rarely  cancer  of  the  liver  may  be  latent,  except 
as  to  a  vague  ill  health  explained  by  the  findings  of  the  autopsy.  In  most 
instances  such  ill  health  grows  worse  more  or  less  rapidly,  and  examina- 
tion of  the  liver  discovers  enlargement,  to  which  may  or  may  not  be  added 
recognizable  nodules.     The  enlargement  may  extend  beyond  the  umbilicus. 


Z', 


K 

'^-- 

• — -^ 

---::::;.' 

"j'_ 

""-'^<-'f 

.-1^^^— 

Fig.  36. — Showing  Approximate  Enlargement  of  the  Liver  Corresponding  to  the  Dif- 
ferent Diseases  Described  in  the  Text — {after  Rindfieisch). 
I.  Position  of  the  diaphragm  to  the  maximum  enlargement  (carcinoma  and  in  abscess), 

//,  //.    Normal    situation   of   the  diaphragm.     //,   ///.   Relative  dullness.     IV. 

Border  of  the  liver  in  cirrhosis.      V.  Border  in  health.      VI.  Lower  border  of  the 

fatty    liver.      VII.    Of  the   amyloid    liver.      VIII.    Of    cancer,    leukemia,    and 

adenoma. 

but  it  is  not  usually  so  great,  and  in  some  cases  there  is  none  whatever. 
To  inspection  the  enlargement  is  first  seen  in  the  upper  zone  of  the  abdo- 
men, and  produces  a  change  of  configuration  which  involves  commonly  the 
whole  upper  abdomen.  Rarely,  the  nodules  may  be  seen.  The  supeiUcial 
veins  are  enlarged. 

The  other  signs  of  ill  health  alluded  to,  apart  from  those  of  a  primary- 
cancer  elsewhere,  are  loss  of  appetite,  nausea,  a  sense  of  epigastric  fullness, 
pain  in  the  epigastric  or  hypochondriac  region  or  in  both  simultaneously. 
The  pain  may  be  lancinating  and  extend  to  the  right  shoulder.     To  this 


474  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

tenderness  is  sooner  or  later  added.  Indeed,  perhaps  tenderness  precedes. 
Emaciation  may  have  preceded  the  more  striking  degree  of  these  symp- 
toms and  increases  rapidly,  while  the  characteristic  cachexia  develops  pari 
passu.  An  examination  of  the  blood  shows  a  reduction  of  hemoglobin  and 
corpuscles,  and  as  the  'blood  becomes  thin  edema  develops.  In  some  cases 
there  is  fever,  especially  toward  the  end,  with  a  temperature  of  ioo°  to 
102°  F.  (37.8°  to  38.9°  C),  more  or  less  intermittent,  but  rarely  associated 
with  rigors. 

Obstructive  jaundice  is  a  frequent  symptom  in  carcinoma  hepatis — it 
may  be  said  in  fully  half  the  cases.  It  is  due  to  compression  of  the  smaller 
biliary  passages,  and  does  not  usually  reach  a  high  degree.  Nor  are  the 
feces  usually  devoid  of  bile.  If  the  latter  event  occurs,  and  the  jaundice  is 
intense,  it  means  that  some  of  the  larger  ducts  are  obstructed,  while  involve- 
ment of  the  gall-bladder  or  the  portal  lymphatics  may  be  suspected.  Jaun- 
diced urine  is  about  as  constant  as  jaundice  itself.  The  presence  of  melanin 
is  said  to  point  especially  to  the  presence  of  the  pigmented  varieties  of 
cancer.     Albuminuria  is,  on  the  other  hand,  unusual. 

Ascites  is  a  rather  infrequent  symptom,  and  can  only  occur  when  the 
portal  vein  or  branches  become  involved  either  by  compression  or  invasion. 
Should,  however,  a  bloody  fluid  be  obtained  by, tapping,  and  a  tumor  of  the 
liver  be  present,  the  indications  are  that  the  tumor  is  cancer.  Enlargement 
of  the  spleen  is  rarely  present  in  cancer  of  the  liver. 

The  duration  of  the  disease  ranges  from  three  to  fifteen  months. 

Diagnosis. — This  is  not  always  easy,  even  if  there  is  enlargement. 
It  is  simplified  if  the  nodules  can  be  felt,  or  if  there  is  recognized  primary 
cancer  elsewhere. 

The  smooth,  enlarged  liver  of  cancer  is  distinguished  from  that  of  the 
more  benignant  conditions  of  fatty  liver  and  amyloid  liver  by  the  absence 
in  these  two  of  grave  symptoms  and  of  jaundice.  The  fatty  liver  is  softer 
than  the  liver  of  cancer,  the  amyloid  is  harder,  more  often  smoother,  while 
its  rounded  border  can  sometimes  be  felt.  It  is  also  accompanied  by  en- 
larged spleen.  In  abscess  of  the  liver  the  organ  may  be  soft  or  doughy  in 
consistence,  and  the  same  may  be  true  of  the  abdominal  walls  over  it. 
There  are  also  the  causes  of  abscess  of  the  liver,  and  among  symptoms  the 
characteristic  chills,  high  fever,  and  sweats. 

Multiple  echinococcus  cysts  may  furnish  similar  local  signs,  even  the 
"  bosselated "  feel,  but  hydatid  disease  is  rare  in  temperate  climes ;  the 
nodules  are  softer,  the  disease  is  of  longer  duration,  and  is  less  rapidly  fol- 
lowed by  wasting.  Enlargement  of  the  spleen  is  quite  common  in  hydatid 
disease,  present,  it  is  said,  in  nine-tenths  of  all  cases.  Jaundice  is  even 
more  frequent  in  this  disease  than  in  cancer — in  four-fifths,  as  contrasted 
with  a  little  more  than  one-half.  Aspiration  may  aid  in  the  solution.  Of 
other  affections  attended  by  uneven  surface  of  the  liver  the  amyloid  organ 
beset  zvith  gummy  nodules  offers  difficulties,  but  the  lesser  gravity,  the  longer 
duration,  and,  especially,  the  syphilitic  history  solve  the  question.  Cancer, 
as  a  rule,  is  not  associated  with  enlarged  spleen,  but  the  rapid  enlargement 
of  the  liver  in  amyloid  disease  sometimes  obscures  the  enlarged  spleen  and 
even  interferes  with  its  development. 

Doubt  sometimes  arises  in  the  presence  of  certain  stubborn  forms  of 
jaundice  as  to  whether  cancer  may  not  be  the  cause,  especially  as  in 
some  of  these  there  is  rather  rapid  loss  of  weight.  If  there  is  enlarge- 
ment of  the  liver,  the  solution  is  less  difficult,  because  in  simple  jaundice 


SYPHILIS  OF  THE  LIVER.  475 

there  is  no  enlargement;  but  in  its  absence  time  alone  can  settle  the  ques- 
tion ;  for  stubborn  as  these  rare  cases  of  jaundice  are,  they  are  less  so  than 
cancer,  while  even  if  they  are  not  followed  by  ultimate  recovery,  their 
course  is  much  longer  than  that  of  cancer.  Should  ascites  arise,  the  ques- 
tion is  settled  in  favor  of  cancer.  It  may  sometimes-  be  difficult  to  decide 
between  cancer  and  hypertrophic  cirrhosis,  which  also  furnishes  an  enlarged, 
hard,  more  rarely  nodular  liver,  with  jaundice.  Carcinoma  occurs  in 
persons  over  forty  years  of  age,  hypertrophic  cirrhosis  in  those  younger. 
Carcinoma  produces  cachexia,  hypertrophic  cirrhosis  does  not.  Carcinoma 
produces  marked  tenderness,  hypertrophic  cirrhosis  but  slight.  A  possible 
cause  in  either  case  must  be  sought,  primary  cancer  elsewhere  pointing  to 
cancer,  and  the  alcoholic  habit  to  cirrhosis,  to  which  also  the  enlarged 
spleen  and  the  absence  of  cachexia  point.  A  family  history  of  cancer,  if 
present,  adds  weight  to  other  signs  of  cancer  of  the  liver. 

There  is  no  special  reason  why  cancer  of  the  liver  should  be  distin- 
guished from  sarcoma  or  adcnom-a,  as  the  clinical  significance  of  the  various 
conditions  is  about  the  same.  But  if,  along  with  a  primary  sarcoma  else- 
where, as  in  the  orbit,  there  appears  enlargement  of  the  liver,  then  the 
inference  is  reasonable  that  a  secondary  sarcoma  is  there  established. 
Melanosarcoma  is  more  likely  to  invade  other  organs,  as  the  lungs,  kidneys, 
spleen,  and  even  the  skin. 

There  is  no  evidence  by  which  secondary  cancer  can  be  distinguished 
from  primary,  except  by  the  presence  of  primary  cancer  elsewhere,  notably 
in  the  stomach,  breast,  large  intestine,  uterus  and  appendages,  and  the  pre- 
sumption based  on  the  fact  that  the  majority  of  all  cases  of  cancer  of  the 
liver  are  secondary.  Careful  search  should,  however,  be  made  for  cancer 
in  all  organs  in  which  primary  cancer  is  likely  to  occur.  The  gastric  secre- 
tion should  be  investigated  chemically,  the  rectum  explored  by  the  finger 
and  speculum,  the  uterus  by  the  finger,  speculum,  and  sound.  Such  inves- 
tigation is  further  useful  in  the  settlement  of  the  diagnosis  of  cancer  of  the 
liver,  for  a  doubtful  case  becomes  confirmed  if  a  primary  focus  can  be  found. 

Prognosis. — This  disease  is  invariably  fatal — usually  in  from  three  to 
fifteen  months. 

Treatment. — This  must  consist  in  attempts  to  relieve  the  discomfort 
and  prolong  the  life  of  the  patient. 


SYPHILIS  OF  THE  LIVER. 

Definition. — Syphilis  of  the  liver  includes  several  morbid  conditions 
<iue  to  this  specific  poison,  which  are  best  considered  under  a  single  title. 

Etiology. — Syphilis  of  the  liver  may  be  the  result  of  acquired  or 
inherited  syphilis. 

Morbid  Anatomy. — i.  The  product  in  the  liver  of  inherited  syphilis 
is  always  a  cellular  infiltrate,  which  may  be  diffuse  or  localized,  (i)  The 
dififuse  infiltrate  produces  an  enlargement  and  hardening  of  the  organ,  which 
gives  place  to  a  reduction  in  size  and  unevenness  due  to  contraction  of  the 
newly-formed  connective  tissue.  {2)  The  circumscribed  product,  more  rare 
as  the  result  of  inherited  syphilis,  is  the  gummy  tumor.  The  gummy  tumor 
is  rather  a  product  of  acquired  syphilis,  but  rarely  also  it  is  found  in  con- 
nection with  hereditary  syphilis. 

2.  The  changes  in  the  liver  due  to  acquired  syphilis  are  regarded  as 


476  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

one  of  its  tertiary  manifestations,  and  do  not  show  themselves  until  some 
time  after  the  primary  infection — it  may  not  be  for  several  years.  They  are 
represented  by  the  syphilitic  gumma  or  syphiloma,  by  an  interstitial  hepa- 
titis, by  amyloid  disease,  and  occasionally  by  endarteritis. 

( I )  Diffuse  interstitial  hepatitis  does  not  differ  essentially  from  the 
more  usual  forms  of  non-specific  cirrhosis.  The  ultimate  product  is  some- 
times very  irregular,  and  the  lobules  preserve  a  palpable  distinctness. 
(2)  The  gumma  is  the  most  characteristic  lesion  of  tertiary  S3'philis. 
It  is  a  nodular  growth,  which  may  be  as  small  as  a  pea  or  smaller,  or  as. 
large  as  an  orange — from  1-5  to  4  inches  (5  millimeters  to  10  centi- 
meters) in  diameter.  A  favorite  seat  is  the  convexity  of  the  organ  near 
the  suspensory  ligament ;  another,  on  the  under  surface  in  the  connective 
tissue  embracing  the  portal  vessels;  while  it  is  also  found  in  the  substance 
of  the  organ.  The  tendency  is  to  cheesy  change  in  the  center  of  the 
nodule,  and  to  contraction,  which  distorts  the  liver  and  reduces  its  size, 
with  the  formation  of  cicatricial  markings  and  furrows.  These  cica- 
trix-like  puckerings  and  fibrous  bands  are  found  also  on  section  of  the 
syphilitic  liver.  (3)  Amyloid  disease  has  been  considered.  (4)  Endarter- 
itis sometimes  invades  the  smaller,  and  even  the  larger,  branches  of  the 
hepatic  artery  and  portal  vein. 

Symptoms. — Syphilitic  changes  in  the  liver  are  often  first  discovered 
at  autopsy.  When  symptoms  are  produced  during  life,  they  are  commonly 
those  due  to  portal  obstruction,  as  already  detailed  in  treating  ordinary 
cirrhosis.  Jaundice  is  not  a  frequent  symptom,  yet  it  was  early  made  a 
matter  of  record.  .  Thus,  Paracelsus  (1789)  is  said  to  have  noted  the  com- 
plication of  syphilis  with  jaundice,  which  could  not  be  cured  until  the 
venereal  disorder  was  overcome.  Portal  (1813)  also  speaks  of  jaundice  as 
one  of  the  evils  following  syphilis,  curable  only  by  the  use  of  mercury. 
Ricord  (1851)  noted  two  cases  of  jaundice  complicated  by  syphilis;  but 
Gubler  (1854)  first  pointed  out  that  jaundice  commonly  comes  on  at  the 
beginning  of  the  secondary  stage,  and  also  treated  of  the  relations  of  jaundice 
to  the  general  infective  process.  He  collected  seven  cases  in  which  jaundice 
followed  syphilitic  infection.  It  accompanied  a  syphilitic  exanthem,  and 
Avas  also  preceded  by  digestive  disorders,  loss  of  appetite,  nausea,  diarrhea, 
bitter  taste  in  the  month,  and  pain  in  the  epigastrium.  1  have  recently  had 
under  my  care  one  case  precisely  fulfilling  these  conditions  pointed  out  by 
Gubler.  The  jaundice  may  be  slight,  moderate,  or  severe.  It  rapidly  at- 
tains its  maximum  intensity,  lasting  a  variable  time,  seldom  more  than  a 
fortnight.  Though  the  explanation  may  not  be  immediately  easy,  Gubler 
gives  sufffcient  reasons  for  justifying  a  relation  of  cause  and  effect.  It  is 
possible  that  the  poison  may  act  like  certain  other  poisons  which  produce 
grave  icterus,  as  phosphorus.  On  the  other  hand,  it  is  quite  as  likely  that 
it  may  arise  from  a  duodenal  and  biliary  catarrh,  the  result  of  the  general 
disturbance,  especially  as  it  is  so  often  associated  with  other  symptoms  of 
this  condition — viz.,  loss  of  appetite  and  nausea. 

Enlargement  of  the  spleen  is  an  associated  symptom  when  there  is 
amyloid  disease,  to  which  ascites  may  also  be  added.  Sometimes  the  larger 
nodules  of  gummy  growth  can  be  felt  through  the  abdominal  walls,  when 
the  diagnosis  must,  be  made  between  syphilis  of  the  liver  and  carcinoma, 
a  differentiation  greatly  aided  by  the  history  of  the  case. 

Diagnosis. — This  depends  most  largely  upon  the  history  of  the  case, 
which   must  be   carefully   sought.     Nor   should   the   physician   be   satisfied 


PARASITES  OF  THE  LIVER.  477 

with  a  negative  history,  in  view  of  the  fact  that  it  is  so  common  for  syphihtic 
subjects  to  deny  infection,  even  though  they  know  it  is  to  their  interest 
to  tell  the  truth.  Careful  examination  should,  therefore,  be  made  for 
secondary  symptoms,  such  as  glandular  enlargement  or  cicatrices  and 
markings  left  by  syphilids. 

Prognosis  and  Treatment. — Patients  should  be  subjected  to  the  usual 
syphilitic  treatment  by  iodid  of  potassium  and  bichlorid  of  mercury  as 
soon  as  the  diagnosis  is  established,  and  even  when  it  is  doubtful.  For 
while  early  treatment  may  be  eiBcient  in  preventing  new  growths,  it  is  less 
certain  that  when  present  they  can  be  removed  by  antisyphilitic  treatment. 


PARASITES  OF  THE  LIVER. 
EcHixococcus  Disease^  or  Hydatid  Cyst  of  the  Liver. 

Etiology  and  Pathogenesis. — The  most  important  of  the  parasitic 
diseases  of  the  liver  is  the  echinococcus  or  hydatid  disease,  due  to  an  inva- 
sion by  the  embryo  or  larva  of  the  tcenia  echinococcus,  a  minute  tape-worm, 
consisting  of  three  or  four  links,  and  about  1-5  inch  (4  to  5  mm.)  long,  whose 
natural  habitat  is  the  upper  part  of  the  intestine  of  the  dog.  It  has  been 
found,  also,  in  the  wolf  and  jackal.  The  worm  is  not  often  found  in  this 
country.  This  rarity  may,  however,  be  more  apparent  than  real,  as  the  par- 
asites are  so  minute  (see  Fig.  37)  as  to  be  easily  overlooked,  forming,  as 
they  do,  minute,  thread-like  bodies,  adhering  to  the  villi  of  the  intestine, 
while  hydatid  disease,  though  not  very  common,  is  still,  nevertheless,  more 
so  than  would  be  expected  from  the  rarity  of  the  worm.  There  are  few 
hospital  physicians  of  much  experience  who  have  not  met  one  or  more 
cases,  though  they  are  most  common  in  foreigners.  In  Australia  and  Ice- 
land, where  the  intercourse  between  men  and  dogs  is  more  intimate,  it  is  a 
comparatively  common  disease.  In  the  latter  country  28  per  cent,  of  all 
dogs  are  said  to  be  infected ;  in  Copenhagen,  4  per  cent. ;  in  Zurich,  3.9 
per  cent.;  in  Lyons,  7.1  per  cent.;  in  Berlin,  i  per  cent.;  and  in  Leipzig, 
none,  as  far  as  investigated. 

The  ovum,  entering  the  human  intestine  with  food  or  drink,  has  its 
egg-shell  dissolved  off  by  the  digestive  fluids ;  the  larva  is  liberated,  and 
bores  its  way  by  its  stilettos  and  booklets  into  a  branch  of  the  portal  vein, 
through  which  it  is  carried  to  the  liver.  Lodging  there,  the  booklets  dis- 
appear, and  the  embryo  becomes  a  small  cyst,  possessed  of  two  lavers — an 
external  cuticle  of  laminated  structure,  the  ectocyst,  and  an  internal  paren- 
chymatous or  germinal  layer,  the  endocyst.  Within  the  cyst  is  a  clear  fluid. 
Surrounding  the  cyst  is  gradually  developed  a  capsule  of  connective  tissue, 
due  to  reactive  inflammation. 

At  the  earliest  stage  at  which  these  bladders  or  resting  embryos  have 
been  with  certainty  observed, — by  Leuckart  in  the  pig  four  weeks  after 
feeding  with  ripe  proglottides, — they  form  solid,  spherical  bodies,  25-100  to 
35-100  of  a  millimeter  in  diameter,  resembling  a  mammalian  &gg,  and 
which  are  subsequently  differentiated  into  the  bladders. 

Development  from  Pros€olex.—^'SN\\en  from  fifteen  to  twenty  milli- 
meters in  diameter  this  proscolex,  or  bladder-worm,  proceeds  to  the  develop- 
ment of  numerous  heads  or  scolices.  It  may  give  rise,  first,  to  a  single  head, 
producing  a  cystkerciis ;  second,  to  many  heads,  each  of  which  is  termed  a 


478 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


cenurus;  third,  to  many  heads  produced,  not  directly  from  the  germinal 
layer,  but  indirectly  from  special  delicate  sacs  called  brood  capsules,  which 
arise  as  minute  elevations  from  the  cells  of  the  germinal  layer.  In  these 
elevations  a  small  spheroidal  cavity  appears,  gradually  increases  in  size,  and 
becomes  lined  internally  with  a  delicate  cuticular  membrane,  outside  of 
which  is  a  layer  of  cellular  structure.  Thus,  the  wall  of  the  brood  capsule 
consists  of  two  layers  like  those  of  the  mother  bladder,  but  inverted  as  to 
relative  position,  as  if  the  brood  capsule  were  an  invagination  of  the  mother 
bladder.  These  brood  capsules  exhibit  active  movements.*  From  the 
internal  wall  of  the  brood  capsule  arises  the  head,  first  as  a  discoidal  thicken- 


Fig-  37- — Taenia  Echinococcus,  from  the  Dog — {after  Heller). 
At  a,  natural  size;  at  b,  magnified. 

ing,  growing  into  an  externally  situated  club-shaped  process,  perforated 
longitudinally  by  a  tube-like  continuation  of  the  cavity.  While  an  external 
protrusion  of  the  brood  capsule,  it  may  be  temporarily  inverted.  At  the 
distal  end  of  this  protrusion,  furthest  from  the  point  of  attachment,  the 
suckers  and  hooks  of  the  head  or  scolex  are  formed.  The  booklets  appear 
as  a  thick  fringe  of  prickles,  all  of  which,  except  the  foremost  rows,  subse- 
quently drop  ofif.  Thus,  in  different  stages  of  development,  heads  to  the 
number  of  ten,  fifteen,  or  twenty  may  live  within  one  capsule,  and  in  large 
bladders  the  included  capsules  may  number  thousands.  From  these,  on 
arriving  in  the  intestine  of  a  suitable  host,  the  proglottides  of  the  strobile, 


*  They  are  easily  ruptured  and  may  escape  observation  altogether,  whence  it  has  been  inferred 
that  connection  between  the  heads  and  brood  capsules  is  temporary,  and  that,  after  separation,  the 
living  scolices  float  free  in  the  fluid  of  the  mother  bladder.  According  toLeuckart,  however,  all  parts 
of  the  echinococcus — mother  bladder,  brood  capsules,  and  heads — are  throughout  life  in  direct  con- 
tinuity with  one  another.  According  to  Verco  and  Stirling,  it  maybe  that  the  scoHces  are  also 
formed  directly  from  the  germinal  membrane,  in  evidence  of  which  they  state  that  thej'  have  ex- 
amined a  specimen  which  shows  four  heads  sprouting  directly  from  the  germinal  membrane  of  an 
exogenously  developed  daughter  cyst. 


PARASITES  OF  THE  LIVER. 


479 


or  sexual  worm,  are  formed  by  lengthening  and  transverse  segmentation. 
The  period  of  development  from  the  scolex  condition  to  that  of  the  adult 
worm  varies  from  four  to  eight  weeks. 

The  hydatid  bladder  thus  described  consists  of  a  single  sac,  which  may 
attain  an  enormous  size,  bearing  on  its  surface  brood  capsules  containing 
scolices  in  varying  number  and  stages  of  development.  This  is  the  form  of 
cyst  known  as  echinococcus  veterinorum,  because  common  in  the  domestic 
animals,  though  frequently  also  found  in  man.* 

Development  by  Daughter  Cysts. — In  another  method  of  development 
secondary  and  completely  separated  bladders  may  be  formed,  either  inside  or 
outside  the  primary  or  mother  cyst,  constituting  daughter  cysts.  The  former, 
or  endogenous  type,  is  that  usually  met  in  man, — echinococcus  hydatidosus  of 
Leuckart,  echinococcus  endo genus  of  Kuhn, — and  arises  either  by  vesicular 
transformation  of  the  scolices  of  the  brood  capsules,  or  by  infoldings  of  the 
parenchymal  layer.  The  daughter  cysts  thus  formed  and  lying  within  the 
parent  cyst,  with  which  they  correspond  in  structure  and  behavior,  also  give 
rise  to  brood  capsules  and  scolices.  These  daughter  bladders  may  also  bud 
endogenously  and  exogenously,  and  produce  a  third  or  fourth  generation 
within  or  without  themselves,  the  whole  brood  being  contained  within  the 
mother  bladder. 


Fig.    38. — Section  through    an    Echinococcus    Cyst    with    Brood    Capsules — {from 

Braun,  after  Wax  Model). 

The  exogenous  type — echinococcus  exogenus  of  Kuhn — is  less  common 
in  man,  but  is  frequently  met  in  domestic  animals,  especially  the  pig.  In 
this  form  the  secondary  bladders  arise  from  small  granular  masses  in  the 
deeper  layers  of-  the  cuticle  of  the  mother  cyst,  probably  ultimately-  derived 
from  the  parenchymal  layer.  They  assume  a  special  cuticular  covering, 
and  their  central  parts  clear  up  and  liquefy.  As  the  centripetal  formation 
of  new  layers  in  the  cuticle  of  the  mother  bladder  goes  on,  with  rupture  of 
the  outer  layers,  the  new  formations  make  their  way  externally  as  separate 
sacs,  and  undergo  subsequent  development  outside  of  the  mother  bladder, 
usually  close  to  it,  though  at  times,  as  in  hydatids  of  bone,  the  individuals 
of  the  resulting  broods  may  He  at  some  distance  from  one  another  and  from 
their  common  parent.  It  is  to  a  special  variety  of  this  latter  that  Virchow 
has  given  the  name  echinocoiccus  multilocidaris,  wherein  the  cysts,  becoming 
surrounded  and  joined  together  by  thick  capsules  of  connective  tissue,  form 
a  hard  tumor  composed  of  vesicles  the  size  of  a  pea,  often  resembling,  en 
masse,  colloid  cancer.  In  the  spaces  are  found  remnants  of  the  echinococcus 
cyst,  at  times  booklets  or  scolices,  by  the  discovery  of  which  their  true 
nature  is  determined.  At  other  times  they  are  barren.  Most  cases  of 
this  form  of  disease  have  been  met  in  Bavaria  and  Switzerland,  but  one  case 


•  J.  C.  Verco  and  E.  C.  Stirling  in  AUbutt's  "  Sj'stem  of  Medicine,"  vol.  ii.,  iSqy,  p.  mo. 


48o  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

being  reported  in  this  country — by  Delafield  and  Prudden,  in  their  "  Patho- 
logical Anatomy,"  third  edition,  page  372.  The  subject  was,  however,  a 
German,  who  had  been  in  the  country  five  years. 

The  fluid  contents  of  the  young  cyst  are  clear  and  limpid,  have  a  specific 
gravity  of  1005  to  1009,  are  non-albuminous,  but  contain  a  small  quantity 
of  chlorid  of  sodium,  occasionally  a  trace  of  sugar,  succinic  acid,  or 
hematoidin.  Scolices  and  booklets  are  almost  always  present,  and  are  of 
great  diagnostic  value. 

The  hydatid  cyst  ranges  in  size  from  that  of  a  pin's  head  to  a  child's 
head.  It  grows  very  slowly,  and  may  be  in  the  liver  for  many  years — 
some  say  as  many  as  twenty.  Ultimately  it  dies,  the  walls  contract,  their 
contents  become  inspissated  and  calcified.  The  walls  also  become  calcified. 
Sometimes  they  suppurate,  the  cysts  forming  large  abscesses ;  or  they  may 
rupture  in  various  directions  with  corresponding  mischief,  including  sudden 
death  from  collapse.  The  bile  passages  and  inferior  cava  have  been  seats  of 
rupture. 

Symptoms. — Small  cysts  may  occasion  no  symptoms,  being  often 
unexpectedly  found  at  necropsy,  and  under  any  circumstances  the  failure  of 
health  is  very  gradual  at  first.  As  cysts  become  large  they  produce  a  sense 
of  weight  or  dragging  in  the  region  of  the  liver,  and  other  symptoms, 
depending  on  their  size  and  situation ;  janndice-  if  they  cause  obstruction  of 
the  biliary  passages ;  dyspnea  and  cardiac  disturbance,  if  they  encroach  on 
the  lungs  or  heart;  pyemic  symptoms, — that  is,  fever,  sweat,  and  sometimes 
chills,  with  rapid  exhaustion, — if  they  suppurate.  The  liver  may  become 
very  much  enlarged,  demonstrable  by  inspection,  palpation,  and  percussion. 
If  there  is  a  single  superficial  cyst,  either  in  the  right  or  left  lobe,  it  may  be 
felt  as  an  elastic  or  even  fluctuating  tumor;  or  there  may  be  the  disitnct 
feel  of  a  nodular  growth  over  the  liver.  If  posterior  in  the  right  lobe,  it 
may  encroach  on  the  inferior  part  of  the  lung  and  pleural  space,  causing 
dullness  on  percussion  posteriorly  and  postero-laterally,  and  other  signs  of 
pleuritic  effusion.  Hydatid  thrill  or  fremitus  is  always  to  be  sought  for. 
It  may  be  found,  if  the  cyst  is  superficial,  by  placing  one  hand  over  the  tumor 
and  tapping  lightly  with  the  fingers  of  the  other.  The  result  is  a  vibrating 
or  trembling  movement  felt  for  a  short  time.  It  is  not  often  obtainable,  and 
is  possible  only  with  superficial  cysts.  It  has  been  ascribed  by  Briangon  to 
the  collision  of  the  daughter  cysts. 

If  rupture  occurs,  other  symptoms  are  added.  The  pleural  cavity  is 
often  invaded,  or  the  lungs,  as  evidenced  by  the  expectoration  of  cysts  and 
booklets ;  the  bile  passages,  by  the  production  of  jaundice  or  increased 
jaundice,  and  the  subsequent  "appearance  of  booklets  and  cysts  in  the  fecal 
discharges.  Rupture  into  the  stomach  is  manifested  by  vomiting  of  hook- 
lets  and  cysts  ;  into  the  vena  cava,  by  embarrassment  of  right  cardiac  action 
and  pulmonary  thrombosis  from  lodgment  of  cysts ;  into  the  pericardium, 
by  fatal  pericarditis ;  into  the  peritoneum,  by  fatal  peritonitis ;  and  into  the 
abdominal  wall,  by  outward  discharge. 

Diagnosis. — The  differential  diagnosis  depends  on  the  recognition  of 
hydatid  fremitus  or  on  some  of  the  pathognomonic  features  just  mentioned, 
and  the  history  of  the  case  in  connection  with  the  slowness  of  development 
of  the  symptoms.  The  resemblance  to  cancer  is  sometimes  very  close,  in 
consequence  of  the  presence  of  nodular  swellings  over  the  liver,  and  to  syphilis 
of  the  liver  for  the  same  reason.  In  cancer  the  health  fails  very  much  more 
rapidly,  but  in  syphilis  scarcely  more  so,  and  the  history  must  here  again  come 


PARASITES  OF  THE  LIVER,  481 

to  our  assistance.  When  suppuration  takes  place,  we  have  the  symptoms  of 
abscess  of  the  hver.  The  recognition  of  sugar  in  the  fluid  obtained  by  tap- 
ping is  presumptive  evidence  of  its  hydatid  nature. 

Prognosis. — When  the  disease  develops  sufficiently  to  manifest  symp- 
toms, the  chance  of  spontaneous  recovery  is  very  slight.  It  is  possible  when 
external  rupture  takes  place,  but  this  should  be  anticipated  by  operative 
interference,  which  is  often  successful. 

Treatment. — Xo  medicinal  treatment  avails,  while  spontaneous  cure  is 
not  infrequent,  by  reason  of  the  death  of  the  parasite  before  the  development 
£>i  the  disease  to  a  recognizable  degree.  A  surgeon  should  be  consulted  as 
soon  as  the  diagnosis  is  made.  A  preliminary  tapping  is  justified  under 
strict  antiseptic  precautions,  and,  in  fact,  has  been  succeeded  by  permanent 
recovery.  Australian  surgeons  have  had  the  largest  experience,  and  it 
appears  to  justify  the  bolder  course  of  incision  and  evacuation  of  the  cysts 
rather  than  the  more  conservative  method  of  first  securing  adhesion  of  the 
sac  to  the  abdominal  walls  and  then  laying  open  the  cyst  and  evacuating  the 
contents.  The  former  practice  of  injecting  the  sac  with  iodin  has  also  been 
discontinued.  Should  suppuration  take  place,  the  treatment  becomes  that  of 
abscess  of  the  liver. 

Other  Parasites  of  the  Liver. 

The  remaining  parasites  of  the  liver  are  of  pathological  rather  than  of 
clinical  interest. 

The  arthropoda  are  represented  by  the  peniastomes,  of  which  the  pen- 
tastomum  denticulatum — larval  form  of  the  pentastomum  or  linguatuJa 
tcenioides — has  been  found  in  the  liver.  The  adult  worm  is  lancet-shaped 
and  marked  with  numerous  rings.  The  female  is  from  three  to  five  inches 
(8  to  13  cm. )  long,  the  male  little  less  than  one  inch  (1.8  to  2.5  cm.).  The 
adult  worm  has  been  found  in  the  nostril  of  man. 

The  cystercus  celhdosce  and  psorosperma  a.re  rare  parasites.  Of  the  lat- 
ter, the  coccidiuin  oviforme,  which  is  very  common  in  the  liver  of  the  rabbit, 
produces  whitish  nodules,  as  in  other  organs,  ranging  in  size  from  that  of  a 
pin  to  that  of  a  split  pea,  and  even  larger.  They  may  produce  fever  of  an 
intermittent  type,  diarrhea,  nausea,  and  tenderness  over  the  liver  or  other 
organ  invaded  with  enlargement.      (See  also  Parasites  at  end  of  volume.) 

In  examining  a  case  of  suspected  hepatic  disease  the  following  questions 
should  be  raised  with  a  view  to  eliciting  important  facts  which  bear  upon 
the  diagnosis :  First,  whether  there  has  been  or  is  syphilis ;  second,  suppu- 
rative disease  or  rickets  ;  third,  alcoholism  ;  fourth,  enlargement  of  the  spleen  : 
fifth,  elevation  of  temperature ;  sixth,  jaundice ;  seventh,  what  has  been  the 
duration  of  the  symptoms? 


DISEASES  OF  THE   PANCREAS. 

Almost  the  only  disease  of  the  pancreas  which  possesses  much  clinical 
interest  is  cancer.  It  is  true  that  Reginald  H.  Fitz  has  invested  the  subject 
of  pancreatitis  with  increased  interest  by  his  masterly  ]\Iiddleton  Goldsmith 
lecture,  but  I  note  that  few  cases  more  are  now  recognized  antemortem  than 
previous  to  its  publication.  The  remaining  diseases  are,  however,  of  great 
pathological  interest. 

31 


482  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


ACUTE  PANCREATITIS. 

Definition. — Acute  pancreatitis  is  an  acute  inflammation,  affecting 
primarily  the  fibrous  and  fatty  interstitial  tissue  of  the  organ.  It  is  a  rare 
affection.  Fitz  divides  it  into  hemorrhagic,  suppurative,  and  gangrenous,  but 
as  suppuration  and  gangrene  are  rather  terminations  than  initial  features, 
and  hemorrhage  is  at  least  a  very  frequent  primary  etiological  feature,  I  pre- 
fer to  treat  the  subject  under  the  single  heading  of  acute  pancreatitis. 

Etiology. — It  may  begin  with  hemorrhage,  which  may  be  traumatic. 
Most  subjects  are  between  twenty-six  and  seventy  years  old.  The  majority 
are  men.  A  few  are  alcoholics.  James  M.  Anders  "^  collected  40  cases  of 
pancreatic  hemorrhage,  in  34  of  whom  the  sex  was  given.  Twenty-five  of 
these  were  males  and  9  females.  The  ages  of  30  were  stated,  of  whom  13, 
or  43.3  per  cent.,  were  over  forty-five.  Many  have  been  previously  subject 
to  gastric  and  gastro-intestinal  derangements,  often  inflammatory.  The 
causative  gastroduodenitis  extends  probably  from  the  bowel  to  the  pan- 
creatic duct. 

Morbid  Anatomy. — This  varies  with  the  stages  or  varieties,  which,  as 
seen  at  necropsy,  are  hemorrhagic,  gangrenous,  and  suppurative.  In  the 
hemorrhagic  stage  the  pancreas  is  enlarged  throughout  or  at  its  head,  and  is 
infiltrated  with  blood,  which  imparts  its  color  in  different  shades  and  may 
invade  the  pancreatic  duct.  The  hemorrhagic  foci  may  alternate  with  white 
spots  of  fat-necrosis.  The  hemorrhage  may  extend  into  the  peri-pancreatic 
tissue  or  the  mesentery,  mesocolon,  omentum,  and  beyond  to  the  brim  of  the 
pelvis.  On  minute  examination  round  cells  and  red  blood  discs  are  found  in 
the  ducts  and  acini.  Many  lobules  are  in  a  state  of  coagulation-necrosis, 
while  bacteria  are  present  in  large  numbers. 

If  the  patient  survive  the  first  few  days, — say  the  fourth  day, — the  con- 
dition passes  on  either  to  gangrene  or  suppuration.  If  to  gangrene,  the  tip 
or  the  entire  gland  may  be  converted  into  an  offensive,  dark,  slate-colored 
mass,  which  softens  and  becomes  shreddy.  Gangrene  may  set  in  almost 
simultaneously  with  hemorrhage.  The  organ  may  become  completely 
sequestrated  in  the  smaller  omental  cavity,  attached  only  by  a  few  shreds. 
The  adjacent  parts  exhibit  the  appearance  of  peritonitis,  with  dirty,  purulent 
extravasate.  Disseminated  fat-necrosis  may  be  present.  The  spleen  may 
be  enlarged  and  its  veins  thrombosed,  as  may  be  also  the  portal  vein. 

In  the  suppurative  termination  the  organ  is  enlarged,  and  contains 
numerous  small  abscesses,  intervening  parts  being  hyperemic.  There  may 
be  peritonitis  of  adjacent  areas  of  the  peritoneum.  There  may  be  diffuse 
suppuration  or  small  abscesses  disseminated  throughout  the  organ.  In  the 
chronic  form  there  may  be  a  solitary  abscess  as  large  as  a  hen's  egg,  with 
cheesy  contents.  The  lesser  omental  cavity  and  peripancreatic  tissue  may 
be  invaded ;  rarely,  also,  the  liver.  Fat-necrosis  in  this  form  is  a  rare  con- 
dition, while  thrombosis  of  the  splenic  and  portal  veins  may  still  occur. 

Symptoms. — The  disease  begins  suddenly  with  abdominal  pain,  some- 
times succeeding  attacks  of  indigestion.  It  is  severe  and  in  the  upper  left 
quadrant  of  the  abdomen  and  in  the  course  of  the  pancreas,  but  it  may  extend 
throughout  the  abdomen.  It  is  ascribed  to  stretching  of  the  celiac  plexus  of 
nerves.     There  is  also  tenderness.     The  pain  is  usually  followed  by  vomit- 

*  "Pancreatic  Hemorrhage,"  "Journal  of  the  American  Med.  Assoc,"  December  2,  i8gg. 


CANCER  OF  THE  PANCREAS.  483 

ing,  rarely  by  nausea  alone.  The  vomited  matter  may  be  bilious  or  black. 
The  upper  abdomen  becomes  swollen  and  tympanitic,  or  the  tympany  may  be 
general.  The  temperature  is  subnormal  or  slightly  elevated.  Death  occurs 
usually  within  three  days,  but  may  be  delayed  a  week.  If  the  patient  lives 
longer,  the  case  becomes  one  of  gangrenous  pancreatitis.  Recovery  may 
occur,  though  rarely. 

If  the  gangrenous  termination  succeeds,  chills,  fever,  abdominal  swell- 
ing, generally  tympanites,  tenderness,  jaundice,  collapse,  and  death  are  added. 

If  suppuration  ensues,  life  may  be  prolonged  for  three  or  four  wrecks, 
and  there  may  be  added  high  temperature  and  irregular  chills,  with  exacer- 
bations and  remissions  and  signs  of  deep-seated  peritonitis  in  the  epigastric 
region. 

Diagnosis. — This  is  based  upon  the  foregoing  symptoms  and  their  sud- 
denness, especially  the  circumscribed  tympany.  The  disease  is  to  be  differ- 
entiated from  the  effects  of  irritant  poison,  perforation  of  the  stomach  or 
biliary  tract,  and  acute  intestinal  obstruction.  The  history  ehminates  cor- 
rosive poison.  Perforation  of  the  stomach  is  preceded  by  symptoms  of  ulcer, 
and  of  the  biliary  passages  by  symptoms  of  gall-stones.  There  is  no  ten- 
derness localized  in  the  region  of  the  pancreas  in  intestinal  obstruction,  which 
is  rare  in  the  upper  part  of  the  small  intestine.  Obstruction  in  the  large 
intestine  must  be  eliminated  by  measures  calculated  to  determine  the  patu- 
lousness  of  the  bowel.  Laparotomy  has  been  done  for  intestinal  obstruction, 
and  pancreatitis  was  found. 

Prognosis  and  Treatment. — The  former  is  almost  always  unfavorable. 
If  recovery  takes  place,  it  is  accidental  rather  than  the  result  of  treatment, 
which,  in  the  main,  can  only  be  palliative,  and  such  as  is  demanded  by  peri- 
tonitis. Surgical  treatment  may  be  called  for,  and  has  been  followed  by- 
recovery.     Drainage  should  be  practiced. 

Chronic  Pancreatitis. — This  consists  of  an  interstitial  overgrowth, 
by  which  the  organ  is  hardened  and  slightly  enlarged.  The  secreting  struct- 
ure is  compressed  and  degenerated.  It  has  frequently  been  found  in  diabetes. 
There  may  be  pigmentary  deposits,  and  pancreatic  calculi  may  be  found  in  the 
ducts. 


CANCER  OF  THE  PANCREAS. 

Morbid  Anatomy. —  Though  a  rare  disease,  it  is  not  infrequently  cor- 
rectly diagnosed.  It  is  usually  primar\-  and  situated  in  the  head  of  the 
organ.  It  is  commonly  scirrhous,  but  it  may  also  be  colloid.  It  is  especially 
apt  to  invade  adjacent  parts  by  contiguity,  and  more  distant  ones  by  metas- 
tasis, especially  the  liver  and  lymph  glands.  It  may  arise  by  contiguity  from 
cancer  of  the  stomach  or  intestines.     It  occurs  in  those  past  middle  life. 

Symptoms. — These  are  not  distinctive.  The  most  valuable  symptom  is 
jaundice .  which  occurs  when  the  head  of  the  organ  is  involved.  It  is  caused 
by  obstruction  of  the  common  bile-duct.  A  -fixed  tumor  may  be  felt  in  the 
pancreatic  region,  and  if  it  be  associated  with  jaundice,  the  pancreas  may  be 
justly  suspected  to  be  its  seat.  If  we  add  to  these  symptoms  fatty  or  greasy 
stools,  the  suspicion  is  fortified.  There  are  symptoms  of  indigestion  and  a 
dull  pain  in  the  epigastrium,  but  these  are  not  distinctive.  Emaciation  and 
loss  of  strength  proceed  irresistibly.     As  the  former  advances  the  aortic  pulse 


484  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

is  transmitted  with  great  distinctness  through  the  transverse  colon  and  pan- 
creas.    There  may  be  ascites  and  diabetes  inellitiis. 

Diagnosis. — Cancer  of  the  pancreas  must  be  differentiated  from  cancer 
of  the  pylorus,  of  the  transverse  colon,  of  the  glands  in  the  hilus  of  the  liver, 
and  from  aortic  aneurysm.  In  case  of  cancer  of  the  pylorus  there  should  not 
be  much  difficulty,  for  the  pyloric  tumor  is  movable  in  a  decided  majority  of 
cases,  and  the  pancreatic  is  fixed ;  the  pyloric  cancer  is  rarely  associated  with 
jaundice,  the  pancreatic  is  almost  always  so ;  pyloric  cancer  produces  dilata- 
tion of  the  stomach,  pancreatic  cancer  does  not. 

Cancer  of  the  transverse  colon  is  rare.  It  is  also  more  movable  than 
pancreatic  cancer,  and  sooner  or  later  obstruction  of  the  bowel  results. 
Cancer  in  the  hepatite  fissure  is  difficult  to  distinguish,  but  it  is  higher  up  and 
more  superficial.  The  tumor  is  also  tender.  Both  are  accompanied  by 
jaundice. 

The  pulsation  communicated  to  the  pancreas  is  very  different  from  the 
expansile  dilatation  of  aneurysin.  Fatty  stools  are  of  great  assistance  in  diag- 
nosis, but  they  are  by  no  means  always  present. 

Sarcoma  is  a  possible  tumor  of  the  pancreas,  but  it  is  not  distinguish- 
able from  cancer,  tuberculosis,  and  syphiloma. 

The  prognosis  is  unfavorable,  and  the  treatment  only  symptomatic. 


CYSTS    OF   THE    PANCREAS. 

Definition. — These  are  retention  cysts,  due  to  closure  of  Wirsung's 
duct  by  concretions  or  cicatricial  contraction.  They  may  become  very  large, 
and  may  even  occupy  the  entire  abdominal  cavity.  They  may  be  slow  or 
rapid  in  development. 

Symptoms. — In  none  of  the  53  cases  thus  far  collected — 35  by  W.  W. 
Johnston  and  18  by  N.  Senn — was  there  fatty  diarrhea,  a  condition  regarded 
as  symptomatic  of  suspended  function  of  the  pancreas.  On  the  other  hand, 
the  stools  may  be  clay-colored  and  putrescent,  probably  because  there  is  a 
simultaneous  obstruction  to  the  descent  of  bile.  A  resulting  tumor  presents 
itself  usually  in  the  left  part  of  the  epigastrium,  between  the  costal  cartilages 
and  the  median  line.  More  rarely  it  is  in  the  neighborhood  of  the  navel.  It 
is  globular,  resisting,  and  inelastic,  changes  its  position  slightly  with  the 
movements  of  the  diaphragm,  and  possesses  some  lateral  motion. 

The  differentiation  of  such  a  tumor,  in  the  absence  of  more  definite 
symptoms,  cannot  be  said  to  Se  easy,  yet  the  diagnosis  was  made  in  seven 
out  of  Senn's  eighteen  cases.  Aspiration  should  be  made.  The  fluid  is 
usually  brown  or  chocolate-colored,  but  sometimes  it  is  transparent.  It 
presents  some  of  the  characteristics  of  pancreatic  fluid,  emulsifying  fats  and 
converting  starch  into  sugar. 

Treatment. — After  exploratory  aspiration  the  treatment  is  surgical. 


CYSTS  OF  THE  PANCREAS.  485 


PANCREATIC   CALCULI. 

History. — The  first  case  of  pancreatic  lithiasis  reported,  so  far  as  1  know,  was  m 
1788  by  Thomas  Cawley.  There  was  diabetes,  and  at  necropsy  the  pancreas  was 
found  stuffed  with  calculi.  In  1882  I  made  a  necropsy  on  a  case  of  diabetes  with 
diarrhea,  in  which  many  calculi  were  found  in  the  pancreas.  In  1883  George  W. 
Johnston  reported  35  cases  collected  from  the  literature.  Minnich  reported  a  case  of 
colic  after  which  calculi  composed  of  calcic  carbonate  and  phosphate  were  found  in 
the  stools;  Lichtheim  made  the  diagnosis  of  pancreatic  calculus  in  a  case  of  severe  colic, 
diabetes,  and  fatty  diarrhea,  confirmed  by  autopsy.  Out  of  1500  autopsies  made  at 
the  Johns  Hopkins  Hospital  up  to  igoi.only  two  cases  of  pancreatic  calculus  were  found. 

Etiology. — Pancreatic  calculi  can  only  be  regarded  as  a  precipitation 
from  an  inspissated  pancreatic  juice  determined  by  some  unknown  cause. 

Morbid  Anatomy. — The  calculi,  commonly  about  as  large  as  a  pea,  are 
contained  in  the  pancreatic  duct  and  its  branches.  They  are  usually 
numerous.  They  may  be  smooth,  round,  faceted,  or  irregular  and  rough 
of  surface.     They  are  composed  of  carbonate  and  phosphate  of  lime. 

Symptoms. — Pancreatic  calculi  are  often  unattended  by  symptoms,  but 
deep-seated  colicky  pain  may  be  present.  The  difficulty  in  distinguishing 
this  from  the  pain  of  biliary  colic  is  increased  by  the  fact  that  jaundice  may 
be  associated  with  either.  Theoretically,  the  pain  of  pancreatic  colic  should 
be  more  deep-seated,  more  central,  and  more  to  the  left.  Practically  this  is 
not  often  found  to  be  the  case.  If  fatty  diarrhea  and  diabetes  are  associated 
with  the  colic,  pancreatic  calculus  may  be  inferred.  Rarely  stones  are  passed 
by  the  bowel,  and  if  such  stones  are  found  to  be  made  up  of  phosphate  and 
carbonate  of  lime,  they  probably  come  from  the  pancreas. 

Treatment  is  mainly  palliative  by  morphin  or  other  anodynes.  Eich- 
horst  has  recommended  hypodermic  injections  of  pilocarpin  to  stimulate  the 
pancreatic  secretion. 


DISEASES  OF  THE  SPLEEN. 

Most  of  the  morbid  states  of  the  spleen  which  possess  clinical  interest 
are  considered  in  connection  with  diseases  of  the  blood  and  with  malaria. 

Splenitis. — Splenitis  occurs  rarely  as  the  result  of  extension  of  inflam- 
mation from  a  neighboring  organ,  such  as  the  stomach,  perinephric  tissue, 
the  diaphragm  and  lungs,  or  as  the  consequence  of  injury. 

The  symptoms  are  tenderness  and  enlargement  in  connection  with  the 
inflammatory  conditions  of  adjacent  organs  referred  to,  and  it  is  upon  the 
association  of  such  symptoms  with  those  in  the  spleen  itself  that  the  diagnosis 
depends. 

Perisplenitis. — This  may  occur  as  the  result  of  tfie  same  causes  as 
produce  splenitis,  and  may  be  recognized  by  the  presence  of  palpable  fric- 
tion fremitus. 

Abscess  of  the  Spleen. — Abscess  of  the  spleen  occurs  along  with 
pyemic  processes  elsewhere,  in  the  presence  of  the  usual  causes  of  pyemia. 
Such  abscess  may  break  into  the  stomach,  bowel,  or  lungs,  as  well  as  into 
the  peritoneal  cavity. 

Rupture  of  the  Spleen. — This  arises  from  severe  injury,  also  from 
extreme  and  sudden  acute  hyperemia,  due  to  malignant  malaria,  and  from 


486  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

rapidly  growing  splenic  tumors.  The  symptoms  are  sudden  pain  in  the 
region  of  the  spleen,  collapse,  pallor,  and  death,  associated  with  the  causes 
named. 

The  Amyloid  Spleen. — This  appears  as  a  hard,  smooth,  and  enlarged 
organ,  associated  with  amyloid  disease  of  other  organs,  such  as  the  liver  and 
kidneys,  especially  when  there  has  been  long-continued  suppuration,  as  in 
hip  disease,  osteomyelitis,  tubercular  consumption,  or  syphilis. 

Atrophy  of  the  Spleen. — On  the  other  hand,  the  spleen  may  be 
reduced  in  size  by  fibroid  overgrowth  and  contraction  due  to  syphilis. 

Hemorrhagic  Infarct  of  the  Spleen. — Infectious  hemorrhagic 
infarct  results  in  abscess  of  the  spleen.  The  non-infectious  is  the  result  of 
embolism  by  a  non-infectious  embolus,  such  as  arises  from  the  cardiac  valves 
in  acute  or  chronic  endocarditis,  from  clots  in  the  cavities  of  the  left  ven- 
tricle, or  from  clots  in  aneurysms  in  the  large  arteries.  After  the  kidney, 
the  spleen  is  the  most  frequent  seat  of  such  lodgment. 

Symptoms. — The  infarction  is  sometimes  ushered  in  by  chills,  vomiting, 
and  painful  enlargement,  the  true  nature  of  which  can  only  be  inferred  when 
the  causes  named  are  present  or  the  symptoms  of  embolism  elsewhere  occur 
simultaneously. 

Neoplasms  of  the  Spleen. — These  are  represented  most  frequently  by 
gummy  tumors,  which  are  almost  never  recognized  before  death.  Carci- 
noma, sarcoma,  and  tuberculosis  occur,  but  are  not  recognizable  by  special 
characters.  A  nodular  and  uneven  spleen  may  be  regarded  as  due  to  cancer 
when  associated  wnth  cancer  elsewhere,  sarcomatous  when  there  is  general 
sarcoma,  tuberculous  if  there  is  tuberculosis  elsewhere,  and  syphilitic  if  asso- 
ciated with  the  history  of  syphilis,  especially  the  congenital  form. 

EcHiNOCOCCUS  OF  THE  Spleen. — The  spleen  may  present  a  fluctuating 
tnmor  the  nature  of  which  can  only  be  determined  by  the  certain  knowledge 
that  a  tumor  of  the  same  kind  exists  elsewhere,  or  by  the  recognition  of 
booklets  in  the  aspirated  fluid.  Should  the  fluctuating  tumor  be  associated 
with  chills  and  fever,  it  is  more  likely  to  be  abscess,  which,  it  is  to  be  remem- 
bered, may  also  begin  as  echinococcus  disease  which  later  takes  on  suppu- 
ration. 

Wandering  Spleen. — This  is  a  term  applied  to  a  condition  of  the  spleen 
analogous  to  the  movable  kidney  and  liver.  It  is  the  direct  result  of  an  elon- 
gation of  the  gastrosplenic  ligament  and  splenic  artery  and  vein.  Under 
these  circumstances  the  usual  splenic  dullness  in  the  midaxillary  line,  between 
the  ninth  and  eleventh  ribs,  has  disappeared,  and  the  spleen  can  usually  be 
felt  elsewhere  in  the  abdominal  cavitv,  usuallv,  however,  on  the  side  below 
its  normal  site,  whence  it  may  be  pushed  into  the  natural  situation,  to  leave 
it  immediately  as  the  upright  position  is  assumed.  Rarely,  it  is  found  in  more 
distant  situations,  even  in  the  pelvis.  At  times  it  may  form  attachments  by 
inflammatory  adhesion  in  the  new  situations,  making  its  restoration  difficult 
or  impossible. 

Symptoms. — The  symptoms  are  not  unchanging.  The  most  constant  is 
a  dragging  sensation,  while  there  may  also  be  the  effects  of  pressure,  which 


ACUTE  PERITONITIS.  487 

vary  with  the  situation.  There  may  be  pressure  on  the  ureter  or  bladder, 
causing  difficuhy  in  micturition ;  upon  the  bowel,  causing  partial  obstruction 
or  pain  by  the  compression  of  sensitive  parts.  The  same  train  of  nervous 
symptoms  which  attends  floating  kidney  may  also  be  present. 

Diagnosis. — Some  difficulty  of  diagnosis  may  result  in  consequence  of 
such  vagueness  of  symptoms.  There  may  be  a  question  between  the  exist- 
ence of  wandering  spleen  and  fecal  tumor.  With  the  former,  the  normal 
splenic  dullness  is  wanting,  though  the  well-known  fact  that  the  dullness  is 
sometimes  very  small  in  health  may  give  rise  to  error.  A  freely  movable 
■cancer  of  the  pylorus,  a  tumor  so  movable  that  it  may  be  felt  in  the  left  hypo- 
chondrium,  may  occasion  similar  difficulty,  which  must  be  settled  in  the  same 
way.  And  so  with  other  abdominal  tumors  of  movable  nature — the  normal 
splenic  dullness  remains.  The  question  as  to  whether  a  movable  organ  is  the 
spleen  or  kidney  is  not  likely  to  be  a  knotty  one,  even  if  the  movable  kidney 
be  the  left,  if  the  same  guide  be  availed  of.  The  difference  in  outline  of  the 
two  organs  may  be  recognized  in  persons  with  thin  abdominal  walls,  and,  in 
rare  instances,  by  the  splenic  notch.  The  possible  coexistence  of  a  movable 
spleen  and  a  movable  kidney  is  to  be  remembered. 

Treatment. — The  treatment  must  consist  of  mechanical  measures  to 
keep  the  spleen  in  place — measures  which  must  be  determined  by  the  require- 
ments of  each  case.     They  are  variously  successful. 


DISEASES  OF  THE  PERITONEUM. 

ACUTE  PERITONITIS. 

Definition. — An  acute  inflammation  of  the  peritoneal  membrane. 

Etiology. — Of  Primary  Peritonitis. — Primary  peritonitis,  or  that 
iorm  which  originates  independently  of  inflammation  of  adjacent  structures, 
is  spoken  of  as  idiopathic  in  origin.  It  is  a  disease  of  such  rarity  that  its 
existence  may  reasonably  be  questioned,  and  there  are  those  who  deny  its 
occurrence  in  toto.     Its  reputed  cause  is  exposure  to  cold. 

2.  Of  Secondary  Peritonitis. — By  this  is  meant  an  inflammation  the 
result  of  invasion  of  the  peritoneum  from  a  primary  focus  of  disease  some- 
w^here  in  the  vicinity,  or  traumatic  agencies,  like  blows  or  punctures  involving 
the  peritoneum.  Formerly,  operations  involving  the  peritoneum  were  fruit- 
ful causes  of  peritonitis,  but  since  aseptic  surgery  has  become  general,  such 
operations  are  done  with  an  immunity  previously  undreamed  of.  There 
are  two  chief  foci  whence  such  inflammation  originates.  One  of 
these  is  the  digestive  tract ;  the  other,  the  genito-urinary  system,  more 
particularly  of  women.  Inflammation  may  also  invade  the  peritoneum  from 
the  liver,  gall-bladder,  spleen,  or  perinephritic  region,  or  from  Pott's  disease 
or  psoas  abscess.  Perforation  of  the  stomach  in  ulcer  or  cancer,  of  the 
intestine  in  typhoid  fever,  appendicitis,  and  dysentery,  are  the  commonest 
causes  originating  in  the  gastro-intestinal  tract.  The  second  focus  is  puru- 
lent inflammation  of  the  Fallopian  tubes  and  the  genito-urinary  tract. 
Endometritis  and  metritis  may  be  the  starting-point  of  such  inflammation, 
which  may  extend  up  the  Fallopiafi  tube,  or  there  may  be  parametritis  with 
suppuration,  the  abscess  arising  from  which  may  rupture  into  the  peritoneal 
cavity.  All  of  the  diflferent  forms  of  secondary  peritonitis  are  infectious, 
and  caused  either  by  organisms  responsible  for  the  primary  disease  or  by 


488  DISEASES  OF  THE  DIGESTIVE  SYSTEAI. 

such  as  are  set  free  with  the  gastric  or  intestinal  contents  by  perforation. 
The  organisms  found  under  these  circumstances  are  the  streptococcus 
pyogenes,  the  staphylococcus  pyogenes  aureus  or  albus,  and  the  bacterium 
coli  commune,  the  latter  especially  after  perforation  of  the  appendix,  also  the 
tubercle  bacillus.  The  ameba  coli  has  been  found  in  the  peritoneal  fluid  in 
amebic  dysentery.  Peritonitis  may  also  occur  from  infection  from  more 
distant  foci  of  suppuration,  when  it  is  also  called  pyemic  peritonitis. 

Finally,  peritonitis  not  infrecjuently  becomes  a  complication  of  pleurisy, 
articular  rheumatism,  and  nephritis  by  a  process  not  thoroughly  determined. 
The  first  is  probably  the  result  of  extension  by  continuity,  since  the  two  cavi- 
ties communicate  by  the  lymph  vessels  of  the  diaphragm.  The  poison  of 
rheumatism,  whatever  it  is,  may.be  the  cause  of  the  peritonitis,  while  the 
retained  excreta  which  accumulate  in  the  blood  in  Bright's  disease  may  act 
similarly. 

Morbid  Anatomy. — This  varies  somewhat  with  the  extent  of  the  peri- 
tonitis and  the  duration  of  the  attack.  First,  there  may  be  a  "  general  "  or 
"  diffuse  "  peritonitis,  or  it  may  be  "  circumscribed."  In  general  peritonitis 
the  peritoneal  surface  of  the  intestinal  coils  is  hyperemic  and  covered  more  or 
less  continuously  with  flakes  of  yellow  lymph  made  up  of  fibrin  and  leuko- 
cytes. This  is  especially  abundant  in  the  sulci  between  the  coils,  while  it 
also  covers  the  convexity.  In  an  earlier  stage,  before  the  exudate  appears, 
the  surface  of  the  peritoneum  is  dull  and  rough,  owing  to  a  desquamation  of 
the  epithelium.  In  the  fl.anks  is  found  a  variable  amount  of  fluid,  which  may 
be  serous,  serofibrinous,  or  purulent,  which,  increasing,  produces  an  appre- 
ciable ascites.  In  prolonged  cases  organization  and  vascularization  from  the 
capillaries  of  the  peritoneum  take  place,  the  solid  contingent  being  formed 
from  the  epithelium  or  wandering  cells,  resulting  in  adhesions  between  the 
coils  of  intestine  and  adjacent  organs.  These  are  at  first  soft  and  easily 
ruptured,  but  later  become  firm  bands.  These  latter  are,  however,  more 
common  in  the  circumscribed  form. 

In  circumscribed  peritonitis  limited  areas  of  lymph  formation  occur  and 
adhesions  are  more  pronounced.  Copious  fibrinoserous  exudate  is  less  fre- 
quent, though  sometimes  quite  large  circumscribed  collections  of  pus  occur,, 
laced  off  from  the  remainder  of  the  peritoneal  cavity  by  organized  tissue. 
Such  abscesses  sometimes  rupture  into  the  general  peritoneal  cavity,  produc- 
ing general  inflammation,  collapse,  and  death. 

Symptoms. —  i.  Of  an  Acute  General  Peritonitis. — The  most  decided 
symptom  is  pain,  usually  of  extreme  severity,  which  is  commensurate  in 
extent  with  that  of  the  inflarpmation.  There  is  also  extreme  tenderness,. 
which  is  similarly  limited.  So  great  is  this  that  any  tension  on  the  abdom- 
inal walls  excites  pain ;  hence  the  legs  are  drawn  up  to  relieve  this,  and  we 
have  the  well-known  position  almost  characteristic  of  general  peritonitis — 
dorsal  decubitus,  with  the  thighs  flexed  on  the  abdomen.  Any  motion  such 
as  straining,  even  the  act  of  breathing  and  the  emptying  of  the  bladder, 
increases  pain.  From  the  nature  of  the  causes  this  pain  is  usually  sudden 
in  occurrence,  succeeding,  as  it  does,  on  perforation,  abscess  rupture,  and 
the  like.  Sometimes,  indeed,  it  is  the  first  intimation  of  any  illness  what- 
ever. Abdominal  distention  is  a  third  characteristic  symptom  of  peritonitis,, 
ascribed  to  a  paralysis  of  the  muscular  coat  of  the  bowel,  and  continues 
throughout  the  attack.  Rarely,  however,  the  abdomen  is  flat,  hard,  and 
board-like.     As  rarely,  too,  pain  is  altogether  absent. 

Among  the  sym.ptoms  which  may  usher  in  the  attack  is  vomiting.     It 


ACUTE  PERITOXITIS.  489 

is  regarded  as  reflex  in  origin,  excited  by  the  inflammation  of  the  peritoneum. 
The  effort  is  sometimes  ineffectual,  and  sometimes  a  perforation  of  the 
stomach  permits  the  more  ready  discharge  of  its  contents  into  the  abdominal 
cavity.  The  vomitus  consists  of  what  happens  to  be  in  the  stomach  at  the 
time,  or  of  mucus  and,  if  the  symptom  is  prolonged,  of  green,  bilious  matter. 
The  primary  vomiting  is  followed  by  abatement  and  exacerbation. 

The  symptoms  which  are  associated  with  these  or  succeed  upon  them 
vary  with  the  nature  of  the  cause  and  extent  of  the  disease.  In  fulminating 
cases  due  to  perforation  of  the  bowel,  as  in  typhoid  and  appendicitis,  they  are 
■the  symptoms  of  collapse — viz.,  extreme  weakness,  cold,  clammy  skin,  fre- 
quent, small,  and  feeble  pulse.  The  pulse  exceeds  120  and  often  reaches  160 
and  even  more.  The  breathing-rate  is  from  30  to  40.  The  temperature  is 
slightly  raised,  remains  about  normal,  or  may  be  subnormal.  Rarely,  it  is 
high, — 104'  to  105^  F.  (40°  to  40.6''  C), — though  the  skin  may  feel  cool  and 
clammy.  The  expression  is  characteristic — Hippocratic.  The  eyes  are 
sunken,  the  cheeks  and  temples  are  collapsed,  and  the  nose  is  pinched.  The 
urine  is  scanty  and  contains  indican. 

If  the  patient  survive,  the  physical  signs  of  eft'usion  make  their  appear- 
ance. There  is  dullness  on  percussion,  first  in  the  flanks,  whence  it  ascends 
as  the  fluid  increases.  If  sufficiently  abundant,  the  dullness  becomes  general 
and  fluctuation  may  be  recognized.  Palpation  and  percussion  both  occasion 
pain.  A  change  of  position  from  the  back  to  the  side  causes  a  change  in 
the  position  of  the  fluid,  and  corresponding  alterations  in  the  physical  signs. 
In  severe  cases  the  diaphragm  is  raised,  the  apex  of  the  heart  dislocated,  and 
the  liver  dullness  may  be  obliterated  in  the  mammillary  line  by  combined 
effusion  and  extreme  tympany.  Similar  obliteration  may  happen  to  the 
splenic  dullness.  Both  may  be  restored  by  turning  the  patient  on  his  side. 
Such  obliteration  is,  however,  far  more  characteristic  in  what  is  known  as 
pneumoperitonitis,  a  form  of  peritonitis  caused  by  perforation  from  an  air- 
containing  organ  into  the  peritoneal  cavity,  and  of  intense  severity,  excited  by 
the  pathogenic  bacteria  thus  admitted.  Acute  pain,  rapidly  developing  col- 
lapse, scarcely  appreciable  pulse,  icy  coldness  of  the  skin,  and  great  distention 
of  the  abdomen  are  the  symptoms.  The  air,  of  course,  occupies  the  highest 
part  of  the  abdominal  cavity,  covering  the  liver  and  spleen,  causing  the 
obliteration  referred  to.  The  distinctive  point  in  the  diagnosis  between  pneu- 
moperitonitis and  the  extreme  degrees  of  the  ordinary  form  is  the  fact  that 
in  the  former  hepatic  dullness  is  absent  even  in  the  midaxillary  line  when  the 
patient  is  on  his  left  side,  whereas,  in  simple  peritonitis,  hepatic  dullness  may 
be  elicited  when  the  patient  is  in  this  position,  though  it  may  not  be  if  he  is  on 
his  back. 

Throughout  all,  the  intellect  is  clear,  and  while  there  is  often  a  total  lack 
of  realization  of  the  incA^itable  and  usually  dreaded  end,  it  is  as  often  thor- 
oughly appreciated  by  the  patient  and  is  viewed  with  a  calmness  which  in- 
creases the  awe  which  always  attaches  to  the  presence  of  the  shadow  of  death. 
Rarely,  in  the  course  of  his  experience,  is  the  physician  called  upon  to  witness 
a  more  painful  scene.  Toward  the  very  end,  how^ever,  a  somnolence  com- 
monly supervenes  which  obscures  the  expiring  moment,  or  a  slight  delirium, 
the  visions  of  which  may  be  interpreted  by  surrounding  friends  as  the  first 
glimpses  into  another  world. 

The  course  of  such  a  case  is  steadily  downward,  reaching  its  end  in  from 
two  to  six  days. 

2.   Of  Acute  Circumscribed  Peritonitis. — The  symptoms  include  those  of 


490  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

the  general  form  in  a  very  mtich  milder  degree.  The  pain  is  less  severe  and 
more  circumscribed,  the  tenderness  proportionate,  while  the  definiteness  of 
neither  is  very  sharp.  \'omiting  may  also  usher  in  the  attack,  and  may  be 
similarly  modified.  There  may  likewise  be  the  signs  of  collapse,  and  the 
patient  is  often  very  weak.  There  is,  however,  more  decided  and  constant 
fever  though  remittent,  as  in  septic  fever  generally,  and  the  cases  run  a  longer 
course,  ending  not  rarely  in  recovery,  but  more  frequently  in  death  from 
exhaustion. 

As  already  mentioned,  circumscribed  abscesses  are  more  frequently 
recognized  by  fluctuation,  and  may  even  point  toward  the  surface,  while  they 
are  as  liable  to  rupture  into  the  general  peritoneal  cavity,  producing  there  the 
symptoms  and  more  usual  fatal  termination  of  general  peritonitis.  This 
mischievous  termination,  at  the  present  day,  is  often  prevented  by  the  timely 
interference  of  the  surgeon.  As  varieties  of  such  abscess  may  be  mentioned 
the  perinephric  abscess,  the  pelvic  abscess,  the  subdiaphragmatic  abscess, 
arising  from  perforation  of  the  stomach  or  colon  or  disease  of  the  liver  or 
spleen,  and  the  periappendicial  abscess.  The  results  of  circumscribed  peri- 
tonitis in  children  are  sometimes  seen  in  the  shape  of  a  painful,  fluctuating 
tumor  in  the  groin.  Circumscribed  peritonitis  is  also  more  or  less  associated 
with  the  symptoms  of  the  disease  which  causes  it. 

Diagnosis. — That  of  general  peritonitis  is  seldom  difficult,  especially  in 
the  fulminating  variety.  Some  days  may,  however,  elapse  before  the  ques- 
tion is  settled,  for  sometimes  the  symptoms  are  closely  simulated  by  those  of 
other  conditions.  Particularly  is  this  the  case  with  the  extreme  tympany 
and  tenderness  which  are  sometimes  associated  with  typhoid  fever,  especially 
w^hen  there  is  deep-seated  ulceration.  It  not  rarely  happens  that  on  these 
symptoms  is  based  the  diagnosis  of  a  peritonitis,  which  is  not  found  at 
necropsy.  Enterocolitis  may  give  rise  to  similar  symptoms.  On  the  other 
hand,  it  has  happened  that  grave  and  fatal  peritonitis  has  eluded  detection, 
having  been  found  for  the  first  time  at  autopsy. 

Hysterical  peritonitis  is  a  term  applied  to  a  condition  met  with  in  women, 
when  every  symptom  of  acute  peritonitis  is  simulated,  even  collapse  itself. 
It  is  needless  to  say  that  patients  do  not  die  of  this  disease,  and  that  time 
settles  the  question  ultimately,  and  when  there  is  recurrence,  as  is  often  the 
case,  a  second  attack  is  not  likely  to  mislead. 

Acttte  hemorrhagic  peritonitis  should  be  mentioned  as  a  variety,  the 
symptoms  of  which  sometimes  are  the  same  as  those  of  the  ordinary  form. 

Circumscribed  peritonitis  is  more  frequently  difficult  of  detection,  and 
its  diagnosis  often  requires  a  knowledge  of  the  presence  of  the  causative  dis- 
ease to  suggest  it.  Fluctuation 'is  only  available  in  diagnosis  when  there  is 
superficial  abscess.  The  exploring  needle  may,  however,  at  times  be 
availed  of. 

Prognosis. — This,  in  general  peritonitis,  is  almost  invariably  fatal,  only 
the  mildest  cases  ofifering  the  possibility  of  recovery.  Modern  surgery  has 
many  times  saved  life  even  in  peritonitis  which  succeeds  perforation  in 
typhoid  fever,  gastric  ulcer,  and  perforated  gall-bladder.  The  duration  of 
most  cases  is  from  two  to  six  days. 

Localized  peritonitis  is  a  more  promising  malady.  A  few  cases  get  well 
by  spontaneous  discharge  of  resulting  abscesses,  more  with  the  assistance  of 
the  surgeon,  and  some  neglected  cases  doubtless  perish  when  timely  aid  from 
this  source  would  have  saved  life. 

Treatment. — ^The  treatment  of  general  peritonitis  succeeding  perfora- 


CHRONIC  PERITONITIS.  491 

ation  consists  for  the  most  part  of  measures  calculated  to  relieve  the  patient's 
sufferings  while  awaiting  the  end.  If  the  opportune  moment  can  be  seized, 
a  laparotomy  may  be  performed,  for  life  has  been  saved  frequently;  but  no 
rule  can  be  laid  down  which  will  aid  in  the  selection  of  such  a  moment.  Local 
measures  looking  toward  cure,  such  as  blisters  and  other  counterirritating 
agencies,  are  useless.  To  relieve  pain,  the  hot  poultice  or  ice-bag  may  be 
used  in  turn.  Sometimes  one  gives  more  relief,  sometimes  another.  After 
this,  opium  may  be  administered  in  the  minimum  degree  necessary  to  relieve 
pain.  I  see  no  advantage  in  the  use  of  opium  for  any  other  purpose,  unless 
"it  be  also  to  allay  vomiting.  It  has  no  effect  in  limiting  the  spread  of  the 
inflammation.  When  doubt  as  to  diagnosis  exists, — as  to  whether  there  is 
true  peritonitis  or  painful  distention  of  the  bowel, — turpentine  may  be  admin- 
istered with  full  doses  of  strychnin,  say  1-30  to  1-20  grain  (0.002  to  0.003 
gm.),  while  turpentine  may  be  applied  locally.  Iced  turpentine  stupes  are 
often  exceptionally  grateful.  Turpentine  enemas  under  these  circumstances 
are  of  doubtful  utility,  in  fact,  may  do  more  harm  than  good,  and  should 
be  discouraged. 

Special  symptoms,  such  as  nausea,  faintness,  and  exhaustion,  require 
the  treatment  usually  appropriate  to  control  them.  For  the  first,  ice  by  the 
mouth  or  locally,  small  doses  of  champagne,  and  counterirritation  are  useful. 
For  failing  strength,  stimulants,  local  heat,  hypodermic  injections  of  ether, 
digitalis,  brandy,  and  strychnin  are  available,  but  I  do  not  approve  of  the 
practice,  so  often  pursued  by  young  hospital  physicians,  of  indiscriminately 
plying  these  measures  when  they  must  evidently  be  unavailing. 

The  treatment  of  circumscribed  peritonitis  permits  the  use  of  local 
measures  not  admissible  in  the  general  form.  Counterirritation  by  blisters, 
and  especially  blood-letting  by  leeches,  is  sometimes  of  signal  service  in 
relieving  symptoms,  and  may  even  effect  a  cure  if  the  primary  causing  dis- 
ease is  removed.  The  surgeon  and  the  gynecologist  should  be  early  sum- 
moned, as  it  is  more  frequently  through  their  assistance  that  a  cure  is 
accomplished. 

CHRONIC  PERITONITIS. 

Etiology. — By  far  the  largest  majority  of  cases  of  chronic  peritonitis 
are  tubercular  in  origin.  Some  cases  are  caused  by  cancer  and  other  morbid 
growths  in  the  abdomen,  while  there  are  also  others  of  simpler  origin.  Thus 
originating,  we  have  both  a  circumscribed  and  a  diffuse  adhesive  peritonitis. 
See  also  Section  on  Tuberculosis  of  the  Peritoneum,  p.  282. 

Local,  Circumscribed,  or  Chronic  Adhesive  Peritonitis. 

This  occurs  between  adjacent  organs,  such  as  the  spleen  and  diaphragm, 
liver  and  diaphragm,  stomach  and  liver,  and  organs  in  similar  relation,  as 
the  result  of  chronic  disease  in  one  or  the  other.  These  adhesive  connections 
are  not  always  close,  but  sometimes  consist  of  bands  of  considerable  length, 
such  as  have  already  been  referred  to  as  occasional  causes  of  obstruction  of 
the  bowel. 

Symptoms. — The  symptoms  of  obstruction  of  the  bowel  are  often  the 
first  evidence  of  the  existence  of  such  adhesive  bands.  Other  symptoms  are 
a  sense  of  restriction  in  the  motion  of  organs  involved,  with  pain  when  such 
motion  occurs ;  also  constipation,  colicky  pains,  and  pains  resulting  from 


492  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

traction  exerted  in  peristalsis.  Other  vague  symptoms  occur  which  go  to 
make  the  patient  uncomfortable,  but  are  not  distinctive.  Should  a  peritoneal 
friction,  however,  be  felt,  more  conclusive  evidence  is  thus  furnished. 
Should  suppuration  attend  chronic  inflammation,  more  distinctive  symptoms 
also  arise.  In  addition  to  the  pain  and  tenderness  a  hectic  fever  may  be 
present,  which  may  guide  to  a  correct  conclusion  with  or  without  the  aid  of 
the  exploring  needle  or  eventual  rupture  into  one  of  the  hollow  abdominal 
organs. 

Diffuse  Chronic  Peritonitis. 

This  may  succeed  upon  acute  diffuse  inflammation  of  mild  degree,  which 
is  followed  by  an  abatement  in  all  the  symptoms.  It  may  occur  in  connec- 
tion with  chronic  cardiac  or  hepatic  disease  where  there  has  been  long-con- 
tinued venous  stasis ;  or  it  may  succeed  the  punctures  of  numerous  tappings 
and,  most  rarely,  chronic  intestinal  disease. 

Morbid  Anatomy. — The  peritoneum  is  thickened.  The  intestinal  coils 
may  be  cemented  to  one  another  and  to  neighboring  organs.  The  liver  and 
spleen  are  sometimes  covered  by  thick,  tough,  grisly  capsules.  The  omen- 
tum and  mesentery  may  be  thickened  and  shrunken.  There  may  be  thick- 
ened nodules,  not  tubercular.  There  is  in  these  cases  rarely  any  considerable 
effusion.  A  hemorrhagic  form,  suggesting  hemorrhagic  pachymeningitis, 
was  described  by  Virchow.  It  is  more  commonly  situated  in  the  pelvis  and 
characterized  by  bloody  effusion. 

Symptoms, — These  exhibit  for  the  most  part  a  diminished  degree  of 
those  characteristics  of  acute  peritonitis,  to  which  may  be  added  tnnwr-like 
swellings  and  thickenings  and  swelling  difficult  to  interpret.  Other  vague 
symptoms  are  engendered  by  them  as  the  result  of  contraction  and  pressure, 
including  pain,  edema,  albuminuria,  irregularity  of  bozvel  action,  and  some- 
times feverishness.  There  is  little  that  is  characteristic  unless  it  be  the  occa- 
sional presence  of  recognizable  effusion.  The  very  slow  forms  attended 
with  extensive  effusion  are  not  separable  from  ascites,  the  result  of  hepatic 
disease,  although  there  are  differences  in  the  effusion.  In  peritonitis  the 
effusion  is  more  turbid,  contains  abundant  albumin,  and  has  a  specific  gravity 
rather  higher  than  the  fluid  of  an  ascites :  1018  as  compared  with  1012. 

A  chronic  peritonitis  not  unusual  in  children  from  two  to  ten  years  old 
is  described  by  Striimpell  and  others.  It  is  associated  with  decided  ascites, 
debility,  and  other  symptoms  of  ill  health  more  or  less  -marked,  while  recovery 
is  the  usual  termination.  Such  a  cause  for  the  ascites  should  not  be  assigned 
without  careful  search  for  others,  especially  disease  of  the  liver. 

Treatment. — The  treatment  must  be  determined  by  circumstances.  It 
is  chiefly  palliative,  unless  operative  interference  promises  more. 

CANCER  OF  THE  PERITONEUM. 

Primary  cancer  of  the  peritoneum  is  an  event  of  extreme  rarity.  Its 
occurrence  as  a  true  epithelial  cancer  must,  however,  be  admitted.  Colloid 
cancer  also  occurs  as  a  diffuse  and  extensive  growth,  relatively  firm,  and 
without  fluctuation.  More  frequently  peritoneal  cancer  is  secondary  to  can- 
cer of  the  stomach,  bowel,  pancreas,  uterus,  or  other  organ ;  most  frequently, 
perhaps,  as  an  extension  by  contiguity,  though  also  by  metastasis.  It  occurs 
in  the  shape  of  sniall  or  larger  nodules  scattered  over  the  peritoneum.     The 


ASCITES. 


493 


former  constitutes  what  is  known  as  miliary  carcinoma.  The  larger  nodules 
are  found  in  the  omentum,  in  Douglas'  cul-de-sac,  around  the  navel  and 
elsewhere,  while  the  retroperitoneal  glands  may  be  simultaneously  involved. 

Symptoms. — These  are  those  of  chronic  peritonitis,  including  effusion, 
with  the  added  cachexia,  and  a  diagnosis  must  be  based  on  these,  the  ante- 
cedent history,  and  the  possible  presence  of  cancer  elsewhere.  The  investi- 
gation must  include  the  uterus  and  the  rectum.  The  physical  resemblance 
of  the  miliary  form  to  tuberculosis  is  very  marked,  and  in  primary  car- 
cinoma the  distinction  is  difficult.  Palpation  may  recognize  friction  in  both. 
^In  both  the  effusion  may  be  bloody,  but  is  more  apt  to  be  so  in  cancer  than 
in  tuberculosis.  The  test  injection  of  tuberculin  should  be  availed  of.  The 
cancerous  patient  is  past  middle  life,  the  tubercular  younger,  tubercular 
peritonitis  being  especially  frequent  in  children. 

The  possible  presence  of  echinococci  in  the  peritoneum  is  to  be  remem- 
bered. The  local  symptoms  may  resemble  those  of  cancer  very  closely. 
The  presence  of  hydatid  tumors  elsewhere,  as  in  the  liver,  of  course  suggests 
the  true  nature  of  the  simulating  disease. 


ASCITES. 
Synonym. — Hydroperitoneum. 

Definition. — Any  freely  movable  collection  of  fluid  in  the  abdominal 
cavity  sufficiently  copious  to  be  recognizable  by  the  physical  signs  furnished. 

Etiology. — Ascites  is  a  symptom  of  any  one  of  a  number  of  diseases 
causing  venous  engorgement  of  the  vessels  draining  the  peritoneum,  but  a 
symptom  of  such  importance  as  to  demand  separate  consideration.  Its 
causes  are  local  and  remote.  The  most  frequent  local  cause  is  obstruction 
to  the  portal  circulation,  commonly  by  some  disease  of  the  liver,  especially 
hepatic  cirrhosis.  Any  growth  or  inflammatory  new  formation  in  the 
gastrohepatic  omentum  or  hepatic  fissure  exerting  pressure  on  the  portal 
vein  may  have  the  same  effect.  Abdominal  tumors  outside  of  the  liver 
large  enough  to  exert  the  requisite  pressure  may  also  produce  ascites. 
Such  are  enlarged  spleen  and  tumor  of  the  ovary  and  even  of  the  uterus. 
Chronic  inflammation  of  the  peritoneum,  whether  tubercular,  cancerous, 
or  simple,  especially  when  the  cancer  and  tuberculosis  involve  the  omentum, 
is  also  a  cause.  More  rarely  cirrhosis  and  emphysema  of  the  lungs  and 
chronic  pleurosy  cause  it.  A  rare  and  peculiar  cause  is  adhesive  pericarditis. 
Ascites  thus  caused  is  apt  to  be  erroneously  ascribed  to  cirrhosis  of  the  liver. 

Remote  causes  include,  first  of  all,  valvular  heart  disease,  the  general 
obstruction  due  to  which  causes  ascites  as  a  part  of  a  general  anasarca,  the 
peritoneal  cavity  being  the  last  invaded.  Rarely,  it  is  the  only  dropsical 
symptom  of  heart  disease,  in  which  event  there  must  be  associated  some 
intermediate  obstructing  state  of  the  liver.  Bright's  disease  is  also  a  cause 
of  abdominal  dropsy,  in  which  disease,  too,  the  peritoneum  is,  as  a  rule, 
last  invaded.  More  rarely  it  occurs  as  a  consequence  of  intense  cachectic 
states,  such  as  the  gravest  forms  of  anemia. 

Symptoms. — Some  fourteen  tq.  twenty  pints  (7  to  10  liters)  are  re- 
quired before  the  physical  signs  to  be  described  are  developed.  The  ab- 
dominal cavity  thus  occupied  is  more  or  less  distended,  pendent  when  the 
patient  is  upright  and  widened  when  the  patient  is  on  his  back,  the  flanks 


494  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

dropping  down  and  outward.  The  fluid  also  flows  from  one  side  to  the 
other  when  the  patient  turns  on  his  side.  If  the  distention  is  excessive, 
"silver  lines,"  such  as  extend  across  the  abdomen  in  pregnancy,  make  their 
appearance,  and  the  umbiHcus  is  obhterated  or  protuberant.  The  super- 
ficial veins — branches  of  the  epigastric — are  distended  and  distinctly  visible 
from  pressure  by  the  fluid  on  the  vena  cava,  by  which  the  return  of  blood 
from  the  lower  extremities  is  interfered  with.  Sometimes  these  superficial 
veins  from  below  are  seen  to  join  those  of  the  mammary  from  above. 
Such  distention,  however,  is  often  contributed  to  by  coincident  portal  ob- 
struction (see  p.  461).  There  may  also  be  edema  of  the  lower  extremi- 
ties. There  is  no  caput  medusse  about  the  navel  unless  the  portal  circulation 
is  also  obstructed. 

As  intimated  in  the  definition,  the  physical  examination  affords  the 
most  reliable  evidence.  To  palpation  there  is  the  succussion  wave,  which 
is  elicited  by  placing  the  palm  of  one  hand  on  the  side  of  the  abdomen 
and  tapping  with  the  fingers  on  the  opposite  side.  A  false  succussion  wave 
is  sometimes  produced  by  this  procedure  in  persons  with  fat,  flabby  belly 
walls,  but  error  may  be  avoided  by  having  an  assistant  place  the  edge  of 
his  hand  vertically  on  the  median  line  while  the  tapping  is  done,  as  in  this 
way  the  false  wave,  which  travels  around  through  the  abdominal  wall,  is 
obliterated.  It  is  always  difficult,  and  sometimes  impossible,  to  palpate 
solid  organs  when  the  abdomen  is  distended  with  fluid.  Such  palpation  is, 
however,  facilitated  by  a  modification  of  the  ordinary  method — viz.,  first 
applying  lightly  only  the  ends  of  the  fingers,  then  suddenly  depressing 
them,  and  so  displacing  the  fluid  that  the  solid  organ  can  be  felt. 

Percussion  elicits  absolute  dullness  over  the  fluid,  while  over  the 
bowels,  which  are  floated  upward,  a  tympanitic  note  is  produced,  which 
changes  with  the  position  of  the  patient.  If  there  is  considerable  effusion 
and  the  patient  lies  on  his  back,  there  is  a  small  oval  area  of  tympany  in 
the  middle  of  the  abdomen.  If  a  small  amount  of  fluid  is  present,  the 
flanks  only  are  filled  in  this  position,  and  there  is  a  large  superficial  area  of 
tympany  in  front,  which  will  be  substituted  by  dullness  if  he  be  placed  in 
the  knee-elbow  position. 

The  statement  that  in  ascites  there  is  dullness  in  the  flanks  must  be 
taken  with  some  allowance,  for  it  sometimes  happens  that  a  tympanitic 
note  may  be  produced  by  percussion  far  back  in  the  flank  behind  the  mid- 
axillary  line,  because  in  this  situation  lie  the  ascending  and  the  descending 
colon,  with  the  posterior  aspect  uncovered  by  peritoneum  and  therefore  inac- 
cessible to  the  fluid. 

Differential  Diagnosis.— The  morbid  condition  which  the  physician 
is  most  frequently  called  upon  to  distinguish  from  ascites  is  probably  the 
ovarian  cyst.  The  ovarian  cyst,  especially  when  large,  furnishes  some 
points  of  resemblance,  yet  there  are  striking  differences.  It  begins  in  one 
side  and  rises  up  from  the  pelvis  toward  the  center  of  the  abdomen,  which 
soon  becomes  the  most  prominent  portion,  w^hile  the  dropsical  eft'usion 
spreads  out  into  both  flanks.  The  ovarian  cyst  distends  one  side  more 
than  the  other  at  first,  and  continues  to  do  this  even  when  large  and  fully 
developed.  It  produces  no  obliteration  or  projection  of  the  navel,  as  does 
abdominal  dropsy.  Palpation  also  recognizes  fluctuation  in  the  ovarian 
cyst,  but  it  is  usually  less  distinct  and  more  circumscribed,  while  in  ascites 
the  wave  passes  all  the  way  across  the  abdomen.  To  percussion,  the  latter 
condition  aft'ords   a  central  tympany  and  dullness   in  the  flanks,   while  in 


ASCITES.  495 

ovarian  cyst  the  flanks  are  resonant  because  the  bowels  are  pushed  into 
them.  This  is  at  least  true  of  one  flank,  even  if  the  other  is  completely 
occupied  by  a  large  tumor.  If  there  is  tympany  in  the  upper  abdomen, 
with  an  ovarian  tumor,  it  is  bounded  below  by  a  convex  line,  while  in  ascites 
its  lower  border  is  concave. 

A  change   of  position   has   less   influence   on   the   dullness   in   ovarian 

tumor  than  in  ascites.     Vaginal  examination  affords  some  information.     In 

ascites   the   vaginal   vault   is   obliterated,   the   uterus   prolapsed,   but    freely 

movable,  while  in  ovarian  tumor  the  vagina  is  less  encroached  upon,  the 

.uterus  being  sometimes  drawn  up  and  less  movable. 

The  characters  of  the  contained  fluid  are,  as  a  rule,  widely  different. 
The  fluid  of  a  simple  ascites  is  usually  transparent,  has  a  low  specific  gravity, 
commonly  below  1012,  and  contains  a  small  quantity  only  of  albumin  and  a 
few  leukocytes.  The  ovarian  fluid  is  usually  dark  and  grumous  in  appear- 
ance, highly  albuminous,  with  a  specific  gravity  of  1020  or  more,  and  reveals 
to  microscopic  examination  numerous  granular  fatty  cells  (compound  gran- 


Fig- 39- — So-called  "  Ovarian  Cells." 

ule  cells),  cholesterin  plates,  and  small,  pale  granular  cells.  These  last 
are  round  or  slightly  oval,  about  the  size  of  a  white  blood-corpuscle,  and 
are  by  some  regarded  as  pathognomonic  of  ovarian  cyst  contents,  and  there- 
fore called  "ovarian  cells."  They  are  found  in  pleuritic  fluids,  pus,  and 
even  ascitic  fluids,  but  they  are  much  less  numerous  in  these.  The  cell  is 
probably  a  degenerated  endothelial  cell  from  the  peritoneum.  The  presence 
of  these  cells  in  large  numbers  is  certainly  a  help  to  the  identification  of 
ovarian  fluids. 

In  rare  instances  the  fluid  of  ascites  is  milk-white.  This  occurs  when 
from  any  cause  there  is  leaking  of  chyle  into  the  peritoneal  cavity — ascites 
chylosus.  In  the  effusion  associated  with  morbid  growths,  such  as  cancer 
and  tuberculosis,  the  fluid  is  also  sometimes  white  in  color,  from  the  pres- 
ence of  an  unusual  number  of  fattily  degenerated  cells  from  these  sources 
or  from  the  peritoneal  endothelium. 

The  over  distended  bladder  has  been  more  than  once  punctured  by  mis- 
take for  ascitic  fluid,  but  this  accident  can  never  occur  if  the  patient  is 
directed  to  empty  his  bladder  or  the  patheter  is  used  before  tapping. 

Hydronephrosis  has  been  confounded  with  ascites,  and  this  is  less  ex- 
cusable than  the  confounding  of  hydronephrosis  and  ovarian  cyst.  In  ad- 
vanced hydronephrosis  the  fluid  may  be  almost  identical  with  that  of  ascites. 


496  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

but  its  mode  of  development  is  from  one  side  and  exceedingly  slow,  while 
there  are  pain  and  tenderness  in  the  region  of  the  kidney.  W.  von  Leube 
relates  a  case  in  which  he  mistook  an  enormously  dilated  stomach  filled 
with  fluid  for  ascites,  and  points  out  how  easily  the  mistake  could  have 
been  avoided  by  the  previous  use  of  a  stomach-tube. 

A  cyst  of  the  omentum  is  a  rare  condition,  but  should  be  remembered 
as  a  possible  one  to  be  distinguished  from  ascites. 

Chronic  peritonitis  is  also  attended  by  effusion,  which  is,  however,  more 
limited  than  in  ascites,  and  the  change  in  the  area  of  dullness  on  change  of 
position  is  less  complete  because  of  the  peritoneal  adhesions,  which  inter- 
fere with  the  ready  movement  of  the  fluid.  In  tubercular  peritonitis,  where 
there  is  less  limitation  by  adhesions,  there  is  also  tenderness.  The  with- 
drawn fluid  is  more  highly  albuminous  and  of  higher  specific  gravity  than 
the  ascitic  fluid. 

Treatment. — The  treatment  of  ascites  is  that  of  the  causing  disease. 
Paracentesis  is  often  necessary  to  relieve  the  discomfort  of  the  patient.  The 
fluid  may  accumulate  with  rapidity  and  the  tapping  require  to  be  repeated 
quite  frequently,  but  it  is  not  true,  as  commonly  supposed  by  the  laity,  that 
a  first  tapping  necessitates  a  second  per  se.  When  frequent  tapping  is 
necessary,  it  is  sometimes  better  to  keep  the  orifice  open  and  allow  the  fluid 
to  drain  away  continuously,  rigid  antiseptic  precautions  being  taken.  Under 
these  circumstances  the  patient  sometimes  improves  rapidly,  as  he  is  re- 
lieved from  the  exhausting  effect  of  the  pressure  and  weight  of  the  large 
amount  of  liquid  and  of  the  constant  dread  of  repeated  tappings. 


SECTION  III. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

DISEASES  OF  THE   NOSE. 

The  first  in  the  natural  order  of  this  system  are  the  nasal  passages. 
These  are  subject  to  but  few  medical  diseases.  They  are  explored  from 
the  front  by  nasal  specula  or  dilators.  The  nares  are  investigated  poste- 
riorly by  the  rhinoscope,  which  is  another  name  for  a  very  small  laryngeal 
mirror.  The  mirror  is,  however,  introduced  differently.  The  position  of 
the  patient  in  relation  to  the  observer  and  source  of  illumination  is  much 
the  same,  but  the  head  of  the  former  is  not  raised,  and  the  tongue  is  best 
held  down  by  the  tongue  depressor  or  the  forefinger.  The  warmed  mirror 
is  introduced  with  the  reflecting  surface  upward,  and  is  passed  backward 
over  the  tongue  behind  the  uvula  until  it  lies  against  the  posterior  wall  of 
the  pharynx.  It  is  then  directed  upward  and  forward,  and  upon  it  will  be 
found  the  nasal  image  and  that  of  the  vault  of  the  phar}mx  (see  Fig.  40). 

ACUTE  RHINITIS. 
Synonym. — Coryza. 

Definition  and  Symptoms. — Simple  acute  inflammation  of  the  nasal 
passages,  giving  rise  to  the  well-known  uncomfortable  full  feeling  which 
all  have  experienced  under  the  name  of  "  cold  in  the  head,"  is  a  frequent 
event.  There  may  be  previous  sneezing.  The  fullness  is  due  to  swelling  of 
the  mucous  membrane,  the  result  of  inflammation,  and  is  sooner  or  later 
followed  by  a  discharge  which,  at  first  watery,  may  or  may  not  become 
mucopurulent.  With  it  comes  relief  of  the  most  uncomfortable  symptom, 
the  nasal  obstruction.  This  is  most  serious  in  nursing  children,  in  whom  it 
renders  sucking  often  very  difficult.  There  may  be  slight  fever,  but  the 
constitutional  disturbance  is  seldom  decided,  and  the  elevation  of  tempera- 
ture is  correspondingly  trifling,  rarely  exceeding  a  degree.  The  nasal 
mucous  membrane  may  be  involved  in  diphtheria,  constituting  diphtheritic 
rhinitis. 

Etiology. — Cold  is  the  most  frequent  cause  of  simple  acute  rhinitis. 
The  exudative  forms,  including  simple  fibrinous  rhinitis  and  nasal  diph- 
theria, are,  of  course,  of  an  infectious  nature. 

Treatment. — When  this  condition  is  associated  with  inflammation  of 
the  adjacent  mucous  membrane  of  the  respiratory  passages  and  of  the 
throat,  its  treatment  is  that  of  the  concurrent  affection.  An  ordinary  cold  in 
the  head  may  sometimes  be  cut  short  by  a  full  dose  of  quinin.  if  given 
early  enough.  When  the  discomfort  is  sufficient  to  require  treatment,  I 
have  had  excellent  results   from  the  inhalation  of  a  solution  of  iodin  in 

32  497 


498 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


ether,  one  or  two  grains  to  the  ounce.  The  discomfort  is  partially  due  to 
the  dryness,  and  this  is  overcome  by  the  application  of  any  simple  ointment^ 
as  cold  cream  or  vaselin,  applied  by  means  of  a  brush  or  the  end  of  the 
finger.  The  same  result  is  better  accomplished  by  the  oil  spray,  for  which 
liquid  paraffin  may  be  used.  Such  applications  to  the  adjacent  parts  are 
also  useful  when  the  discharge  is  irritating.  In  infants  it  is  not  unusual 
to  apply  the  grease  to  the  exterior  of  the  nose,  and  it  may  be  that  some  good 
effect  is  thus  produced.  Dobell's  solution  may  also  be  spraved  into  the 
nose,  and  when  dry  discharges  accumulate,  they  should  be  washed  out  b\- 
gentle    injections   of   tepid    salt   water.     Dobell's    solution    is    composed    of 


^pip'Totii^' 


-ZofyerJofv^ 


Fig.  40.— Illustrating  Technique  of  Rhinoscopic  Examination— (a//^r  Sahh). 

sodium  borate  one  dram  (4  gm.),  sodium  bicarbonate  one  dram  (4  gm.), 
glycerite  of  carbolic  acid  (U.  S.  P.)  two  drams  (8  gm.),  and  water  one 
pint  (0.5  liter). 

V* 

CHRONIC  NASAL  CATARRH. 
Synonyms. — Chronic  Rhinitis:  Ozena. 


Definition. — Chronic  inflammation  of  the  nasal  mucous  membrane,, 
associated  with  increased  secretion  and  loss  of  the  sense  of  smell. 

Etiology. — Chronic  catarrh  of  the  nasal  passages  may  be  the  result  of 
acute  inflammation  frequently  recurring,  but  more  commonly  it  arises  from 
Special  causes.  Only  a  small  number  of  the  cases  of  rhinitis  so  common 
in  the  so-called  scrofulous  are  the  result  of  tuberculosis  of  the  mucous  mem- 
brane of  the  nose,  but  tuberculosis  of  the  nasal  passages  does  occur,  and 


CHRONIC  NASAL  CATARRH.  499 

must  be  recognized  as  a  cause  of  chronic  nasal  catarrh.  A  more  frequent 
cause  is  syphilis.  It  must  be  admitted,  however,  that  these  very  persons 
known  as  "  scrofulous  " — that  is,  persons  with  fair,  soft,  and  translucent  skin, 
in  whom  inflammations  run  a  slow  course — are  more  subject  to  the  disease, 
and  that  it  arises  in  them  either  spontaneously  or  is  excited  by  the  more 
ordinary  causes,  such  as  recurring  "  colds."  In  consequence  of  the  offensive 
odor  frequently  associated  with  one  form  of  chronic  nasal  catarrh — the 
atrophic — it  has  been  termed  ozena. 

Morbid  Anatomy. — Two  broad  divisions  of  chronic  nasal  catarrh  are 
jnade  from  the  anatomical  standpoint — the  hypertrophic  and  the  atrophic. 
In  the  hypertrophic  there  is  a  thickening  of  the  mucous  membrane,  while 
in  the  atrophic,  a  thinning  or  atrophy  is  present.  In  the  hypertrophic  ca- 
tarrh, the  membrane  is  red,  swollen,  and  spongy.  The  cavernous  tissue 
over  the  turbinated  bones  shares  in  the  process,  and  the  nasal  cavities  may 
be  encroached  upon  from  all  sides.  The  protrusion  becomes  more  promi- 
nent as  the  disease  progresses,  and  to  it  is  added  a  greater  or  less  hypersecre- 
tion of  mucus. 

In  the  atrophic  or  fetid  form,  the  nasal  mucous  membrane  is  thinned, 
the  cavities  are  enlarged,  and  within  them  are  found  the  thick,  yellowish- 
green  crusts  which,  in  decomposing,  give  rise  to  the  characteristic  offensive 
odor  of  this  form  of  rhinitis.  The  atrophic  process  involves  all  the  tissues, 
from  the  epithelium  down  to  and  including  the  underlying  bone.  The 
accessory  sinuses  connected  with  the  nose — the  frontal,  ethmoidal,  and 
maxillary — may  all  become  implicated  in  this  disease  by  extension  from  the 
nasal  chambers,  and  may  become  the  seats  of  chronic  purulent  inflammation. 

Symptoms. — The  two  principal  forms  of  nasal  catarrh  have  certain 
symptoms  in  common.  In  both  there  is  more  or  less  marked  obstruction 
to  nasal  respiration.  In  the  hypertrophic  form,  however,  this  is  due  to 
actual  narrowing  of  the  nasal  chambers  by  the  overgrowth  of  the  con- 
tained structures,  while  in  the  atrophic  form  it  is  due  to  the  choking  of 
the  passages  by  the  large  masses  of  inspissated  mucus  and  muco-pus. 
There  is  generally  some  slight  impairment  of  the  sense  of  smell  in  the 
hypertrophic  form,  while  in  the  atrophic  it  is  more  often  completely 
abolished.  Both  forms  are  usually  accompanied  by  disturbances  of  secre- 
tion in  the  nasopharynx,  and  these  lead  to  those  noisy  efforts  at  clearing 
the  throat  termed  "  hawking."  The  ozena,  or  fetid  odor,  is  symptomatic 
only  of  the  atrophic  variety.  No  odor  is  attached  to  simple  hypertrophic 
catarrh. 

Hypertrophic  nasal  catarrh  is  apparently  much  more  common  in  the 
United  States  of  America  than  in  Europe — indeed,  the  observations  of  the 
specialists  go  to  show  that  almost  every  person  is  more  or  less  the  subject 
of  these  hypertrophic  processes,  of  which,  in  many  instances,  he  is  quite 
ignorant  until  examination  has  shown  their  presence. 

Treatment. — The  proper  local  treatment  of  chronic  nasal  catarrh, 
Avhich  is  by  far  the  most  important,  demands  such  special  measures  as  in 
the  main  can  only  be  carried  out  by  accomplished  specialists.  This  treat- 
ment, therefore,  so  far  as  can  be  taken  up  in  this  book,  can  only  be  palliative, 
or,  if  curative,  limited  to  the  early  stage  of  the  disease.  In  all  forms  of 
chronic  catarrh  the  most  important  pleasures  to  be  employed  by  the  physi- 
cian, as  distinguished  from  the  specialist,  are  those  which  have  for  their 
purpose  the  attaining  of  the  greatest  amount  of  cleanliness  of  the  affected 
regions.     The   simplest   means    for  accomplishing  this   purpose   is   sniffing 


500  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

from  the  palm  of  the  hand  simple  salt  solution  of  the  strength  of  a  teaspoon- 
ful  of  sodium  chlorid  to  a  pint  (0.5  liter)  of  water,  or  some  one  of  the 
substitutes  named  below. 

This  method,  however,  accomplishes  the  purpose  but  feebly,  and  the 
same  solution  can  be  more  effectually  introduced  by  the  irrigator  or  nasal 
douche.  There  is  much  dift'erence  of  opinion  among  specialists  as  to  the 
efficiency  and  safety  of  the  douche.  Doubtless,  harmful  results  have  suc- 
ceeded its  careless  use,  among  which  are  said  to  have  been  inflammation 
of  the  middle  ear  and  meningitis.  Carl  Seller  claims,  as  did  the  late  Dr. 
Elsberg,  of  Xew  York,  that  these  may  be  avoided  by  the  observance  of 
proper  precautions.  According  to  Seller,  the  best  irrigator  is  a  tin  vessel 
holding  a  pint  (0.5  liter)  and  provided  v/ith  an  opening  in  its  bottom,  to 
which  a  rubber  tube  may  be  attached,  furnished  at  the  end  by  a  nozzle  made 
of  glass,  rubber,  or  wood  which  fits  into  the  nostril.  The  vessel  is  filled 
with  fluid,  warmed  to  a  temperature  slightly  above  blood-heat,  and  the 
douche  should  be  so  placed  upon  a  table  or  mantel  that  it  does  not  stand 
more  than  an  inch  above  the  eyebrows  of  the  patient.  If  higher,  too  great 
pressure  may  result,  and  the  fluid  be  forced  into  the  frontal  sinuses,  causing 
the  frontal  headache,  or  into  the  Eustachian  tube,  causing  otitis  media. 
The  nozzle  is  introduced  into  one  nostril,  and  the  head  being  inclined  forward, 
the  water  runs  up  in  that  side  of  the  nose  'until  it  reaches  the  velum 
palati.  when  it  passes  around  into  the  other  side  and  through  it,  bathing 
the  mucous  membrane  and  washing  out  the  mucus  or  loosening  it  so  that 
it  may  be  forced  out  by  gentle  blowing.  It  is  important  that  the  liquid 
used  should  be  of  the  same  temperature  as  the  blood,  and  of  the  strength 
which  is  secured  by  the  proportion  named.  The  plain  salt  solution  may  be 
substituted  by  alkaline  solutions,  such  as  solutions  of  sodium  bicarbonate 
and  borate,  of  the  strength  of  one  dram  (4  gm.)  of  either  to  the  pint 
(0.5  liter),  or  of  a  half  dram  (2  gm.)  of  each  combined.  The  dDuche 
sometimes  fails  of  its  purpose  when  the  nasal  passages  are  obstructed  by 
deviation  of  the  septum  or  bony  hypertrophies.  It  should  first  be  used 
carefully,  therefore,  under  the  direction  of  the  physician,  who  will  desist 
when  he  finds  obstruction.  It  remains  then  to  use  the  hand,  as  directed, 
or  the  nasal  spray  apparatus. 

Whatever  the  dangers  of  the  douche,  they  do  not  extend  to  the  spray. 
As  ordinarily  used,  it  is,  however,  much  less  efficient.  A\  e  may  use  with  it 
varying  proportions  of  "  listerine  "  *  and  water,  say  from  one  to  four  up  to 
equal  parts ;  also  an  alkaline  solution  composed  of  listerine  one  part,  water 
four  parts,  and  a  half  dram  (2  gm.)  each  of  sodium  bicarbonate  and  sodium 
borate.  When  large  quantities  are  required  to  wash  out  the  nasal  cavities, 
the  postnasal  syringe  may  be  used  instead  of  the  nasal  douche.  Listerine  is 
disinfectant  and  deodorizing,  but  salicylic  acid  and  carbolic  acid  may  be 
added  to  solutions  for  these  purposes.  A  plug  of  borated  or  salicylated 
cotton  may  be  used  for  a  like  purpose. 

Recently,  Dr.  J.  Aluller,  of  A^ienna  and  Carlsbad,  has  availed  himself 
of  the  pressure  of  condensed  carbonic  acid  for  producing  the  spray.  He 
finds  that  a  pressure  equivalent  to  one  and  a  half  atmospheres  is  quite  suf- 
ficient where  a  pressure  of  seven  atmospheres  by  atmospheric  air  is  neces- 
sary. Dr.  Miiller,  when  at  Carlsbad,  uses  the  water  of  the  Sprudel  Spring 
at  blood-heat,  and  when  at  Vienna,  an  artificial  Sprudel  water.  These 
sprays  are  played  into  each  nostril  ten  to  fifteen  minutes  at  a  time,  and  for 

*  For  a  formula  for  a  solution  similar  to  listerine,  spts.  th3-mol  comp.,  see  p.  310. 


HAY  FEVER.  501 

a  like  period  into  the  fauces.     This  treatment  is  most  searching,  and  yet 
harmless,  as  I  can  attest  from  a  thorough  personal  examination. 

General  treatment,  although  not  so  important  as  the  local,  is  still  of 
great  value,  and  the  general  health  of  the  patient  should  be  carefully  looked 
after.  In  view  of  the  fact  that  atrophic  rhinitis  is  very  apt  to  occur  in 
scrofulous  persons,  cod-liver  oil  is  a  tonic  always  indicated,  and  should  be 
given  for  a  long  time,  intermitting  occasionally  to  avoid  derangement  of  the 
stomach.  It  should  be  associated  with  iron,  and  even  with  arsenic.  Other 
tonics  should  be  given  as  indicated,  and  the  best  of  food  should  be 
prescribed,  including  an  abundance  of  meat,  eggs,  and  cream.  Wholesome 
ventilation  should  be  secured  for  the  indoor  life,  while  as  much  time  should 
be  spent  in  the  open  air  as  possible.  The  air  indoors  is  especially  apt  to  be 
contaminated  by  the  breathing  of  the  patient  with  atrophic  rhinitis,  and  on 
this  account  good  ventilation  is  imperative.  If  syphihs  is  present,  it  should 
receive  appropriate  treatment  at  once. 


HAY  FEVER. 

Synonyms. — Catarrhus  ccstk'us:  Hay  Asthma;  Autumnal  Catarrh;  Rose 
Cold;  Pollen  Catarrh;  J^asoinotor  Coryza. 

Definition. — A  catarrhal  affection  of  the  upper  air-passages,  associated 
with  asthmatic  dyspnea  and  occurring  in  the  late  summer  or  autumn  and 
spring  of  the  year. 

Historical. — Hay  fever  v:a.s  first  described  by  Bostock,  an  English  phj'sician,  in 
1819,  the  description  being  based  upon  his  own  experience.  He  ascribed  i't  to  heat. 
Elliotson,  in  1839,  appears  to  have  been  the  first  to  suggest  pollen  as  its  exciting 
cause.  Blakely's  observations  in  his  own  case  (1873)  confirmed  this  view,  which  is 
now  generally  held.  Phoebus'  classic  work  was  published  in  German}^  in  1862.  The 
first  elaborate  work  by  an  American  was  that  of  \Yyman,  of  Cambridge.  George  M. 
Beard,  of  New  York,  in  1S76  called  attention  to  the  neurotic  factor.  In  1877  Elias 
Marsh,  of  New  Jerse}-,  read  a  paper  in  which  he  added  further  evidence  to  the  pollen 
theory.  Voltolini,  of  Breslau,  was  the  first  to  point  out  an  anatomical  cause — a  nasal 
polyp,  the  removal  of  which  was  followed  by  the  cure  of  the  case.  Since  then  numer- 
ous observers  have  added  evidence  in  this  direction,  including  Hack,  in  Germany,  and 
Harrison  Allen,  Charles  E.  Sajous,  AVilliam  H.  Daly,  John  O.  Roe,  and  John  N. 
Mackenzie  in  this  country. 

Etiology.—  In  -a  large  proportion  of  cases,  hay  fever  has  as  its  funda- 
mental condition  an  anatomical  change  in  the  nasal  passages,  such  as  hvper- 
trophy  of  the  mucous  membrane,  a  polypoid  growth,  a  deflection  of  the 
septum,  or  a  lowered  position  of  the  inferior  turbinated  bones  so  that  thev 
rest  upon  the  floor  of  the  nose.  These  conditions  are  not  always  demon- 
strable, but  they,  or  some  allied  source  of  reflex  irritation,  produce  an  irrita- 
bility. This  may  be  increased  by  a  neurotic  constitution,  though  the  latter 
may  not  manifest  itself  until  after  the  attacks  have  become  habitual,  so  that 
at  times,  at  least,  it  is  more  likely  that  the  neurosis  is  a  result,  rather  than  a 
cause,  of  the  disease.  A  third  necessary  etiological  factor  is  an  irritant. 
This  irritant,  whatever  it  is,  originates  usually  in  the  spring  or  the  late 
summer.  In  the  spring,  it  has  been  regarded  as  coexistent  with  the  fra- 
grance of  roses ;  hence  the  term,  "  rose  cold."  In  the  autumn,  the  pollen  of 
flowering  plants  is  commonly  regarded  as  the  exciting  cause,  and  in  certain 
instances  this  seems  to  have  been  conclusively  demonstrated,  as  by  Blakely 
in  his  own  case.  Other  substances  are,  however,  capable  of  acting  similarly, 
and  it  is  not  unlikely   that  they  are  numerous.     Changes   of  temperature 


502  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

may  excite  attacks ;  also  emotional  causes,  imaginary  odors,  and  the  like. 
Heredity  is  an  important  factor  in  its  causation,  successive  generations  being 
attacked  with  astonishing  regularity. 

Localities  variously  favor  it.  Generally,  cities  furnish  more  cases  than 
the  country,  and  low  countries  more  than  elevated  ones,  yet  certain  seaside 
places  are  absolute  cures  for  many  cases.  Such  a  place  is  Long  Beach, 
N.  J.,  where  is  located  Beach  Haven,  a  seaside  resort,  fifty  miles  from  Phila- 
delphia, which  has  long  been  a  resort  for  the  victims  of  hay  fever.  The 
disease  is  more  common  in  the  United  States  than  in  Europe,  and  in  the 
United  States  than  elsewhere  in  America.  It  is  more  common  in  men  than 
in  women,  there  being  three  cases  of  the  former  to  every  two  of  the  latter. 

Morbid  Anatomy. —  There  is  no  morbid  anatomy  other  than  that  re- 
ferred to  in  the  remarks  on  the  etiology  of  the  disease. 

Symptoms. — The  onset  of  hay  fever  may  be  quite  sudden,  coming  on 
with  remarkable  regularity  often  on  the  same  day  of  the  month  each  year. 
At  other  times  it  is  more  gradual  in  its  onset.  It  frequently  begins  with 
sneezing,  and,  indeed,  may  consist  entirely  of  inveterate  sneezing.  At  other 
times  there  are  asthmatic  attacks  of  great  severity,  closely  resembling  those 
of  bronchial  asthma,  constituting  the  "  asthmatic  type "  of  the  disease. 
Again,  there  may  be  obstinate  cough,  with  or  without  expectoration;  or 
there  may  be  an  alternation  of  the  two  symptoms,  but  generally  there  is 
more  or  less  persistent  shortness  of  breath.  There  is  also  often  great  de- 
pression of  spirits,  and  victims  have  even  been  impelled  to  suicide.  The 
eyes  are  sufifused  with  redness,  and  there  may  be  conjunctivitis. 

Diagnosis. — The  diagnosis  furnishes  no  difficulty.  The  season  of  the 
year  and  the  periodical  recurrence  of  the  cough  and  asthma  combine  to 
make  the  recognition  easy. 

Prognosis. — Patients  seldom  die  of  hay  asthma,  yet  I  have  known  cases 
which  seemed  to  be  almost  dying  when  they  reached  the  haven  which 
afforded  them  relief. 

Treatment. — ^The  cure  of  an  individual  attack  is  seldom  accomplished 
except  by  removal  from  the  district  in  which  the  patient  resides.  The 
White  Mountains  and  the  Adirondack  Mountains  are  favorite  resorts  in  the 
eastern  part  of  the  United  States,  and  Bethlehem,  N.  H.,  is  the  Mecca  of 
American  hay-fever  victims,  though  other  places  in  the  same  neighborhood- 
are  equally  exempt.  The  Catskills  and  Alleghanies  are  less  celebrated. 
Certain  seaside  resorts  have  also  a  deserved  reputation :  Beach  Haven,  N.  J., 
has  already  been  mentioned ;  Fire  Island,  on  the  Atlantic  Coast  outside 
of  New  York  Bay;  the  Isles  of  Shoals,  Nantucket,  and  Mount  Desert,  on 
the  New  England  coast,  are  others.  Sometimes  a  sea  voyage  will  abort  a 
threatened  attack,  and  some  persons  are  quite  exempt  while  at  sea. 

A  few  cases  have  been  totally  cured  by  operations  on  the  nasal  cavi- 
ties, such  as  correcting  deviations,  and  the  removal  of  hypertrophic  proc- 
esses by  the  knife  or  actual  cautery. 

Home  treatment,  at  best,  is  uncertain  and  but  partially  successful,  and. 
as  is  always  the  case  with  a  malady  so  difficult  to  cure,  the  number  of 
remedies  is  legion.  Of  late,  irrigation  of  the  nasal  passages  by  the  nasal 
douche  or  spray  with  simple  salt  solution  or  weak  solutions  of  quinin,  one 
grain  (0.065  gm.)  to  the  ounce  (15  c.  c),  has  been  used,  with  varying  re- 
sults. Helmholtz  was  the  first  to  suggest  quinin  solution,  and  thought  it 
efficient.  The  oil  spray  is  probably  the  most  efficient  measure  of  this  kind. 
Cod-liver  oil  is  preferred  by  some.     A  strong  solution  of  cocain — 4  to  10 


HAY  FEVER.  503 

per  cent. — applied  with  a  brush  affords  temporary  rehef,  but  the  effect 
soon  wears  away,  and  there  is  danger  of  forming  the  cocain  habit.  Sub- 
nitrate  of  bismuth  and  boric  acid,  1-2  dram  (2  gm.)  to  the  ounce  (15  gm.) 
of  vasehn  or  simple  ointment,  will  sometimes  allay  the  itching.  Solution 
of  suprarenal  extract  will  be  considered  later.  Boric  acid,  ten  grains  (0.65 
gm.)  to  the  ounce  (30  c.  c.)  of  water,  may  be  used  for  the  conjunctivitis. 

It  is  usual  to  give  quinin  internally  also,  in  doses  of  10  to  15  grains 
(0.65  to  I  gm.)  a  day.  lodid  of  potassium  and  belladonna,  so  efficient 
in  bronchial  asthma,  are  of  little  use  in  hay  asthma,  but  I  have  known  them 
to  be  of  service.  The  iodid  is  better  given  in  small  doses,  frequently 
repeated,  as  3  grains  (0.2  gm.)  every  two  hours.  Fowler's  solution  has 
some  reputation.  Morphin  is  undoubtedly  a  useful  palliative,  but  its 
employment  is  to  be  deferred  until  other  measures  fail.  From  1-8  to  1-2 
grain  (0.008  to  0.03  gm.)  may  be  required,  and  the  smaller  doses  should 
he  tried  first.  Chloral  is  also  of  undoubted  use  as  a  palliative,  and  is  much 
safer  than  morphin,  with  which  it  may  be  combined.  It  renders  smaller 
doses  of  the  anodyne  more  efficient,  and  may  be  given  in  combination  with 
1-24  to  1-12  grain  (0.0027  to  0.0055  gni-)  of  morphin  at  short  intervals. 
Suprarenal  extract  has  acquired  considerable  reputation  in  the  treatment 
of  hay  fever.  S.  Solis  Cohen  and  Beamon  Douglass  were  among  the  first 
to  report  favorably  on  its  effect.  It  acts  by  reducing  turgescence  of  th^ 
turbinated  tissue.  It  is  used'  externally  and  internally.  For  local  appli- 
cations a  fresh  solution  is  made  by  shaking  the  dried  extract  with  water, 
and  after  allowing  it  to  stand  for  an  hour  or  two  the  clear  solution  is  re- 
inoved  from  the  top  and  the  precipitate  discarded.  In  the  shape  of  a  spray 
the  solution  may  be  used  every  two  hours  until  the  symptoms  have  subsided, 
repeating  the  treatment  on  the  appearance  of  obstruction,  coryza,  and  sneez- 
ing. Internally  it  may  be  given  in  the  tablet  form  or  in  a  capsule.  Five  to 
ten  grains  are  administered,  day  and  night,  every  two  hours  until  an  exami- 
nation of  the  nasal  membrane  shows  that  the  vasomotor  paralysis  is  under 
control,  or  until  giddiness  or  palpitation  is  noticed.  After  this  improvement 
the  same  dose  may  be  given  every  three  hours,  then  every  six  hours,  and 
finally,  only  twice  daily,  which  is  continued  during  the  hay-fever  season. 
If  the  dose  is  too  rapidly  diminished  and  the  symptoms  reappear,  one  tablet 
should  again  be  given  every  two  hours  until  the  symptoms  are  controlled. 
Mild  cases  may  be  comparatively  comfortable  during  the  season  when  the 
€xtract  is  used  in  this  way.  If  the  pure  dried  extract  is  used  one  to  three 
grains  may  be  given  in  a  capsule. 


DISEASES  OF  THE  LARYNX. 

Examination  of  the  Larynx. — For  the  proper  investigation  of  the 
morbid  states  of  the  larynx  the  laryngoscopic  mirror  has  become  almost 
as  indispensable  as  the  stethoscope  in  the  study  of  diseases  of  the  chest. 
Only  under  the  most  favorable  circumstances,  when  direct  sunlight  is  avail- 
able, may  it  be  used  with  natural  light.  In  such  event,  the  head-mirror, 
intended  to  direct  the  light  upon  the  throat  and  laryngoscope,  should  be 
plane.  Artificial  light  is  far  more  convenient,  and  for  its  management  a 
concave  mirror  is  required.  The  light  may  be  directed  upon  the  throat  by 
means  of  a  condensing  lens,  but  the  mirror  is  not  only  more  convenient, 
but  also  less  costly.     The  patient  should  sit  in  front  of  the  examiner,  whose 


504 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


eyes  should  be  on  a  level  with  the  mouth  of  the  former,  at  a  distance  of 
about  one  foot.  The  convenience  of  a  head-rest  and  a  stool  which  can  be 
raised  or  lowered  to  suit  the  stature  of  the  patient  is  at  once  apparent. 
The  light  should  be  placed  on  the  right  of  the  patient's  head,  and  a 
little  behind  it,  at  about  the  level  of  the  ear.  The  head-mirror  is  then 
adjusted  upon  the  middle  of  the  examiner's  forehead,  no  attention  being 
paid  to  the  central  perforation.  The  patient's  head  should  be  slightly 
raised  and  the  light  reflected  into  the  open  mouth,  of  which  a  general  sur- 
vey should  first  be  made.  The  patient's  tongue  is  held  down  by  a  tongue 
depressor,  or  drawn  out  with  the  aid  of  a  napkin,  and  may  be  held  by  the 


lotrerK^x^Y!' 


Fig.  41. — Illustrating  Technique  of  Laryngoecopic  Examination — {after  Sahli). 

patient  himself.  The  larynx  is  thus  drawn  up  at  the  same  time.  The 
mirror,  slightly  warmed  and  tested  upon  the  back  of  the  hand,  is  then 
carried  carefully  over  the  tongue,  between  it  and  the  palate,  without  touch- 
ing either,  or  gagging  will  inevitably  result,  especially  at  the  first  exami- 
nation. The  uvula  is  gently  pushed  up  by  the  mirror,  and  the  handle 
carried  to  one  side,  and  raised  or  lowered  until  the  larynx  comes  into  view. 
Practice  is,  of  course,  necessary  to  secure  success.  The  patient  is  requested 
to  say  "  Ah,"  in  order  that  the  epiglottis  may  be  made  to  rise  and  the  vocal 
cords  approach  each  other. 

As  stated,  much  practice  is  required  on  the  part  of  both  patient  and 


ACUTE  CATARRHAL  LARYNGITIS.  505 

physician  to  enable  the  latter  to  avail  himself  of  the  mirror  in  the  most 
satisfactory  manner.  Some  persons  can  barely  allow  the  mouth  to  be 
approached,  while  others  are  not  at  all  sensitive.  The  mirror  should  be  at 
once  withdrawn  on  the  occurrence  of  gagging-,  and  gradually  its  presence 
will  be  sufficiently  endured.     Various  devices  have  been  suggested  for  the 


Fig,  42. — Natural  Size  of  Image  of  the  Vocal  Apparatus. 

1,1,1.  Rings  of  the  windpipe.  2.  Cricoid  cartilage,  3,3,3,3.  Thyroid  cartilage. .  4,4,4. 
Epiglottis.  5,5.  Vocal  cords.  7,7.  Ventricular  bands  or  false  vocal  cords.  8,8. 
Back  part  of  the  tongue.     M.  Cricothyroid  membrane. 

improvement  of  the  illumination  in  the  use  of  the  laryngoscope,  and  they 
include  the  electric  light,  but  for  these  the  reader  is  referred  to  books 
especially  devoted  to  the  subject. 

The  best  shape  for  the  laryngeal  mirror  is,  on  the  whole,  circular, 
but  special  conditions  may  demand  the  oval  form.  Figure  42  shows  the 
image  at  rest  and  during  phonation. 


ACUTE  CATARRHAL  LARYNGITIS. 

Etiology. — The  most  common  cause  of  catarrhal  laryngitis  is  cold,  but 
predisposition  plays  a  most  important  part.  Such  predisposition  may  be  the 
result  of  previous  attacks  of  laryngitis,  or  it  may  be  brought  about  by  con- 
stant use  of  the  organ  in  speaking  and  singing;  whence  it  is  common  with 
persons  thus  engaged.  In  these  occupations  the  larynx  is  hyperemic  from 
overuse,  and  this  hyperemia  is  ever  ready  to  be  fanned  into  active  inflamma- 
tion. Exposure  to  cold  is  constantly  at  hand  to  furnish  the  exciting  cause. 
Laryngitis  is  also  brought  about  by  the  inhalation  of  irritating  vapors  or 
gases,  while  intemperate  smoking  and  the  use  of  strong  alcoholic  drinks  are 
also  causes  of  the  hyperemia  so  readily  converted  into  an  inflammation. 
Catarrhal  laryngitis  is  frequently  associated  with  catarrh  of  the  adjacent 
parts,  as  of  the  nose  and  pharynx,  trachea,  and  bronchi. 

Morbid  Anatomy. — It  is  characteristic  of  the  mucous  membrane  of  the 
larynx,  and,  indeed,  of  the  trachea  and  larger  bronchi  below  it,  that  it  loses, 
postmortem,  the  anatomical  characters  of  the  inflammatory  process  as  they 
appear  during  life.  It  is  only  by  the  image  in  the  laryngeal  mirror,  there- 
fore, that  we  can  obtain  an  idea  of  these  appearances  as  they  present  them- 
selves during  active  inflammation.  The  picture  thus  obtained  by  the  laryn- 
geal mirror  is  one  of  intense  redness,  with  swelling.  These  changes  involve 
the  true  and  false  vocal  cords  and  the  trachea  below,  as  well  as  the  epiglottis 


5o6  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

above.  The  latter  appears  in  strong  contrast  to  the  yellowish-pink  of  health. 
Even  greater  is  the  contrast  between  the  appearance  of  the  vocal  cords  and 
the  pearly  white  of  health.  If  secretion  has  set  in,  streaks  of  mucus  may  be 
seen  in  places.  Excessive  swelling  of  these  parts  is  known  as  edema  of  the 
glottis,  but  it  is  not  frequent  in  simple  acute  laryngitis  and  will  be  described 
separately. 

Symptoms. — The  most  constant  symptoms  of  acute  laryngitis  are 
hoarseness  and  cough,  which  vary  with  the  degree  of  the  swelling  and 
hyperemia,  and  which  also  give  rise  to  a  sense  as  of  something  present  in  the 
larynx  and  a  constant  desire  to  clear  the  throat.  In  high  degrees  of  inflamma- 
tion there  may  be  aphonia.  To  these  there  is  sometimes  added  pain  in  deglu- 
tition; with  higher  degree  of  inflammation  there  is  a  feeling  of  constriction 
or  oppression.  The  cough  is  more  or  less  husky  and  often  stridulous.  It  is 
further  characterized  by  its  dryness  and  som.etimes  the  act  is  painful.  Both 
these  features  disappear  with  the  establishment  of  secretion.  There  is  gen- 
erally a  slight  febrile  movement,  seldom  very  high.  All  of  these  symp- 
toms are  aggravated  as  the  disease  becomes  more  severe,  culminating  in  the 
intense  distress  and  impending  suffocation  accompanying  edema  of  the 
glottis. 

Treatment. — The  patient  should  be  kept  in  a  uniformly  warm,  moist 
air,  while  special  inhalations  of  such  air  are  extremely  useful  both  in  giving 
him  comfort  and  in  abating  the  inflammation.  They  require  no  complicated 
apparatus.  A  piece  of  rubber  tubing  may  be  attached  to  the  spout  of  a  tea- 
pot or  kettle,  or  the  steam  may  be  collected  by  an  ordinary  funnel  and  carried 
thence  to  the  mouth.  For  obvious  reasons,  care  should  be  taken  that  the 
funnel  be  not  allowed  to  become  too  hot.  Special  appliances  in  the  shape  of 
a  steam  atomizer,  more  costly  and  scarcely  more  useful,  may  be  used  instead 
of  the  simple  measures.  Cold  applications  may  be  made  to  the  outside  of  the 
throat.  More  rarely  counterirritation  by  mustard  may  answer  better.  The 
irritative  cough  may  require  to  be  relieved  by  anodynes,  which  may  consist  of 
small  doses  of  opium  or  some  one  of  its  preparations  or  derivatives. 
Expectorants  are  of  doubtful  value,  and  certainly  are  not  nearly  so  useful  as 
the  simple  measures  which  have  been  mentioned. 


SPASMODIC  CATARRHAL,  OR  FALSE  CROUP. 

Definition  and  Symptoms. — What  is  known  as  spasmodic  croup  in 
children  of  from  one  to  five  years  is  acute  catarrhal  laryngitis,  to  which  is 
added  a  spasm  of  the  glottis,  producing  the  hard,  stridulous  breathing,  with 
croupy  cough  characteristic  of  this  affection,  which,  once  heard,  is  never 
forgotten.  It  is  produced  by  the  same  causes.  To  the  croupy  cough  are 
added  extreme  restlessness  and  an  anxious  expression.  The  attacks  gener- 
ally come  on  suddenly  at  night,  the  child  waking  from  a  sound  sleep, 
although  warning  is  often  given  by  some  disturbance  of  respiration  while 
the  child  still  sleeps.  There  is  little  fever.  The  next  day  the  child  may 
appear  almost  or  quite  well,  or  there  may  be  a  slight  croupy  cough,  yet  there 
may  occur  another  attack  on  the  following  night  and  even  the  third,  while 
in  very  severe  cases  the  recurrences  continue  for  a  week. 

Diagnosis. — The  only  condition  with  which  spasmodic  croup  can  be 
confounded  is  diphtheritic  croup,  and  then  only  if  no  membrane  is  visible. 


SPASMODIC  CATARRHAL  OR  FALSE  CROUP.  507 

The  throat  should  always  be  examined.  In  diphtheria,  suddenness  of  onset 
seldom  occurs,  and  the  child  is  much  sicker  previous  to  the  croup.  There 
is  high  fever  and  the  anxiety  of  expression  is  much  greater. 

Prognosis. — The  prognosis  in  all  forms  of  acute  laryngitis  is  generally 
favorable,  and  death  is  very  rare  from  spasmodic  croup.  Carelessness  may, 
however,  prolong  an  attack. 

Treatment. — The  favorite  measure  to  break  the  paroxysm  of  croup 
in  children  is  an  emetic.  The  simplest  of  emetics  is  ipecacuanha,  which 
may  be  given  in  the  shape  of  the  wine  or  syrup  in  the  dose  of  1-2  dram 
-to  a  dram  (2  to  4  c.  c.)  every  few  minutes  until  vomiting  is  produced. 
The  mineral  emetics  are  more  prompt,  but  more  depressing  in  their 
action.  An  excellent  remedy  for  the  purpose  is  powdered  alum  with 
molasses  or  honey,  which  may  be  given  in  teaspoonful  doses,  repeated 
every  ten  or  fifteen  minutes  until  vomiting  is  produced,  but  it  is  not  often 
necessary  to  give  a  second  dose.  While  waiting  for  the  action  of  the 
emetic  the  little  patient  may  be  put  into  a  hot  bath, — temperature  98^  to 
112°  F.  (36.7°  to  44.4°  C), — and  some  mustard  may  be  added.  The  tem- 
perature is  kept  up  by  the  addition  of  hot  water,  as  required.  The  majority 
of  attacks  of  spasmodic  croup  may  be  broken  up  in  this  way  without  further 
treatment.  Between  the  paroxysms  the  child  should  receive  small  doses  of 
syrup  or  wine  of  ipecac,  say  five  to  ten  minims  (0.33  to  0.66  c  c),  until 
nausea  is  produced,  or  small  doses  of  powder  of  ipecac  conveniently  in  the 
shape  of  triturates  containing  1-20  grain  (0.003  g^n-)  fo^"  ^^i  infant  a  year 
old.  An  opiate  is  particularly  useful  at  bedtime,  and  by  means  of  it  a 
child  may  often  be  tided  through  a  night  without  an  attack. 

Just  as  early  as  possible  in  the  treatment  an  aperient  should  be  given, 
than  which  none  is  better  than  castor  oil,  but  calomel  is  also  an  admirable 
remedy  for  children,  given  in  doses  of  from  one  to  three  grains  (0.06  to 
0.2  gm.).  When  there  is  fever,  aconite  and  sweet  spirits  of  niter  in 
appropriate  doses  should  be  given.  Special  pains  should  be  taken  to 
maintain  a  uniform  temperature  and  avoid  drafts,  especially  when  the 
child  is  perspiring  freely,  and  it  is  on  this  account  that  bed  is  the  safest 
place. 

Counterirritation  by  weak  mustard  plasters  is  an  adjunct  to  treatment 
which  should  never  be  omitted,  while  gentle  permanent  irritation  is  very 
useful.  It  may  be  secured  by  any  of  the  rubber-spread  plasters  now  sold, 
Icnown  as  porous  plasters  or  capcine  plasters.  In  severe  cases,  ice  to  the 
exterior  of  the  throat,  or  cloths  wrung  out  of  iced  water  should  be  used, 
especially  when  there  is  much  fever. 

Parents  are  naturally  anxious  to  secure  some  treatment  by  which  the 
recurrence  of  attacks  is  prevented.  It  is  to  be  remembered  that  a  gradually 
increasing  immunity  comes  with  added  years.  Certainly  no  medicine  can 
accomplish  anything.  It  is  possible,  however,  to  do  something  by  care  and 
judicious  outdoor  life,  by  which  is  secured  a  "  hardening  "  or  protection 
against  the  more  usual  causes  of  larv'ngitis.  As  an  instance  of  neglect 
of  ordinary  care  may  be  mentioned  the  practice  so  common,  especially 
among  the  poorer  classes,  of  allowing  children  with  their  heads  uncovered 
to  be  at  an  open  doorway  or  open  window  in  the  cooler  seasons  of  the 
y^ear.  Often  a  mother  will  be  seen  standing  with  her  infant  thus  exposed 
in  her  arms.  Such  exposure  is  very  apt  to  be  followed  by  an  attack  of  croup 
the  same  night.  Children  are  also  often  too  warmly  clad  while  in  the 
house,  so  that  their  bodies  are  constantly  moist  with  perspiration.     In  this 


5o8  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

condition  a  current  of  air,  even  when  not  very  cold,  will  often  produce 
spasmodic  laryngitis.  Children  who  are  housed  are  much  more  susceptible 
to  croup  than  those  who  spend  a  portion  of  each  day  in  the  open  air. 


SIMPLE  CHRONIC  CATARRHAL  LARYNGITIS. 

Etiology. — The  causes  of  non-specific  chronic  catarrhal  laryngitis  are 
chiefly  those  which  have  been  already  mentioned  as  producing  the  predispo- 
sition to  acute  laryngitis — that  is.  the  constant  use  of  the  voice  in  speaking 
and  singing,  excessive  smoking,  and  the  use  of  strong  alcoholic  drinks. 
Laryngitis  occasioned  by  smoking  and  whisky-drinking  is  often  accom- 
panied by  chronic  granular  pharyngitis.  So,  too,  frequently  recurring 
attacks  of  acute  catarrhal  laryngitis  independent  of  predisposing  cause,  and 
the  long-continued  inhalation  of  slightly  irritating  substances  are  to  be 
included  among  the  causes  of  chronic  inflammation. 

Morbid  Anatomy. — The  morbid  anatomy  of  simple  chronic  catarrhal 
laryngitis  is  commonly  not  widely  different  from  that  of  the  acute  form. 
There  are  the  same  redness  and  swelling,  but  the  former  is  less  vivid.  The 
chronic  hoarseness  which  is  so  constantly  associated  with  it  is  due  to  a  per- 
manent thickening  of  the  parts  concerned  in  the  production  of  the  voice. 
Ulceration  is  not  com^mon,  although  there  may  be  superficial  erosions.  The 
follicular  glands  are  often  distended,  and,  if  the  inflammation  is  long  kept 
up,  a  hyperplasia  of  the  squamous  epithelium  may  result  in  a  moderate 
villous  outgrowth  on  the  cords.  Nodular  swellings  on  the  vocal  cords  are 
also  recognized,  but  rare,  condition,  known  as  choriditis  tiiberosa  or  pachy- 
dermia laryngis.  Relaxation  of  one  or  both  cords  is  often  present,  and 
maintains  the  voice  symptoms  as  long  as  it  continues. 

Symptoms. —  The  most  prominent  symptom  of  chronic  laryngitis 
is  hoarseness,  which  is  found  in  every  degree  from  a  simple  roughness  of 
the  voice  to  almost  entire  loss  of  it.  There  are  also  more  or  less  pain  and 
discomfort,  but  these  are  not  ordinarily  conspicuous  symptoms,  except  when 
an  attempt  is  made  to  use  the  voice.  There  is  a  decided  disposition 
to  cough,  with  a  view  to  getting  rid  of  some  foreign,  substance  which 
seems  to  be  in  the  larynx.  The  cough  also  varies  in  degree.  It  may 
be  a  mere  hack,  or  it  may  be  scraping  or  ringing.  It  is  also  variously 
effectual  in  bringing  up  a  secretion  of  mucus  and  muco-pus,  scanty  for  the 
most  part. 

Prognosis. — The  prognosis  of  chronic  catarrhal  laryngitis  is  not  en- 
couraging for  total  recovery,  largely,  perhaps,  because  it  is  so  difficult  to 
induce  the  patient  to  comply  with  the  conditions  essential  to  his  cure. 
Could  this  entire  co-operation  be  secured,  sometimes  withheld  through 
no  fault  of  his  own,  it  is  not  unlikely  that  better  results  would  follow  treat- 
ment. 

Treatment. — The  treatment  of  chronic  catarrhal  laryngitis  requires, 
first,  the  removal  of  its  causes,  whatever  they  may  be.  The  public  speaker 
cannot  expect  to  be  cured  of  his  malady  v/hile  he  continues  the  use  of  his 
voice,  nor  can  the  singer,  or  he  who  works  among  irritating  vapors,  nor  the 
ban  vivant  who  will  not  give  up  his  alcohol.  Next  to  the  removal  of  the 
cause  comes  the  use  of  local  measures,  for  internal  medication  with  a  view 
to  local  effect  is  not  promising.  Of  course,  the  patient's  general  condition 
must  be  looked  after  and  his  strength  maintained,  but  local  treatment  is 


TUBERCULAR  LARYNGITIS.  509 

mainly  to  be  relied  upon.     Applications  to  the  larynx  may  be  made  in  four 
different  ways : 

1.  By  inhalation. 

2.  By  lozenge  or  troche. 

3.  By  insufflation. 

4.  Direct  application. 

The  general  practitioner  must,  in  the  main,  confine  himself  to  the  first 
three,  and  much  may  be  accomplished  by  them,  particularly  by  the  judicious 
use  of  the  atomizer.  Cases  are  rare  in  which  the  direct  application  of  medi- 
cated substance  to  the  larynx  is  necessary,  and  requiring  as  they  do  the 
simultaneous  skillful  use  of  the  laryngeal  mirror,  they  are  for  the  most  part 
relegated  to  the  specialist. 

Inhalations  are  further  divided  into  three : 

(a)  Nebulae,  or  atomized  fluid — sprays. 

(b)  Steam  or  vapor. 

(c)  Volatile  substances. 

1.  A  great  variety  of  apparatus  is  employed  for  spraying  medicated 
solutions  into  the  larynx,  and  undoubtedly  the  most  efficient  is  the  com- 
pressed-air machine  with  spraying  tubes,  but  the  cheaper  forms  of  atomizers 
are  also  useful.  Many  excellent  machines  are  to  be  had,  but  rubber  tubes 
are  to  be  preferred  where  chemically  active  solutions  are  to  be  used.  A 
double  hand-ball  secures  a  more  continuous  stream  of  spray  than  a  single 
one.  The  spray  should  be  thrown  into  the  wide-open  mouth,  and  advan- 
tage taken  of  inspiration  to  draw  it  into  the  larynx,  and  a  very  little  practice 
will  teach  the  patient  how  to  accomplish  this.  Astringents  are  the  favorite 
medicaments,  of  which  alum  and  tannin  are  the  most  usual — of  alum  a  3 
per  cent,  solution,  15  grains  (i  gm.)  to  the  ounce  (30  c.  c.)  of  water;  of 
tannin,  a  i  to  2  per  cent,  solution,  5  to  10  grains  (0.32  to  0.65  gm.) 
to  the  ounce  (30  c.  c).  Other  substances  are  sulphate  of  zinc,  15  grains 
(i  gm.)  to  the  ounce  (30  c.c.)  ;  chlorate  of  potash,  15  grains  (i  gm.)  to 
the  ounce  (30  c.  c.)  ;  sulphate  of  iron  and  ammonia,  1-2  to  i  dram  (2  to 
4  gm.)  to  the  ounce  (30  c.c).  Before  any  of  these  solutions  are  used, 
however,  the  larynx  should  be  cleansed  from  mucus  by  an  alkaline  spray, 
say  Dobell's  solution,  or  dilute  listerine  alkalized. 

Steam  inhalation  may  consist  of  hot  steam  alone,  or  the  vapor  may  be 
charged  with  a  volatile  substance.  The  efficiency  of  the  former  in  acute 
laryngitis  has  already  been  referred  to,  and  it  is  in  acute  disease  that  it  is 
chiefly  used.  Benzoin,  benzoic  acid,  and,  for  chronic  conditions,  cubebs  and 
benzonate  of  ammonia  are  among  the  substances  added.  A  teaspoonful  of 
the  compound  tincture  of  benzoin  may  be  added  to  a  pint  of  water  at  140°  F. 
(60"  C),  and  placed  in  any  one  of  the  numerous  inhalers,  of  which,  how- 
ever, none  is  better  than  an  ordinary  teapot.  Volatile  substances  like 
nitrite  of  amyl  are  commonly  inhaled  for  spasmodic  bronchial  disorders,  to 
the  treatment  of  which  further  allusion  will  be  made. 

2.  The  lozenge  or  troche  is  a  favorite  medium  for  medicating  the  larynx, 
and  is  often  useful.  Few  have  failed  to  realize  the  effect  of  a  stimulating 
lozenge  in  clearing  the  throat,  or  the  soothing  effect  of  one  of  the  anodyne 
or  demulcent  kind.  An  infinite  variety  is  made,  and  the  properties  sought 
are  stimulating,  astringent,  or  anodyne,  or  a  combination  of  two  or  more 
of  these.  Among  the  first  is  the  lozenge  of  benzoic  acid,  the  strength 
of  1-2  grain  (0.03  gm.)  to  each  lozenge;  the  cubeb  lozenge  contains  from 
one    to   two   grains    (0.065    to    0.13    gm.)    each;    the    ammonium    chlorid 


5IO  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

lozenge  contains  three  to  five  grains  (0.2  to  0.32  gm.)  ;  the  potassium 
chlorate  lozenge  contains  five  grains  (0.32  gm.).  The  astringent  lozenge 
is  made  up  of  tannic  acid  one  grain  (0.065  gm.),  catechu  two  grains  (0.13 
gm.),  kino  two  grains  (0.13  gm.),  gallic  acid  two  grains  (0.13  gm.).  Seda- 
tive lozenges  contain  opium  in  very  small  quantities,  say  1-20  to  i-io  grain 
(0.002  to  0.006  gm.)  in  each,  or  of  morphin  1-30  to  1-15  grain  (0.002  to 
0.004  gin-))  lactucarium  extract  one  grain  (0.065  grii-)j  althea  one  grain 
(0.065  gm.).  The  selection  of  a  suitable  adjuvant  in  the  preparation  of 
lozenges  is  best  left  to  the  apothecary.  Three  to  five  lozenges  a  day  at 
various  intervals  are  allowed  to  dissolve  in  the  mouth. 

3.  The  treatment  of  the  larynx  by  insiMation  is  sometimes  very  useful. 
The  difficulty  in  the  preparation  of  the  powder  is  such  that  it'  may  be  irri- 
tating from  a  failure  to  secure  sufBcient  subdivision  of  its  constituents.  The 
powder  is  applied  by  means  of  an  instrument  known  as  the  insufflator. 
Starch  is  the  basis  of  most  of  this  class  of  remedies.  Among  the  astringent 
powders  are  tannic  acid  and  powdered  starch,  equal  parts ;  alum  and  pow- 
dered starch,  equal  parts.  Sedative  powders  contain  of  acetate  of  morphin 
two,  five,  eight,  and  ten  grains  (0.13,  0.32,  0.52,  0.65  gm.)  to  1-2  ounce 
(15  gm.)  of  iodoform.  Pure  iodoform  is  also  used;  three  drams  each 
(12  gm.)  of  iodoform  and  subnitrate  of  bismuth  with  1-2  ounce  (15  gm.) 
powdered  starch;  also  borate  of  sodium  three  drams  (12  gm.),  powdered 
starch  1-2  ounce  (15  gm.). 

4.  The  direct  application  is  usually  made  by  means  of  a  brush,  sponge, 
or  cotton  wad.  The  favorite  remedy  is  the  solution  of  nitrate  of  silver  of 
the  strength  of  from  ten  to  fifteen  grains  (0.65  to  i  gm.)  to  the  ounce  (30 
c.  c),  the  weaker  solutions  being  first  used,  as  they  are  often  quite  effectual. 
The  application  should  only  be  made  after  considerable  experience,  and 
always  with  the  aid  of  the  laryngeal  mirror,  which,  indeed,  should  be  used 
whenever  possible  in  making  applications  of  any  kind.  Local  treatment  with 
nitrate  of  silver  should  be  used  every  three  or  four  days,  the  larynx  being 
previously  cleansed  with  a  weak  alkaline  spray.  Ten  per  cent,  solution  of 
resorcin  in  glycerin  is  a  good  application. 

The  selection  of  these  various  forms  of  medication  in  chronic  laryngitis 
must  be  based  on  the  requirements  of  the  case,  but  the  order  in  which  they 
generally  prove  most  useful  seems  to  be  about  as  follows,  subject,  however, 
to  frequent  variation : 

1.  Inhalation  of  medicated  spray. 

2.  Inhalation  of  stimulating  vapor,  especially  when  there  is  much  se- 
cretion. 

3.  Topical  applications  by  "the  cotton  wad. 

4.  Insufflation  of  powders. 

Topical  applications  with  the  brush  are  likely  to  be  made  much  earlier 
by  the  specialist  than  by  the  general  practitioner. 

The  frequent  association  of  chronic  laryngitis  with  nose  and  throat 
conditions  renders  associated  treatment  necessary  in  these  cases.  In  such, 
the  method  of  spraying  devised  by  J.  Miiller  and  described  on  p.  500  is  an 
efficient  aid. 


TUBERCULAR  LARYNGITIS.  511 


TUBERCULAR  LARYNGITIS. 

Etiology. — The  occurrence  of  primary  tubercular  laryngitis,  long  de- 
nied, has  come  to  be  generally  conceded  as  possible,  though  rare.  With 
the  accepted  view  of  the  etiology  of  tubercular  phthisis,  tubercular  laryngitis 
of  the  primary  kind  ought  to  be  of  frequent  occurrence,  for  if  the  tubercle 
bacillus  reaches  the  respiratory  passages  from  without,  the  first  point  of 
attack  would  naturally  be  the  larynx.  The  fact  that  such  is  not  the  case 
-can  only  be  explained  on  the  ground  that  the  bacillus  fails  to  find  in  the 
mucous  membrane  of  the  larynx  conditions  as  favorable  for  its  growth 
and  multiplication  as  it  finds  in  the  deeper  portions  of  the  lung.  Since 
tuberculosis  of  the  larynx  is  commonly  secondary  to  the  same  affection 
of  the  lungs,  the  bacillus  probably  invades  the  larynx  from  the  expectoration, 
inoculation  being  favored  by  the  greater  or  less  friction  between  the  vocal 
cords.  Tubercular  laryngitis  occurs  as  a  complication  of  20  to  25  per  cent, 
of  all  cases  of  pulmonary  tuberculosis. 

Morbid  Anatomy. — To  the  essential  morbid  anatomy  of  tubercular 
laryngitis  is  always  added  that  of  simple  catarrhal  laryngitis.  The  latter 
has  been  described.  The  first  stage  of  miliary  tuberculosis  without  ulcera- 
tion is  sometimes  recognized  by  the  laryngoscope,  appearing  sometimes  as 
pearly  granulations  in  the  mucous  membrane,  more  frequently  as  a  less  dis- 
tinctive, close,  small-celled  infiltrate.  The  tubercular  ulcer  is  more  easily 
discovered,  yet  it  possesses  no  one  anatomical  character  by  which  it  can 
be  infallibly  recognized.  Nor  are  all  the  ulcers  in  the  larynx  associated 
with  tuberculosis  of  the  lungs  necessarily  tubercular.  The  larynx  is  more 
vulnerable  to  the  ordinary  causes  of  simple  Mryngitis  under  these  circum- 
stances, while  the  constant  coughing  and  gagging  in  consumption  may  of 
themselves  cause  laryngitis.  The  true  tubercular  ulcer  results  from  the 
caseation  and  disintegration  of  the  miliary  tubercle.  The  ulcer  thus  pro- 
duced by  the  fusion  of  adjacent  miliary  tubercles  is  at  one  stage  more  or 
less  characteristic  by  its  racemose  or  sinuous  edge,  resembling  in  this  re- 
spect the  conglomerate  tubercular  ulcer  elsewhere.  Its  favorite  seat  is 
the  posterior  part  of  the  larynx,  viz.,  the  posterior  part  of  the  vocal  cords, 
the  interarytenoid  fold  and  the  laryngeal  surface  of  the  arytenoid  cartilages. 
The  epiglottis  is  less  commonly  invaded,  and  the  ventricular  bands  more 
seldom.  In  the  case  of  the  epiglottis  there  is  swelling,  succeeded  by  ulcera- 
tions. 

Symptoms. — ^The  early  symptoms  of  tubercular  laryngitis  differ  in 
no  way  from  those  of  simple  catarrhal  laryngitis,  and  it  is  the  intractability 
of  the  disease  which  often  gives  the  first  intimation  of  its  tubercular  nature. 
The  stage  of  simple  hoarseness  with  which  it  is  always  ushered  in  varies 
also  in  duration,  but  sooner  or  later  it  is  succeeded  by  the  aphonia  and  the 
painful  whispering  voice  which  are  so  characteristic  of  ulceration  of  the 
vocal  cords  or  the  other  parts  intimately  concerned  in  the  production  of 
the  voice.  Sooner  or  later,  too,  painful  deglutition  sets  in  as  a  result  of  the 
extension  of  the  ulcerative  process  to  the  more  exposed  portions  of  the 
larynx.  The  pain  on  deglutition  is  often  agonizing,  and  is  due  to  the  fact 
that  during  the  act  the  constrictor  mpscles  of  the  pharynx  squeeze  the  sensi- 
tive epiglottis  and  arytenoids.  Inanition  and  emaciation  characteristic  of 
the  latter  stages  of  the  disease  now  rapidly  increase,  and  death  is  often  a 
welcome  relief  to  the  sufferer. 


512  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Diagnosis. — Just  suspicion  attaches  to  an  obstinate  laryngitis  associ- 
ated with  acknowledged  tuberculosis  of  the  lung.  With  obstruction  of  the 
larynx  the  auscultatory  signs  of  tuberculosis  are  sometimes  wanting,  so  that 
we  must  depend  on  the  percussion  sounds  entirely.  As  has  been  intimated, 
the  distinctive  features  of  the  ulceration  are  scarcely  sufficiently  w^ell  marked 
to  enable  us  to  recognize  the  tubercular  ulcer  by  the  laryngoscope,  and  to 
distinguish  it  either  from  the  ulceration  of  sypliilis  or  that  of  certain  stages 
of  malignant  disease.  To  distinguish  it  from  the  former,  tuberculosis  else- 
Avhere  and  the  history  of  the  case  may  help  to  a  conclusion,  while  in  case 
of  further  doubt,  the  tuberculin  test  or  the  therapeutic  test  by  iodids  and 
mercurials  may  be  used.  Syphilitic  laryngitis,  even  when  it  is  ulcerative, 
quickly  yields  to  these  remedies,  as  a  rule,  while  the  tubercular  condition 
is  quite  unaffected  by  them.  \\{\h  the  healing  of  the  former  comes  also 
the  tendency  to  contraction  so  characteristic  of  all  cicatrization,  and  especially 
of  that  of  syphilitic  ulcers.  It  is  also  to  be  remembered  that  syphilitic 
ulceration  and  tubercular  ulceration  are  sometimes  associated.  The  in- 
volvement of  the  tongue  in  the  infiltrating  and  ulcerating  process  is  more 
characteristic  of  tuberculosis. 

Prognosis. — The  prognosis  of  tubercular  laryngitis  is  unfavorable  at 
best.  It  is  true  that  of  late  years  the  reported  cures  of  laryngeal  tubercu- 
losis have  become  much  more  numerous,  but  these  still  bear  a  verv  small 
proportion  to  the  cases  that  progress  from  bad  to  worse,  in  spite  of  the  most 
skilled  treatment.  It  is  to  be  expected  that  primary  tubercular  laryngitis 
is  much  more  easily  curable  than  the  form  secondary  to  consumption  of  the 
lungs.  Severe  pain  and  signs  of  stenosis  of  the  larynx  are  unfavorable 
symptoms. 

Treatment. — All  measures  which  have  been  mentioned  as  useful  in 
the  treatment  of  chronic  catarrhal  laryngitis  are  also  more  or  less  so  in 
tubercular  disease,  with,  however,  less  complete  and  less  permanent  results. 
IMar^'elous  effects  have  been  reported  as  following  the  use  of  lactic  acid, 
while  iodoform  and  even  alkaline  inhalations  are  also  said  to  have  healed 
tubercular  ulcers.  We  hear  much  less  of  lactic  acid  of  late.  Two  note- 
worthy cases  illustrative  of  its  efficiency  are  reported  by  Dr.  Percy  Kidd 
in  "  The  Clinical  Journal  "  (London),  July  31,  1895.  It  requires  the  skill  of 
the  specialist  for  its  application.  All  local  treatment  must  be,  of  course,  asso- 
ciated with  that  of  general  tuberculosis  of  the  lungs.  The  painful  deglutition, 
which  is  at  once  so  characteristic  and  so  distressing,  has  been  relieved  by  the 
use  of  cocain  applied  directly  to  the  larynx  by  the  brush  or  by  the  spraying 
apparatus.  The  latter  is  the^  more  convenient,  because  it  can  be  used  by 
the  patient  himself.  For  this  purpose  a  2  per  cent,  solution  is  suitable. 
A  stronger — 10  or  20  per  cent. — may  be  necessary,  but  this  must  be  applied 
with  a  brush  by  a  second  person.  They  should  be  used  some  minutes 
before  the  taking  of  food,  as  deglutition  is  rendered  less  painful  for  the 
time  being  by  their  successful  application.  Solutions  of  morphin  may 
be  sprayed  for  the  same  purpose,  or  the  morphin,  either  pure  or  mixed 
with  powder  or  starch,  may  be  insufflated  upon  the  painful  larynx.  When 
the  pain  is  persistent  and  frequent  applications  are  necessary,  I  have  found 
none  more  satisfactor}'  than  the  official  solution  of  morphin  sprayed  into 
the  larynx. 


EDEMA  OF  THE  GLOTTIS.  513 


SYPHILITIC  LARYNGITIS. 

Etiology  and  Morbid  Anatomy. — It  is  not  necessary  to  dwell  on  the 
etiology  of  syphilitic  laryngitis,  as  there  is  but  one  cause — the  virus  of  syphilis. 
Syphilitic  laryngitis  may  be  either  secondary  or  tertiary,  and  may  occur  at 
any  time  in  the  course  of  the  disease  subsequent  to  the  second  or  third  month 
following  infection.  Like  tubercular  laryngitis,  the  morbid  anatomy  of  the 
syphilitic  form  is  associated  with  that  of  simple  catarrhal  laryngitis  of  the 
chronic  kind.  Excessive  mucous  and  muco-purulent  secretions  cover  the 
surface  of  the  epiglottis  and  the  vocal  cords,  while  the  ulcer  of  syphilitic 
laryngitis  is  usually  more  distinctive  in  its  characters  than  is  that  of  tubercu- 
lar laryngitis.  The  milder  forms  of  syphilitic  laryngitis  are  not  accom- 
panied by  ulceration  and  are  in  no  way  peculiar,  from  the  anatomical 
standpoint.  The  most  distinctive  anatomical  manifestation  of  syphilis  in 
the  larynx  is  the  mucous  patch,  like  that  on  mucous  membranes  elsewhere. 
It  is  found  on  the  epiglottis,  in  the  laryngeal  wall,  and  on  the  epiglottidean 
folds ;  rarely,  on  the  vocal  cords.  The  patches  are  rarely  replaced  by 
ulceration.  The  breaking  down  of  the  syphilitic  gumma  gives  rise  to  an- 
other form  of  syphilitic  ulcer,  often  of  greater  depth.  The  ulcer  may  come 
to  a  standstill  at  any  stage,  and  cicatrization  take  place  with  deformity  and 
permanent  change  of  voice.  In  addition,  necrosis  of  the  laryngeal  cartilages 
is  not  infrequent;  portions  of  these  being  at  times  expectorated.  Among  the 
results  of  cicatrization  are  stenosis,  resulting  sometimes  in  complete  obstruc- 
tion, necessitating  even  tracheotomy  for  their  relief. 

Symptoms. — These  are  essentially  the  same  as  in  tubercular  laryngitis, 
hoarseness,  cough,  aphonia,  pain  in  deglutition. 

Diagnosis. — The  diagnosis  of  S3'philitic  laryngitis  is  justified  in  the  ab- 
sence of  tuberculosis  elsewhere,  especially  when  the  history  of  primary 
syphilis  is  present. 

Prognosis. — The  prognosis  of  this  form  of  laryngitis  is  rather  more 
favorable  than  that  of  tubercular  disease,  especially  if  the  diagnosis  be  made 
early.  The  effect  of  contraction  after  healing  is,  however,  often  serious  in 
producing  stenosis,  or,  at  least,  a  permanent  impairment  of  the  voice. 

Treatment. — The  treatment  of  syphilitic  laryngitis  is  the  treatment 
for  the  general  affection  plus  the  topical  treatment.  The  latter  includes 
the  use  of  measures  to  free  the  larynx  of  mucus  and  muco-pus,  these  being 
followed  by  applications  of  strong  solutions  of  nitrate  of  silver  to  the 
ulcers,  or  even  the  solid  stick.  An  insufflation  of  iodoform,  in  combination 
with  bismuth  and  a  little  morphin,  is  an  excellent  addition  to  the  treatment. 


EDEMA  OF  THE  GLOTTIS. 

Definition. — By  edema  of  the  glottis  is  meant  edema  of  those  parts 
which  immediately  surround  that  opening. 

Symptoms. — Its  consideration  has  been  deferred  to  this  place  because 
it  so  commonly  results  from  the  other  conditions  which  have  just  been 
described,  or  accompanies  them.  Tljus,  it  may  occur  in  connection  with 
acute  laryngitis,  though  rarely,  and  occasionally  with  the  tubercular  and 
syphilitic  form.  It  not  infrequently,  also,  is  a  complication  of  general  dis- 
eases attended  with  dropsy,  especially  Bright's  disease,  more  rarely  typhoid 

33 


514  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

fever,  smallpox,  and  even  diseases  of  the  heart.  In  any  of  the  latter  condi- 
tions it  may  come  on  quite  suddenly.  The  more  precise  situation  is  the  sub- 
mucous tissue  of  the  aryteno-epiglottic  folds  or  of  the  ventricular  bands. 
The  edema  may  also  involve  the  epig*lottis.  It  occurs  most  frequently  in 
middle  life,  but  it  also  happens  in  the  young. 

An  additional  symptom  of  this  condition  is  a  feeling  of  intense  oppres- 
sion or  suffocation.  The  breathing  is  stridulous,  and  the  efforts  of  the  pa- 
tient to  obtain  air  may  bring  into  play  all  the  extraordinary  muscles  of  respi- 
ration, the  whole  expression  being  in  extreme  cases  one  of  great  anguish. 

Treatment. — For  the  mild  degrees  of  edema  of  the  glottis  the  prompt 
application  of  a  blister  to  the  larynx  is  often  sufficient  to  relieve  the  symp- 
toms. Another  remedy  of  some  value  in  the  milder  cases  is  a  direct  spray, 
frequently  repeated,  of  a  solution  of  alum,  20  grains  (1.3  gm.)  to  the  fluid 
ounce  (30  c.  c).  In  the  treatment  of  the  severer  cases,  cold  plays  an  im- 
portant role.  Ice  should  be  constantly  kept  in  the  mouth,  as  well  as  applied 
externally  by  means  of  ice-bags.  If  obtainable,  the  Leiter  coil  may  be  used. 
When  danger  is  imminent,  and  time  is  too  limited  to  wait  for  the  tardy 
action  of  blisters,  a  half  dozen  or  more  leeches  may  be  applied  over  the 
region  of  the  larynx.  These  failing  to  afford  relief,  scarification  of  the 
edematous  tissues  is  to  be  promptly  performed,  and,  as  dernier  ressorts, 
either  intubation  or  tracheotomy. 

The  hypodermic  administration  of  pilocarpin  has  been  remarkably 
successful  in  some  cases,  and  particularly  when  the  symptoms  are  of  a 
sthenic  nature  this  should  never  be  omitted.  One-quarter  of  a  grain  (0.0165 
gm.)  is  the  proper  dose  thus  administered. 


PARALYSIS  OF  THE  LARYNGEAL  MUSCLES. 

To  understand  these  clearly  it  is  necessary  to  remember — 

1.  That  there  are  eight  intrinsic  muscles  of  the  larynx,  five  of  which  are 
muscles  of  the  vocal  cords  and  rima  glottidis,  and  three  connected  with  the 
epiglottis.  The  former  are  the  crico-thyroid,  the  posterior,  and  lateral  crico- 
arytenoid, the  arytenoid  and  the  thyro-arytenoid.  The  muscles  of  the  epi- 
glottis are  the  thyro-epiglottideus  and  the  superior  and  inferior  aryteno- 
epiglottideus. 

2.  That  the  epiglottis  is  depressed  by  the  thyro-epiglottidean  and  the 
aryteno-epiglottidean  muscles.  The  aryteno-epiglottideus  superior  constricts 
the  superior  aperture  of  the  larynx  when  it  is  drawn  upward  during  degluti- 
tion and  the  opening  closed  "by  the  epiglottis.  The  aryteno-epiglottideus 
inferior,  together  with  fibers  of  the  thyro-arytenoidei,  compress  the  sacculus 
laryngis.  The  epiglottis  is  raised  by  the  genio-hyo-glossus,  the  genio-hyoid, 
and  the  mylo-hyoid  muscles. 

3.  That  the  separation  of  the  vocal  cords  or  opening  of  the  glottis  is 
accomplished  by  the  posterior  crico-arytenoid  muscles  alone,  while  its  closure 
is  effected  by  the  lateral  crico-arytenoids,  the  arytenoid  muscle,  and  the  thyro- 
arytenoids. The  crico-thyroids,  acting  in  conjunction  with  the  arytenoid, 
become  tensors  of  the  vocal  cords,  producing  the  different  degrees  of  tension 
tiecessary  to  delicate  modulations  of  the  voice  in  speaking  or  singing,  while, 
at  the  same  time,  narrowing  the  opening  of  the  glottis. 

The  right  and  left  inferior  or  recurrent  laryngeal  nerves  supply  all  the 
intrinsic  muscles  of  the  larynx  on  their  respective  sides  except  the  crico- 


PARALYSIS  OF  THE  LARYNGEAL  MUSCLES. 


515 


thyroid,  which  derives  its  motor  innervation  from  the  superior  laryngeal 
nerve. 

This  is  the  generally  accepted  view  of  the  motor  nerve  supply  to  the 
larynx,  although  it  has  been  shown  to  be  subject  to  occasional  variations. 
It  is  to  be  remembered  that  the  motor  fibers  of  these  nerves  are  originally 
derived  from  the  spinal  accessory  nerve  by  branches  to  the  vagus  before  the 
latter  leaves  the  cranial  cavity.  Consequently,  motor  paralysis  may  be  due 
to :  ( I )  Degenerative  changes  in  the  spinal  accessory  nuclei  in  the  floor  of 
the  fourth  ventricle ;  or  (2)  pressure  on  or  destruction  of  the  spinal  accessory 
fibers  before  they  join  the  vagus;  or  (3)  degeneration,  injury,  or  pressure 
suffered  by  the  vagus  trunk  or  its  superior  and  inferior  or  recurrent 
branches;  or  (4)  the  paralysis  may  be  myopathic. 

As  effects  of  one  or  more  of  these  causes  we  may  find  the  following  con- 
ditions : 

1.  Paralysis  of  the  thyro-epiglottidean  and  aryteno-epiglottidean  mus- 
cles, resulting  in  a  rigidly  upright  position  of  the  epiglottis,  and  the  opening 
of  the  superior  aperture  of  the  larynx. 

2.  Paralysis  of  the  crico-thyroid,  enfeebling  the  voice  and  lessening  the 
ability  to  produce  the  higher  tones.  Examination  by  the  laryngoscope  dis- 
closes imperfect  approximation  of  the  cords,  a  lack  of  visible  vibration  in 
them,  and,  at  times,  if  the  paralysis  be  unilateral,  a  higher  position  of  the 
unaffected  cord. 

3.  Laryngoplegia  or  total  paralysis  of  a  vocal  cord.  This  is  usually  the 
result  of  pressure  upon  the  recurrent  nerve  trunk.  If  the  paralysis  is  uni- 
lateral, the  symptoms  are  not  at  all  striking.  Respiration  is  not  affected ;  the 
voice,  perhaps,  is  slightly  modified  and  easily  fatigued,  but  it  is  far  from  being 
wholly  stippressed.     Inspection  by  the  mirror  shows  the  affected  cord  in 


Fig  43. — Cadaveric  Position  of  the  Left 
Vocal  Cord,  Midway  between  Ad- 
duction and  Abduction  in  Paralysis 
of  the  Crico-arytenoid  Muscle  due 
to  lesion  of  the  left  Recurrent 
Laryngeal  Nerve  at  the  moment  of 
Inspiration — (after  von  Zie?n5sen). 


Fig.  44. — Complete  Both-sided  Ab- 
ductor Paralysis  of  the  Posterior 
Crico-arytenoid  Muscles  (the  Open- 
ers of  the  Larynx)  at  the  Moment  of 
Inspiration — (after  von  Ziemssen). 


what  is  called  the  "  cadaveric  "  position,  one  that  is  midway  between  abduc- 
tion and  adduction.  On  phonation,  the  sound  cord  is  seen  to  pass  beyond  the 
median  line  and  approximate  itself  more  or  less  closely  to  the  other.  The 
corresponding  arytenoid  cartilage  is  also  drawn  in  front  of  that  of  the 
affected  side,  and  the  glottis  is  thus  given  an  oblique  position  (see  Fig.  43). 

In  bilateral  recurrent  laryngeal  paralysis  both  cords  are  in  the  cadaveric 
position,  and  remain  so  both  during  respiration  and  upon  attempted 
phonation. 

4.  Paralysis  of  the  abductors  of  the  glottis,  the  posterior  crico-arytenoid 
muscles.  Unilateral  abductor  paralysis  due  to  pressure  upon  the  recurrent 
nerve  is  not  uncommon.     The  affected  cord  remains  in  the  middle  line  in 


5i6 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


consequence  of  the  unopposed  action  of  the  adductor  muscle.  Phonation  is 
not  interfered  with,  and  dyspnea  occurs  only  in  case  of  severe  exertion,  so 
that  this  aflfection  is,  doubtless,  often  overlooked. 

Bilateral  abductor  paralysis  is  rare,  and  is  generally  dependent  upon 
central  degenerative  change.  The  cords  are  found  in  the  middle  line  with 
but  a  very  narrow  chink  between  them,  and  respiration  is  consequently  noisy 
and  much  embarrassed.  Slight  exertion  or  emotional  disturbance  may  pro- 
voke alarming  dyspnea,  and  at  times  prompt  tracheotomy  becomes  necessary 
(see  Fig.  44). 

5.  Paralysis  of  the  thyro-arytenoid  muscles,  whose  office  is  to  relax  and 
approximate  the  vocal  cords.  This  is  usually  bilateral  and  is  quite  common. 
It  may  be  caused  by  voice  strain,  by  exposure  to  cold,  or  it  may  accompany 
catarrhal  laryngitis.     Approximation  of  the  cords  is  incomplete,  an  elliptical 


Fig.  45. — Paralysis  of  the  Internal 
Thyro-arytenoid  Muscles  (Tensors 
of  the  Vocal  Cords)  in  Acute  Laryn- 
gitis. 

Position  of  the  vocal-  cords  during  pho- 
nation. 


Fig.  46. — Paralysis   of  the  Transverse 

and  Oblique  Arytenoid  Muscles 
(the  Respiratory  Closers  of  the 
Glottis) — (after  von  Ziemsseti). 
Position  in  laryngitis  of  the  vocal  cords 
during  phonation,  the  respiratory 
glottis  remaining  open. 


space  remaining  between  them  which  leads  to  hoarseness  and  feebleness  of 
the  voice.     The  laryngoscopic  appearance  is  seen  in  Figure  45. 

6.  Paralysis  of  the  arytenoid  muscles.  This  may  occur  alone,  the  usual 
causes  being  cold,  catarrhal  laryngitis,  or  hysteria.  A  triangular  gap  is 
found  between  the  vocal  processes  in  attempted  phonation,  and  the  voice  is 
very  feeble  or  wholly  extinct  (see  Fig.  46). 


Fig.  47. — Bilateral  Paralysis  of  the  Thyro-arytenoids  Combined  with  Paresis  of 

the  Arytenoid. 

7.  Combined  paralysis  of  the  arytenoid  and  thyro-arytenoid  muscles. 
In  this  condition  the  mirror  discovers  a  narrow,  hour-glass  opening  between 
the  cords,  caused  by  the  suspended  activity  of  these  muscles,  while  the  lateral 
crico-arytenoids  bring  the  tips  of  the  vocal  processes  together  (Fig.  46). 

Etiology. — The  causes  producing  paralysis  of  these  muscles  are  largely 


ACUTE  BROXCHITIS. 


517 


pressure  by  morbid  growths  within  and  without  the  larynx,  among  the  latter 
being  conspicuously  aneurysm  of  the  arch  of  the  aorta  and  mediastinal 
tumors.     Laryngitis  and  hysteria  are  also  frequent  causes. 

Treatment. — The  first  effort  of  treatment  in  all  these  conditions  should 
be  directed  to  the  removal  of  their  causes.  Unless  this  be  possible,  the  prog- 
nosis is  necessarily  unfavorable.  Catarrhal  processes  must  be  cured.  The 
asthenia  following  diphtheria  is  to  be  overcome  by  general  tonics  and  nerve 
invigorants.  Electricity  is  frequently  of  great  value,  the  galvanic  or  faradic 
currents  being  selected  as  each  case  may  require.  Hysterical  paralvses  are 
best  treated  by  electricity,  chiefly  for  the  moral  effect.  Brilliant  results  often 
succeed  this  treatment,  but  relapses  frequently  occur. 


DISEASES    OF  THE    TRACHEA  AND  BRONCHIAL     TUBES. 

ACUTE  BROXCHITIS. 
Syxonyms. — Acute  Bronchial  Catarrh;  Acute  Tracheobronchitis. 

Definition. — An  acute  intiammation  of  the  tracheal  and  bronchial 
mucous  membrane.  It  is  essentially  a  symmetrical  disease,  the  bronchial 
tree  in  both  lungs  being  more  or  less  uniformly  invaded. 

Etiology. — The  most  frequent  cause  of  acute  bronchitis  is  the  action  of 
cold  in  chilling  the  body.  It  often  succeeds  an  ordinary  coryza  or  cold  in 
the  head  or  a  laryngitis,  the  inflammation  extending  from  the  upper  air- 
passages  downward.  It  is  naturally  more  prevalent  in  the  winter  than  in 
the  summer.  It  is  usually  a  symptom  of  influenza,  whether  epidemic  or 
sporadic.  Invariably,  too,  it  accompanies  m.easles.  of  which  it  is  the  most 
annoying  symptom.  ]\Iore  rarely  it  is  caused  by  irritating  fumes.  A 
microbic  origin  of  acute  bronchitis  is  possible  in  certain  cases,  but  such 
origin  cannot  supplant  the  more  usual  causes  described. 

Morbid  Anatomy. — The  mucous  membrane  of  the  trachea  and  large 
bronchi  is  congested  and  more  or  less  covered  with  a  tough  mucus,  rich  in 
cells,  the  hyperemia  being  especially  marked  about  the  glands  whence  comes 
the  secretion.  Decided  cellular  infiltration  of  the  mucosa  does  not  occur  in 
ordinary  cases,  because  of  the  almost  tendinous  basement  membrane  which 
intervenes  between  the  blood-vessels  and  the  mucosa. 

Symptoms. — Cough  is  the  most  constant  and  conspicuous  symptom. 
At  the  beginning  it  is  hard  and  dry,  wdthout  expectoration :  sometimes  it  is 
painful.  As  the  disease  advances  it  gradually  becomes  looser.  In  the  milder 
degrees  there  is  no  shortness  of  breath,  but  in  the  severe  there  is  a  var}-ing 
degree  of  dyspnea  with  a  sense  of  oppression  or  constriction  in  the  front  of 
the  chest,  caused  by  stenosis  of  the  bronchial  lumina,  due  to  the  swelling  of 
the  mucous  membrane  and  the  presence  of  secretion.  Fezrr  in  mild  degree 
is  commonly  present,  but  the  temperature  rarely  exceeds  loi^  F.  (38.3°  C). 
If  it  does,  there  is  reason  to  suspect  a  more  deep-seated  involvement  of  the 
smallest  or  capillary  tubules,  whence  the  name  capillarv  bronchitis,  referred 
to  in  considering  bronchopneumonia.  This  extension  is  particularly  apt  to 
take  place  in  children  and  old  person,s,  in  whom  the  physician  should  always 
be  on  the  lookout  for  it.  With  the  access  of  fever  the  pulse  is  correspond- 
ingly accelerated.     Rarely,  a  cliill  may  usher  in  the  disease. 

The  scanty  expectoration  of  acute  bronchitis  is  at  first  glairy  or  mucoid, 


5i8  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

and  later  muco-purulent.  With  the  appearance  of  the  latter  the  cellular  ele- 
ment, composed  of  pus-cells  and  desquamated  epithelium,  becomes  more 
abundant.  With  the  abatement  of  the  disease  the  pus-cells  become  again  less 
numerous  and  finally  disappear. 

Physical  Signs. — There  may  be  absolutely  no  physical  signs — inspection, 
palpation,  percussion,  and  auscultation  being  alike  negative.  In  other  cases 
inspection  may  recognize  increased  frequency  of  breathing,  and  possibly 
increased  rate  of  the  cardiac  apex-beat  if  there  be  fever.  Palpation  may 
appreciate  a  rhonchal  fremitus  if  there  be  sufficient  narrowing  of  the  breath- 
ing tubes.  It  may  be  found  anywhere  on  either  side,  and  is  usually  tran- 
sient. Percussion  continues  invariably  clear  so  long  as  the  bronchitis  is 
uncomplicated.  Auscultation  furnishes  the  most  distinctive  and  constant 
physical  sign,  the  presence  of  dry  rales,  the  sonorous  and  sibilant,  which  may 
invade  either  or  both  lungs,  and  may  also  be  transient,  coming  and  going. 
To  these  may  be  added  harshness  of  breathing  sounds.  When  resolution  sets 
in,  bubbling  rales  may  take  the  place  of  the  sonorous  and  sibilant,  in  conse- 
quence of  the  presence  of  liquid  secretion.  For  physical  signs  of  capillary 
bronchitis  see  Bronchopneumonia. 

Diagnosis. — This  is  generally  easy.  The  presence  of  the  dry  rales  and 
a  clear  percussion  note  belong  to  no  other  condition  than  acute  bronchitis  and 
bronchial  asthma,  but  to  the  latter  are  added  the'  signs  of  spasmodic  contrac- 
tion of  the  bronchi,  notably  the  panting  breathing.  The  same  clearness  of 
percussion  note  continues  with  the  appearance  of  moist  rales,  unless  there  be 
the  complication  of  capillary  bronchitis  or  pneumonia. 

Prognosis, — Very  often  the  symptoms  subside  without  treatment  in  the 
course  of  two  or  three  days.  The  cough  becomes  loose,  expectoration  is  easy, 
fever  and  other  unpleasant  symptoms  disappear,  and  in  a  week  the  patient  is 
well.  Suitable  treatment  may  hasten  such  an  issue.  In  other  instances, 
especially  in  persons  who  are  weak  and  debilitated,  no  such  speedy  termina- 
tion takes  place,  but  even  in  many  of  these  after  a  long  interval  the  patient 
recovers.  More  rarely,  particularly  in  the  very  young  and  old,  the  inflamma- 
tion travels  down  into  the  smallest  tubes,  producing  the  capillary  bronchitis 
alluded  to.  In  other  instances  still,  especially  after  several  attacks,  and  in 
the  old  particularly,  chronic  bronchitis  may  supervene  with  the  symptoms 
and  physical  signs  which  will  be  described  when  considering  it. 

Treatment. — The  best  treatment  for  a  case  of  ordinary  acute  bronchitis 
is  "  the  bed."  Twenty-four  to  forty-eight  hours  in  a  warm  bed  will  go 
farther  to  cure  such  a  case  promptly  than  all  the  cough  medicines  ever  pre- 
scribed. Such  a  course  is  not,  however,  always  possible,  and  the  physician 
is  often  expected  to  cure  acute'bronchitis  while  the  patient  is  on  his  feet  and 
even  attending  to  business.  The  patient  should,  however,  be  put  to  bed 
if  possible.  Next  to  rest  in  bed  is  counterirritation.  Turpentine  and  mus- 
tard are  the  best  agents.  A  turpentine  stupe  or  weak  mustard-plaster 
applied  to  the  front  of  the  chest  will  aid  greatly  in  allaying  cough  and  reliev- 
ing the  sense  of  oppression. 

Cough  medicines  are,  of  course,  expected,  and  are  useful.  In  the  ordi- 
nary simple  bronchitis,  especially  when  there  is  moderate  fever,  there  are  few 
rem.edies  more  efficient  than  the  simple  solution  of  citrate  of  potash  of  the 
United  States  Pharmacopeia,  in  doses  of  1-2  ounce  (15  c.  c.)  every  two  hours. 
It  may  be  desirable  to  add  a  few  drops  of  wine  of  ipecac  or  wine  of  antimony 
to  each  dose  to  increase  the  relaxing  effect,  while,  if  the  fever  is  decided,  one 
minim   (0.055  c.  c.)   of  the  tincture  of  aconite  will  aid  in  breaking  it.     A 


CHROXIC  BROXCHITIS. 


519 


diaphoretic  effect  is  further  encouraged  by  adding  thirty  minims  (2  c.  c.)  of 
the  spirit  of  nitrous  ether.  By  such  measures  the  cough  is  usually  loosened 
in  twenty-four  hours,  the  dry  rales  are  substituted  by  moist  ones,  and  con- 
valescence progresses.  If  there  is  decided  oppression,  it  may  be  relieved  by 
inhaling  the  steam  from  a  hot  saturated  solution  of  chlorid  of  ammonium,  or 
the  compound  tincture  of  benzoin  floated  on  hot  water,  while  in  children  an 
emetic  dose  of  ipecac  may  produce  the  desired  relaxation. 

The  cough  may,  however,  be  so  constant  as  to  harass  the  patient  and  keep 
him  awake  in  spite  of  the  measures  suggested.  In  this  event  an  opiate  is 
^necessary,  and  a  small  quantity  of  morphin,  say  1-16  to  1-12  grain  (0.004  to 
0.0055  gm.)  for  an  adult,  may  be  added  to  the  combination  previously  recom- 
mended. It  is,  perhaps,  on  the  whole  better  to  administer  the  opium  sepa- 
ately,  and  of  all  the  preparations,  Dover's  powder  is  probably  the  best. 
Indeed,  Dover's  powder  alone  is  one  of  the  best  medicines  in  acute  cough  in 
■doses  of  2  1-2  grains  (0.16  gm.)  every  two  hours,  preferably  in  a  pill  or 
capsule;  or  if  it  be  at  night  and  a  prompt  eft'ect  be  desired,  five  grains  (0.32 
gm.)  or  even  ten  grains  (0.65  gm.)  in  one  dose  will  often  act  like  a  charm. 
Codein  is  a  good  preparation  of  opium,  and  has  the  advantage  of  disturbing 
the  system  less  than  some  others.  It  may  be  given  in  doses  of  1-4  to  1-2 
grain  (0.016  to  0.032  gm.)  as  often  as  necessar}-  to  quiet  cough.  Heroin  is 
a  popular  modern  remedy  of  this  class,  given  in  doses  of  1-20  to  1-12  of  a 
grain  (0.003  to  0.0055  g™-)- 

Should  convalescence  be  slow  and  expectoration  prolonged,  the  ammo- 
nium chlorid  in  five-  to  ten-grain  (0.32  to  0.65  gm.)  doses  with  syrup  or 
tincture  of  squills  may  be  substituted  for  the  sedative  mixture,  and  quinin 
and  restorative  measures  added  to  the  treatment.  If  the  cough  is  parox- 
ysmal, the  preparations  of  belladonna  may  be  given,  and  are  often  efficient  in 
controlling  the  paroxysms  where  opium  is  contra-indicated  or  deemed  un- 
necessary. So,  too,  when  secretion  is  copious  and  cannot  be  expectorated, 
belladonna  tends  to  diminish  it,  and  may  be  given  with  expectation  of  relief. 
Copious  secretion  in  children  is  somewhat  removed  by  an  emetic.  To  this 
end  alum  and  honey  may  be  given  or  syrup  of  ipecacuanha  in  teaspoonful 
doses.  All  such  measures  are,  however,  depressing  and  may  be  succeeded  by 
recurrence  of  secretion,  and  should  be  used  onlv  when  necessary. 


CHROXIC  BROXCHITIS. 
Synonym. — Chronic  Bronchial  Catarrh. 

Definition. — A  chronic  inflammation  of  the  mucous  lining  of  the  large 
•and  medium-sized  bronchial  tubes,  commonly  symmetrical. 

Etiology. — Uncomplicated  and  primary  chronic  bronchitis  usually 
develops  gradually,  representing  the  accumulating  remnants  of  frequently 
recurring  "  colds,"  each  of  which  leaves  something  behind  it  until  the  chronic 
condition  is  established.  A  bronchitis  that  is  associated  with  or  consequent 
itpon  another  disease  may  continue  and  become  chronic  after  the  disease  has 
disappeared.  This  may  happen  with  measles  or  influenza,  or  even,  rarely, 
pneumonia. 

Chronic  bronchitis  constantly  attends  other  affections  as  a  consequence. 
The  most  common  of  these  causes  is  tubercular  consumption,  but  it  is  also 
the  result  of  diseases  which  favor  congestion  of  the  air-tubes  bv  reason  of 


520  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

the  obstruction  to  the  circulation  which  they  cause,  such  as  cardiac  valvular 
disease.     Especially  is  this  true  of  mitral  disease  and  Bright's  disease. 

Morbid  Anatomy. — The  bronchial  mucous  membrane  is  bathed  with  a 
dirty  gray  secretion  derived  from  the  mucous  glands,  which  are  sometimes 
hypertrophied.  The  darker  color  is  due  to  inhaled  "  blacks,"  exfoliated 
degenerate  cells,  and  sometimes  to  decomposed  blood.  On  scraping  this 
mucus  away,  there  may  be  little  or  no  change  of  appearance ;  at  other  times 
there  may  be  a  decided  hyperemia.  In  places  the  mucous  membrane  may  be 
thickened  by  cellular  infiltration  ;  at  others  it  may  be  thinned,  producing  some- 
times a  lattice-like  appearance,  because  of  the  prominence  of  the  bands  of 
elastic  tissue  which  resist  the  atrophic  process.  In  old  cases  there  is  often 
dilatation,  which  may  be  saccular,  fusiform,  or  cylindrical,  and  sometimes 
cavernous  dilatations  are  present,  usually  about  the  center  of  the  lung.  It 
is  in  the  latter  more  particularly  that  the  mucous  membrane  is  found  thinned 
and  the  mucous  glands  atrophied ;  at  others,  ulcerated.  In  other  old  cases 
there  are  ulceration  and  necrosis  of  the  cartilaginous  rings. 

Symptoms  and  Course. — The  chief  symptom  of  chronic  bronchitis  is 
cough,  which  is  troublesome  in  various  degrees,  and  is  apt  to  be  worse  at 
night  or  in  the  morning.  Frequently  it  is  paroxysmal,  the  spells  terminat- 
ing in  free  expectoration  of  the  secretion  which  has  excited  the  coughing. 

Chronic  bronchitis  is  commonly  attended  with  free  expectoration,  either 
in  the  manner  just  described  or  more  uniformly  distributed  through  the  day. 
The  expectorated  matter  is  usually  muco-purulent  or  purulent,  the  color 
deepening  to  yellow  as  the  proportion  of  pus  corpuscles  increases,  and  becom- 
ing darker  in  hue  with  the  admixture  of  dead  epithelium  and  decomposed 
blood.  The  quantity  is  sometimes  very  large,  amounting  to  1-2  liter  (a  pint) 
or  more  in  the  twenty-four  hours.  As  the  quantity  increases,  however, 
the  consistence  diminishes,  and  it  may  be  thin  and  watery.  To  such 
copious  expectoration  the  name  of  brojichorrhea  is  applied.  IMore  com- 
monly it  is  purulent,  containing  greenish-yellow^  masses  which  are  coughed 
up  easily.  The  bronchi  are  usually  more  or  less  dilated  in  these  cases.  The 
more  copious  secretion  of  bronchorrhea  or  bronchial  blennorrhea  usually 
separates,  on  standing,  into  two  portions — a  superficial  sero-mucous  portion, 
which  may  be  frothy,  and  a  lower  thick  portion  made  up  more  largely  of  pus- 
cells.  In  addition  to  such  pus-cells  the  microscope  discovers  squamous  epi- 
thelium from  the  mouth,  columnar  cells  from  the  deeper  air-passages,  bacteria, 
and  sometimes  a  few  blood-corpuscles,  as  well  as  the  delicate  whetstone- 
shaped  cn-stals  known  as  Charcot's  crystals. 

Respiration  is  accelerated  in  various  degrees,  but  except  in  the  rare 
forms  to  be  described  and  on  exertion,  dyspnea  is  never  so  marked  as  even 
in  mild  cases  of  tubercular  consumption.  The  absence  of  fever  is  character- 
istic as  contrasted  with  tubercular  consumption,  which  chronic  bronchitis  so 
often  resembles  in  other  respects.  Sometimes  there  is  slight  elevation  of 
temperature,  rarely  exceding  100°  F.  ('37.8°  C). 

After  chronic  bronchitis  has  existed  for  a  long  time  in  the  old.  especially 
when  secretion  continues  copious  w^hile  expectoration  becomes  difficult,  there 
sometimes  superv^enes  a  condition  of  lozv  fever,  probably  septic,  from  absorp- 
tion of  putrid  matters,  and  unless  expectoration  can  be  re-established,  the 
patient  sinks  and  the  fatal  end  is  not  very  remote. 

The  appetite  commonly  remains  quite  good,  and  the  patient  maintains 
his  weight  for  a  long  time.  After  a  while,  however,  the  appetite  and  diges- 
tion are  apt  to  fail,  especially  if  there  is  much  expectoration,  and  then  the 


CHRONIC  BRONCHITIS.  521 

patient  loses  weight.  Some  subjects  of  chronic  bronchial  catarrh  remain 
quite  corpulent  and  well  nourished  throughout  a  long  illness,  and  except  for 
the  cough,  the  amount  of  disturbance  is  often  remarkably  slight.  There  is 
no  pain,  except  sometimes  about  the  attachment  of  the  diaphragm  in  the  lower 
thorax  in  consequence  of  the  harassing  cough. 

A  variety  of  chronic  bronchitis  is  the  asthma  humidum  of  the  older 
authors,  called  by  Laennec  catarrhe  pituiteux.  It  is  characterized  by  still  more 
copious  serous  expectoration,  amounting  sometimes  to  two  liters  (quarts)  in 
the  twenty-four  hours  of  thin,  frothy  sputum,  and  by  severe  paroxysms  of 
coughing. 

Rarely,  the  cough  is  "  dry,"  without  expectoration  except  small,  tough, 
tenacious  masses  of  mucoid  matter.  These  are  brought  up  after  paroxysms 
of  coughing,  often  of  great  severity.  This  dry  variety — the  catarrhe  sec  of 
Laennec — is  commonly  associated  with  emphysema,  and  is  a  very  troublesome 
form. 

Still  another  variety  of  chronic  bronchitis  is  well  called  putrid  or  fetid 
bronchitis,  in  which  the  secretions  decompose  in  the  air-passages  and  acquire 
a  sweetish,  sickening,  and  disgusting  odor,  which  may  pervade  an  entire 
apartment  and  make  the  patient  a  nuisance  to  himself  and  others.  The 
decomposition  is  due  to  the  bacteria  of  decomposition,  the  action  of  which  is 
doubtless  favored  by  retention  of  secretion  in  dilated  bronchi  and  phthisical 
cavities,  and  in  a  decided  majority  of  cases  it  succeeds  an  ordinary  chronic 
bronchitis.  It  also  sometimes  follows  an  empyema  which  perforates  into 
the  lung.  At  times  it  is  said  to  be  primary.  The  expectoration  is  copious 
and  correspondingly  thin.  It  also  separates  into  layers :  an  upper  one  of 
frothy,  muco-purulent  matter  in  which  occur  separate  masses,  and  an  inferior 
of  thicker,  greasy,  purulent  matter.  In  the  latter  the  naked  eye  often  recog- 
nizes dirty  gray  masses  about  as  large  as  a  pea,  known  as  Dittrich's  plugs, 
which  on  microscopic  examination  are  found  to  contain  pus,  bacteria,  and 
detritus  of  uncertain  origin,  together  with  delicate  acicular  fat  crystals. 
Among  other  fungi  are  found  also  leptothrix  filaments,  which  must  not  be 
mistaken  for  elastic  tissue. 

The  chief  additional  symptoms  are  fever — it  may  be  septic — with 
increase  of  cough  and  pain  in  the  side.  There  is  also  sometimes  a  chill. 
These  symptoms  may  again  abate  and  those  of  the  more  usual  form  of 
chronic  bronchitis  prevail,  subject  to  exacerbation  and  improvement.  The 
effect  of  the  fetid  form,  as  might  be  expected,  is  more  severe  on  the  constitu- 
tion, and  there  are  loss  of  appetite,  indigestion,  and  failing  health.  The 
fingers  may  be  clubbed,  as  in  phthisis.  Secondary  purulent  meningitis  and 
abscess  have  appeared  from  the  transfer  of  pus  germs.  The  physical  signs 
do  not  differ  from  those  of  chronic  bronchitis  and  bronchiectasis,  to  be 
described. 

Physical  Signs. — Physical  signs  of  a  decided  character  more  constantly 
attend  chronic  bronchitis  than  acute.  They  present,  however,  no  unchanging 
picture.  There  may  be  nothing  apparent  to  inspection,  or  the  frequently  asso- 
ciated complication  of  emphysema  of  the  lungs  may  be  the  cause  of  a  dimin- 
ished excursion  of  respiratory  motion,  and  the  roundness  or  barrel  shape  of 
the  chest  characteristic  of  that  disease  may  be  seen.  Such  emphysema  may 
give  dimunition  of  the  normal  tactile  fremitus  and  to  percussion  a  hyper- 
resonance.  In  the  vicinity  of  a  superficial  dilated  bronchus  filled  with  secre- 
tion there  may  be  impairment  of  resonance.  The  resonance  is,  however, 
restored  after  copious  expectoration,  or  the  percussion  signs  of  a  cavity  may 


522  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

be  substituted,  though  in  the  middle  or  lower  part  of  a  lung  instead  of  the 
apex,  as  in  consumption.  Vesiculo-tympanitic  or  even  tympanitic  resonance 
may  be  present  from  relaxation  of  lung  tissue,  especially  in  the  lower  pos- 
terior part  of  the  lungs. 

Auscultation  may  also  be  negative,  but  much  more  frequently  recog- 
nizes an  alteration  or  combination  of  harsh  and  feeble  breathing,  sonorous 
and  sibilant  rales,  with  moist  rales  of  all  sizes,  variously  modified  by  differ- 
ent distances  from  the  ear  and  varying  consistence  of  the  secretion.  The 
moist  rale  is  the  most  characteristic  sign  of  chronic  bronchitis. 

Diagnosis. — This  is  not  usually  difficult,  for  while  the  symptoms,  in- 
cluding coarser  appearance  of  the  sputum,  sometimes  closely  resemble  those 
of  tubercular  consumption,  the  physical  signs  do  not,  except  when  a  dilated 
bronchus  presents  the  same  signs  as  a  cavity.  Such  a  dilatation  is,  however, 
found  in  the  middle  of  the  lung,  and  furnishes  its  signs  in  the  neighborhood 
of  the  angle  of  the  scapula,  rather  than  at  the  apex.  The  absence  of  fever 
and  especially  of  tubercle  bacilli  from  the  sputum  after  careful  examination 
is  confirmatory  evidence  of  the  absence  of  tubercular  consumption,  but 
above  all,  the  tuberculin  test  will  settle  the  question. 

Prognosis. — This  is  unfavorable  as  to  recovery,  but  favorable  as  to 
termination.  The  patient  rarely  dies  of  the  direct  effect  of  the  disease, 
being  generally  carried  off  by  some  intercurrent  affection,  often  croupous 
pneumonia.  In  the  old,  however,  a  condition  described  on  page  521  may 
intervene,  or  a  bronchopneumonia  may  supervene  and  terminate  fatally. 
On  the  other  hand,  many  patients  the  subject  of  chronic  bronchitis  live  for 
years  in  comparative  comfort,  getting  almost  well  in  the  summer  and  re- 
lapsing in  the  winter. 

Treatment. — If  it  were  possible  to  remove  every  person  with  simple 
chronic  bronchitis  uncomplicated  by  heart  or  kidney  disease  to  a  warm 
climate,  they  would  probably  get  well.  Certainly  is  this  true  of  the  earlier 
stages.  Aluch  may,  however,  be  done  at  home  to  prevent  the  exacerbations 
due  to  cold,  each  of  which  adds  a  little  to  the  previous  chronic  condition,  by 
care  in  avoiding  exposure.  This  consists  mainly  in  dressing  warmly  and 
remaining  indoors  in  bad  weather.  Heretical  as  it  may  seem,  my  experi- 
ence teaches  me  that  old  persons  can  better  bear  a  little  "  bad  air  "  than 
"  cold  air,"  and  it  is  wiser  to  submit  to  a  little  "  closeness  "  than  to  encoun- 
ter very  cold  air  for  the  sake  of  "  ventilation  " ;  it  is,  of  course,  better  to 
have  both,  if  possible.  It  is  especially  important  that  the  old  should  be 
warmly  clad  with  wool  next  the  skin,  and  precautions  against  cold  feet 
should  be  especially  secured.  When  bronchitis  complicates  other  diseases, 
as  heart  disease  and  kidney  disease,  the  treatment  of  these  is  important. 

In  the  way  of  medicine,  much  can  be  done  by  the  stimulating  expec- 
torants. The  terebinthinates  are  the  best,  and  of  these  one  of  the  best  is 
terebene.  Five  to  ten  minims  (0.3  to  0.6  c.  c.)  in  a  capsule  every  three 
hours  is  a  proper  dose.  Terpene,  another  derivative  of  turpentine,  may  be 
given  in  doses  of  i  1-2  grains  (o.i  gm.)  in  pill  as  often,  or  it  may  be  given 
in  mixture  with  enough  alcohol  to  dissolve  it.  Turpentine  itself  is  a  good 
remedy,  in  doses  of  from  ten  to  twenty  minims  (0.6  to  1.3  c.  c).  Creasote 
is  an  admirable  remedy  in  chronic  bronchitis  :  one  grain  or  minim  (0.06  c.  c.) 
or  two  minims  (0.12  c.  c)  three  times  a  day,  increased  gradually  to  five  grains 
(0.3  c.  c),  or  even  more  than  three  times  a  day,  will  after  a  while  diminish 
the  secretion  and  the  cough.  Creasotol,  or  the  carbonate  of  creasote,  is  a 
much  more  pleasant   remedy,   and  may  be   given  in  doses   of  ten  minims 


CHRONIC  BRONCHITIS.  523 

(0.6  c.  c),  which  may  be  increased.  Sandalwood  oil  or  balsam  of  tolu  or 
Peru  may  be  substituted.  The  compound  tincture  of  benzoin  is  another  old 
but  good  remedy.  Other  stimulating  expectorants,  like  the  carbonate  of 
ammonium  or  the  aromatic  spirit  of  ammonium,  are  often  useful,  but  they 
lose  their  effect  after  a  time.  The  carbonate  of  ammonium,  to  be  useful, 
must  be  given  often — five  to  ten  grains  (0.32  to  0.65  gm.)  every  two  hours. 
The  ammonium  chlorid  is  indicated  where  less  of  a  stimulating  effect  is 
necessary — 5  to  15  grains  (0.32  to  i  gm.)  four  times  a  day  in  combi- 
nation with  the  syrup  of  squill  in  15-minim  (i  c.  c.)  doses,  both  in  the 
•compound  licorice  mixture.  In  some  cases  the  iodid  of  potassium  is  very 
useful,  especially  when  secretion  is  scanty.  It  should  be  kept  up  for  some 
time.  Among  the  more  recent  drugs  recommended  for  chronic  bronchitis 
is  hydrastis  canadensis  in  doses  of  20  to  30  minims  (1.25  to  1.85  c.  c.)  of  the 
fluid  extract  four  times  daily.  It  is  advised  when  there  is  muco-purulent 
expectoration,  of  which  it  changes  the  character  and  reduces  the  consistency 
with  diminution  of  cough. 

Inhalations  of  medicated  vapors  are  sometimes  useful.  Th^  com- 
pound tincture  of  benzoin  may  be  thus  used,  also  turpentine.  They  may 
be  placed  on  the  surface  of  boiling-hot  water,  the  vapor  from  which  will 
carry  the  medicated  preparation  with  it,  and  may  be  conducted  to  the  air- 
passages  through  a  cone  of  paper  placed  over  the  vessel  containing  the 
medicament.  These  vapors  are  more  efficient  than  atomized  fluids.  Simple 
steam  or  vapor  from  a  two  per  cent,  solution  of  common  salt  or  of  sodium 
bicarbonate  may  be  used.  If  there  is  fetor,  carbolic  acid  may  be  used  in  the 
atomizer,  a  two  per  cent,  solution,  or  thymol  one  part  in  1000. 

Alkalinity  is  an  essential  condition  of  easy  secretion  from  the  air 
passages,  so  that  both  inhalations  and  internal  remedies  should  fulfill  this 
condition.  Hence,  simple  liquor  potassse,  U.  S.  P.,  in  fifteen-  to  twenty- 
minim  (i  c.  c.  to  1.25  c.  c.)  doses  in  milk  is  a  good  remedy.  To  this  end 
the  free  use  of  alkaline  mineral  waters,  as  those  of  Vals,  Vich}^,  and  Ems, 
is  useful. 

Digitalis  and  strychnin  are  excellent  medicines,  especially  the  latter. 
Both  stimulate  the  cardiac  action  and  aid  in  pumping  the  blood  through 
the  lungs  with  increased  force,  thus  causing  relief  to  the  congested  mucous 
surfaces.     Strychnin  in  ascending  doses  may  be  given  with  advantage. 

As  to  health  resorts  suitable  for  cases  of  chronic  bronchitis,  those  with 
a  dry  climate,  not  too  cold,  should  be  selected  for  cases  with  copious  secre- 
tion, such  as  southern  Georgia  and  the  Carolinas  or  New  Mexico  in  this 
country,  or  for  stronger  persons  the  cooler  climate  of  Colorado.  For  cases 
of  dry  bronchitis  the  warmer  moist  climates  of  Florida  are  very  suitable. 
In  this,  as  in  all  other  diseases,  the  factor  of  complete  bodily  and  mental 
rest  enters  largely  into  the  cure. 

Chronic  bronchial  catarrhs  always  improve  in  summer,  and  it  is  gen- 
erally sufficient  if  the  patient  be  directed  to  leave  the  hot  and  noisome  city 
and  spend  his  summers  either  in  the  mountains  or  at  the  seaside,  where 
the  air  is  pure  and  bracing. 

Of  foreign  resorts,  those  of  southern  Europe,  especially  Italy,  the 
"western  Riviera,  San  Remo.  Mentone,  and  Cannes,  are  suitable,  while  still 
better,  if  they  can  be  availed  of,, are  Egypt,  Algiers,  and  the  island  of 
Madeira. 


524  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

BRONCHIECTASIS,  OR  BRONCHIAL  DILATATION. 

Historical. — Laennec  (1S19)  was  the  first  to  describe  anatomically  bronchial  dila- 
tation, and  his  admirable  account  remains  at  the  present  day  the  standard  description 
of  the  condition.  It  should  be  mentioned,  however,  that  Laennec  himself  tells  how 
his  attention  was  first  called  to  it  by  Cayol,  at  that  time  a  student,  but  afterward  a 
professor  of  medicine,  who  was  "astonished  at  finding  a  diseased  state  of  the  lung 
which  up  to  that  time  had  remained  undescribed."  This,  according  to  Laennec,  was 
in  iSoS.  Laennec  attributes  the  formation  of  bronchiectatic  cavities  to  mechanical 
cause — viz.,  the  pressure  of  bronchial  secretion.  Andral  (1823)  called  into  play  dis- 
turbances of  nutrition,  and  Reynaud  (1835)  the  respiratory  act. 

Etiology. — The  most  common  cause  of  bronchiectasis  is  chronic  bron- 
chitis, either  simple  or  tubercular,  the  effect  of  the  inflammation  being  to 
weaken  the  bronchial  walls  so  that  they  yield  to  the  inspiratory  and  expira- 
tory strain  to  which  they  are  subjected  in  the  act  of  coughing.  It  is,  there- 
fore, often  associated  with  emphysema.  The  same  cause  contributes  to  the 
bronchial  dilatation  following  bronchopneumonia,  measles,  and  whooping- 
cough  in  children.  Accumulated  secretion  is  also  a  factor,  as  seen  in  the 
dilated  bronchi  which  succeed  obstruction  of  a  bronchial  tube  by  a  foreign 
body,  or  compression  by  aneurysm  or  mediastinal  tumor.  The  traction 
associated  with  fibroid  induration  is  also  a  cause  of  bronchial  dilatation ; 
hence  we  find  it  in  association  with  interstitial  pneumonia  and  sometimes  in 
chronic  pleurisy.  Finally,  bronchial  dilatation  is-rarely  a  congenital  defect, 
in  which  event  it  is  also  commonly  unilateral  and  general — bronchiectasis 
universalis  of  Grawitz. 

Morbid  Anatomy. — Bronchial  dilatation  is  cylindrical  and  sacculated. 
The  terms  explain  themselves.     Both  forms  may  occur  in  the  same  lung. 

In  the  cylindrical  form,  which  is  the  more  common,  dilated  tubes  of 
nearly  equal  caliber  may  run  through  the  substance  of  the  lung,  from  the 
root  to  the  pleural  surface,  producing  an  appearance  not  unlike  the  fingers 
of  a  glove.  More  frequently  the  smaller  tubes  only  are  affected,  dilatation 
being  recognized  at  autopsy  by  the  inequality  of  lumen,  rather  than  by  ante- 
mortem  physical  signs.  It  may,  however,  be  suspected  in  any  case  of 
chronic  bronchitis  with  copious  expectoration. 

The  saccular  bronchiectases  are  spherical  or  oval  dilatations,  into  which 
the  tube  merges  gradually  or  suddenly.  They  may  attain  a  diameter  of 
from  two  to  three  inches  (5  to  8  cm.),  more  or  less.  The  lung  tissue  about 
a  saccular  dilatation  is  rarely  normal.  Commonly,  the  dilatations,  single  or 
multiple,  are  surrounded  by  indurated  and  contracted  lung  tissue,  the  trac- 
tion of  which  on  the  bronchial  wall  produces  the  dilatation.  Adhesion  of 
the  lung  to  the  costal  pleura  also  contributes,  and  large  subpleural  cysts  are 
at  times  thus  formed  by  the  contracting  tissue.  The  cavities  thus  produced 
are  commonly  at  the  base  of  the  lung,  while  in  chronic  phthisis  they  are 
found  at  the  apex.  Cylindrical  and  saccular  dilatation  may  also  be  associ- 
ated under  these  circumstances.  In  universal  bronchiectasis  the  entire 
bronchial  tree  is  converted  into  a  series  of  sacs  communicating  one  with  the 
other.  Alany  cavities  in  pulmonary  consumption  are  primarily  bronchiec- 
tatic cavities. 

In  all  forms  there  is  decided  change  in  the  bronchial  wall,  the  prin- 
cipal feature  of  which  is  atrophy.  This  atrophy  not  only  attacks  the 
mucous  coat,  but  also  the  muscular,  and  sometimes  the  elastic  tissue  and 
cartilage,  reducing  the  wall  to  a  thin,  smooth  membrane,  lined  with  pave- 
ment epithelium,  instead  of  the  usual  cylindrical  form.  At  times  over- 
growth, involving  particularly  the  connective  tissue,  takes   place,   forming 


BRONCHIECTASIS.  525 

lattice-like  projections  on  the  inner  surface  of  the  tube  already  referred  to 
in  treating  of  chronic  bronchitis.  At  other  times  ulcerative  processes  de- 
velop, perforating  the  bronchus  and  invading  the  lung  parenchyma,  con- 
verting the  bronchiectasis  into  an  ulcerating  cavity. 

Symptoms. — These,  in  addition  to  those  of  the  disease  with  which 
the  bronchiectasis  is  associated,  are  the  peculiar  sputum  and  paroxysmal 
cough.  The  sputum  furnishes  the  most  distinctive  feature,  from  which 
alone  the  diagnosis  can  sometimes  be  made.  It  is  muco-purulent,  of  a  dirty 
yellowish-green  color  and  unpleasant,  stale,  and  sweetish  odor,  though  not 
.exactly  fetid,  as  in  fetid  bronchitis.  It  is  often  raised  in  mouthfuls — another 
characteristic.  It  also  separates  into  layers,  usually  three,  of  which  the  upper 
is  frothy  and  thin,  the  middle  mucoid,  and  the  lowest  made  up  of  pus  and 
epithelium  in  various  stages  of  fatty  degeneration,  acicular  fat  crystals,  and 
sometimes  red  blood  discs  and  hematoidin  crystals  sufficient  to  color  it. 
Elastic  tissue  of  the  lung  is  not  usually  present ;  nor  are  tubercle  bacilli, 
unless  there  is  associated  tuberculosis  with  ulceration  of  the  bronchial  walls. 

The  cough  is  paroxysmal,  because  it  is  not  usually  excited  until  the 
sac,  which  is  often  insensitive,  becomes  full  enough  to  irritate  the  healthy 
mucous  membrane,  when  cough  is  at  once  excited  and  continues  until  the 
cavity  is  empty.  The  paroxysms  are  usually  in  the  morning,  when  they  may 
be  excited  by  a  change  in  position.  After  their  termination  there  is  com- 
monly a  long  period  of  rest  until  the  sac — or  a  sac — is  again  filled.  The 
more  paroxysmal  the  cough  and  copious  the  expectoration  in  chronic  bron- 
chitis, the  more  likely  is  there  to  be  a  dilated  bronchus.  Very  characteristic 
is  the  absence  of  fever. 

Physical  Signs. — When  distinctively  present,  they  are  those  of  a  cavity 
in  the  lung,  readily  recognizable  when  near  enough  to  the  surface.  They 
include  tympanitic  percussion  note,  bronchial  and  even  amphoric  breathing, 
bronchophony  or  pectoriloquy  if  the  cavity  is  empty.  If  it  contains  liquid, 
gurgling  may  be  heard  and  the  percussion  note  is  dull.  To  palpation  there 
is  usually  increased  vocal  fremitus,  caused  by  surrounding  consolidation. 
All  signs  vary  according  as  the  cavity  is  filled  or  emptied  of  secretion. 
A  restricted  breathing  excursion  may  also  be  present,  uninfluenced  by  the 
state  of  the  cavity,  whether  full  or  empty. 

Diagnosis. — A  bronchiectatic  cavity  is  usually  distinguished  from  a 
phthisical  cavity  by  the  absence  of  tubercle  bacilli  and  elastic  tissue  from  the 
sputum  of  the  former,  the  situation  of  the  cavity  in  the  center  instead  of  at 
the  apex  of  the  Ivmg,  the  history  of  its  development,  the  absence  of  cachexia 
and  fever.  Hypertrophy  of  the  right  ventricle  is  more  frequent  in  bron- 
chiectasis, but  may  also  be  present  in  fibroid  phthisis  with  or  without 
bronchiectasis. 

A  circumscribed  empyema  which  has  ruptured  into  the  lung  is  much 
more  sudden  in  its  development  than  bronchiectasis,  while  the  history  of  a 
previous  pleurisy  is  superadded.  A  coincident  external  perforation  of  an 
empyema  would  clear  up  all  doubt.  A  true  abscess  of  the  lung  which  has 
found  its  way  into  a  bronchus  has  also  a  different  history  of  origin,  suc- 
ceeding, as  it  usually  does,  a  pneumonia,  a  massive  hemorrhage,  or  trau- 
matic cause.  The  same  is  true  of  gangrene  of  the  lung,  which  is,  however, 
disclosed  by  the  extreme  fetor  of  thp  breath  and  expectoration. 

Treatment. — This  includes  that  of  chronic  and  fetid  bronchitis,  to 
which  may  be  added,  under  favorable  circumstances,  the  injection  of  sacs 
and  their  drainage.     It  is  to  he  remembered,  however,  that  physical  signs 


526  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

are  sometimes  misleading,  and  that  what  seems  to  be  the  clearest  evidence  as 
to  the  exact  site  of  a  sac  is  not  always  to  be  relied  upon.  I  well  remember 
a  case  of  my  own  in  which  there  seemed  to  be  the  most  conclusive  evi- 
dence of  the  presence  of  a  dilated  bronchus  below  the  angle  of  the  left  scap- 
ula— evidence  satisfactory  not  merely  to  myself,  but  also  to  my  colleagues, 
William  Pepper  and  J.  William  \M'iite.  At  my  request.  Dr.  White  opened 
the  thorax  by  exsecting  parts  of  two  ribs,  when,  to  our  astonishment,  no 
cavity  could  be  found  by  the  cautious  use  of  exploring  needles.  Prompt 
closure  of  the  wound  was  followed  by  healing,  and  the  patient  lived  for 
eight  months. 

The  cure  of  well-established  bronchiectasis  is  impossible,  except,  per- 
haps, in  young  persons.  Something  may  be  done  to  prolong  life  and  make 
the  patient  more  comfortable  and  less  disagreeable  to  others.  To  this  end 
we  must  aim  at  the  evacuation  and  disinfection  of  the  offensive  purulent 
secretion,  and  as  far  as  possible  the  obliteration  of  cavities.  For  the  first 
of  these,  the  inhalation  of  crude  creasote  vapor  was  recommended,  first  by 
Arnold  Chaplin,  and  indorsed  by  Theodore  Dyke  Acland  in  an  exhaustive 
paper  on  this  subject.  Intralaryngeal  injections  of  oily  and  antiseptic  sub- 
stances have  been  employed,  with  doubtful  results.  The  difficulties  in  the 
way  of  operation  are  shown  in  the  first  paragraph  on  treatment. 


BROXCHIAL  ASTHMA. 

Definition. — Bronchial  or  spasmodic  asthma  is  a  paroxysmal  asthma 
or  a  panting  for  breath,  which  is  the  direct  result  of  a  contraction  of  bron- 
chial tubes. 

Etiology. — There  is  some  diversity  of  opinion  as  to  the  etiology^  of 
bronchial  asthma.  This  much,  however,  is  admitted,  that  in  some  way 
there  is  produced  a  narrowing  of  the  smaller  bronchi. 

Various  explanations  of  the  narrowing  are  suggested.  Some  allege  a 
simple  swelling  of  the  mucous  membrane  to  be  a  cause.  Such  swelling  is 
variously  spoken  of  as  "  fluctionary  "  (Traube),  "vasomotor  turgescence  " 
(Weber),  "diffuse  hyperemic  swelling,"  or  "exudative"  inflammatory 
swelling  (Curschmann).  On  the  whole,  the  older  view  of  Trousseau,  that 
the  narrowing  is  due  to  a  spasmodic  contraction  of  the  muscular  coat,  seems 
the  most  likely  one,  and  has  recently  received  the  support  of  Biermer. 
Mention  should  be  made  of  the  theory  of  "Wintrich  and  Bamberger  that 
asthma  consists  in  a  tonic  spasm  of  the  diaphragm,  a  theory  which  Riegel 
has  further  developed  by  ascribing  the  spasm  to  a  superexcitation  of  the 
phrenic  nerve,  resulting  in  a  partially  inhibited  excursion  of  the  diaphragm. 

Accepting  Trousseau's  view  of  a  primary  spasmodic  contraction  of 
the  bronchi,  it  becomes  necessarily  a  reflex  act,  the  causes  of  which  are 
various.  It  implies,  first,  a  hyperexcitability  of  the  reflex  center.  Hence 
bronchial  asthma  is  not  infrequent  in  neurotic  persons,  and  has  even  been 
classed  as  a  functional  nervous  disease  with  neuralgia  and  epilepsy,  with 
which  it  is  said  to  alternate  at  times.  Such  hyperexcitability  is  sometim.es 
inherited,  so  that  bronchial  asthma  often  runs  in  families.  Presupposing 
such  excitability,  numerous  peripheral  causes  may  supervene,  the  most  fre- 
quent of  which  is  bronchitis.  It  very  often  happens  that  an  asthmatic  sub- 
ject has  an  attack  of  asthma,  brought  on  by  "  taking  cold,"  the  incident 
bronchitis  being  the  exciting  event. 


BRONCHIAL  ASTHMA. 


527 


Comparatively  modern  studies  have  demonstrated  the  association  of 
some  affections  of  the  throat  and  nasal  passages  with  bronchial  asthma,  and 
that  their  removal  has  resulted  in  its  cure.  Among  these  have  been  en- 
larged tonsils,  chronic  catarrh,  nasal  polypi,  and  the  like.  Other  causes 
in  susceptible  persons  are  impressions  of  certain  odors,  pleasant  and  un- 
pleasant, notably  that  of  flowers  or  plants  in  early  summer,  whence  the 
term  "  rose  "  asthma  and  hay  asthma,  both  of  which  are  allied  affections. 
A  change  of  air,  as  from  town  to  country,  or  the  reverse,  or  from  mountain 
to  lowland,  acts  similarly.  Causes  more  remote  than  those  of  the  nasal 
^passages,  such  as  gastric  derangement,  intestinal  worms,  uterine  disease, 
may  be  admitted.  Purely  emotional  causes,  as  fright  and  emotion,  may  also 
act.  The  frequency  of  bronchial  asthma  in  children  has  already  been 
mentioned.     It  is  more  common  in  the  male  sex. 

Morbid  Anatomy. — Whatever  may  be  the  morbid  state  of  the 
tubular  structure  of  the  lung  during  an  attack  of  asthma,  there  are  no  post- 
mortem appearances  which  are  distinctive  of  it.  In  the  first  place,  the 
chance  is  seldom  offered  at  the  opportune  moment,  and  I  know  of  no  report 
of  a  necropsy  made  on  a  person  dying  during  an  attack  of  asthma.  In  the 
case  of  the  asthmatic  dying  at  other  times,  there  may  be  found  the  morbid 
states  peculiar  to  chronic  bronchitis  and  emphysema,  but  nothing  more. 

Symptoms, — The  symptoms  of  an  attack  of  spasmodic  asthma  are 
unmistakable.  The  typical  asthmatic  is  apparently  in  good  health  between 
the  attacks,  and  often  is  so  up  to  the  time  of  the  attack,  which  then  comes 
on  suddenly,  often  at  night.  At  other  times  there  is  a  prodromal  stage,  a 
feeling  of  thoracic  discomfort  or  "  tightness "  in  the  chest,  or  an  anxious, 
nervous,  restless  feeling,  the  import  of  which  is  well  understood  by  the  victim. 

The  attack  consists  of  a  long-drawn-out  inspiratory  act,  in  which  it  is 
evident  the  air  cannot  get  into  the  lung  fast  enough  to  meet  the  demands 
of  the  besoin  de  respirer.  The  auxiliary  muscles  of  respiration,  the  sterno- 
cleidomastoid, and  the  scaleni,  do  their  best  to  enlarge  the  thorax,  but  that 
is  not  the  difficulty.  It  is  the  contracted  tubes  which  resist  the  entrance  of 
the  air.  Even  more  marked  are  the  effort  and  the  duration  of  expiration ; 
hence  the  dyspnea  is  spoken  of  as  an  expiratory  dyspnea.  The  abdom- 
inal muscles  are  the  auxiliaries  here,  and  they  contract  strongly  and  assume 
a  board-like  hardness.  The  air  is  heard  to  whistle  as  it  enters  and  passes 
out  of  the  chest.  The  patient  sits  in  an  upright  position,  or  leans  slightly 
forward,  and  often  astride  of  a  chair  grasps  the  back  with  his  hands,  for  it 
is  by  fixing  the  shoulders  that  he  can  bring  the  extraordinary  muscles  of 
respiration  into  play.  His  face  is  anxious,  pale,  or  it  may  be  cyanotic,  and 
few  more  distressing  pictures  are  seen.  Notwithstanding  his  efforts,  they 
fail  of  their  purpose  and  comparatively  little  air  enters  the  lungs.  With 
all  these  efforts,  the  breathing  is  not  accelerated, — at  least  accelerated  to  any 
marked  degree, — while  in  a  few  instances  the  breathing-rate  is  diminished. 
The  temperature  is  normal  or  subnormal,  and  the  pulse  is  accelerated  and 
small. 

The  attacks  last  for  a  variable  period,  rarely  less  than  an  hour,  and 
unless  broken  up,  sometimes  several  hours.  They  may  terminate  as  suddenly 
as  they  began,  sometimes  with  a  spell  of  coughing.  On  the  other  hand, 
cough  is  not  a  fmirked  symptom,  and  in  brief  paroxysms  of  asthma  may  be 
altogether  wanting.  In  the  severe  ones,  however,  it  is  present,  accompanied 
by  a  tough  and  scanty  expectoration,  containing  rounded  masses  of  matter, 
either    yellowish    or   grayish   translucent — the    "  perles  "    of   Laennec.     On 


q28 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


minute  examination,  these  are  found  to  be  made  up  of  the  so-called  Cursch- 
mann's  spirals,  together  with  numerous  swollen  and  fatty  degenerated  pus- 
cells  and  cells  shed  by  the  bronchial  mucous  membrane  and  alveoli.  The 
spirals  have  long  been  recognized,  but  were  first  studied  bv  Ungar  and 
Curschmann.  They  appear  to  be  made  up  of  mucin  spirally  arranged,  en- 
tangling pus-cells  and  alveolar  epithelium.  A  second  form  of  Curschmann's 
spirals  contains,  in  the  inside  of  a  tightly-wound  spiral  of  mucin  fibrils, 
another  bright,  clear  filament.  The  spirals  are  believed  by  Curschmann  to 
be  formed  in  the  finer  bronchioles,  and  to  be  a  product  of  bronchiolitis. 
Their  spiral  form  is  unexplained.  The  sputum  also  sometimes  contains 
crystals  of  calciiun-  oxalate  and  calcium  phosphate.  The  yellow  masses 
contain,  in  addition  to  the  cells  named,  various  numbers  of  acicular  crystals, 
which  were  first  found  by  Leyden  in  the  sputum  of  asthmatic  patients,  and 
therefore  called  Leyden's  crystals.  They  are  identical  with  the  so-called 
Charcot's  crystals,  found  in  leukemic  spleen,  bone-marrow,  and  semen. 

In  addition  to  the  cases  of  typical  asthma  in  patients  perfectly  comfort- 
able between  attacks,  and  for  which  the  foregoing  description  is  intended, 


— <a 


I.  II. 

Fig.  48. — Curschmann's  Spirals — {after  Curschma7i7t). 
I,  Natural  size  ;  II  and  III,  enlarged  ;  a,  a,  central  thread. 

patients  with  chronic  bronchitis  and  emphysema  are  subject  to  attacks  which 
may  be  called  symptomatic  asthma.  The  symptoms  are,  however,  similar 
and  need  not  be  repeated.  It  is  to  be  remembered,  too,  that  emphysema 
is  caused  by  asthma,  as  well  as  that  chronic  bronchitis  and  emphysema  may 
cause  asthma. 

Physical  Sig)is. — These  are  also  characteristic.  Inspection  notes  the 
most  labored  effort  in  breathing,  yet  the  chest  moves  but  slightly.  It  is  in 
a  state  of  permanent  inflation.  The  spaces  above  and  below  the  clavicle 
and  above  the  sternum,  the  intercostal  spaces,  and  the  pit  of  the  stomach 
are  drawn  in  from  the  same  cause — that  is,  the  thoracic  cavity  not  being 
filled  from  within,  the  external  atmospheric  pressure  forces  the  yielding  por- 
tions inward.  Rhonchal  fremitus  is  recognized  by  palpation,  while  vocal 
fremitus,  obscured  by  the  rhoncus,  is  further  diminished  by  a  frequently 
associated  emphysema.  Percussion  is  negative  in  uncomplicated  asthma, 
but  if  asthma  is  associated  with  emphysema,  it  may  produce  abnormal 
resonance.     Auscultation    discovers    the    most    striking    and    easiest    recog- 


BRONCHIAL  ASTHMA.  529 

nized  of  the  physical  signs.  All  over  the  chest  are  heard  sonorous  and 
-sibilant  rales,  inspiratory  and  expiratory,  the  latter  longer  and  more  marked. 
In  fact,  for  the  most  part,  they  do  not  require  the  ear  to  be  placed  close  to 
the  chest.  They  may  be  heard  at  a  distance.  The  vesicular  murmur,  on 
the  other  hand,  is  inaudible.  Later  in  the  attack,  as  secretion  increases,  the 
rales  become  moist.  It  is  to  be  remembered  that  chronic  bronchitis,  em- 
physema, and  asthma  may  also  complicate  one  another  and  render  corre- 
spondingly complex  the  physical  signs. 

Diagnosis. — This  can  usually  be  made  at  a  glance.  Spasm  of  the 
glottis  and  paralysis  of  the  abductors  of  the  glottis  produce  similar  efiforts 
at  breathing,  but  the  dyspnea  is  inspiratory  and  unattended  by  the  lung 
sounds  characteristic  of  asthma,  while  the  history  will  be  found  different. 
Hysterical  dyspnea  furnishes  no  physical  signs,  while  in  cardiac  asthma 
also  the  breathing  sounds  are  normal,  or  there  is  crepitation.  (See  also 
Cardiac  Asthma.) 

Prognosis. — Bronchial  asthma,  though  a  distressing  disease,  is  not  a 
fatal  one.  Very  often  the  attacks  grow  more  infrequent  and  milder  as  the 
patient  grows  older,  and  they  may  disappear  altogether,  while  in  some  cases 
they  increase  in  severity  and  frequency  with  age.  In  other  cases  a  cure  is 
•effected  by  discovering  and  removing  the  cause. 

Treatment. — The  first  object  in  the  treatment  of  asthma  is  to  relieve 
the  paroxysm.  This  is  best  accomplished  by  a  hypodermic  injection  of 
morphin,  1-4  grain  (0.0165  gm.),  with  1-150  grain  (0.00044  gm.)  of  atropin, 
which  may  be  repeated  in  an  hour  if  ineffectual.  If  morphin  is  not  at  hand, 
nitrite  of  amyl  may  be  inhaled  from  a  handkerchief  on  which  a  few  drops 
have  been  placed,  or  a  pearl  may  be  broken,  if  one  of  these  be  at  hand.  In 
the  absence  of  amyl  nitrite,  chloroform  or  ether  may  be  similarly  used. 
After  the  paroxysm  is  broken,  every  effort  should  be  made  to  discover  a 
cause  for  the  recurring  attacks.  The  nose  may  be  responsible,  and  should 
be  carefully  examined  for  any  one  of  the  causes  referred  to.  Possible  periph- 
eral irritation,  whether  by  error  of  diet,  gastric  derangement,  uterine 
or  other  distant  reflex  cause,  should  be  sought  and  corrected.  These  are 
not  always  easily  found,  but  sometimes  they  are.  Bronchitis,  when  present, 
also  requires  treatment  by  the  usual  remedies. 

It  is  needless  to  say  that  when  special  external  causes,  such  as  odors 
or  exhalations,  or  undiscoverable  peculiarities  of  location  are  responsible, 
they  should  be  eliminated.  "With  all  our  efforts,  however,  the  cause  remains 
in  perhaps  a  decided  majority  of  cases  undiscovered.  But  even  under  these 
circumstances  we  have  in  the  iodid  of  potassium  and  belladonna  two  drugs 
which  possess  undoubted  power  to  relieve  bronchial  asthma  and  even  to 
avert  attacks.  A  certain  measure  of  relief  is  almost  always  secured  by 
these  drugs,  and  in  many  cases  the  effect  is  magical.  From  five  to  ten 
grains  (0.33  to  0.65  gm.)  of  the  iodid,  and  three  to  seven  minims  (0.2  to 
0.5  c.  c.)  of  the  tincture  of  belladonna  should  be  given  every  three  hours 
until  relief  is  permanent.  Lobelia,  formerly  much  used  instead  of  bella- 
donna, has  fallen  into  disuse,  probably  on  account  of  its  disagreeable  nau- 
seous effect.  The  fumes  of  burning  paper  impregnated  with  nitrate  of 
potash  and  stramonium  are  also  useful  adjuvants,  and  cigarettes  and  pastiles 
made  out  of  such  paper  are  constantly  employed  for  their  effect.  These 
substances  form  the  basis  of  most  of  the  advertised  remedies  for  asthma. 

The  diet  of  asthmatics  should  be  exceedingly  simple,  as  indiscretions 
in  it  are  often  the  exciting  causes  of  attacks.     No  fixed  rules  for  climatic 

34 


530  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

treatment  can  be  laid  down,  as  conditions  favorable  to  different  cases  are 
exceedingly  capricious.  On  the  whole,  high,  dry  climates  are  most  suitable 
for  pure  asthmatics, — /.  e.,  those  cases  uncomplicated  wnth  emphysema, — 
though  moist,  warm  climates,  such  as  those  of  Florida  and  Madeira  and  the 
Canary  Islands,  are  also  servicable,  especially  when  there  are  catharrhal 
symptoms ;  or  southern  California,  where  the  climate  is  also  warm  and 
equable,  but  drier.  When  there  is  emphysema,  high  altitudes  are  not  well 
borne.  Cold  and  moist  climates  are  harmful.  Oxygen  breathing  is  often 
helpful,  as  is  also  inhalation  of  compressed  air  in  the  pneumatic  cabinet. 


PLASTIC  OR  FIBRINOUS  BRONCHITIS. 

Definition. — This  is  a  rare  form  of  inflammation  of  a  part  of  the 
bronchial  tree,  commonly  chronic,  but  occasionally  acute,  in  which  a  fibrin- 
ous mold  cJf  the  bronchus  and  its  branches  is  formed  and  expelled.  It  does 
not  include  those  instances  wdiich  occur  in  connection  with  croup  or  diph- 
theria as  an  extension  downward,  or  in  pneumonia  by  centripetal  extension. 

Etiology. — No  definite  cause  for  this  bronchitis  is  known,  though  it  is 
frequently  associated  with  tuberculosis — in  ten  out  of  twenty-one  cases 
studied  by  Model.  It  occurs  at  all  ages,  and  though  more  common  be- 
tween ten  and  thirty,  has  occurred  at  seventy-two.  It  has  happened  in 
more  than  one  member  of  a  family.  It  is  found  more  commonly  in  males 
and  in  the  spring  months.  Other  associations  named  are  probably  acci- 
dental, as  with  skin  diseases.  In  the  chronic  form,  which  consists  in  recur- 
ring attacks  extending  over  many  years,  the  same  part  of  the  bronchial  tree 
is  apparently  attacked  each  time. 

Morbid  Anatomy. — As  primarily  expectorated,  the  exudate  is  a  round 
mass  mixed  with  blood  and  mucus.  This  mass,  sometimes  quite  large, 
may  be  unrolled,  when  it  is  found  to  be  a  true  cast,  of  dendritic  shape  and 
hollow  interior,  of  the  trunk  and  branches.  The  latter  may  even  terminate 
in  bulbous  ends  corresponding  to  the  infundibula.  The  mold  is  true  fibril- 
lated  fibrin,  in  which  are  embedded  numerous  leukocytes.  It  is  whitish 
or  yellowish-gray  in  color,  and  concentrically  laminated.  In  the  latter 
feature  it  differs  from  the  branching  clots,  which  occasionally  form  in  a 
bronchus  and  branches  after  hemorrhage  into  the  lungs.  These  are  solid 
and  homogeneous.  A  fine  specimen  of  one  of  these  is  in  the  pathological 
museum  of  the  University  of  Pennsylvania.  The  true  fibrinous  casts  are 
usually  I  1-2  to  2  inches  (3.75  to  5  cm.)  long,  but  may  be  five  or  six  inches 
(12.5  to  15  cm.)  long.  The  tubes  whence  the  casts  come  are  not  super- 
ficially changed,  but  on  minute  examination  have  been  found  bereft  of 
epithelium.  The  submucous  tissue  may  be  swollen  and  infiltrated  with 
serum.  Charcot's  crystals  and  Curschmann's  spirals  have  occasionally  been 
found. 

Symptoms. — These  are  those  of  an  ordinary  bronchitis  of  severe 
form.  There  are  aggravated  cough  and  dyspnea.  Sometimes  this  is  pre- 
ceded by  a  stage  in  which  there  is,  for  a  variable  time,  prolonged,  bronchial 
catarrh  of  ordinary  severity.  At  times  the  attack  is  ushered  in  by  rigor, 
and  there  are  high  fever,  pain  in  the  side,  and  soreness.  There  is  slight 
expectoration  until  the  cast  is  loosened  and  expelled.  The  cough  preceding 
the  expulsion  does  not  usually  last  more  than  a  few  hours,  though  it  does 
sometimes  continue  for  days.     With  the  expulsion  of  the  cast  comes  prompt 


EMPHYSEMA  OF  THE  LUXGS.  531 

relief  for  the  time  being.  It  is  sometimes  followed  by  slight  hemoptysis, 
which  may  also  rarely  precede  the  expulsion.  The  expectoration  of  a  single 
cast  does  not,  however,  terminate  the  attack.  After  twenty-four  to  forty- 
eight  hours  the  cough  and  dyspnea  return,  and  another  cast  is  expelled. 
This  may  be  kept  up  for  several  days,  after  which  the  attacks  cease  to  recur. 
Smaller  pieces  may  be  expelled.  The  attacks  may  occur  but  once  in  a 
lifetime,  or  they  may  be  repeated  at  intervals  for  3-ears. 

Physical  Signs. — These  are  usually  those  of  bronchitis.  There  is  no 
dullness  on  percussion,  unless  it  be  from  consolidation  due  to  collapse  of 
-the  lung.  There  may  be,  according  to  Walshe,  circumscribed  pneumonia 
with  crepitant  rale  and  rusty  sputum.  The  effort  at  breathing  is  labored, 
and  if  there  is  obstruction  of  a  large  tubule,  there  may  be  retraction  of  the 
lower  ribs  during  inspiration.  The  cast  then  begins  to  be  loosened,  and 
moist  rales  make  their  appearance. 

Diagnosis. — The  rarity  of  the  disease  is  so  great  that  in  the  absence 
of  distinctive  physical  signs  the  true  condition  is  rarely  suspected.  In  re- 
curring attacks  the  true  nature  of  so  severe  an  attack  of  bronchitis  may  be 
suspected. 

Prognosis. — This  is  usually  favorable,  although  the  symptoms  are 
often  alarming.     N.  S.  Davis  has  reported  two  fatal  cases  of  the  acute  form. 

Treatment. — The  disease,  so  long  as  its  true  nature  is  undetermined, 
is  treated  as  an  ordinary  bronchitis.  If  its  true  nature  is  suspected,  the 
vapor  from  alkaline  solutions  should  be  inhaled,  or  these  should  be  sprayed 
into  the  larynx.  Lime-water  is  one  of  those  commonly  employed.  Alka- 
line solutions  may  be  of  the  strength  of  thirty  grains  (2  gm.)  of  sodium 
bicarbonate  to  the  fluid  ounce  (30  c  c.)  of  water.  Jaborandi  or  its  active 
principle,  pilocarpin,  may  be  tried.  Emetics  should  also  be  employed  when 
the  breathing  is  much  embarrassed.  They  sometimes  have  the  effect  of 
discharging  the  cast.  lodid  of  potassium  is  recommended,  and  should 
certainly  be  used  when  the  attack  is  protracted. 


DISEASES  OF   THE  LUNGS. 

EMPHYSEMA  OF  THE  LUNGS. 

Synonyms. — Alveolar  Ectasia;  Increase  of  Volume  of  the  Lang. 

Definition. — There  are  two  applications  of  the  term  emphysema,  and 
they  have  very  different  significations.  In  the  iirst  place,  there  is  interlobular 
or  interstitial  emphysema,  in  which,  in  consequence  of  rupture  of  air  vesicles 
deep  in  the  lung  structure,  the  air  escapes  into  the  interlobular  tissue  and 
may  collect  there  like  rows  of  beads  outlining  the  lobules,  while  under  the 
pleura  larger  vesicles  may  form.  This  form  occurs  after  wounds  of  the 
lung,  and  in  severe  and  persistent  whooping-cough,  and  in  cough  of 
bronchial  asthma,  in  both  of  which  the  expiratory  strain  is  very  great.  It 
is  also  termed  acute  emphysema.  It  is  not.  however,  demonstrable  clinic- 
ally, except  in  those  cases  in  which  it  takes  place  at  the  root  of  the  lung 
and  the  air  travels  along  the  trachea' until  it  reaches  the  subcutaneous  tissue 
of  the  neck  and  chest-walls.  It  gives  rise  to  a  peculiar  crepitation  to  the 
touch.  A  similar  condition  of  the  subcutaneous  tissue  may  be  due  to  in- 
filtration of  the  tissues,  with  gas  arising  from  decomposition.     It  is  found 


532  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

in  the  neighborhood  of  wounds  which  take  on  an  unhealthy  action,  and 
where  decomposition  leads  to  the  generation  of  gas.  This  form  of  em- 
physema is,  of  course,  more  circumscribed  than  that  due  to  a  wound  of  the 
lung. 

The  second  form,  vesicular  emphysema,  is  an  overdistention  followed  by 
atrophy  of  air  vesicles,  either  symmetrical,  involving  both  lungs,  or  local- 
ized. It  occurs  in  certain  portions  of  a  lung  adjacent  to  another  which  can- 
not, from  some  cause,  expand  fully  in  inspiration.  Such  are  portions 
of  the  lung  adjoining  tubercular  areas,  or  areas  of  collapsed  lung,  or  adjacent 
to  parts  whose  expansion  is  prevented  by  pleuritic  adhesions.  It  is  particu- 
larly the  anterior  parts  of  the  lung  that  are  the  seat  of  localized  emphysema 
in  the  latter  case.  When  such  complemental  dilatation  is  impossible,  as  is 
often  the  case  in  extensive  pleuritic  adhesions,  the  chest-wall  must  sink  in 
to  occupy  the  space.  Perhaps  all  emphysema  is  more  or  less  localized,  but 
in  general  or  symmetrical  emphysema  very  much  larger  areas  of  both  lungs 
are  involved.  The  distended  air  vesicles  are  useless,  w^hile  many  of  them 
are  also  atrophied.  The  former  is  also  called  hypertrophic,  but  pseudo- 
hypertrophic would  be  a  much  more  suitable  term,  because  there  is  no  true 
hypertrophic  enlargement. 

The  term  "  compensatory  "  is  also  applied  to  localized  emphysema,  but 
this  term  should  not  be  applied  unless  the  dilatation  is  truly  compensatory — 
that  is,  is  the  result  of  an  effort  on  the  part  of  a  lung  or  portion  of  it  to  sup- 
plement the  office  of  another  more  or  less  useless  lung,  when  the  condition 
is  really  developmental,  and  not  degenerate. 

A  third  form  of  emphysema  of  the  lungs  is  known  as  atrophic  emphy- 
sema; it  is  called  also  by  Sir  William  Jenner  small-lunged  emphysema.  In 
it  the  whole  lung  and  thorax  may  be  reduced  in  size,  and  even  the  respiratory 
muscles  may  be  atrophied.  It  is  a  disease  of  old  persons,  and  is  to  be  re- 
garded as  an  involution  process.  There  is  a  true  atrophy  of  air  vesicles, 
and  bullae  of  various  sizes  are  formed  by  the  wasting  of  intermediate  vesicles. 

The  section  is  limited  to  the  consideration  of 

Vesicular  Emphysema — Pseudo-hypertrophic  Emphysema. 

Etiology, —  By  far  the  larger  number  of  cases  of  emphysema  are  the 
result  of  chronic  bronchitis.  This  bronchitis  may  begin  in  childhood.  It 
may  begin  as  whooping-cough,  from  which  the  child  has  not  completely  recov- 
ered, or  succeeding  which  it  has  been  subject  to  constantly  recurring  attacks 
of  acute  bronchitis.  It  is  scarcely  likely,  if  the  lung-tissue  preserved  its 
proper  integrity,  that  even  under  the  forced  inspiratory  strain  of  coughing 
the  air  vesicles  would  undergo  the  dilatation  and  destruction  characteristic  of 
emphysema.  With  chronic  bronchitis  there  is  sooner  or  later  an  impairment 
in  the  nutrition  of  the  air  vesicles,  which  makes  them  more  yielding  and  more 
likely  to  give  way  under  the  strain.  Blowing  on  wind  instruments  and  glass- 
blowing,  as  well  as  occupations  requiring  muscular  strain  and  the  lifting  of 
heav}^  weights,  are  assigned  as  causes.  Bronchial  asthma  is  another  cause. 
In  all  these  cases  both  inspiration  and  expiration  co-operate  to  produce  the 
strain,  but  it  is  probable  that  expiration  is  the  more  potent  factor.  The  severe 
cough  of  chronic  bronchitis  begins  with  a  deep  inspiration  which,  while  harm- 
less to  a  healthy  air  vesicle,  may  overdistend  a  weak  one.  Then  follow  closure 
of  the  glottis  and  a  forcible  contraction  of  the  muscles  of  expiration — abdom- 
inal muscles.     The  latter  compress  especially  the  lower  part  of  the  lung,  and 


EMPHYSEMA  OF  THE  LUNGS.  533 

as  the  air  cannot  escape,  it  is  forced  into  the  peripheral  parts,  overdistending 
the  air  vesicles  there.  Again,  the  expiratory  muscles  compress  the  bron- 
chioles more  than  the  air  vesicles,  impede  the  exit  of  air  from  the  latter,  and 
thus  overstrain  them.  So,  also,  in  horn-blowing  and  muscular  strain  we  have 
the  effect  of  deep  inspiration,  and  especially  the  increased  pressure  during 
expiration,  with  the  glottis  closed.  We  may  admit  also  a  valve-like  effect  of 
certain  plugs  of  mucus,  which  permit  the  entrance  of  air  during  inspiration, 
but  do  not  allow  its  exit.  Thus,  the  vesicles  become  filled  with  air  which  can- 
not get  out.  Since  the  air  is  forced  in  the  direction  of  least  resistance,  it  is  the 
air  vesicles  in  the  apices  and  edges  of  the  lungs  which  dilate  first.  This  is 
probably  one  way  in  which  expiratory  strain  acts  in  producing  dilatation. 
The  valve-like  action  may  also  be  in  the  opposite  direction,  permitting  the  air 
to  get  out  of  the  vesicles,  but  preventing  it  from  getting  into  them,  and- thus 
finally  a  portion  of  the  lung  becomes  collapsed.  The  inspired  air  must  go 
somewhere  else,  and  produces  what  may  be  called  a  collateral  dilatation. 

I  believe  also  that  much  public  speaking  and  perhaps  singing  may  lead 
to  emphysema,  especially  as  the  speaker  grows  older,  because  the  lung  is  held 
inflated  a  longer  time  than  in  ordinary  speaking. 

The  vesicles  thus  overdistended  finally  lose  their  elasticity,  like  an  over- 
distended  india-rubber  air  balloon,  which,  after  repeated  distentions,  loses  its 
power  to  recoil.  Succeeding  the  overdilatation  comes  atrophy  cf  the  vesicles, 
and  with  this  the  blood-vessels  surrounding  them  are  destroyed.  Although 
under  these  circumstances  the  lung  occupies  more  space,  its  blood-aerating 
power  is  diminished.  The  circulation  is  cut  down  to  the  larger  trunks,  and 
the  blood  takes  a  short  cut,  as  it  were,  from  the  pulmonary  arteries  to  the  pul- 
monary veins.  The  aeration  of  the  blood  is  thus  rendered  difficult  or  impos- 
sible, accounting  in  part  for  the  dyspnea. 

There  is  also  reason  to  believe  that  heredity  plays  a  decided  role  in  the 
causation  of  emphysema,  and  that  congenital  defect  often  takes  the  place  of 
acquired  nutritive  retrogression.  This  was  first  shown  by  the  late  James 
Jackson,  of  Boston,  who  found  that  in  eighteen  out  of  twenty-eight  cases  one 
or  both  parents  were  affected.  Accordingly,  too,  emphysema  is  surprisingly 
common  in  children,  and  in  adults  may  often  be  traced  back  to  childhood. 

Morbid  Anatomy. — The  emphysematous  chest  is  often  highly  char- 
acteristic, in  that  the  anteroposterior  diameter  is  greatly  increased,  making 
the  two  diameters  nearly  or  quite  equal,  producing  the  "  barrel  shape."  On 
opening  the  thorax  in  an  adult  the  cartilages  are  found  calcified,  and  on  rais- 
ing the  sternum  the  greater  volume  of  the  lungs  at  once  shows  itself.  They 
are  in  a  state  of  permanent  inspiration,  meeting  by  their  edges  in  the  medias- 
tinal space  and  almost  or  entirely  covering  the  pericardium.  Nor  do  they  col- 
lapse when  removed  from  the  chest. 

The  individual  air  vesicles  are  not  only  dilated,  but  large  numbers  of 
them  are  atrophied,  producing  bulte  of  various  sizes,  from  the  walls  of  which 
extend  inward  edges  which  are  the  remnants  of  vesicles,  so  that  the  large 
vesicle  has  been  aptly  compared  to  a  frog's  lung  with  its  semipartitions.  The 
pleura  is  pale  and  the  lungs  are  especially  so,  partly  from  atrophy  of  the  pul- 
monary capillaries  which  accompanies  the  destruction  of  the  vesicles,  associ- 
ated with  diminution  in  the  natural  pigment.  The  lung  surface  pits  readily 
on  pressure.  The  distention  and  destruction  are  not  limited  to  the  periphery 
of  the  lungs,  but  are  also  found  in  the  center  and  toward  the  root,  where 
large  bullae,  two  to  three  inches  (5  to  8  cm.)  in  diameter,  may  be  found. 

The    bronchi    exhibit   the    changes    already    described   under    Chronic 


534  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Bronchitis  and  Bronchiectasis.  An  important  anatomical  change,  not  usu- 
ally demonstrable  before  death  because  of  the  voluminous  lungs,  is  hyper- 
trophy of  the  right  ventricle  of  the  heart,  due  to  the  extra  effort  required  to 
drive  the  blood  through  the  diminished  vascular  area  in  the  lungs.  In  the 
later  stages  the  hypertrophy  has  given  way  to  dilatation,  and  there  may  be 
relative  insufficiency  of  the  tricuspid  valve  with  dilatation  also  of  the  right 
auricle.  In  a  few  cases  there  is  hypertrophy  of  the  whole  heart.  There  is 
sometimes,  also,  atheroma  of  the  pulmonary  artery  and  of  the  other  blood- 
vessels, or  there  may  be  associated  pulmonary  tuberculosis  of  the  fibroid 
variety,  as  well  as  Bright's  disease. 

Symptoms. — The  typical  emphysematous  subject  may  often  be  recog- 
nized by  his  peculiar  round-shouldered  stoop  and  barrel-shaped  chest. 
Rarely,  this  form  of  emphysema  is  an  acute  or  comparatively  rapid  develop- 
ment, succeeding  whooping-cough ;  but  the  approach  of  the  disease  is  mostly 
gradual,  the  first  symptom  to  develop  and  remain  constant  being  shortness 
of  breath,  which  is  partly  due  to  the  fact  that  the  air  in  the  vesicles  does  not 
undergo  the  usual  interchange.  In  health  the  intercostal  muscles,  the  dia- 
phragm, and  auxiliary  muscles  of  respiration  enlarge  the  thoracic  box,  and 
the  lungs  expand  to  fill  it  partly  by  their  own  resiliency,  but  chiefly  to  fill  the 
vacuum,  producing  the  act  of  inspiration,  while  the  air  is  expelled  in  expira- 
tion partly  by  the  recoil  of  the  elastic  tissue  and  partly  by  the  pressure  of  the 
contracting  thorax.  This  natural  resiliency  is  absent  in  a  large  degree,  while 
the  thoracic  box  also  remains  in  a  state  of  "  rigid  dilatation."  The  lung  is 
always  filled  with  air,  but  it  is  air  charged  with  carbonic  acid  and  does  not 
change.  As  a  consequence  the  patient  makes  increased  efforts  to  draw  the 
air  into  the  lungs,  tut  as  the  air  vesicles  are  already  filled,  these  efforts  are 
ineffectual.  The  dyspnea,  which  is  but  slight  at  first  and  is  brought  about 
only  by  exertion,  soon  becomes  decided  and  constant.  The  pulse-rate  is  also 
accelerated,  but  the  temperature  is  usually  normal.  Cyanosis  is  a  character- 
istic symptom  in  established  cases,  owing  to  the  universal  presence  of 
unaerated  blood. 

Aside  from  these  symptoms  are  mainly  those  of  the  associated  bronchitis, 
— viz.,  coiigh,  expectoration,  and  sometimes  oppression, — while  variations  in 
these  add  to  or  abate  his  discomfort.  With  failure  of  the  right  heart  come 
venous  engorgement,  dropsy,  and  effusions  into  the  serous  sacs.  Tubercu- 
losis of  the  fibroid  type  sometimes  develops. 

Physical  Signs. — The  physical  signs  are  not  always  distinctive.  Inspec- 
tion reveals  a  rounded  chest,  with  increased  circumference  and  wide  inter- 
costal spaces  in  the  hypochondriac  regions,  but  narrow  above.  The  epigas- 
tric angle  is  obtuse.  The  resiiit  is  the  well-known  "  barrel-shaped  "  chest. 
More  rarely  the  emphysema  may  be  so  circumscribed  as  to  produce  local  bulg- 
ing, by  preference  over  the  upper  lobe  of  the  right  and  lower  lobe  of  the  left 
lung.  Expansion  of  the  chest-wall  is  diminished,  while  the  scaleni  and 
sternocleidomastoid  muscles  stand  out  distinctly.  The  chest  does  not  expand, 
but  is  raised  up  by  these  muscles,  which  are  hypertrophied ;  the  apex-beat  is 
not  visible,  but  may  be  felt  displaced  downward  and  to  the  right,  and  is  often 
difficult  to  find,  because  covered  up  by  the  enlarged  lung.  The  breathing  is 
rapid.  There  may  be  retraction  of  the  lower  intercostal  spaces  and  the  upper 
abdomen  instead  of  swelling  out  during  inspiration,  because  of  failure  of  the 
diaphragm  to  descend.  Vocal  fremitus  is  diminished,  while  the  natural 
resiliency  of  the  chest-walls  is  substituted  by  increased  resistance. 

Percussion  produces  resonance  exaggerated  in  various  degrees,  some- 


EMPHYSEMA  OF  THE  LUXGS. 


535 


times  amounting  ahnost  to  tympany,  the  result  of  the  overdistention  of  the 
air  vesicles,  whose  elasticity  is  spent.  To  auscultation  vocal  resonance  is 
decreased  because  of  the  diminished  vibration  in  the  air  columns.  Feeble 
crackling  is  sometimes  heard.  Striimpell  says  the  vesicular  murmur  is  at 
times  exaggerated  and  ''  shuffling,"  at  others  "  rougher  and  more  indefinite." 
Roughness  and  exaggeration  seem  impossible  in  true  emphysematous  areas. 
They  may  be  present  in  adjacent  supplementally  acting  areas.  If  bronchitis 
is  present,  its  sounds  are  associated,  and  often  obscure  all  else.  The  pul- 
monary second  sound  at  the  second  left  interspace  is  accentuated  on  account 
of  the  hypertrophy  of  the  right  ventricle,  but  the  heart-sounds  are  usually 
obscured  by  the  extra  covering  of  the  lung.  With  dilatation  of  the  right 
ventricle,  which  sooner  or  later  succeeds,  the  increased  accentuation  dis- 
appears. 

Interlobular  emphysema,  in  which  the  connective  tissue  between  the 
lobules  is  infiltrated  with  air  as  the  result  of  rupture  of  air  vesicles  caused  by 
violent  acts  of  coughing  or  by  wounds  of  the  lung,  aftords  no  physical  signs, 
or  rarely  any  symptoms.  The  shape  of  the  chest  in  such  cases  is  not  altered. 
Suddenness  of  onset  is  characteristic  of  this  form  of  emphysema,  and  it  is 
apt  to  be  associated  with  a  similar  infiltration  of  the  tissues  of  the  neck,  which 
gives  rise  to  a  very  distinctive  crepitation  on  palpation. 

Diagnosis. — This  is  not  usually  difficult,  at  least  in  true  symmetrical 
emphvsema.  In  pneumothorax  there  is  some  simulation  of  the  symptoms 
of  emphysema.  There  is  the  same  shortness  of  breath,  and  there  is  some 
resemblance  in  the  physical  signs.  There  is  bulging  of  the  chest,  which  is, 
however,  more  marked  on  one  side  than  on  the  other.  On  the  other  hand,  it 
is  rather  rare  to  have  a  uniform  symmetrical  emphysema,  and  we  may  have 
here  also  a  greater  prominence  of  one  side  than  of  the  other.  Thus,  the  parts 
of  the  chest  more  likely  to  be  affected  with  emphysema  are  the  upper  part  of 
the  right  lung  and  the  lower  part  of  the  left.  Also  in  the  matter  of  percus- 
sion, both  emphysema  and  pneumothorax  give  hyperresonance.  Pneumo- 
thorax, however,  gives  more  marked  tympany  than  emphysema.  It  has 
always  seemed  to  me  that  the  clearness  of  resonance  found  in  emphysema  has 
been  exaggerated  in  the  text-books.  The  hyperresonance,  although  often 
marked,  is  not  always  so.  The  unyielding  chest-walls  modify  it.  The  hvper- 
resonance  of  pneumothorax  is  a  real  tympany,  comparable  to  that  obtained 
over  the  distended  abdomen.  In  both,  the  thickness  of  the  chest-walls  exerts 
a  modifying  eft'ect.  ^Metallic  tinkling  is  a  distinctive  sign  of  pneumothorax, 
caused  by  the  dropping  of  fluid  from  the  perforated  lung  into  the  air-resound- 
ing pleural  sac.  In  the  lower  portion  of  the  chest  with  pneumothorax  there 
is  always  eft'usion,  which  gives  flatness  on  percussion,  and  a  line  of  separa- 
tion between  tympany  and  flatness  is  demonstrable.  Pneumothorax  is  sud- 
den in  its  occurrence,  whereas  emphysema  develops  gradually.  It  is,  how- 
ever, not  impossible  for  the  two  affections  to  be  combined. 

There  is  still  another  condition  with  which  emphysema  may  be  con- 
founded, though  it  is  of  rare  occurrence;  I  refer  to  diaphragmatic  hernia,  in 
Avhich  tympanitic  resonance  is  a  striking  symptom.  I  had  under  mv  observa- 
tion for  a  long  time  a  very  singular  case,  in  which  there  had  been  a  sudden 
development  of  symptoms.  The  condition  came  on  suddenly,  while  the 
patient,  a  man,  was  engaged  in  a  scrimmage  or  wrestle.  He  was  seized  with 
a  sudden  sharp  pain  in  his  left  side,  and  a  day  or  two  later  began  to  have  a 
peculiar  pufifing  respiration.  With  this  there  was  extraordinary  clearness  on 
percussion  over  the  region  of  the  left  lung.     He  was  examined  repeatedly  by 


536  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

myself  and  others,  but  no  one  thought  of  the  true  cause — none  suspected  dia- 
phragmatic hernia.  Acute  emphysema  was  thought  of.  The  autopsy  showed 
that  almost  one-half  of  the  abdominal  viscera  was  in  the  pleural  cavity,  and 
that  the  lung  was  pushed  into  the  upper  portion  of  the  chest,  occupying  a 
space  about  the  size  of  the  fist.  This  man  presented  the  bulging,  the  short- 
ness of  breath,  and  the  hyperresonance  peculiar  to  emphysema. 

The  Skodaic  hyperresonance — resonance  above  a  pleural  effusion — also 
resembles  that  of  emphysema,  but  attention  to  the  history  and  physical  signs 
other  than  resonance  will  discover  the  true  cause  of  the  resonance. 

Prognosis. — This,  except  in  cases  of  acute  emphysema,  which  heals  spon- 
taneously, is  unfavorable  as  to  cure.  The  course  is,  however,  always  a 
chronic  one,  and  much  may  be  done  for  the  comfort  of  the  patient.  No- 
classes  of  cases  are  so  benefited  by  admission  into  hospitals  as  members  of 
the  laboring  class  afflicted  with  emphysema. 

Treatment. — It  is  impossible,  so  far  as  we  know,  to  restore  destroyed 
lung  texture.  If  a  number  of  air  vesicles  have  been  converted  into  one  sac 
or  bladder-like  cavity,  there  are  no  means  by  which  these  vesicles  can  be 
restored.  At  the  same  time,  when  the  patient  is  young,  there  is  some  hope 
of  cure  if  the  structural  loss  is  not  too  great.  Effort  must  be  directed  mainly 
to  averting  those  conditions  which  complicate  and  increase  the  emphysema. 
As  I  have  said,  chronic  bronchitis  is  its  most  frequent  cause,  and,  therefore, 
we  must  try  to  relieve  this  condition  by  every  means  in  our  power.  As  the 
general  health  is  often  impaired,  it  is  as  important  that  this  should  be  re- 
established as  that  the  bronchitis  should  be  relieved.  The  blood  is  to  be 
restored  to  a  proper  composition  by  tonic  remedies,  like  cod-liver  oil  and  iron, 
and  the  very  best  food  that  the  patient  can  procure.  To  the  cod-liver  oil  and 
iron  should  be  added  strychnin  in  full  doses,  1-30  to  1-12  grain  (0.0022  to 
0.0027  gn^-)>  while  arsenic  is  an  admirable  tonic  either  in  the  shape  of 
Fowler's  solution,  five  drops  at  a  dose  for  an  adult,  or  of  arsenious  acid, 
1-30  grain  (0.0022  gm.). 

While  the  bronchitis  is  treated  by  the  usual  remedies,  it  is  of  the  utmost 
importance  that  the  stomach  should  be  kept  in  good  condition,  and  that  diges- 
tion should  not  be  interfered  with,  while  more  than  ordinary  care  is  required 
in  the  selection  of  remedies  for  the  bronchitis.  A  very  useful  measure  in 
these  cases  is  counterirritation,  which  in  no  way  interferes  with  digestion. 
This  may  be  applied  in  various  ways ;  blisters,  iodin,  and  mustard  may  be 
used.  A  mustard  plaster  can  be  so  prepared  that  it  may  be  worn  continuously 
without  discomfort — taking  mustard  and  flour  in  the  proportion  of  one  to 
five,  and  using  equal  parts  of  the  white  of  an  egg  and  glycerin  with  which  to 
mix  it  instead  of  water. 

Strychnin  is  an  admirable  remedy,  not  only  as  a  tonic,  but  it  may  also  be 
regarded  as  an  expectorant,  and  secretions  in  the  lungs  are  often  disposed  of 
by  its  use.  It  has  also  the  effect  of  improving  the  nutrition  of  the  muscular 
tissue  of  the  walls  of  the  bronchi,  as  it  has  of  improving  the  muscular  tissue 
in  general.  Full  doses  should  be  given — not  less  than  1-30  grain  (0.002  gm.) 
three  times  a  day,  increased  gradually  to  1-12  grain  (0.0055  gn^-)-  This  is  to 
be  kept  up  for  a  long  time. 

Bronchial  asthma  is  one  of  the  most  serious  and  frequent  complications, 
and  often  overshadows  all  else.  There  is  no  more  eiBcient  means  of  breaking 
up  such  an  attack  than  the  hypodermic  injection  of  1-4  grain  (0.0165  gm.) 
of  morphin  with  1-120  grain  (0.00055  g^n-)  of  atropin.  This  will  usually 
relieve  the  paroxysm  almost  immediately.     If  relief  is  not  complete,  the 


TUMORS  OF  THE  LUNG.  537 

injection  may  be  repeated  and  renewed  every  six  hours.  The  various  inhala- 
tions employed  for  asthma  may  be  used,  such  as  the  smoke  of  burning  stra- 
monium or  tobacco,  ether,  chloroform,  and  amyl  nitrite.  Of  course,  in  con- 
nection with  the  attacks  of  asthma  the  other  remedies  of  service  in  relaxing 
spasm,  such  as  belladonna  and  iodid  of  potassium,  may  be  given.  Tincture  of 
belladonna  in  doses  of  five  to  ten  minims  (0.31  to  0.62  c.  c.)  combined  with 
ten  grains  (0.66  gm.)  of  iodid  of  potassium  will  break  up  so  much  of  this 
condition  as  is  due  to  spasmodic  contraction  of  the  tubules. 

To  relieve  the  constant  dyspnea,  the  treatment  suggested  some  years 
ago  bv  Waldenburg  is  one  the  usefulness  of  which  is  only  limited  by  its  rela- 
tive difficulty  in  application  and  the  costliness  of  the  necessary  apparatus.  It 
consists  in  the  inspiration  of  compressed  air  and  the  expiration  into  rarefied 
air.  It  is  evident  that  if  compressed  air  can  be  introduced  into  the  vesicles, 
the  aeration  of  the  blood  will  be  more  perfect,  and  that  if  the  patient  breathe 
into  rarefied  air,  the  residual  air,  which  it  is  so  difficult  to  get  rid  of,  will  be 
more  effectually  sucked  out.  The  compressed-air  chamber  has  a  similar 
purpose. 

Expiration  may  also  be  aided  by  compression  of  the  chest,  intermittently 
applied  so  as  to  coincide  with  natural  breathing.  This  must  usually  be  prac- 
ticed by  a  nurse  or  an  attendant,  but  Striimpell  describes  in  his  text-book  a 
simple  contrivance  devised  by  a  patient  of  his  own  for  self-treatment.  It 
consists  of  two  boards  fastened  behind  and  allowed  to  project  forward  on 
each  side  in  front,  so  that  the  patient  himself,  taking  hold  of  the  projecting 
ends,  can  compress  his  own  chest  with  each  act  of  expiration. 


TUMORS  OF  THE  LUNG. 

The  lungs  are  subject  to  morbid  growths  classified  as  tumors,  though, 
owing  to  their  situation,  they  rarely  present  the  macroscopic,  tumor-like 
qualities. 

They  include  carcinoma,  and  many  of  the  histioid  tumors. 

Etiology  and  Morbid  Anatomy. — Carcinoma  occurs  rarely  as  a  primary 
growth,  but  is  not  infrequent  as  a  secondary  new  formation.  Primary  can- 
cer presents  itself  usually  in  the  shape  of  a  white  or  yellowish  nodule  two  to 
four  inches  (5  to  10  cm.)  in  diameter.  It  is  found  in  the  upper  lobe  of  one 
lung,  posteriorly  and  externally ;  more  seldom  in  other  parts.  It  probably 
originates  in  the  alveolar  epithelium,  and  causes  secondary  infiltration  of  the 
bronchial  glands  and  pleura.  It  may  be  represented  by  any  of  the  three  prin- 
cipal forms,  scirrhous,  encephaloid,  or  epitheliomatous,  also  by  colloid  and 
melanotic.  It  occasions  a  reactive  pneumonia  in  the  lung  tissue  about  it, 
and  often  furnishes  the  physical  signs  of  this  affection. 

There  also  occurs  in  the  lung  a  primary  peribronchial  cancer,  dissemi- 
nated in  nodules  throughout  the  lung  along  the  bronchi,  smaller  nodules  on 
the  smaller  bronchi,  and  larger,  irregular  masses  on  the  larger,  varAdng  in 
size  from  that  of  a  pea  to  a  walnut.  It  produces  also  infiltration  of  the 
lymph  glands  at  the  root  of  the  lung.  Sarcoma  is  also  a  rare  form  of  pri- 
mary tumor  of  the  lung. 

jMore  frequently  both  carcinoma  and  sarcoma  are  found  in  the  shape 
of  secondary  nodules  invading  both  lungs.'  From  three  to  twenty  opaque 
W'hite  nodules,   1-2  inch    (1.25  cm.),  more  or  less,  in  diameter,  are  found 


538  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

irregularly  scattered  through  each  lung.  Every  variety  of  primary  cancer 
may  be  thus  represented  secondarily  in  the  lung.  Its  origin  is  probably 
embolic,  and  it  may  be  secondary  to  cancer  elsewhere,  most  frequently  in  the 
breast. 

As  elsewhere,  these  growths  generally  present  themselves  after  middle 
life,  primary  cancer  affecting  either  sex  about  equally,  while  secondary  is 
more  common  in  women,  consistently  with  the  more  frequent  occurrence  of 
cancer  elsewhere  in  women. 

The  histioid  tumors  are  represented  by  a  subpleural  enchondroma,  occur- 
ring, rarely,  primarily  as  large  as  a  walnut ;  more  frequently,  secondary  to 
occurence  elsewhere,  when  it  may  attain  a  large  size.  Other  histioid  tumors 
are  myxoma,  adenosarcoma,  dermoid  cysts,  hydatid  cysts,  fibromata,  osteo- 
mata,  and  gummy  tumors. 

Symptoms. — Carcinoma  and  sarcoma  may  both  be  latent,  or  at  most 
produce  such  vague  symptoms  that  it  does  not  occur  to  physician  or  patient 
to  locate  them.  There  may,  however,  be  pain,  oppression,  cough,  expecto- 
ration, and  superficial  signs  of  vascular  obstruction,  such  as  lividity  of  the 
face  and  swelling  of  the  upper  extremities.  The  encroachment  of  the  larger 
cancerous  masses  upon  the  pleural  cavity  may  be  marked.  Pressure  on  the 
trachea  and  bronchi  may  occur  and  occasion  great  dyspnea,  while  the  heart 
may  be  dislocated.  The  pneumogastric  and  recurrent  laryngeal  nerves  are 
sometimes  involved,  occasioning  the  various  forms  of  paralysis  of  the  vocal 
cords  and  aphonia.  The  reactive  pneumonia  referred  to  may  present  the 
physical  signs  distinctive  of  this  disease,  and  it  is  probably  thus  that  the 
prune- juice  expectoration,  thought  to  be  quite  characteristic  of  cancer  of  the 
lung — ten  times  oiit  of  eighteen,  as  elaborated  by  Stokes  many  years  ago, — 
originates.  This  complication,  too,  may  occasion  the  fever  which  is  some- 
times present. 

The  external  lymphatic  glands,  as  those  in  the  neighborhood  of  the 
clavicle,  may  be  involved  and  exhibit  enlargement. 

Sooner  or  later,  if  the  patient  lives  long  enough, — that  is,  if  his  life  is 
not  destroyed  by  some  encroachment  on  the  breathing  or  vascular  function, — 
he  emaciates,  and  becomes  cachectic  and  debilitated.  The  more  usual  dura- 
tion of  the  disease  is  from  six.  to  eight  months,  but  death  is  liable  to  occur 
suddenly  from  the  causes  named. 

Physical  Signs. — These,  of  course,  are  indefinite,  and  it  is  probably  their 
indefinite  and  irregular  manifestation,  with  the  symptoms  named,  which  will 
suggest  the  nature  of  their  cause.  Physical  signs  of  pneumonia  and  pleurisy, 
either  alone  or  combined,  may  be  present,  the  voice  and  breathing  sounds  and 
percussion  note  being  affected"  accordingly. 

Diagnosis. — This,  in  the  case  of  primary  cancer  elsewhere,  is  suggested 
whenever  any  of  the  symptoms  named  occur  in  a  pronounced  degree  and  are 
sufficiently  long  continued.  In  the  case  of  primary  growths,  the  diagnosis 
must  longer  remain  doubtful,  and  we  must  study  and  await  the  development 
of  the  more  distinctive  symptoms. 

The  non-malignant  tumors  present  no  signs  by  which  they  can  be  dis- 
tinguished from  the  malignant,  except  that  their  course  is  less  rapid  and 
they  develop  no  cachexia. 

Treatment. — This  consists  only  in  measures  calculated  to  relieve  symp- 
toms and  to  make  the  patient  comfortable. 


ACUTE  PLEURISY.  539 

DISEASES  OF  THE  PLEURA. 

ACUTE  PLEURISY. 

Definition. — Acute  inflammation-  of  the  serous  investment  of  the  lung 
or  of  its  reflection  on  the  ribs  and  diaphragm. 

Etiology. —  I  still  believe  that  pleurisy  may  be  caused  by  simple  chilling 
of  the  body  during  exposure  to  cold,  in  other  words,  that  not  every  pleurisy 
is  a  tubercular  pleurisy.  Doubtless  more  cases  are  tubercular  than  was  for- 
merly supposed,  but  it  does  not  seem  likely  that  the  large  number,  exhibiting 
the  physical  signs  of  pleurisy,  from  which  recovery  is  apparently  complete, 
can  originate  in  this  way.  At  the  same  time  it  must  be  admitted  that  the 
proportion  of  cases  which  are  tubercular  in  origin  is  very  much  larger  than 
was  at  one  time  supposed,  and,  moreover,  that  many  cases  of  tuberculosis 
supposed  to  have  succeeded  upon  pleurisy  have  really  been  primary  tuber- 
cular pleurisy. 

The  conclusions  of  a  very  important  paper  read  by  Richard  C.  Cabot 
before  the  Association  of  American  Physicians  in  May,  1902  *  may  be  said 
to  be  the  most  recent  expression  of  our  knowledge : 

1.  Eighty  per  cent,  of  the  cases  of  uncomplicated  serous  pleurisy  are  in 
good  health  after  five  years  or  more  (more  than  half  of  these  have  been  fol- 
lowed for  ten  years  or  more). 

2.  Ninety  per  cent,  are  apparently  in  full  health  at  the  end  of  from  two 
to  five  years — that  is,  the  pleurisy  had  no  immediate  connection  with  any 
other  affection. 

3.  Fifteen  per  cent,  of  the  cases  have  sooner  or  later  developed  demon- 
strable tuberculosis  of  lung  or  bone,  but  in  only  three  per  cent,  has  this  tuber- 
culosis manifested  itself  within  two  years  of  the  date  of  pleural  efifusion. 

4.  The  type  of  tuberculosis  which  occurred  in  these  cases  was,  as  a  rule, 
mild  and  of  slow  course.  Death  did  not  occur  until  five  years  or  more  after 
the  pleurisy  in  one-half  of  the  23  cases  which  developed  obvious  tuberculosis. 
Six  of  the  23  are  still  alive,  despite  the  tuberculosis,  after  periods  of  ten,  nine, 
six,  four,  two,  and  one  year. 

5.  Nevertheless,  a  very  rapid  form  of  tuberculosis  may  develop  many 
years  after  the  pleurisy — nine  years  and  sixteen  years,  respectively,  in  two 
cases  of  this  series — so  that  the  patient  is  never  safe  from  the  possibility  of 
death  from  tuberculosis  merely  because  his  pleurisy  lies  ten  or  fifteen  years 
Ibehind  him. 

6.  A  study  of  the  clinical  records  of  the  whole  group  of  patients  under 
consideration  shows  that  among  those  who  have  remained  in  perfect  health 
for  five  years  or  more  only  25  per  cent,  had  any  family  history  or  past  history 
of  tuberculosis,  while  of  those  who  have  become  tuberculous  67  per  cent,  had 
tuberculosis  in  their  immediate  family  or  in  their  own  past  history.  A  care- 
ful history,  therefore,  is  of  great  importance  in  the  prognosis  of  pleural  effu- 
sion. On  the  other  hand,  the  physical  signs  during  the  course  and  convales- 
cence of  the  pleurisy  were  not  markedly  different  in  the  group  of  cases  in 
which  tuberculosis  later  developed  from  the  signs  in  those  who  have  remained 
well. 

7.  Recurrence  of  the  pleurisy  itself  in  patients  who  have  recovered  from 
the  original  attack  occurred  in  only  five  cases,  or  3  per  cent,  of  this  series. 

*  "  Transactions  of  the  Association  of  American  Physicians,"  vol.  xvii.,  igo2,  p.  156. 


540  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

Reaccumulation  of  the  fluid  immediately  after  tapping  is  rare,  occurring  in 
only  two  cases,  or  1.3  per  cent. 

8.  Among  the  14  patients  who,  after  recovering  from  the  pleurisy,  died 
of  some  other  disease  not  one  developed  any  disease  which  could  reasonably 
be  considered  a  result  of  the  pleurisy — the  causes  of  death  were  alcoholism, 
hepatic  cancer,  dysentery,  pulmonary  embolism,  mitral  stenosis,  aortic 
regurgitation,  chronic  nephritis  (3),  cerebral  hemorrhage,  measles,  pneu- 
monia (3). 

9.  Finally,  no  attempt  was  made  to  discover  what  percentage  of  this 
whole  group  of  cases  is  due  to  tuberculosis.  So  far  as  the  statistics  go  the 
cases  may  be  all  of  tuberculous  origin. 

What  his  figures  do  tend  to  prove  is  that  whether  pleurisy  means  tuber- 
culosis or  not,  the  outlook  is  bright,  provided  no  family  history  of  tubercu- 
losis clouds  it.  If  pleurisy  means  tuberculosis,  it  is  a  very  mild  form  of  tuber- 
culosis and  one  from  which  recovery  is  usually  complete  under  proper 
treatment. 

In  addition  to  tuberculosis  as  a  primary  cause  of  pleurisy  we  must 
mention  rheumatism  and  chronic  Bright's  disease  as  predisposing  causes, 
at  least.  It  should  be  said,  also,  of  the  latter  that  a  certain  proportion 
of  them  have  been  relegated  to  the  tubercular  pleurisies.  The  pleurisies 
which  go  to  make  up  the  sum  of  the  phenomena  of  pyemia  are  of  undoubted 
microbic  origin.  If  rheumatism  be  microbic,  then,  too,  the  pleurisies  which 
occur  secondary  to  it  must,  of  course,  be  referred  to  the  same  category. 
In  addition  to  these  instances  of  primary  and  secondary  pleurisy  must  be 
mentioned  those  which  are  the  result  of  extension  of  inflammation  by 
continuity  and  contiguity,  as  from  the  adjacent  lung  to  the  pleura  over 
it  or  from  the  diaphragm  to  the  pleura  above  it ;  also  pleurisies  of  traumatic 
origin. 

Morbid  Anatomy. — The  morbid  anatomy  of  pleurisy  will  be  best 
understood  by  supposing  every  pleurisy  to  begin,  as  it  probably  does,  with 
a  dry  stage,  a  plenritis  sicca,  whatever  may  be  its  subsequent  course.  Thus 
considered,  the  earliest  stage  of  all  pleurisies  has  a  hyperemic  basis,  suc- 
ceeded immediately  by  a  roughness  of  surface  due  to  loosening  and  detach- 
ment of  the  epithelium,  a  roughness  increased  by  the  addition  of  fresh 
inflammatory  lymph  composed  of  transuded  fibrin  and  wandered-out  leuko- 
cytes from  the  subpleural  blood-vessels.  Further  progress  of  such  pleurisy 
is — 

First,  toward  resolution,  in  the  course  of  which  the  product  described 
liquefies  and  is  reabsorbed. 

Second,  toward  organization  and  adhesion,  in  which  vascularization  and 
fibrillation  take  place  and  the  two  surfaces  of  the  pleura  are  more  or  less 
permanently  glued  together  over  an  area  corresponding  to  that  of  inflamma- 
tion. This  is  the  probable  explanation  of  the  little  patches  of  adhesion 
so  frequently  found  at  autopsies,  some  of  which  may  have  formed  without 
the  consciousness  or  discomfort  of  the  patient,  while  others  have  succeeded 
upon  a  "  stitch  "  in  the  side  which  has  been  passed  by  as  of  little  conse- 
quence. Other  instances  of  this  primary  adhesive  inflammation  are  found 
between  the  opposed  surfaces  of  pleural  membrane  covering  tubercular 
deposits  in  the  lung,  or  limited  pneumonic  areas,  or  morbid  growths,  such 
as  gummy  tumors,  cancers,  and  sarcomata. 

Third,  toward  serous  accumulation  constituting  exudative  pleurisy,  in 
which  varying  quantities  of  fluid  are  transuded  into  the  pleural  cavity.     In 


ACUTE  PLEURISY.  541 

this  usually  clear,  straw-colored  exudate  may  be  suspended  shreds  of  the 
yellowish  plastic  lymph  already  described,  which  accumulates  also  most 
abundantly  where  the  movement  of  the  pleural  surfaces  is  least,  as  in  the 
chinks  and  corners  of  the  pleural  cavity.  This  effusion  also,  in  a  large 
number  of  cases,  is  absorbed,  allowing  the  pleural  surfaces  to  approach 
each  other  and  again  unite  by  what  is  known  as  secondary  adhesive  inflam- 
mation, organization  taking  place  as  before,  producing  either  continuous 
fusion  or  bands  of  new  tissue  attaching  different  parts  of  the  pleural  surface. 
The  question  as  to  how  the  process  of  exudation  is  stopped  is  an  interesting 
-one,  which  cannot  be  satisfactorily  answered,  though  it  is  probable  that 
pressure  of  accumulated  fluid  and  contraction  incident  to  organization,  as 
well  as  cessation  of  the  cause,  may  be  a  part. 

The  ordinary  serous  fluid  which  commonly  fills  the  sac  in  sero- 
fibrinous pleurisy  is  a  highly  albuminous  liquid,  sometimes  coagulating 
spontaneously,  in  which  may  be  found  a  few  leukocytes,  exfoliated  endo- 
thelial cells,  shreds  of  fibrin,  and  sometimes  a  few  red  blood  discs, 
^lodifications  are  those  in  which  the  red  blood-corpuscles  are  much  in- 
creased, producing  a  bloody  fluid,  or  in  which  leukocytes  are  variously 
numerous,  short  of  a  number  sufficient  to  justify  the  term  pus.  Urea, 
uric  acid,  and  sugar  are  sometimes  found  in  pleural  exudates.  The  quantity 
of  fluid  ranges  from  half  a  liter  to  four  liters  ( i  pint  to  4  quarts). 

Fourth,  toward  pus-formation,  in  which  either  primarily,  from  the 
outset,  or  secondarily, — that  is,  some  time  after  the  process  has  com- 
menced,— the  microbes  of  suppuration  become  active,  and  produce  a  puru- 
lent product  or  an  empyema.  The  onset  of  this  wandering  out  of  number- 
less colorless  cells  is  often  announced  by  a  chill.  Even  such  an  accumulation 
of  pus  may  in  rare  instances  disappear  without  active  interference,  per- 
miitting  the  approximation  and  union  of  the  two  pleural  surfaces.  The 
pleural  surfaces  thus  apposed  are,  however,  comparable  to  an  ulcer,  and 
the  union  and  repair  take  place  by  formation  of  cicatricial  tissue.  This  is 
subject  to  the  contraction  usual  to  such  tissue,  dragging  not  only  the  heart 
and  lungs  out  of  place,  but  also  in  extreme  cases  the  ribs  and  vertebrae,  pro- 
ducing slight  lateral  curvature  of  the  spine. 

Various  displacements  of  adjacent  organs  are  caused  by  the  liquid 
effusion,  in  right-sided  pleurisies  the  liver  is  depressed.  A  very  strik- 
ing case  came  under  my  notice,  in  which  the  liver  was  pushed  so  far 
forward  and  downward  as  to  produce  the  appearance  of  an  abdominal  tumor 
to  the  left  of  the  epigastrium.  In  left-sided  pleurisies  the  heart  may  be 
displaced  so  far  that  the  apex  will  be  to  the  right  of  the  sternum.  The 
displacements  from  traction  after  organization  are  difiicult  to  describe,  but 
the  heart  may  be  dragged  so  that  its  apex  is  much  higher  than  is  normal 
or  further  to  the  right,  while  the  parts  of  lung  adherent  are  drawn  in 
various  directions,  with  the  production,  at  times,  of  bronchiectatic  cavities. 
If  the  patient  die  while  large  liquid  effusions  are  present,  the  lung  is  also 
found  compressed  into  the  back  part  of  the  pleural  sac. 

Symptoms. — The  initial  symptom  of  pleurisy  is  usually  pain — at  first 
in  the  side.  It  may,  however,  be  preceded  by  a  chill,  and  at  times  there 
may  be  a  short  prodrome  of  discomfort  in  no  way  peculiar.  The  pain  in  bad 
cases  is  of  the  severest  kind,  and  among  the  pains  most  difficult  to  relieve. 
It  is  sharp  and  cutting  in  character,  aggravated  by  breathing,  so  that  the 
patient  takes  the  shortest  breath  possible,  and  the  breathing  is  made  up  of 
short,    hurried   gasps.     Cough   likewise    causes    agonizing   pain,    and   it   is 


542  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

accordingly  restrained.  Xor  is  the  pain  in  these  cases  always  confined  to 
the  chest,  but  may  shoot  down  into  the  abdomen  and  back.  The  latter 
probably  implies  that  the  diaphragmatic  pleura  is  involved.  Fever  is  also  a 
constant  symptom,  but  is  not,  as  a  rule,  so  high  as  in  pneumonia.  At  the 
beginning  the  temperature  may  be  102°  or  103°  F.  (38.9°  or  39.4°  C),  but 
it  subsides  early,  even  though  the  other  symptoms  abate  but  partially,  and 
under  any  circumstances  it  falls  much  lower  after  a  week  or  ten  days  unless 
there  is  purulent  exudate,  when  the  fever  assumes  a  hectic  type.  The  cougli 
is  peculiar  enough  to  require  special  mention.  It  is  a  short  cough,  attended 
with  little  expectoration,  and  is  a  much  less  conspicuous  feature  than  in 
pneumonia.  Its  characteristic  shortness  is  due  to  the  pain  caused  by  the 
act  of  coughing,  on  account  of  which  the  act  is  cut  short.  The  decubitus 
of  pleurisy  is  quite  constantly  on  the  affected  side,  in  order  that  the  unaf- 
fected side  may  be  free  to  expand.  The  patient  also  has  less  pain  when  he 
lies  on  the  affected  side,  because  the  range  of  its  motion  is  restricted.  This 
pertains  to  pleurisies  associated  with  copious  effusions,  as  well  as  dry 
pleurisies. 

While  the  majority  of  pleurisies  begin  in  this  way,  a  certain  number 
also  begin  insidiously.  For  days  and  even  weeks  the  patient,  while  feel- 
ing uncomfortable  and  doubtless  feverish  and  slightly  dyspneic,  continues 
his  occupation,  and  even  when  the  physician  is  called,  scarcely  mentions 
symptoms  which  suggest  an  examination  of  the  thorax.  Such  pleurisies 
are  known  as  latent  pleurisies.  They  are  latent  only  to  superficial  observa- 
tion. Closer  investigation  promptly  reveals  the  physical  signs  of  a  pleural 
effusion. 

It  has  already  been  mentioned  that  purulent  pleurisies  may  be  primary 
or  secondary.  In  any  event,  they  are  most  frequently  tubercular,  and  an 
examination  of  the  pus  from  such  a  pleurisy  not  infrequently  discovers  the 
tubercle  bacillus  in  it. 

Physical  Signs. — Acute  pleurisy  is  also  resolvable  clinically  into  three 
stages,  each  of  which  is  characterized  by  physical  signs  more  or  less  dis- 
tinctive. They  include  a  dry  stage,  a  stage  of  effusion,  and  a  stage  of  reso- 
lution or  absorption. 

The  Urst  or  dry  stage  is  characterized  anatomically  by  the  presence  of 
the  so-called  lymph  or  exudate  on  the  pleural  surfaces.  During  this  is  re- 
vealed to  inspection  a  restrained  expansion  of  the  affected  side,  often  thrown 
into  jerks  or  catches  because  of  the  pain  suffered  in  a  continuous  inspira- 
tion. The  expansion  on  the  opposite  side  is  full  and  unhampered.  The 
patient  lies  on  the  affected  side.  Palpation  may  recognize  a  fremitus  corre- 
sponding to  the  friction  of  the  two  pleural  surfaces.  Percussion  in  this 
stage  is  negative,  except  that  it  may  cause  pain,  but  auscultation  recognizes 
the  friction  sound,  which  will  be  further  characterized  in  treating  diagnosis. 
It  may  be  at  a  single  spot  in  the  inframammary  or  infra-axillary  space,  and 
hence  be  overlooked.  At  other  times  it  may  be  noted  over  a  considerable 
area.  According  as  the  inflammatory  process  stops  here  with  resolution  or 
continues  into  the  second  or  stage  of  effusion,  there  may  or  may  not  be 
other  signs. 

The  signs  of  the  second  stage  vary  with  the  amount  of  liquid  in  the  sac; 
with  a  small  amount  the  lungs  are  slightly  floated  up,  and  there  may  be  no 
signs,  unless  it  be  a  vesiculotympany  above  the  line  of  the  fluid,  a  Skodaic 
resonance  by  mediate  relaxation  of  the  air  vesicles.  The  effusion,  however, 
rarely   remains   so  trifling,   but   commonlv   rises   to   the   midchest.     In   the 


ACUTE  PLEURISY,  543 

upright  position  of  the  patient  inspection  recognizes  in  a  spare  person  shal- 
lowness and  perhaps  obliteration  of  the  lower  intercostal  spaces.  The  motion 
of  the  chest-wall  is  lessened  both  in  the  vertical  and  transverse  directions. 

To'  palpation  vocal  fremitus  is  diminished  over  the  area  of  effusion,  but 
may  be  increased  in  the  lung  above  it.  To  percussion  there  is  absolute 
flatness  over  the  area  of  effusion,  but  the  line  of  demarcation  is  not  every- 
where at  the  same  level,  being  higher  behind  than  in  front.  The  late  Cal- 
vin Ellis  first  called  attention  to  an  S-like  curve  in  the  line  of  demarcation 
which  is  said  to  be  diagnostic.  Very  important  in  the  diagnosis  is  the  fact 
that  the  fluid  changes  its  level  when  the  position  of  the  patient  is  changed, 
and  correspondingly  the  line  of  dullness  is  altered.  There  is  also  an 
abnormal  sense  of  resistance  to  the  finger  in  percussing  over  the  area  of 
effusion.  Above  the  effusion,  especially  anteriorly,  there  is  again  Skodaic 
resonance  by  mediate  relaxation,  and  even  rarely  a  "  cracked-pot  "  sound. 
Tympany  may  also  be  due  to  the  proximity  of  a  distended  stomach.  Meas- 
urement discovers  that  the  circumference  of  the  affected  side  is  a  centimeter 
(0.4  in.)  or  more  greater  than  that  of  the  other  side. 

To  auscultation  the  breathing  sounds  are  inaudible  or  very  feeble,  as 
compared  to  the  corresponding  portion  of  the  opposite  side,  but  vocal  reso- 
nance, though  diminished,  is  still  distinctly  heard  where  the  collection  of  fluid 
is  moderate.  Above  the  line  of  dullness  there  is  occasionally  a  friction  sound, 
and  close  to  the  root  of  the  lung  bronchial  breathing  may  be  heard.  This 
is,  however,  more  apt  to  be  the  case  when  the  effusion  is  larger  and  the 
lung  is  further  compressed.     Egophony  is  also  sometimes  heard. 

When  the  effusion  is  larger,  filling  up  two-thirds  or  three-fourths  of 
the  pleural  sac,  the  effects  described  are  increased,  while  new  ones  are 
added.  Inspection  notes  that  respiratory  movement  is  still  more  hampered, 
that  the  intercostal  spaces  are  widened  and  even  bulging,  while  fluctuation 
may  sometimes  be  recognized  through  them.  The  heart  is  displaced  by 
the  accumulated  fluid,  and  if  the  fluid  be  in  the  left  sac,  the  apex  is  often 
found  far  over  to  the  right  of  the  median  line,  and  if  in  the  right,  the  apex 
may  be  pushed  further  to  the  left.  The  heart-sounds  are  not,  however, 
altered.  On  the  opposite  side  the  breathing  movements  are  supplementally 
increased.     There  is  complete  absence  of  vocal  fremitus  on  the  affected  side. 

Percussion  is  absolutely  flat  all  over  the  effusion,  and  Skodaic  reso- 
nance is  not  now  obtainable,  because  the  lung  is  too  thoroughly  compressed 
up  into  the  apex  of  the  sac.  Resistance  to  pressure  is  marked.  On  auscul- 
tation bronchial  breathing  may  be  heard  at  the  upper  posterior  portion  of 
the  lung,  because  the  large  tubes  are  still  pervious  to  air,  and  the  compressed 
lung  intensifies  the  sound.  Sometimes  bronchial  breathing  is  heard  in  more 
peripheral  parts  of  the  chest,  probably  conducted  hither  along  a  band  of  ad- 
hesion or  along  a  rib.  Elsewhere  there  is  absence  of  breath-sounds.  Vocal 
resonance  and  whispering  voice  are  alike  absent,  or  the  former  is  very  feeble. 
In  certain  situations,  too,  high  up,  where  there  is  but  a  thin  film  between 
the  chest-wall  and  the  lung,  there  may  be  egophony,  but  this  is  more  likely 
to  be  present  as  the  fluid  is  being  absorbed. 

In  the  third  stage,  if  resolution  takes  place  with  a  gradual  retrocession 
of  the  fluid  and  the  re-expansion  of  the  lung,  we  have  a  return  to  normal 
physical  signs.  There  may  be,  too,  a  friction  rediix.  A  considerable  time 
is,  however,  required  for  absorption,  and  it  is  often  many  days  before  the 
normal  breathing  sounds  are  heard  with  their  usual  intensity  or  the  natural 
fremitus  is  felt.     Often,  on  the  other  hand,  resolution  is  not  complete,  and 


544  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

the  two  surfaces  become  glued  together,  constituting  a  plastic  pleurisy,  and 
the  feebly-heard  breathing  sounds  and  diminished  fremitus  and  vocal  reso- 
nance remain  more  or  less  permanent  (chronic  pleurisy).  There  then  re- 
main the  symptoms  and  sequelae  of  a  chronic  pleurisy.  In  cases  of  purulent 
pleurisies,  if  recovery  takes  place  it  is  always  by  adhesion  of  the  apposed 
surfaces.     (See  Chronic  Pleurisy.) 

In  connection  with  the  heart,  pleuropericardial  friction  may  be  heard 
if  the  pleura  covering  the  portion  of  the  lung  adjacent  to  the  pericardium  is 
involved.  The  apex-beat  may  not  be  discoverable  if  it  is  so  dislocated  as  to 
be  covered  by  the  sternum,  and  it  often  happens  that  the  heart  must  be 
located  by  its  signs. 

Varieties  of  Acute  Pleurisy. — Tubercular  pleurisy  is  a  pleurisy  due 
to  the  invasion  of  the  pleura  by  the  tubercle  bacillus,  and  has  been  con- 
sidered when  treating  of  tuberculosis. 

Diaphragmatic  pleurisy  is  a  painful  form  of  pleurisy,  in  which  the  pleural 
covering  of  the  diaphragm  is  involved,  either  alone  or  along  with  the  re- 
maining pleura.  It  is  usually  dry,  plastic,  but  may  also  be  exudative,  with 
a  serofibrinous  or  purulent  product.  The  pain  is  low  down  in  the  thorax 
in  the  zone  of  the  diaphragm,  and  is  often  aggravated  by  deglutition  as  well 
as  by  breathing.  Because  of  the  pain  in  breathing,  the  diaphragm  is  fixed 
and  the  patient  breathes  by  the  upper  thorax.  Of  diagnostic  value  is  the 
fact  that  the  pain  may  be  increased  by  pressure  at  the  insertion  of  the 
diaphragm  at  the  tenth  rib. 

Hemorrhagic  pleurisy,  characterized  by  bloody  effusion,  is  found  in 
asthenic  states,  however  induced,  in  tubercular  pleurisy,  in  which  event 
the  hemorrhage  occurs  from  the  young  blood-vessels,  and  in  cancerous 
pleurisy ;  also  sometimes  in  persons  otherwise  healthy.  It  is,  of  course, 
not  to  be  confounded  with  blood-stained  serum,  caused  by  wounding  a 
blood-vessel  in  the  act  of  tapping  or  with  a  hematothorax  from  rupture  of  an 
aneurysm. 

Encysted  or  circumscribed  pleurisy  is  a  form  of  purulent  pleurisy  in 
which  adhesions  form  so  as  to  produce  loculi,  or  spaces  which  are  filled  with 
pus.  They  are  quite  difficult  to  recognize  during  life — in  fact,  they  are 
commonly  found  when  exploring  the  chest  with  the  needle.  More  rarely 
they  are  revealed  to  physical  examination,  dull  percussion  areas  being 
found  in  alternation  with  clear  areas.  Such  physical  signs  should  suggest 
the  use  of  the  needle  to  clear  up  the  diagnosis.  These  collections  some- 
times pulsate  and  become  pulsating  pleurisies.  Pulsating  pleurisies  are  al- 
most invariably  on  the  left  si4e  and  receive  in  some  way  the  impulse  of  the 
heart,  which  in  turn  is  communicated  to  the  eye  or  hand  of  the  observer. 
The  possible  confounding  of  these  with  aneurysm  will  be  again  referred  to. 

In  interlobular  pleurisy  the  apposed  surfaces  of  two  lobes  of  the  lung 
are  agglutinated,  and  sometimes  a  sac  of  pus  is  pent  up  between  them, 
forming  a  variety  of  encysted  pleurisy.  Such  an  abscess  may  break  into  a 
bronchus.     It  is  not  usually  recognized  before  autopsy. 

Diagnosis. — The  certain  diagnosis  of  pleurisy  depends  almost  entirely 
upon  the  physical  signs,  for,  however  severe  the  other  symptoms,  there  is 
nothing  in  them  by  w^hich  the  disease  can  be  surely  recognized.  In  the 
majority  of  cases  of  pl-eurisy  the  diagnosis  is  made  easy  by  the  aid  of  these 
signs.  It  is  true  there  is  a  certain  resemblance  between  pleurisy  and  pneu- 
monia in  the  first  stage  of  each,  and  in  that  stage  a  diagnosis  is  often  difficult, 
especially  when  the  physical  signs  are  not  distinct.     The  resemblance  of  the 


ACUTE  PLEURISY.  545 

friction  sound  to  the  crepitant  rale  is  well  recognized.  The  usual  distinctive 
features  are  the  superficial  situation  and  the  intermittent  character  of  the 
friction  sound,  its  presence  during  expiration  as  well  as  inspiration,  and  if 
confined  to  one  of  these  acts,  rather  to  expiration,  while  the  crepitant  rale 
is  heard  only  during  inspiration.  The  friction  sound  is  also  usually  rougher 
and  more  circumscribed,  while  it  may  sometimes  be  heard  better  with  the 
stethoscope.  Pain  is  very  apt  to  be  elicited  in  pleurisy  if  the  stethoscope  is 
pressed  hard  upon  the  chest.  As  the  pleurisy  becomes  dry  and  adhesions 
form,  the  friction  sound  resembles  more  closely  that  of  creaking  leather. 

In  the  second  stage  of  pleurisy,  too,  furnishing  as  it  does  a  dullness  on 
percussion  like  that  of  the  same  stage  of  pneumonia,  and  frequently  bron- 
chial breathing,  we  have  also  a  resemblance  in  the  physical  signs.  But  it 
is  true  of  the  bronchial  breathing  of  pleurisy  that  it  is  comimonly  best  heard 
at  the  upper  border  of  the  dullness  and  least  where  the  dullness  is  most 
marked ;  whereas,  in  pneumonia  the  bronchial  breathing  is  most  intense 
where  the  consolidation  is  greatest.  Above  all,  in  pleurisy  zcith  effusion  there 
are  diminished  vocal  fremitus  and  diminished  vocal  rcsoiance ;  in  pneumonia, 
increased  vocal  fremitus  and  increased  vo'cal  resonance.  There  is  commonly, 
further,  in  pleurisy  with  effusion,  a  change  of  level  of  the  dullness  with  a 
change  of  the  position  of  the  patient,  which  is  not  the  case  in  pneumonia. 
The  egophonic  voice  is  also  often  here  present  in  pleurisy;  whereas  we  have 
only  bronchophony  in  pneumonia.  Finally,  in  the  differential  diagnosis  be- 
tween acute  pleurisy  and  pneumonia,  the  trifling  cough  and  absence  of  ex- 
pectoration in  the  former  are  valuable  signs,  though  it  must  not  be  forgotten 
that  in  old  persons  there  is  sometimes  very  little  cough  in  pneumonia. 

As  to  further  differential  diagnosis,  pleurisy  in  the  dry  stage  has  been 
mistaken  for  muscular  rheumatism,  intercostal  neuralgia,  periostitis,  and 
caries  of  the  ribs,  and  even  gastralgia  and  ulcer  of  the  stomach.  The  ab- 
sence of  fever  in  the  first  two,  the  circumscribed  situation  of  disease  of  the 
ribs,  and  the  associated  history  of  gastralgia  and  ulcer  of  the  stomach,  serve 
to  differentiate  them. 

The  confusion  of  mediastinal  tutnors  arising  from  the  pleura  itself  with 
pleurisy  is  a  natural  error,  especially  since  such  tumors  in  their  turn  pro- 
duce pleurisy.  In  pleurisy,  the  physical  signs  are  commonly  limited  to  one 
side,  while  in  mediastinal  tumor  the  fremitus  is  less  diminished,  the  dullness 
extends  upward,  is  more  irregular,  and  more  circumscribed ;  while  symp- 
toms of  compression  of  nerves  and  vessels,  and  of  encroachment  on  the 
esophagus  sooner  or  later  make  their  appearance.  Repeated  exploratory 
punctures  may  be  necessary  to  settle  the  diagnosis,  which,  after  all,  may 
require  some  time. 

The  impulse  of  a  pulsating  empyema  sometimes  very  strongly  suggests 
an  aneurysm,  but  the  empyema  furnishes  no  murmurs  or  pressure  symptoms, 
while  the  location  is  usually  different  from  that  of  aneurysm. 

Prognosis. — The  prognosis  of  acute  pleurisy  depends  largely  upon  its 
cause.  The  simple  pleurisies  which  are  the  result  of  cold  always  get  well, 
and  recovery  is  the  termination  in  most  cases  even  when  there  is  large  effu- 
sion, if  the  exudate  remains  serous.  It  has  already  been  said  that  a  purulent 
pleurisy  is,  in  the  vast  majority  of  instances,  tubercular.  We  have  learned, 
however,  that  a  tubercular  pleurisy  is,  not  necessarily  fatal,  and  it  is  more 
than  likely  that  some  of  the  cases  of  healed  empyema  with  which  we  are 
familiar  are  instances  of  such  recovery.  Others  are  cured  by  the  introduc- 
tion of  drainage-tubes  and  exsection  of  ribs,  but  often  the  patient  slowly 

35 


546  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

succumbs  to  the  exhausting  effect  of  the  ihness  or  to  tuberculosis  of  the 
lungs.  Not  a  very  rare  event  is  the  spontaneous  rupture  of  such  a  pleurisy 
outward,  an  event  better  anticipated  by  paracentesis.  Very  stubborn,  too, 
are  the  somewhat  rarer  cases  in  which  perforation  takes  place  from  the 
pleural  sac  into  the  lungs,  adding  the  symptoms  of  a  pneumothorax  to  those 
of  the  pleurisy.     Yet  even  these  sometimes  heal  spontaneously. 

Though  not  a  frequent  event,  sudden  death,  when  least  expected,  is 
sufificiently  so  to  make  it  important  that  one  should  be  on  his  guard  for  it. 
It  is  not  alone  when  the  chest  is  full,  or  during  a  tapping,  that  it  occurs,  but 
it  may  happen  several  days  after  a  large  part  of  an  effusion  has  been  removed. 
Pulmonary  thrombosis  is  probably  the  most  frequent  cause.  A  case 
of  my  own  terminated  thus,  when  convalescence  was  thought  to  be  estab- 
lished, and  the  patient  expressed  himself  better  than  on  any  day  during  his 
illness.  At  the  necropsy,  a  white  "  chicken-fat  "  clot  was  found  in  the  right 
ventricle,  extending  as  a  red  clot  into  the  pulmonary  artery.  The  chest 
was  partly  filled  with  serofibrinous  fluid.  Edema  of  the  opposite  lung  and 
degeneration  of  the  heart  muscle  are  probable  causes,  suggested  by  WeiL 
Obstruction  to  the  circulation  by  dislocation  of  the  heart  or  twisting  of  the 
great  vessels  has  also  been  suggested  as  a  cause. 

Treatment. — Many  simple  pleurisies  doubtless  get  well  of  themselves, 
with,  perhaps,  more  or  less  adhesion  of  the  lung,  which  may  be  the  cause 
of  certain  unexplained  restrictions  in  expanding  the  chest.  For  very  severe 
cases  of  pleurisy,  local  blood-letting  is  the  promptest  measure  of  relief,  and 
there  is  no  condition  in  which  so  delightful  an  effect  comes  to  the  suffering 
patient  gasping  for  breath  and  racked  with  pain.  I  am  confident,  too,  that 
the  duration  of  many  pleurisies  would  be  shortened  by  such  a  treatment.  In 
its  absence,  the  next  best  measure  is  the  application  of  a  blister,  which  seems- 
to  suspend  the  process,  as  well  also  as  to  relieve  the  pain  in  the  less  severe- 
cases.  Succeeding  the  blister,  a  cotton  jacket  or  a  poultice  should  be  ap- 
plied, for  a  time  at  least.  Anodynes — morphin  hypodermically  is  the  best — 
are  often  necessary  to  relieve  the  pain,  and  must  sometimes  be  repeated,, 
while  I  have  even  known  repetition  to  be  inefficient  and  unsatisfactory,  when 
a  blood-letting  produced  prompt  relief. 

Even  where  the  effusion  is  considerable,  it  often  passes  away  without 
any  very  active  measures.  The  blister  aids  in  its  absorption,  however,  and. 
the  iodid  of  potassium  may  be  used  in  co-operation — ^five  to  ten  grains 
(0.32  to  0.65  gm.)  every  six  hours.  If  there  is  much  delay,  however,  in. 
the  absorption  of  fluid,  paracentesis  thoracis  should  be  practiced  as  soon  as 
the  fever  has  subsided.  It  is  an  operation  every  physician  should  be  ready  to 
do  without  calling  on  the  surgeon.  I  prefer  for  it  the  line  of  the  angle  of 
the  scapula  between  the  eighth  and  ninth  ribs,  and,  while  it  is  true  that  the 
chest-wall  is  a  little  thicker  here,  and  sometimes  perforation  is  not  immedi- 
ately easy,  it  is  a  point  freer  from  danger  to  adjacent  organs  than  the  side 
where  the  chest-walls  are  really  thinner.  The  point  for  tapping  preferred 
by  others  is  the  seventh  interspace  in  the  midaxillary  line.  The  interspaces 
are  made  wider  and  the  operation  easier  if  the  arm  of  the  side  to  be  operated 
is  carried  over  to  grasp  the  opposite  shoulder.  The  needle  should  be 
introduced  close  to  the  upper  margin  of  the  rib,  so  as  to  avoid  wounding 
the  intercostal  artery.  Local  anesthesia  should  be  obtained  by  the  applica- 
tion of  ice  and  salt,  or  by  chlorid  of  ethyl.  It  is  particularly  in  the  insidious 
forms  of  pleurisy  that  the  tapping  of  the  chest  becomes  necessary,  because 
they  seem  to  be  as  slow  to  disappear  as  they  are  slow  to  make  their  presence 


CHRONIC  PLEURISY.  547 

known.  A  further  indication  for  paracentesis  is  aggravated  dyspnea.  The 
operation  is  usually  well  borne,  though  sometimes  faintness  results.  It  is, 
therefore,  well  to  fortify  the  patient  in  advance  with  an  ounce  of  whisky,  and 
if  faintness  results,  to  desist.  Sudden  death  during  the  operation  has  hap- 
pened in  rare  instances.  On  the  other  hand,  sudden  death  has  occurred  more 
frequently  in  cases  of  full  pleura  without  operation.  When  this  accident 
occurs,  it  is  more  than  likely  that  the  heart  was  previously  damaged. 

Empyemas  almost  never  get  well  after  a  simple  tapping.  The  pus 
reaccumulates,  and  the  symptoms  and  physical  signs  are  renewed.  Free 
-opening  should  be  made  without  delay,  and  a  good  large  drainage-tube 
passed  into  the  chest  through  an  upper  and  out  through  a  lower  opening  in 
the  chest-wall.  The  drainage-tube  is  often  very  much  too  small.  In  the 
event  of  failure  of  the  drainage-tube  to  effect  a  cure,  which  at  best  requires 
weeks,  with  daily  washing  out  of  the  chest  cavity,  exsection  of  a  part  of  one 
or  two  ribs  is  sometimes  practiced  with  better  results.  A  cure  means  thor- 
ough union  of  the  pulmonary  and  costal  pleurae,  and  complete  obliteration 
of  the  pleural  sac. 


CHRONIC  PLEURISY. 

Definition  and  Pathogeny. — Under  the  term  chronic  pleurisy  are 
included  several  morbid  states,  the  result  of  inflammatory  processes  of 
longer  duration  than  a  few  weeks.  These  include  both  exudative  and  dry 
or  plastic  pleurisies. 

1.  Exudative  pleurisies,  characterized  by  liquid  product,  include — 

(a)  The  condition  already  spoken  of  as  latent  pleurisy  associated  with 
effusion. 

(&)  Suppurative  pleurisies,  all  of  which,  though  they  may  originate 
acutely,  are  always  of  long  duration,  and  may  therefore  be  appropriately 
classified  as  chronic. 

2.  Plastic  pleurisies,  characterized  by  a  dry  product.  These  originate 
in  two  ways :  First,  they  are  plastic  from  the  beginning — that  is,  the  so- 
called  lymph  first  deposited  becomes  permanently  organized  as  a  more  or 
less  thick  layer  uniting  the  pleural  surfaces.  Such  primary  adhesions  are 
more  usual  in  circumscribed  areas  of  pleural  surface.  Second,  the  same 
result  follows  when  the  surfaces  separated  by  the  more  copious  sero- 
purulent  transudate  reapproach  each  other  as  the  latter  is  absorbed,  pro- 
ducing secondary  adhesions.  Third,  we  have  a  most  distinctive  product  of 
chronic  pleurisy  in  the  cicatricial  tissue,  which  succeeds  the  healing  of  the 
extensive  suppurative  surfaces  forming  the  walls  of  an  empyema  and  which 
also  closely  cements  the  lung  to  the  costal  pleura. 

Mention  should  also  be  made  of  the  form  of  chronic  pleurisy  resulting 
in  a  thick  interpleural  deposit  of  slow  formation,  also  tubercular  in  origin, 
which  extends  its  new  formation  from  the  pleura  into  the  interlobular  tissue 
of  the  lung,  dividing  it  or  dissecting  it  in  extreme  cases  into  distinct  areas, 
well  shown  upon  section,  which  has  given  rise  to  the  name  pneumonia 
dissecans,  or  pleurogenous  pneumonia.  This  form  of  pneumonia  has  its 
type  in  the  pleuropneumonia  of  cattle.  I  have  met  one  striking  instance 
of  this  form  of  chronic  pleurisy  of  tubercular  origin  in  man.  Any  one  of 
these  varieties  of  chronic  pleurisy  may  originate  as  a  tubercular  pleurisy, 
and  probably  most  of  them  are  of  this  kind. 


548  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

The  morbid  product  of  chronic  pleurisy  requires  no  further  description 
than  has  just  been  given,  and  in  the  description  of  the  morbid  anatom}^  of 
acute  pleurisy,  which  necessarily  included  to  some  extent  that  of  its  frequent 
termination  in  the  chronic  form.  The  adhesion  between  the  lungs  and  the 
ribs  is  variously  close  and  the  product  variously  thick,  insomuch  that  while 
usually  the  two  surfaces  are  easily  dragged  apart,  sometimes  it  is  impossible 
to  do  this  without  lacerating  the  lung.  Attention  may  again,  however, 
be  called  to  the  displacement  of  viscera,  the  retraction  of  the  chest-wall,  and 
curvature  of  the  spinal  column,  which  sometimes  take  place  as  a  consequence 
of  the  extreme  contraction  of  the  plastic  product  of  chronic  pleurisy  in  its 
most  aggravated  form — that  with  empyema. 

Treatment. — It  need  only  be  added  to  what  has  already  been  said  in 
the  treatment  of  acute  pleurisy  that,  in  chronic  pleurisy  especially,  chest 
gymnastics,  consisting  in  systematic  inspiratory  efforts  and  massage  of  the 
thoracic  walls,  must  be  availed  of.  Operative  procedures  must  be  consid- 
ered in  conjunction  with  the  surgeon.  Mild  local  measures,  such  as  counter- 
irritation  by  iodin  and  counter-irritating  ointments,  may  be  useful  to  relieve 
pain,  which  sometimes  annoys  the  subjects  of  chronic  pleurisy.  Nothing 
more  can  be  accomplished  by  active  counter-irritation  by  blisters. 

HYDROTHORAX  AND  HE^vIATOTHORAX. 

Definition. — The  term  hydrothorax  is  applied  to  any  accumulation  of 
clear  serum  in  the  pleural  sacs. 

Etiology. — It  is  the  result  mainly  of  resistance  to  the  free  circulation 
of  the  blood  through  the  vascular  basis  of  the  pleural  membrane.  It  occurs 
as  a  part  of  general  dropsy,  however  caused,  but  Bright's  disease  or  valvular 
heart  disease  are  the  most  frequent  causes.  Hence  the  chest  should  be 
frequently  examined  in  these  diseases,  as  hydrothorax  may  be  the  first 
symptom  of  dropsy.  Hydrothorax  is  usually  bilateral  in  both  renal  and 
heart  affections.  In  a  careful  study  of  this  subject  by  J.  Dutton  Steele,* 
based  upon  a  large  number  of  autopsies  with  cardiac  hydrothorax,  in  about 
83  per  cent,  of  cases  the  eff'usion  was  bilateral,  and  in  17  per  cent,  unilateral. 
Of  the  bilateral,  70  per  cent,  were  unequal  in  distribution,  and  of  these,  three- 
fourths  were  greater  on  the  right  side.  Of  the  13  unilateral  cases,  10  were 
right-sided  and  3  left-sided.  The  usual  explanation  of  this  preference  of 
pleural  effusion  to  the  right  side  in  cardiac  hydrothorax  is  that  more  fre- 
quently pressure  is  exerted  by  a  dilated  right  auricle  upon  the  root  of  the 
right  lung,  interfering  with  the  return  circulation  from  the  pleural  sacs. 
Left  unilateral  eff'usion  occurs  as  the  result  of  pressure  upon  the  root  of  the 
left  lung  and  left  superior  intercostal  vein.  Unequal  bilateral  pleural  eff'u- 
sions  must,  therefore,  be  due  to  unequal  pressure  on  the  roots  of  the  two 
lungs.  The  serous  fluid  in  hydrothorax  is  characterized  by  the  small  amount 
of  albumin  as  compared  with  that  exuded  in  pleurisy. 

Symptoms. — The  symptoms  are  those  of  pleuritic  eff'usion,  both  as  to 
subjective  symptoms  and  physical  signs.  Crepitant  rales  are  sometimes 
heard  in  the  lung  above  the  eff'usion,  due  to  its  retraction  and  to  partial 
atelectasis. 

Treatment. — This  is  considered  under  that  of  the  diseases  causing  the 
hydrothorax. 

*  "Distribution  and  Etiology  of  Cardiac  Hydrothorax."  "University  Medical  Jilagazine,"  vol.  ix., 
iiSq-,  p.  56:5. 


PNEUMOTHORAX.  549 

Hematothorax  is  a  term  applied  to  any  accumulation  of  blood  in  the 
thorax,  however  caused.  It  may  be  due  to  the  wounding  of  vessels,  maUg  • 
nant  disease,  or  aneurysmal  rupture.  The  symptoms  and  physical  signs  and 
treatment  are  those  of  pleural  effusion. 


PNEUMOTHORAX. 

Synonyms. — Hydro  pneumothorax ;  Pyopneumothorax. 

Definition. — Pneumothorax  means  air  in  the  thorax,  but  the  term  is 
limited  to  the  condition  in  which  there  is  air  in  a  pleural  sac.  It  is  almost 
always  accompanied  by  a  liquid  inflammatory  exudate,  usually  purulent  or 
seropurulent,  whence  the  terms  pyopneumothorax  and  seropneumothorax. 
The  effects  of  pneumothorax  are  compression  of  the  lung,  almost  always 
dislocation  of  the  heart  toward  the  opposite  side,  and  in  some  instances  dis- 
placement of  the  liver  and  spleen.  Pneumothorax  is  almost  without  excep- 
tion one-sided,  though  it  is  not  impossible  for  it  to  be  double. 

Etiology. — The  most  frequent  cause  is  perforation  of  the  pleura  over 
a  phthisical  cavity  or  a  hemorrhagic  infarct,  or  over  a  septic  bronchopneu- 
monic  focus,  or  gangrene  of  the  lung.  Other  causes  are  perforating  wounds 
of  the  lung,  perforation  of  the  diaphragm  due  to  malignant  disease  in  the 
abdomen,  especially  cancer  of  the  stomach  or  colon,  or  of  the  esophagus. 
Perforation  into  the  lung  from  the  pleural  side  may  occur  in  empyema. 
Rupture  of  the  lung  due  to  straining  has  caused  it.  The  opening  may  be 
valvular,  so  as  to  admit  air  intermittently. 

Symptoms. — Sudden  pain  and  increased  dyspnea  usually  usher  in  a 
perforation  causing  pneumothorax,  though  the  effect  may  be  more  gradual. 
Sometimes  the  symptoms  are  more  severe,  constituting  those  of  collapse — 
faintness,  frequent  pulse,  and  loivered  temperature.  Later,  at  least  slight 
fever,  corresponding  acceleration  of  pulse  and  breathing  rate,  continue  while 
the  condition  lasts.  Pneumothoraces  have  also  been  found  postmortem 
when  unsuspected  before  death,  having  occurred  without  producing  symp- 
toms. The  patient  may  be  orthopneic,  or  may  lie  upon  the  affected  side, 
for  the  same  reason  as  in  pleurisy.  Pleurisy  is  a  frequent,  but  not  invariable, 
consequence,  and  superadds  its  own  symptoms,  most  palpably  effusion. 

Physical  Signs. — These  are  the  most  distinctive  symptoms.  Inspection 
recognizes  commonly  a  bulging  half-chest,  with  the  intercostal  spaces  oblit- 
erated or  prominent,  as  compared  with  the  opposite  side.  The  breathing  is 
frequent  and  short.  Palpation  recognizes  absent  or  very  indistinct  vocal 
fremitus,  the  lungs  being  no  longer  in  contact  with  the  chest-wall,  which  is 
also  in  a  state  of  tension  interfering  with  vibration.  The  percussion  note  is 
resonant,  often  ringing  and  amphoric  over  the  upper  part  of  the  side, — that 
containing  air, — while  over  the  area  below,  containing  the  fluid,  there  is 
absolute  dullness.  On  the  other  hand,  there  may  be  dullness  over  the 
air-containing  space,  instead  of  tympany,  on  account  of  the  extreme  high 
tension  checking  all  vibration.  We  may  also  meet  here  that  interesting 
modification  of  tympany  known  as  Biemer's  change  of  note,  based  upon 
the  fact  that  with  a  given  tension  the  larger  an  air-containing  cavity, 
the  lower  the  pitch  of  the  percussion  note.  If  the  patient  with  pyopneu- 
mothorax sits,  or  especially  stands,  in  the  upright  position,  the  pleural  air- 
containing  space  is  enlarged,  because  the  weight  of  the  fluid  pushes  the  dia- 


550  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

phragm  downward,  whereas  in  the  horizontal  position  the  fluid  flows  into 
the  gutter  between  the  ribs  and  spinal  column,  the  diaphragm  rises,  the 
cavity  becomes  smaller,  and  the  pitch  of  the  percussion  note  is  raised. 
There  is  also  the  usual  change  of  level  of  the  dullness  corresponding  with 
change  of  position,  as  in  pleurisy  with  effusion. 

Auscultation  recognizes  feeble  or  absent  vesicular  murmur  in  the  situa- 
tions where  it  is  present  in  health,  while  amphoric  breathing  may  be  sub- 
stituted— bronchial  breathing  of  a  metallic  character.  Ringing  amphoric 
bronchophony  is  also  heard  when  the  patient  speaks.  An  interesting  aus- 
cultation sign  is  the  so-called  "  metallic  tinkling,"  a  sound  ascribed  to  the 
dropping  of  liquid  from  the  seat  of  perforation  into  the  fluid  below.  Here 
also  is  produced  in  its  typical  expression  the  "  coin-clinking  "  sound  con- 
veyed to  the  ear  of  the  auscultator  listening  at  the  back  of  the  chest,  while 
a  coin  placed  against  the  chest  in  front  is  tapped  by  another  coin.  This  is 
a  sign  usually  limited  to  pneumothorax,  though  it  may  also  be  produced 
over  bronchiectatic  cavities.  Here,  too,  may  be  produced  the  well-known 
Hippocratic  succussion  sound  by  shaking  the  body  of  the  patient,  the 
splashing  being  intensified  in  the  air-distended  cavity. 

Diagnosis. — Almost  the  only  condition  with  which  pneumothorax  may 
be  confounded  is  diaphragmatic  hernia,  the  physical  signs  of  which  very 
closely  resemble  those  of  pneumothorax.  The'  causes  of  diaphragmatic 
hernia  are  usually  severe  traumatic  agencies,  such  as  compression  between 
cars  or  under  masses  of  earth,  yet  occasionally  more  trifling  causes  produce 
it,  as  in  the  case  referred  to  on  page  535.  If  such  a  condition  be  suspected, 
all  doubt  may  be  settled  by  passing  a  stomach-tube  or  sound,  which  will 
disclose  the  exact  position  of  the  viscera.  A  distended  stomach  itself  is 
named  as  a  source  of  confusion  with  pneumothorax,  and  it  is  true  that 
succussion  and  metallic  tinkling  can  be  elicited  in  it  in  great  perfection. 
The  absence  of  distention  of  the  thorax  itself,  the  limitation  of  the  physical 
signs  to  the  neighborhood  of  the  stomach,  their  association  with  movements 
of  the  stomach  quite  independently  of  breathing,  point  to  the  proper  source. 
Pneumothorax  is  scarcely  likely  to  be  confounded  with  large  tubercular 
cavities,  for  while  the  latter  furnish  amphoric  signs  over  them,  vocal  fremitus 
is  increased,  or  at  least  remains  distinct,  while  with  pneumothorax  vocal 
fremitus  is  diminished  or  absent.  Further,  there  is  at  least  no  prominence 
over  cavities,  while  there  is  often  depression,  and  succussion  signs  cannot  be 
elicited.  Finally,  cavities  are  circumscribed.  Bronchiectatic  cavities  furnish 
signs  behind  and  below  the  scapula,  and  therefore  more  in  the  situation  of 
those  of  pneumothorax,  but  there  is  dullness  instead  of  tympany,  no  bulging, 
and  vocal  fremitus  probably  remains  distinct,  while  there  is  often  pec- 
toriloquy, never  present  in  pneumothorax. 

Treatment. — This  is  mainly  symptomatic.  Sudden  pain  and  extreme 
dyspnea  must  be  treated  by  morphin,  preferably  subcutaneously ;  em- 
barrassing accumulation  of  fluid  by  thoracentesis  and  draining  of  the  sac, 
and  in  extreme  cases  the  air  may  be  liberated  in  a  similar  manner.  Often 
pneumothorax  gives  surprisingly  little  inconvenience,  and  it  is  by  no  means 
impossible  for  spontaneous  healing  to  take  place.  Potain  suggested  re- 
placing the  air  and  fluid  by  sterilized  air,  but  such  air  would  soon  be  sub- 
stituted by  impure  air.  Operative  interference  has  been  carried  out  with 
more  or  less  success.* 

*  See  a  paper  on  the  "  Operative  Treatment  of  Pneumothorax,"  by  Samuel  West,  "  British  Medical 
Journal,"  Novejiber27, 1897,  p.  7568. 


MEDIASTINAL  DISEASE.  551 


MORBID  GROWTHS  OF  THE  PLEURA. 

These  are  rare  and  will  be  considered  to  some  extent  in  treating  medi- 
astinal disease.  The  pleura  is  subject  to  carcinoma  and  to  sarcoma,  the 
clinical  phenomena  of  which  are  identical.  Most  cases  of  carcinoma  of 
the  pleura  arise  by  contiguous  growth  from  primary  cancer  of  the  lung. 
Secondary  cancer  of  the  pleura  occasionally  arises  by  metastasis  from  the 
mammary  gland  or  lungs. 

Sarcoma  occurs  as  a  primary  growth  in  the  shape  of  the  so-called 
endothelial  carcinoma  of  Wagner,  which  starts  from  the  endothelial  cells 
of  the  lymphatics  and  connective  tissue.  It  also  gives  rise  to  secondary 
■deposits  in  the  lungs,  lymphatic  glands,  the  liver,  and  muscles. 

The  symptoms  of  any  one  of  these  forms  of  growth  are  those  of 
chronic  pleurisy,  varying  in  intensity  with  the  extent  of  the  growth,  single 
secondary  nodules  often  giving  rise  to  no  symptoms,  while  the  diffuse 
forms,  spreading  from  the  lungs,  cause  all  the  symptoms  described  as 
belonging  to  chronic  pleurisy,  the  lung  symptoms  being  relatively  insignifi- 
cant. In  the  meantime  the  true  nature  of  the  disease  may  long  remain 
unknown,  its  real  nature  being  determined  with  the  development  of  cachexia 
toward  the  end,  the  decline  of  strength,  and  probably  secondary  deposits  in 
discoverable  localities.  The  bloody  character  of  the  effusion  is  a  sign  point- 
ing to  malignant  disease  of  the  sarcomatous  or  carcinomatous  type. 

The  prognosis  is  altogether  unfavorable,  and  treatment  is  palliative 
■only. 

There  are  also  sometimes  found  in  connection  with  the  pleura  chon- 
droma and  lipoma,  while  calcification  sometimes  takes  place  in  chronic  in- 
flammatory products. 

Echinococcns  or  hydatid  disease  is  occasionally  found  in  the  pleural 
cavity.  Of  this,  the  first  clinical  symptom  is  hydrothorax,  the  fluid  from 
which  is  non-albuminous,  differing  in  this  respect  from  that  of  pleurisy  and 
to  a  less  degree  from  that  of  ordinary  hydrothorax.  The  only  unmistakable 
evidence  of  hydatid  disease  is  the  presence  of  booklets  and  fragments  of  the 
hydatid  cysts  in  the  aspirated  fluid.     Here,  also,  the  product  may  be  purulent. 


MEDIASTINAL  DISEASE. 

Definition. — Under  mediastinal  disease  are  included  all  anatomically 
morbid  conditions  situated  in  the  mediastinal  space,  except  diseases  of  the 
heart,  aorta,  trachea,  and  esophagus.  By  far  the  greater  number  of  these 
are  tumors,  but  simple  lymphadenitis,  abscess,  and  hemorrhage  are  also 
included. 

Anatomical. — In  consequence  of  the  difficulty  attending  the  concep- 
tion of  the  mediastinum  and  its  contents.  I  precede  the  consideration  of 
mediastinal  disease  by  a  brief  anatomical  description  of  the  mediastinum  and 
its  spaces. 

The  mediastinum  is  bounded  in  front  by  the  sternum,  posteriorly  by  the 
vertebral  column  from  the  lower  edge  of  the  fourth  dorsal  vertebra  down- 
ward, and  laterally  by  the  two  pleurse.  Clinicians  are  in  the  habit  of  subdi- 
viding this  space  into  the  anterior,  middle,  and  posterior  mediastinum  or 


552 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


mediastinal  spaces.     The  portion  above  this  is  called  by  anatomists  (notably 
Struthers  and  Gray),  whom  I  follow,  the  upper  or  superior  mediastinum: 

The  superior  mediastinum  is  that  portion  of  the  interpleural  space  above 
the  upper  level  of  the  pericardium,  between  the  manubrium  sterni  in  front 
and  the  upper  dorsal  vertebrae  behind,  and  bounded  below  by  a  plane  passing" 


Pulmonary  artery. 


Pulmonarv 


iry        J 
veins.    ( 


Left  bronchus 


Descending  aorta. 


Dorsal  vertebra. 


Ascending  aorta. 


Superior  cava. 


Right  bronchus. 


E-opihagus. 


Fig.  49. — Section  through  Frozen  Thorax  at  Second   Interspace   in  Front,   Looking" 
from  above  down-^-ard,  Showing  Mediastinal  Spaces. 


from  the  junction  of  the  manubrium  with  the  body  of  the  sternum  backward 
to  the  lower  border  of  the  fourth  dorsal  vertebra.  It  contains  the  origins  of 
the  sternohyoid  and  sternothyroid  muscles,  and  the  lower  end  of  the  longus 
colli ;  the  transverse  portion  of  the  arch  of  the  aorta ;  the  innominate,  the  left 


Ascending  aorta 


Sternum. 


Pulmonary  artery. 


Superior  cava. 


Right  bronchus. 


Esophagus 


Pulmonarv  vein- 


Left  bronchus. 


Dorsal  vertebra. 


Descending  aorta. 


Fig.  50.— Section   through  Frozen  Thorax  at  Second  Interspace  in   Front,   Looking 
from  below  upward,  Showing  Mediastinal  Spaces. 

carotid,  and  left  subclavian  arteries ;  the  superior  vena  cava  and  the  innomi- 
nate veins,  and  the  left  superior  intercostal  vein ;  the  pneumogastric,  cardiac, 
phrenic,  and  left  recurrent  laryngeal  nerves:  the  trachea,  esophagus,  and 
thoracic  duct,  and  the  remains  of  the  thymus  gland  with  lymphatics. 

The  anterior  space  of  the  lower  or  clinical  mediastinum  is  bounded  in 


MEDIASTINAL  TUMORS.  553. 

front  by  the  sternum,  posteriorly  by  the  pericardium,  and  laterally  by  the 
pleura.  It  is  wider  below  than  above,  and  is  narrowest  in  the  middle,  since 
at  this  point  the  two  pleural  edges  approach  each  other,  while  in  some 
instances  they  are  actually  in  contact.  The  anterior  mediastinum  contains  the 
origins  of  the  triangularis  sterni  muscles ;  the  internal  mammary  vessels  of 
the  left  side ;  a  quantity  of  loose  areolar  tissue ;  a  few  lymphatic  glands,  with 
lymphatics  from  the  upper  surface  of  the  liver  and  two  or  three  lymphatic 
glands  called  anterior  mediastinal  glands. 

The  middle  space  contains  the  heart  in  its  pericardial  sac,  the  ascending 
aorta,  the  superior  vena  cava,  the  pulmonary  artery  and  veins,  the  phrenic 
nerves,  the  bifurcation  of  the  trachea,  and  the  roots  of  the  lungs,  with 
numerous  lymphatic  glands.  It  is  broader  than  the  anterior  or  posterior 
mediastinal  space. 

The  posterior  space  is  triangular  in  form,  and  is  bounded  behind  by  the 
vertebral  column.  Its  anterior  boundary  is  the  pericardial  sac  and  the  roots 
of  the  lungs ;  its  lateral  walls,  the  pleurae.  It  contains  the  descending  portiort 
of  the  arch  and  the  descending  thoracic  aorta;  the  greater  and  less  azygos 
veins,  the  thoracic  duct,  the  pneumogastric  and  splanchnic  nerves,  the. 
esophagus,  and  some  lymphatics. 


•    MEDIASTINAL  TUMORS. 

Historical. — The  celebrated  English  physician  and  acute  observer,  Thomas  Willis 
(1621-75),  seems  to  have  been  the  first  to  have  made  an  observation  on  mediastinal 
disease.  H.  Boerhaave  recorded  a  steatoma  of  the  anterior  mediastinum  in  1742. 
Joseph  Lieutaud  (1703.80)  described  several  cases.  Boole  published  others  in  1812, 
and  J.  G.  C.  F.  M.  Lobstein  gave  the  first  text-book  description  in  1835,  after  which 
cases  multiplied,  although  the  number  which  came  under  the  notice  of  any  single 
observer  was  always  few.  F.  Strauscheed  analyzed  112  cases  in  1887,  and  Hobart  A. 
Hare  collected  520  cases  in  his  Fothergillian  Essay  in  1889.  Out  of  7566  autopsies  at 
the  Marine  Hospital  at  Cronstadt,  158  subjects  were  found  to  have  tumors  of  the 
mediastinum  said  to  be  malignant.  A  study  of  mediastinal  disease  by  the  late 
William  Pepper  and  Alfred  Stengel,  published  in  the  Transactions  of  the  Association 
of  American  Physicians  in  1895,  is  noteworthy. 

Pathology  and  Morbid  Anatomy. — The  varieties  of  growth  consist 
mainly  of  sarcoma,  including  lymphosarcoma,  carcinoma,  simple  lymphad- 
enoid  tumors ;  more  rarely  cysts,  dermoid  and  hydatid,  fibroma,  lipoma, 
gumma,  and  chondroma ;  also  the  teratoma  myomatoids  of  Virchow.  Sar- 
coma and  carcinoma  and  lymphadenoid  tumors  make  up  the  larger  number. 
Most  observers  have  found  more  carcinomata  than  sarcomata,  but  in  the  light 
of  the  fact  that  many  tumors  formerly  described  as  cancerous  are  at  the 
present  day  acknowledged  to  be  sarcomata,  it  is  more  than  likely  that  the 
latter  have  always  predominated.  Hilton  Fagge  and  Douglas  Powell  were 
the  first  to  announce  this,  and  William  Pepper  and  Alfred  Stengel,  in  their 
monograph  published  in  1895,  came  to  the  same  conclusion. 

The  majority  of  tumors  in  the  anterior  mediastinum  start  from  the 
remnant  of  the  thymus  gland  and  are  lymphosarcomata.  The  lymphatic 
structures  in  the  anterior  mediastinum  furnish  a  few.  In  the  middle  medias- 
tinum the  lymphatic  glands  are  the  principal  starting-points  of  the  relatively 
frequent  lymphosarcomata.  The  carcinomata  are  usually  primary,  but  sec- 
ondary carcinoma  is  not  infrequent.^  The  breasts,  lungs,  and  stomach  are 
among  the  primary  seats  named.  The  secondary  cancers  do  not  usually 
attain  a  large  size.  Cancer  may  extend  from  the  abdomen  to  the  lymphatic 
glands  of  the  chest  by  vascular  embolism,  by  direct  spread  of  the  disease  to 


554  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

the  under  surface  of  the  diaphragm,  through  which  it  may  penetrate  along 
the  lymphatics  into  the  chest  and  glands,  or  by  embolism  through  the  thoracic 
duct  to  the  chest  and  then  by  retrograde  embolism  to  the  mediastinal  glands. 

The  pleura  is  also  a  frequent  starting-point  of  mediastinal  growths. 
Among  these  are  the  so-called  endotheliomata  of  Wagner  and  Schulz,  start- 
ing in  the  endothelium  of  lymphatic  vessels  and  sometimes  the  surface  endo- 
thelium. They  are  sarcomata  or  carcinomata  according  as  the  endothelium 
is  counted  mesoblastic  or  endodermic  in  origin.  The  cases  of  primary  can- 
cer of  the  pleura  are  probably  endothelioma.  Fibrous,  fatty,  and  calcareous 
tumors  of  the  pleura  are  of  rare  occurrence.  The  lungs  also  contribute 
tumors  to  this  locality — carcinoma,  primary  and  secondary,  and  sarcoma, 
primary  and  secondary.  Of  the  primary  tumors,  carcinoma  is  the  more  com- 
mon, but  primary  sarcoma  of  the  lymphatic  glands  surrounding  the  bronchi 
and  within  the  lungs  near  the  root  is  not  very  rare.  The  clinical  symptoms 
are  the  same  as  when  the  glands  around  the  bronchi  outside  of  the  medias- 
tinum are  affected.  The  cancers  may  start  from  the  surface  epithelium  of 
the  bronchi,  from  the  mucous  glands,  or  from  the  alveolar  epithelium  of  the 
lung.  Finally,  from  the  esophagus,  also,  start  cancerous  tumors  invading 
the  mediastinum,  usually  small,  though  not  always.  From  these  the  pos- 
terior mediastinum  and  lungs  may  also  be  invaded. 

Symptoms. — ^Mediastinal  tumors  may  be  latent.  Their  symptoms  when 
present  are,  in  a  word,  those  of  pressure.  Such  pressure  may  involve  the 
lungs,  the  trachea,  the  bronchi,  the  esophagus,  the  heart,  the  vessels,  and  the 
nerves  of  this  locality.  They  include  symptoms,  subjective  and  objective,  of 
the  usual  kind,  and  also  physical  signs.  It  will  be  remembered  that  the  symp- 
toms of  aneurysm  are  also  largely  those  of  pressure,  and  it  is  chiefly  from 
aneurysm  that  mediastinal  tumor  is  to  be  distinguished,  often  a  matter  of 
some  difficulty.  The  division  by  Pepper  and  Stengel  into  three  groups  affords 
the  most  convenient  mode  of  studying  these  symptoms.  These  groups 
are : 

1.  Those  in  which  the  anterior  mediastinum  is  the  seat  of  the  growth. 

2.  Those  involving  the  middle  and  posterior  spaces. 

3.  Those  in  which  the  pleura  or  superficial  portion  of  the  lung  is  involved. 
I.  Intrathoracic  Tumors  Situated  in  the  Anterior  Mediastinum. — The 

symptoms  are  mainly  those  arising  from  pressure  exerted  on  the  venous 
trunks,  the  superior  vena  cava,  and  the  right  and  left  innominate  veins.  The 
yielding  walls  of  these  vessels  as  contrasted  with  the  firmer  adjacent  arteries 
easily  suffer  compression,  and  may  even  be  penetrated  by  the  growths  which 
may  proliferate  within  them,  sometimes  causing  occlusion  by  thrombosis. 
The  consequence  is  distention  of  the  -veins  of  the  upper  part  of  the  body — the 
head,  neck,  and  upper  chest,  sometimes  the  arms.  Coldness,  lividity,  edema, 
and  clubbing  of  the  ends  of  the  fingers  resvilt,  while  the  superficial  venous 
channels  may  be  dilated  and  tortuous.  From  pressure  on  the  arteries  may 
result  inequality  of  the  radial  pulses.  Of  the  nerves,  the  inferior  laryngeal 
is  especially  liable  to  compression,  with  resulting  hoarseness  and  aphonia. 
The  sympathetic  is  also  sometimes  compressed,  with  consequent  inequality 
of  pupils,  the  pneumogastric  being  less  frequently  involved  than  when  the 
tumor  occupies  a  more  posterior  situation.  As  the  tumor  enlarges  and  the 
air-passages  are  intruded  upon,  dyspnea  makes  its  appearance.  Dyspnea  is 
usually  of  the  inspiratory  kind.  Pericarditis  and  pleurisy,  with  pain,  hydro- 
pericardium,  and  pleural  effusion  may  be  present.  With  the  prolongation  of 
the  disease  the  patient  wastes,  but  it  is  said  that  cachexia  is  less  apt  to 


MEDIASTINAL  TUMORS.  555 

develop  than  in  malignant  growths  of  the  posterior  mediastinum.     Pain  is 
not  always  present — indeed,  it  is  said  to  be  less  marked  than  in  aneurysm. 

Physical  Signs  of  Groivths  in  the  Anterior  Mediastinum. — To  inspec- 
tion the  sternum  is  frequently  pushed  forward,  and  in  a  few  instances  eroded. 
Vocal  fremitus  may  be  either  increased  or  diminished.  Percussion  elicits 
abnormal  dullness,  characterized  by  more  or  less  irregular  shape.  Pulsation 
may  occur,  but  is  rare,  while  the  sharp  diastolic  shock  of  aneurysm  is  want- 
ing. If  the  tumor  extends  upward  sufficiently,  it  may  be  felt  in  the  supra- 
sternal fossa.  Auscultation  over  the  area  of  dullness  may  be  negative,  but 
sometimes  the  breath-sounds  and  heart-sounds  are  well  transmitted,  while  a 
distinct  systolic  bruit  may  be  produced  by  pressure  on  the  aorta  or  the  pul- 
monary artery.  Secondary  enlargement  in  the  cervical  lymphatic  glands 
sometimes  makes  its  appearance. 

2.  Intrathoracic  Tumors  in  the  Middle  and  Posterior  Portions  of  the 
■Spaces  around  the  Bronchi,  Esophagus,  Aorta,:  and  Nerves,  and  in  which 
the  symptoms  predominate  over  the  physical  signs. — The  first  effect  is  likely 
to  be  pressure  on  the  trachea  and  bronchi.  Hence  dyspnea  is  an  important 
and  early  symptom  of  tumors  in  this  situation,  and  the  inspiratory  effort  is 
■extreme.  Pressure  here  is  also  exerted  upon  the  vena  cava  ascendens, 
whence  results  edema  of  the  abdominal  walls  and  lozver  extremities.  The 
effect  of  pressure  on  the  arteries  is  not  serious.  From  pressure  on  the  vagus 
nerve  arises  pecidiar  cough,  paroxysmal  and  whooping.  Sometimes  it  is 
loud  and  ringing,  at  other  times  constant  and  hacking.  This  is  said  to  be  due 
to  the  joint  involvement  of  one  vagus  and  the  pulmonary  plexus ;  whereas 
experimentally  two  pneumogastrics  are  required  to  be  cut  to  produce  this 
symptom.  The  explanation  is  in  the  involvement  of  the  pulmonary  plexus. 
Mucopurulent  and  even  blood-stained  sputa  may  attend  the  cough.  The 
latter  is  sometimes  a  sign  of  perforation  of  the  bronchial  wall.  Dsyphagia 
from  pressure  on  the  esophagus  is  a  symptom  in  this  group,  sometimes, 
indeed,  the  only  one.  It  is  not,  however,  invariably  present.  Vomiting, 
cardiac  palpitation,  with  irregularity,  and  syncope,  when  present,  are  also 
ascribed  to  the  pneumogastric  involvement.  Pressure  upon  the  asygos  veins 
may  cause  edema  of  the  upper  part  of  the  abdomen  and  serous  effusion  in  the 
chest,  while  pleural  effusions  are  also  due  to  complicating  inflammations  or 
neoplasms  of  the  pleura.  Fever  may  be  a  symptom  of  tumor  of  the  posterior 
inediastinum.  It  is  usually  moderate,  but  is  sometimes  high  and  irregular, 
followed  by  sweating.  On  the  other  hand,  there  may  be  lowered  tem- 
perature, as  in  tumor  of  the  anterior  mediastinum  from  impeded  circu- 
lation. 

Cachexia  is  much  more  frequent  in  this  group  of  symptoms,  as  might  be 
expected  from  the  greater  severity  and  disturbing  effect  of  the  disease, 
including,  as  it  does,  destructive  process  involving  bone  and  lung  structure, 
as  well  as  severe  and  deep-seated  pain. 

Physical  Signs. — It  is  evident  that  in  this  group  the  physical  signs  play 
a  secondary  role,  and  except  as  the  result  of  modified  breathing  by  pressure 
and  impairment  of  resonance  to  percussion,  have  little  significance. 

3.  Tumors  Originating  in  the  Pleura  and  Lung,  and  in  which  the 
symptoms  and  physical  signs  are  of  equal  prominence.  The  former  is  the 
more  frequent  starting-point,  but  the  ivnderlying  lung  is  usually  soon  invaded 
and  may  be  more  frequently  the  actual  starting-point  than  is  commonly  sup- 
posed. Naturally,  the  symptoms  -first  produced  arc  those  of  pleurisy,  and 
the  disease  is  generally  so  regarded  at  first,  being  characterized  by  the  com- 


556  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

paratively  sudden  onset,  sharp  pain,  cough,  embarrassed  breathing,  and 
pleuritic  effusion.  Instead  of  abating  ultimately,  as  is  the  course  in  pleurisy, 
these  symptoms  grow  worse,  especially  the  pain,  which  extends  along  the 
intercostal  nerves  and  their  distribution  and  to  the  neck  and  arms.  The 
cough  also  persists,  while  the  expectoration  may  become  bloody  and  include 
sometimes  cells  from  the  morbid  growth. 

Paracentesis,  too,  is  successful,  and  often  furnishes  in  the  peculiarity  of 
its  product  valuable  aid  in  the  diagnosis,  because,  instead  of  being  clear  or 
nearly  so,  it  is  apt  to  be  bloody  or  slightly  chyliform  from  the  presence  of 
fatty  matter.  This  fatty  character  has  been  found  where  there  were  cancer 
and  sarcoma.  The  diagnostic  importance  of  certain  large,  swollen  cells  of 
endothelial  nature,  which  seem  to  become  detached  and  transformed  only  in 
case  of  pleuritic  disease  of  malignant  character,  is  insisted  upon  by  Fraenkel. 
To  the  information  gained  from  the  fluid  obtained  by  tapping  are  added  also 
unusual  resistance  to  the  trocar  and  imperfect  relief  to  the  dyspnea.  Rapid 
emaciation,  anemia,  and  cachexia  complete  the  picture,  while  all  doubt  is 
removed  if  secondary  growths  make  their  appearance  in  the  lungs,  as  not 
infrequently  happens. 

Diagnosis. — In  view  of  the  similarity  of  symptoms  to  aneurysm,  the 
history  of  the  case  in  mediastinal  disease  becomes  of  the  utmost  importance, 
but  shortness  of  breath,  the  bulging  of  the  thorax,  irregular  outline  of  per- 
cussion dullness,  the  feebleness  of  breathing  sounds,  the  dislocation  of  the 
heart  and  sometimes  of  the  abdominal  organs,  the  symptoms  of  venous 
engorgement,  which  are  usually  more  marked  in  mediastinal  disease,  the 
more  rapid  course,  and  secondary  metastatic  deposits  are  strong  points  in 
favor  of  the  latter  as  contrasted  with  aneurysm.  Laryngoscopic  examination 
with  a  view  to  discovering  any  constriction  of  the  trachea  from  pressure  by 
the  tumor  may  be  availed  of.  The  subjects  of  mediastinal  disease  are  usually 
younger  than  those  of  aneurysm.  Bony  erosion  and  pain  are  less  frequent. 
Constitutional  disturbance  and  emaciation  are  more  marked.  Diastolic  shock 
is  never  present  in  mediastinal  disease,  while  pulsation,  if  present,  is  not 
expansile. 

Confusion  with  pleurisy  and  pericarditis  is  a  natural  error  when  the 
symptoms  involving  the  pleura  and  pericardium  are  recalled,  and  here  the 
slower  development  of  the  symptoms  associated  with  those  of  compression 
of  the  various  mediastinal  tissues  and  absence  of  tendency  to  improve  should 
lead  to  suspicion  of  the  true  nature  of  the  disease. 

The  nature  of  the  tumor  may  even  be  suspected  from  certain  features. 
Thus,  rapid  growth,  metastatic  deposits  in  the  glands  of  the  neck  and  apices 
of  the  lungs,  cachexia,  and  tumors  in  other  situations  point  to  malignancy. 
Especially  may  sarcoma  be  suspected  if  the  subject  be  a  youthful  one. 
Abscess  may  be  suspected  if  there  is  a  history  of  injury,  caries,  or  pyemia, 
or  if  there  is  abscess  of  the  lung  or  empyema  attended  by  the  supervention  of 
pressure  symptoms.  Hemorrhage  may  be  suspected  also  when  there  is 
trauma  and  the  symptoms  develop  very  rapidly. 

Treatment. — There  is  no  treatment  for  mediastinal  disease,  except  such 
as  may  suggest  itself  for  the  palliation  of  symptoms. 

Mediastinal  Abscess. — Separate  mention  should  be  made  of  mediastinal 
abscess,  since  it  is  relatively  not  a  very  rare  disease.  Out  of  Hare's  520 
cases  of  disease  of  the  mediastinum  115  were  abscesses,  as  contrasted  with 
134  cases  of  cancer  and  98  of  sarcoma,  21  cases  of  lymphoma,  7  of  fibroma. 


MEDIASTIXAL  TUMORS.  557 

II  of  dermoid  cyst,  8  of  hydatid  cyst,  with  isolated  cases  of  gumma,  chon- 
droma, and  Hpoma. 

The  abscesses  were  found  in  the  majority  of  instances  in  males,  most 
often  in  the  anterior  mediastinum,  and  most  could  be  traced  to  traumatic 
causes.  Other  causes  were  tuberculosis,  the  eruptive  fevers,  and  erysipelas. 
A  few  cases  of  mediastinal  abscess  also  originate  in  the  bronchial  and  tracheal 
lymphatic  glands,  as  tubercular  lymphadenitis.  In  fifty-four  cases  the 
abscess  was  acute. 

Of  symptoms,  substernal  pain,  sometimes  throbbing,  was  the  most  con- 
-spicuous.  To  this  was  added  fez'er  in  acute  cases;  sometimes  chills  and 
szueats.  Erosion  of  the  sternum  and  burrowing  along  a  rib  into  the  abdomen 
were  noted,  also  rupture  into  the  trachea  and  esophagus.  In  chronic  abscess 
the  pus  may  become  inspissated — cheesy.  Suppurative  lymphadenitis  has 
been  known  to  terminate  thus,  previous  symptoms  having  been  masked  by 
the  lung  afifection.  Rarely  are  we  able  to  detect  fluctuation  at  the  edge  of 
the  sternum  and  in  the  suprasternal  notch,  where  there  may  be  pulsation. 
Only  as  the  abscess  becomes  large  enough  to  encroach  upon  the  air-passages 
does  it  cause  dyspnea. 

The  physical  sigjis  are  not  distinctive.  They  are  essentially  those 
described  in  the  general  description  of  mediastinal  disease.  Fever,  throbbing 
pain,  fluctuation,  and  the  history  of  trauma  are  symptoms  which,  if  added, 
aid  the  diagnosis. 

As  to  treatment,  given  a  correct  diagnosis,  operative  interference  is 
justified,  and  likely  to  afford  relief  if  the  pus  is  reached. 

Simple  Lymphadenitis. — This  probably  occurs  to  a  degree,  in  all  inflam- 
matory^ affections  of  the  bronchi  and  of  the  lungs,  but  is  rarely  recognizable. 
The  glands  are  mostly  in  the  posterior  mediastinum,  and  their  enlargement 
may  be  appreciable  to  percussion  in  the  upper  interscapular  region  behind, 
though  lymphatic  enlargement  may  contribute  also  to  dullness  in  the  region 
of  the  manubrium.     Tuberculosis  may  aft"ect  these  glands. 


SECTION   IV. 

DISEASES    OF    THE    HEART   AND   BLOOD-VESSELS. 
GENERAL  SYMPTOMATOLOGY  OF  CARDIAC  DISEASE. 

I.  Shortness  of  Breath,  Cardiac  Asthma. — Shortness  of  breath  is  com- 
monly the  first  symptom  of  cardiac  disease.  At  first  it  is  very  shght,  being 
felt  only  on  exertion.  As  the  disease  advances  it  is  induced  by  slighter  efifort, 
and  finally  it  is  more  or  less  permanent.  The  higher  degrees  are  commonly 
characterized  as  cardiac  asthma.  It  differs  essentially  from  bronchial  or 
spasmodic  asthma : 

1.  In  that  there  is  no  spasmodic  contraction  of  the  bronchial  tubes. 

2.  In  that  the  essential  morbid  change  is  an  overfilling  of  the  pulmonary 
capillaries  which,  intruding  on  the  lumen  of  the  air  vesicles,  interferes  with 
the  access  of  air  to  the  blood,  causing  diWaffOfxa^or  panting,  an  effort  by  fre- 
quent and  deep  breathing  to  accomplish  aeration..  The  overfilling  of  the  pul- 
monary capillaries  is  commonly  caused  by  a  backing  of  blood  from  the  left 
heart  into  the  lungs,  because  of  valvular  insufficiency,  or  it  may  be  caused 
by  a  weak  right  heart. 

The  same  results  follow  in  the  so-called  paretic  cardiac  asthma  due  to 
dilatation  of  the  left  ventricle.  This  is  a  common  condition  of  the  senile 
heart  in  consequence  of  its  imperfect  nourishment,  and  is  especially  prone 
to  occur  when  a  feeble  heart  is  forced  to  overcome  an  unusual  resistance. 
Such  is  the  increased  arterial  tension  due  to  arteriosclerosis  and  chronically 
contracted  kidney,  both  of  which  are  often  associated  with  shortness  of  breath. 
In  both  the  blood  does  not  pass  from  the  arteries  into  the  veins  so  freely  as  it 
ought.  So  long  as  the  heart  is  well  nourished  it  hypertrophies  in  these  dis- 
eases and  overcomes  the  resistance,  but  as  soon  as  its  nutrition  fails,  it  slowly 
undergoes  dilatation,  the  blood  is  backed  into  the  lungs,  and  the  asthma 
occurs. 

In  cardiac  asthma  as  contrasted  with  bronchial  asthma  there  is  an 
absence  of  the  wheezing  rales  which  characterize  the  latter  and  obscure  the 
vesicular  element  of  the  breathing  sound,  at  first  unaltered  in  cardiac  asthma. 
Later,  if  edema  of  the  lungs  occur,  there  may  be  small,  m,oist  rales,  crepitant 
or  subcrepitant,  and  still  later,Mf  the  air  vesicles  fill  up,  bronchial  breathing" 
with  an  impairment  of  resonance.  In  bronchial  asthma  if  there  happen  to 
be,  as  indeed  there  often  is,  associated  emphysema,  there  is  hyperresonance. 
Under  these  circumstances  the  normal  areas  of  cardiac  and  hepatic  dullness 
are  diminished.  Bronchial  asthma  is  an  asthma  of  expiration,  as  spasm  of 
the  larynx  furnishes  an  asthma  of  inspiration.  In  the  former  the  lungs  are 
overdistended  and  the  difficulty  lies  in  getting  them  emptied.  Hence  expira- 
tion is  four  or  five  times  longer  than  inspiration.  Yet  it  is  ineffectual.  In 
cardiac  asthma  there  is  no  obstruction  to  inspiration  or  expiration  and  both 
share  in  the  overeffort  to  accomplish  the  perfect  aeration  of  the  blood.  The 
air  vesicles  do  not  receive  enough  air  to  aerate  the  blood  because  the  latter  is 
in  excess.     Cardiac  asthma  and  bronchial  asthma  are  sometimes  associated. 

2.  Palpitation. — The   second   symptom   characteristic  of  heart   disease 

558 


ACUTE  PERICARDITIS.  559 

and  next  in  order  of  frequency  after  shortness  of  breath  is  palpitation.  By 
palpitation  is  meant  undue  frequency  of  the  heart's  action,  with  or  without 
irregularity.  It  succeeds  very  early  upon  shortness  of  breath,  or  is  coincident 
with  it,  and  is  more  common  in  mitral  disease  than  in  aortic  disease.  It 
varies  greatly  in  degree,  being  at  times  scarcely  noticeable  by  the  patient,  and 
at  others  exceedingly  distressing.  The  rate  attained  by  the  heart  under  these 
circumstances  is  sometimes  as  great  as  200  in  a  minute,  more  frequently  120 
to  150. 

3.  Slow-pulse. — Unnaturally  slow  action  of  the  heart  as  a  symptom  of 
organic  heart  disease  is  not  infrequent.  The  number  of  heart-beats. 
is  reduced  to  forty,  twenty,  or  even  less.  It  is  more  frequently  associated 
with  muscular  disease  of  the  heart  and  disease  of  the  coronary  arteries, 
and  is  distinct  from  nervous  bradycardia,  to  be  separately  considered.  The 
immediate  cause,  as  in  the  case  of  palpitation,  is  deranged  innervation  of  the 
heart,  the  inhibitory  nerves,  with  their  ganglia  situated  in  the  heart  muscle, 
being  the  usual  medium  by  which  it  is  brought  about. 

4.  Pain. — Pain  is  not  so  frequent  in  heart  disease  as  is  palpitation  or 
dyspnea.  It  is  of  two  kinds — a  dull,  aching  pain  and  a  sharp  pain  of  great 
severity,  radiating  through  the  heart  and  down  the  arms,  especially  the  left 
arm.  Sometimes  the  patient  complains  of  a  sensation  as  if  the  heart  was 
being  compressed,  or  even  as  if  grasped  in  a  vise.  The  pain  is  associated 
with  an  anxious  expression  and  feeling,  including  a  sense  of  impending  death,, 
which  is  characteristic  of  the  severer  forms  of  angina  pectoris.  Pain  of  this 
kind  is  apt  to  be  associated  with  disease  of  the  muscular  substances  of  the 
heart,  of  its  blood-vessels,  and  of  the  aortic  valves.  Pain  is  less  common  in 
mitral  disease,  and  when  present  is  more  likely  to  be  of  a  dull,  aching 
character. 

5.  Dropsy. — Dropsy  is  the  last  of  the  symptoms  characteristic  of  heart 
disease.  It  does  not  occur  with  every  form  of  heart  disease,  being  for  the 
most  part  absent  in  disease  of  the  aortic  valves  and  most  common  in  mitral 
disease.  Not  every  case  of  mitral  disease  is  associated  with  dropsy,  but  it 
occurs  sooner  or  later  in  the  vast  majority  of  cases.  Very  rarely  it  is  the  first 
symptom  noticed,  and  first  makes  its  appearance  almost  invariably  in  the  lower 
extremities.  It  is  the  direct  consequence  of  backing  of  the  blood  into  the 
venous  side  of  the  circulation,  and  is  due  to  the  transudation  or  filtration  of 
its  watery  elements.  The  serum  is,  as  it  were,  strained  out.  When 
unchecked,  the  swelling  extends  from  the  feet  to  the  legs,  thighs,  the  trunk, 
abdominal  walls,  and,  last  of  all,  serous  cavities  and  especially  the  peritoneal 
cavity,  producing  ascites.  The  pleural  sacs  may,  in  rare  instances,  be  the 
first  seats  of  transudation  in  heart  disease.  (See  remarks  on  Hydrothorax, 
page  548.)  These  simple  transudates  are  usually  free  of  albumin,  as  con- 
trasted  with  inflammatorv  exudates. 


DISEASES  OF  THE   PERICARDIUM. 

ACUTE  PERICARDITIS. 

Definition. — An  inflammation  of  the  serous  covering  of  the  heart  and  of 
its  reflection  on  the  inner  surface  of'the  pericardial  sac. 

Etiology. —  By  far  the  larger  number  of  cases  of  pericarditis  are  due  to 
some  toxic  substance  in  the  blood,  such  as  is  developed  in  the  infectious  dis- 
eases, or  to  some  excrementitious  matters  which  accumulate  in  the  blood 


56o  DISEASES  OF  HEART  AND  BLOOD-VESSELS 

because  of  deficient  elimination.  Other  cases  arise  per  contiguum,  a  few  cases 
are  traumatic,  and  those  that  cannot  be  accounted  for  are  called  idiopathic. 
Acute  articular  rheumatism  or  its  cause  is  by  far  the  most  frequent  etiological 
factor,  from  30  to  70  per  cent,  of  all  cases  being  ascribed  to  it.  The  greater 
the  severity  of  the  primary  disease,  the  more  likely  is  it  that  the  complication, 
pericarditis,  will  occur ;  yet  it  arises  also  in  the  mildest  cases,  and  has  some- 
times even  preceded  the  rheumatic  attack.  It  may  be  that  certain  seeming 
idiopathic  cases  are  due  to  the  toxin  of  rheumatism  spending  itself  on  the 
pericardium  instead  of  on  the  joints.  Other  infectious  diseases  causing  it  are 
pyemia,  scarlet  fever,  typhoid  fever,  diphtheria,  and  even  measles.  Bright's 
disease  is  one  of  the  best  recognized  causes  of  pericarditis,  and  it  is  probably 
the  excrementitious  matters  which  accumulate  in  the  blood  in  this  disease 
which  are  responsible  for  it.  Such  dyscrasic  states  of  the  blood  as  are  repre- 
sented by  scurvy  and  pupura  hsemorrhagica  play  an  important  part  in  its  pro- 
duction. Tuberculosis  of  the  pericardium  is  a  common  cause  of  pericarditis. 
Tubercular  pericarditis  may  be  part  of  a  general  tuberculosis  or  a  secondary 
infection  from  the  lungs. 

Diseases  of  adjacent  organs  which  cause  pericarditis  are  chronic  valvular 
disease,  pleuropneumonia,  pleurisy,  especially  tubercular  pleurisy,  morbid 
growths  in  the  vicinity,  ulcerative  disease  of  the  esophagus,  disease  of  the 
bronchial  glands  and  bronchi,  disease  of  the  vertebrae,  ruptured  aneurysm, 
abscess  of  the  heart,  or  invasion  of  the  pericardium  by  suppuration  through 
the  diaphragm. 

Morbid  Anatomy, — The  appearances  vary  with  the  stage  of  the  dis- 
ease. Ordinary  acute  pericarditis  is  met  with  in  one  of  three  stages.  The 
Urst  stage  is  represented  by  hyperemia  and  its  consequences.  The  initial 
events  are  hyperemic  redness,  followed  by  roughness  caused  first  by  loosen- 
ing and  detachment  of  the  epithelium,  and  further  increased  by  deposits  of 
fresh  inflammatory  lymph.  This  lymph  is  spread  at  first  in  yellow  flakes 
over  the  surface  of  the  pericardium. 

From  this  point  onward  morbid  appearances  vary  with  the  mode  of  ter- 
mination. This  may  be  by  resolution,  when  the  products  described  undergo 
fatty  degeneration  and  are  absorbed,  restoring  the  normal  state.  More  fre- 
quently there  supervenes  the  second  stage,  in  which  the  liquid  transudate 
increases,  separating  the  two  surfaces  of  the  pericardium  and  distending  the 
sac.  This  transudate  is  a  clear,  straw-colored  fluid  in  which  may  be  found 
floating  flakes  of  lymph  above  described.  The  quantity  of  fluid  varies  greatly, 
amounting  sometimes  to  a  liter  (2  pints)  or  more.  In  favorable  cases  it,  too, 
is  reabsorbed,  and  the  two  pericardial  surfaces  are  reapposed  with  or  without 
tmion  of  the  apposing  surfaces.  Sometimes  this  union  is  complete,  so  that 
the  two  surfaces  are  separated,  with  difficulty,  or  it  may  be  partial,  by  bands 
of  varying  length.  At  other  times  the  second  stage  is  represented  by  imme- 
diate organization  without  intervening  transudation — primary  adhesive 
inflammation. 

The  term  third  stage  is  usually  applied  to  the  phenomena  succeeding  the 
transudation  described.  They  include  organization  or  suppuration.  The 
former  may  be  adhesive  in  various  degrees  or  villous.  The  latter  occurs 
when,  union  being  apparently  prevented  by  the  constant  motion  to  which  the 
two  surfaces  are  subjected,  organization  takes  place  without  attachment  of 
the  opposing  surfaces,  and  a  peculiar  villous  product  results,  characterized 
by  numerous  projections,  uniform  in  size  and  shape,  resembling  closely  the 
papillae  on  a  sheep's  tongue.     These  papillae,  composed  of  vascular  connective 


ACUTE  PERICARDITIS.  561 

tissue,  originate  in  the  usual  way  by  an  outgrowth  and  vascularization  of  the 
connective  tissue  of  the  serous  membrane,  and  not  by  organization  of  the 
€xuded  lymph,  as  was  formerly  supposed.  This  lymph  undergoes  fatty 
■degeneration  and  absorption. 

The  more  unfavorable  cases  terminate  in  suppuration,  which  may  also 
be  primary  or  secondary.  In  the  former  instances  there  is  at  once  a  rapid 
outwandering  of  leukocytes  and  the  formation  of  a  purulent  fluid  in  the  peri- 
cardium— pyopericardium.  In  the  secondary  form  the  clear,  serous  transu- 
date is  substituted  by  pus,  an  event  which  is  usually  ushered  in  by  a  chill 
.and  is  followed  by  hectic  fever.  The  cause  of  the  suppuration  in  either  case 
is  the  access  of  the  usual  pus  organisms,  the  streptococcus  and  the  staphy- 
lococcus. The  contents  of  the  pericardium  may  become  cheesy,  especially  if 
the  inflammation  is  tubercular. 

Symptoms. — Clinically,  as  well  as  anatomically,  we  seek  to  separate  the 
stages,  first  of  roughening,  second  of  effusion,  and  third  of  absorption  or 
organization,  chiefly  by  aid  of  the  physical  signs. 

Pericarditis  is  sometimes  ushered  in  by  a  chill.  More  frequently  a  sharp 
pain  in  the  region  of  the  heart  initiates  the  attack,  previous  to  which  there 
may,  however,  have  been  a  sense  of  discomfort  or  distress  about  the  organ, 
which  may,  indeed,  be  the  only  subjective  symptom.  The  pain  and  discom- 
fort may  be  referred  to  the  epigastrium.  To  these  symptoms  may  be  added 
dyspnea  or  orthopnea.  There  is  also  fever,  which  is  not  very  high — tempera- 
ture 102°  F.  (39.9°  C.) — unless  there  be  previous  disease  with  fever,  when 
the  pericardial  complication  adds  an  increment.  The  pulse  is  frequent  and 
the  patient  restless  and  uncomfortable.  There  is  often  tenderness  over  the 
region  of  the  heart,  which  may  be  brought  out  by  percussion  or  pressure  with 
the  stethoscope.  The  position  assumed  by  the  patient  varies :  sometimes  he 
may  prefer  to  lie  on  the  affected  side,  at  other  times  on  his  back  or  on  the  right 
side,  or  he  may  prefer  to  sit  up.  Finally,  there  may  be  no  subjective  symp- 
toms added  to  those  of  the  primary  disease,  in  which  case  the  pericarditis 
must  be  discovered  only  by  the  physical  examination,  or  it  may  escape  detec- 
tion altogether  until  the  necropsy  reveals  it. 

As  the  effusion  distends  the  pericardium  and  encroaches  on  the  lung, 
the  difficulty  in  breathing  increases,  dyspnea  becomes  more  marked,  the  action 
of  the  heart  more  disturbed,  frequent,  and  irregular.  When  very  large,  it  may 
press  upon  the  left  lung.  It  may  even  influence  the  percussion  note  in  the 
tipper  lobe  below  the  clavicle,  causing  there  a  tympanitic  note — Skodaic 
resonance — by  indirect  relaxation.  Much  more  frequently  the  lower  lobe 
is  compressed,  sometimes  completely  emptied  of  air,  whence  the  percussion 
note  in  the  lower  axilla  and  about  the  angle  of  the  scapula  may  be  Skodaic  or 
impaired  in  resonance  or  even  absolutely  dull.  The  breathing  sounds  may 
b)e  feeble,  broncho-vesicular,  more  rarely  bronchial,  and  there  may  be 
egophony.  These  signs  are  not  to  be  confounded  with  those  due  to  pleuritic 
effusion,  which  are  characterized  by  diminished  or  absent  tactile  fremitus, 
T/hich  is  not  the  case  in  compression  by  a  distended  pericardial  sac,  where  it  is 
rather  increased.  Attention  was  called  to  these  symptoms  as  far  back  as  1857 
"by  H.  Bamberger,  whence  they  are  known  as  Bamberger's  sign.*  The  nor- 
mal state  -of  the  lung  may  be  in  part  restored  by  changing  the  position  of  the 
patient,  causing  him  to  lean  forward,  jie  on  his  right  side,  or  assume  the  knee- 
elbow  position. 

*  "Lehrbuch  der  Krankheiten  des  Herzens  von  H.  Bamberger,"  Wien,   1857. 

36- 


562  DISEASES  OF  HEART  A\D  BLOOD-VESSELS. 

William  Ewart  has  called  attention  to  signs  similar  to  those  described 
by  Bamberger  below  the  right  mamma ;  also  to  an  area  of  dullness  below  the 
ninth  rib  between  the  spine  and  a  line  drawn  through  the  angle  of  the 
scapula  and  to  a  less  degree  to  the  right  of  the  spine.  In  this  area,  known  as 
Ewart's  posterior  pericardial  patch  of  dullness,"  the  respiratory  sounds  are 
also  absent  and  the  voice  sounds  are  feeble.  He  ascribes  this  sign  to  an 
altered  dorsal  relation  of  the  liver  due  to  pressure  of  the  pericardial  effusion. 
Ewart  has  also  called  attention  to  what  he  calls  the  "  first  rib  sign,"'  also 
recognized  by  palpation.  The  upper  edge  of  the  first  rib  may  be  followed 
round  by  the  finger  tip,  because  the  clavicle  is  apparently  raised  above  its 
normal  position,  by  the  efifusion.  which  must  of  course  be  large. 

Still  larger  effusions  produce  dysphagia  in  consequence  of  encroachment 
on  the  esophagus.  Aphonia  may  occur  from  pressure  on  the  recurrent 
laryngeal  nerve.  The  pressure  of  the  full  sac  on  the  aorta  may  produce  the 
pulsus  paradoxus  of  Griesinger  and  Kussmaul,  in  which  the  pulse  beat  is 
weakened  and  accelerated  during  inspirations. 

A  certain  degree  of  prominence  of  the  epigastrium  may  result  from  the 
encroachment  of  distended  pericardium,  while  the  excursion  of  breathing 
movement  mav  be  noticeablv  greater  on  the  rigrht  side. 


Fig.  51. — Pulsus  Paradoxus. 

Influence  of  Respiration  upon  the  sphygmogram  (after  Riegel);  I,  During  inspiration; 

E,  During  expiration. 

Physical  Signs. — In  the  first  stage  there  may  be  pain  in  response  to 
pressure,  but  the  physical  sign  characteristic  of  this  stage  is  the  friction 
sound.  It  may  be  associated  with  an  impulse  stronger  than  natural.  The 
friction  sound  is  of  the  greatest  importance  in  diagnosis.  It  is  a  superficial 
to-and-fro  sound  heard  directly  under  the  ear,  commonly  loud  and  rasping, 
never  blowing,  sometimes  creaking.  It  is  loudest  over  the  middle  of  the 
heart.  It  is  not  conducted  as  are  the  murmurs  at  the  valves  in  the  direction 
of  the  blood  current.  It  is  often  influenced  by  changes  of  position  or  by 
breathing.  The  rub  may  sometimes  be  felt  by  the  hand  placed  over  the 
heart.  In  the  first  stage,  at  least,  it  lasts  a  short  time. — a  day  or  two  at  most 
and  sometimes  only  a  few  hours, — and  disappears  with  the  filling  of  the  peri- 
cardium by  effusion.  It  may  sometimes  be  brought  out  or  intensified  by  hav- 
ing the  patient  lean  over  on  the  stethoscope. 

The  second  stage,  or  that  of  eft'usion,  exhibits  usually,  but  not  always, 
signs  discoverable  to  inspection  or  palpation,  or  to  both.  They  depend  on  the 
amount  of  effusion.  If  large,  the  precordium  may  be  bulging,  the  interspaces 
obliterated,  and  the  impulse  undulating,  tumultuous,  and  indistinct.  As  the 
effusion  increases  the  heart  is  pushed  further  and  further  away  from  the 
chest-wall  and  assumes  a  more  horizontal  position,  while  the  impulse,  feebler 
and  feebler  to  vision  and  touch,  may  disappear  altogether.  Percussion  fur- 
nishes the  most  striking  change.  The  area  of  dullness  is  enlarged — peculiarly 
enlarged.  It  becomes  rudely  triangular  or  truncated  pyramidal  with  the 
apex  toward  the  inner  end  of  the  left  clavicle  and  the  base  as  low  as  the 


ACUTE  PERICARDITIS.  563 

seventh  rib,  and  extending  in  extreme  cases  from  nipple  to  nipple,  even 
pushing  the  diaphragm  and  liver  dow^nward.  The  absence  of  resonance  in 
the  fifth  intercostal  space,  to  the  right  of  the  stefntim,  is  known  as  Rotch's 
sign  in  pericarditis,  and  has  been  assigned  considerable  diagnostic  value.  It 
is  not  impossible,  however,  that  a  similar  dullness  may  be  caused  by  a  circum- 
scribed pleuritic  eif  usion  or  even  great  enlargement  of  the  heart.  The  cardio- 
hepatic  angle  as  determined  by  percussion,  normally  an  acute  or  a  right  angle, 
may  become  obtuse.  Auscultation  confirms  palpation.  The  conditions  of 
friction  sound  are  removed  more  or  less  by  separation  of  the  opposed  peri- 
rardial  surfaces.  Yet  the  sound  does  not  always  disappear.  The  heart- 
sounds  are  indistinct  and  best  heard  at  the  top  of  the  sternum.  Sometimes 
there  is  a  basic  systolic  murmur. 

The  third  stage  represents  a  return  to  the  normal  state  of  affairs,  which 
may  come  about  with  the  intermediation  of  a  friction  rednx  or  not;  or  adhe- 
sions may  form  between  the  heart  and  the  sac,  embarrassing  its  movements 
permanently,  and  producing  retraction  of  the  chest-wall  with  systole.  On 
the  other  hand,  necropsy  has  often  revealed  close  adhesions  between  the  heart 
and  the  pericardium  which  were  not  suspected  during  life.  Permanent 
roughening,  represented  by  the  "  sheep's  tongue  "  surface  or  other  roughen- 
ing or  adhesions,  may  produce  permanent  friction  sound,  and  the  pericarditis 
is  chronic. 

Physical  Signs  of  Chronic  Adhesive  Pericarditis  or  Adherent  Pericar- 
dium.— These  differ  materially.  They  are  most  easily  studied  in  children,  in 
whom  the  condition  is  especially  apt  to  occur  after  rheumatism.  Their  study 
is  further  facilitated  by  dividing  the  condition  into  two  groups : 

1.  Simple  adhesion  of  the  pericardial  and  epicardial  layers.  These  are 
the  cases  more  frequently  overlooked,  sometimes  giving  rise  to  no  symptoms 
and  first  found  at  necropsy. 

2.  Adherent  pericardium,  with  chronic  mediastinitis  and  fusion  of  the 
outer  layer  of  the  pericardium  zvith  the  pleura  and  to  the  chest-ivalls,  a  serious 
form,  leading  to  marked  hypertrophy  and  dilatation,  especially  in  children. 
To  inspection  and  palpation  the  precordium  is  bulging,  the  impulse  is  more 
diffuse,  extending  sometimes  from  the  third  to  the  sixth  interspace,  and  from 
the  right  parasternal  line  to  outside  the  left  nipple.  The  apex  may  be  dis- 
placed in  various  degrees  from  its  natural  site ;  it  may  be  to  the  right  of  its 
normal  position  and  above  it  or  down  toward  the  epigastrium.  It  is  some- 
times multiple,  or  spreads  in  a  wave-like  manner  over  the  area  named.  At 
other  times  the  systole  is  associated  with  a  tugging  retraction  of  the  chest- 
zvall,  which  is  especially  evident  in  thin  persons  and  is  regarded  by  some  as 
the  most  valuable  sign  of  adhesion  of  the  pericardium.  It  is  most  frequently 
noted  between  the  seventh  and  eighth  ribs  in  the  left  parasternal  line.  This 
may  be  followed  by  a  rapid  rebound  of  the  chest-wall,  known  as  the  diastolic 
shock.  It  may  be  associated  with  a  coincident  collapse — the  diastolic  col- 
lapse of  the  cervical  veins,  due  to  a  sudden  emptying  of  these  vessels  con- 
sequent on  the  expansion  of  the  chest-wall,  a  sign  first  described  by  Fried- 
reich. Broadbent's  diaphragm  sign  has  recently  attracted  much  attention — a 
systolic  tug  which  is  communicated  through  the  adherent  diaphragm  to  its 
points  of  attachment,  especially  on  the  left  side  behind,  between  the  eleventh 
and  twelfth  ribs.  It  is  distinct  and  apart  from  the  tugging  in  the  left  para- 
sternal line,  between  the  seventh  and  eighth  ribs,  to  which  attention  had  been 
previously  called.  Furthermore,  owing  to  the  attachment  of  the  pericard- 
ium to  the  central  tendon  of  the  diaphragm  this  muscle  does  not  descend  with 


564  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

inspiration,  and  consequently  the  usually  visible  movement  of  the  epigas- 
trium during  this  act  does  not  take  place. 

It  is  in  adhesive  pericarditis,  too,  that  we  sometimes  have  the 
pulsus  paradoxus,  referred  to  on  page  562.  First,  Griesinger,  and  later  Kuss- 
maul,  called  attention  to  it  as  a  constant  symptom  of  cicatricial  mediastinitis, 
due  to  the  dragging  of  the  cicatricial  tissue  on  the  great  vessels  during  inspi- 
ration. It  happens,  too,  when  the  great  vessels,  already  compressed  by  the 
exudate,  are  further  encroached  upon  by  the  expanding  lung,  making  the 
pulse  smaller  and  more  frequent.  This  is  more  frequently  demonstrable  by 
the  sphygmograph,  but  in  extreme  cases  may  be  appreciated  by  the  finger. 
It  is  not  a  pathognomonic  sign  of  either  event,  but  if  associated  with  an 
inspiratory  distention  of  the  cervical  veins,  it  points  strongly  to  adhesive 
pericarditis. 

To  percussion  there  is  usually  a  large  increase  in  the  normal  area  of  car- 
diac dullness,  commonly  upward  and  to  the  left,  sometimes  as  high  as  the 
first  interspace.  Often  the  pericardium  is  adherent  to  the  adjacent  pleura, 
in  which  event  the  area  of  cardiac  dullness  is  not  influenced  by  deep  breath- 
ing, a  sign  pointed  out  by  C.  J.  B.  Williams  as  of  great  value  in  diagnosis. 

Auscultation  may  be  entirely  negative,  or  there  may  be  a  modification  of 
the  usual  friction  sound  which  closely  resembles  the  creaking  of  leather.  A 
galloping  or  fetal  rhythm  may  be  present,  or  there  may  be  a  loud  systolic 
murmur  at  the  apex,  which  has  often  given  rise  to  the  erroneous  diagnosis 
of  mitral  valve  disease,  being  due  to  relative  insufficiency.  Endocardial  dis- 
ease may,  however,  coexist,  especially  in  children.  A  presystolic  murmur  is 
sometimes  heard. 

The  possible  association  of  chronic  adhesive  pericarditis  and  medias- 
tinitis with  proliferating  peritonitis,  perihepatitis,  and  splenitis  should  be 
remembered. 

Diagnosis. — In  all  cases  of  acute  articular  rheumatism  the  heart  should 
be  frequently  examined,  because  pericarditis  often  supervenes  with  feebly 
pronounced  subjective  symptoms.  At  the  outset  the  distinction  is  to  be  made 
between  pericarditis  and  acute  endocarditis,  which  even  more  frequently  suc- 
ceeds on  rheumatism  with  subjective  symptoms  no  more  distinctive.  There 
is  usually  not  much  difficulty  in  acute  cases.  The  to-and-fro  rhythm,  heard 
directly  under  the  ear,  usually  most  distinct  over  the  center  of  the  heart,  and 
the  absence  of  sounds  transmitted  in  accordance  with  the  laws  of  transmission 
of  the  valvular  abnormal  sounds,  are  distinctive  features  of  the  cardiac  fric- 
tion. If,  however,  one  of  the  to-and-fro  elements  is  wanting,  the  difficulty  is 
greater  and  errors  do  occur.  Close  study  must  be  made  as  to  transmission. 
It  is  further  characteristic  of  the  friction  sound  that  it  is  increased  in  loudness 
by  pressing  the  chest-wall  with  the  stethoscope,  while  this  is  not  the  case  in 
endocardial  murmurs.  Such  pressure  is,  however,  often  painful  to  the 
patient.  In  chronic  valvular  defects  there  are  changes  in  the  size  and  posi- 
tion of  the  heart  which  are  not  present  in  the  first  stage  of  acute  pericarditis. 
When  both  acute  endocarditis  and  pericarditis  are  present,  the  difficulty  is 
greatly  increased  and  one  or  the  other  condition  is  likely  to  be  overlooked. 

The  "  pleuropericardial  "  friction  sound  or  "  extra-pericardial  "  friction 
sound  is  to  be  distinguished  from  pericardial  friction  sound.  It  is  a  sound 
similar  in  rhythm  to  the  pericardial  sound,  but  the  primar}'  conditions  of  its 
causation  are  in  a  pleuritis  involving  the  opposed  surface  of  the  mediastino- 
costal  sinus  of  the  left  side.  It  is  more  commonl}-  heard,  therefore,  over  the 
left  border  of  the  heart.     It  is  the  combined  product  of  the  respiratory  and 


ACUTE  PERICARDITIS.  565 

cardiac  action,  being  usually  louder  during  expiration.  It  generally  ceases 
during  a  deep  inspiration,  because  at  this  time  the  cardiac  action  cannot  pro- 
duce the  required  rubbing.  On  the  other  hand,  this  is  sometimes  the  very 
condition  under  which  the  friction  sound  is  loudest.  Simply  holding  the 
breath  may  also  stop  it,  though  not  necessarily,  because  the  heart  motion  pro- 
duces it.  This  influence  of  the  breathing  one  way  or  the  other  is,  however, 
of  importance  in  diagnosis,  while  other  symptoms  must  also  be  taken  into 
consideration.  Thus,  if  it  be  a  pleurisy,  the  pleural  friction  sound  is  probably 
heard  elsew^here,  and  there  are  the  other  symptoms  of  a  pleurisy  present, 
-.while  those  of  a  pericarditis  are  absent.  Unlike  the  true"  pericardial  friction 
sound  the  pleuropericardial  friction  sound  is  uninfluenced  by  bending  the 
body  forward,  but  is  heard  with  equal  distinctness  with  the  body  in  any  posi- 
tion. Difficulties  again  increase  when  it  is  associated,  as  it  sometimes  is  in  a 
pleuro-pneumonia,  with  endocarditis.  It  also  occurs  in  tubercular  phthisis, 
where  it  is  sometimes  associated  with  a  systolic  click  due  to  the  simultaneous 
expulsion  of  a  bubble  of  air  from  a  portion  of  softened  lung. 

For  diagnosis  between  pericarditis  with  effusion  and  dilatation  of  the 
heart  see  page  605,  It  is  in  this  differential  diagnosis  particularly  that 
Rotch's  sign  and  the  diff'erence  as  determined  by  percussion  of  the  cardio- 
hepatic  angle  become  valuable.  It  must  be  remembered,  however,  that 
Rotch's  sign  is  not  always  present,  even  when  there  is  considerable  effusion. 
The  possibility  of  a  circumscribed  pleuritic  effusion  must  also  not  be  over- 
looked. Bamberger's  sign — dullness  in  the  region  of  the  angle  of  the  le'ft 
scapula — should  be  sought ;  also  Ewart's  posterior  pericardial  patch. 

Prognosis. — The  course  of  pericarditis  varies  with  dift'erent  cases.  In 
an  ordinary  uncomplicated  case  passing  to  recovery,  the  duration  is  one  to 
three  weeks,  even  when  there  is  considerable  eff'usion,  which  is  often 
absorbed  with  surprising  rapidity.  In  other  cases,  especially  in  cachectic 
subjects,  the  duration  is  longer.  Relapses  occur.  When  adhesion  results, 
convalescence  is  greatly  prolonged,  and  in  many  cases  the  heart  is  perma- 
nently crippled.  On  the  other  hand,  extensive  adhesions  are  sometimes 
found  at  necropsy  where  no  lesion  was  suspected.  The  pyopericardial  cases 
are  usually  fatal. 

Treatment. — Prompt  treatment  is  of  the  greatest  importance  in  peri- 
carditis. Rest  is  an  absolutely  essential  condition.  As  soon  as  the  diagno- 
sis is  made,  a  blister  is  of  the  greatest  value.  There  is  no  other  disease  in 
which  I  am  so  satisfied  of  the  efficiency  of  a  blister.  It  should  be  at  least 
three  inches  (7.5  cm.)  square.  I  am  confident  that  it  helps  to  prevent 
effusion  and  also  to  promote  the  absorption  of  effusion.  Along  with  this, 
measures  to  relieve  pain  are  indicated.  Nothing  is  so  satisfactory  as  mod- 
erate doses  of  morphin  administered  hypodermically,  associated  wdth  atropin 
in  the  proportion  of  1-150  grain  (0.00044  g™-)  of  the  latter  to  1-4  grain 
(0.0165  gm.)  of  the  former.  Cold  applications  to  the  pericardium  by  Lei- 
ter's  coil  or  the  ice-bag  are  sometimes  useful.  At  other  times  hot  applica- 
tions are  more  comforting. 

Digitalis  in  moderate  doses  is  usually  indicated  to  steady  the  heart  at 
its  work,  without,  however,  stimulating  it  too  forcibly.  For  the  same  reason 
alcohol  and  ammonia,  especially  the  aromatic  spirit  of  ammonia,  are  indi- 
cated. Strychnin  is  a  valuable  heart  tonic.  Liquid  food,  including  milk 
and  broths,  should  be  adhered  to  until  convalescence  is  established.  Eggs 
may,  however,  be  early  allowed. 

If  the  effusion  is  very  large,  tapping  the  pericardium  may  be  necessary 


566  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

to  relieve  the  patient,  although  practically  the  relief  which  first  follows  a 
successful  operation  is  rarely  followed  by  complete  recovery.  The  aid  of 
the  surgeon  should  be  secured  if  possible,  but  if  not,  puncture  may  be  made 
in  the  fourth  interspace,  an  inch  (2.5  cm.)  to  the  left  of  the  edge  of  the 
sternum.  If  made  in  the  fifth  interspace,  the  puncture  should  be  made  a 
little  further  out — say  i  1-2  inches  (3.5  cm.).  A  safe  point  which  may  be 
used  in  large  effusions  is  the  left  xiphocostal  angle,  at  which  the  needle 
should  be  pushed  upward  and  backward.  When  the  pericardial  fluid  is  pus, 
a  simple  tapping  is  insufficient.  Free  incision  should  be  made,  and  free 
drainage  should  be  established  with  aseptic  precautions.  John  B.  Roberts* 
collected  thirty-five  cases  of  suppurative  pericarditis  treated  by  incision,  of 
which  fifteen  recovered  and  twenty  died.  It  is  not  impossible  that  if  oper- 
ation were  done  earlier,  better  results  would  follow. 

The  treatment  of  chronic  adhesive  pericarditis  is  mainly  symptomatic, 
and  directed  to  building  up  the  strength  of  the  patient. 


OTHER  PERICARDIAL  AFFECTIONS. 

Other  affections  of  the  pericardium  are  hydropericardium,  hemoperi- 
cardium,  pneumopericardium,  and  tuberculous  pericarditis,  rarely  morbid 
growths. 

Hydropericardium. — This  term  is  applied  to  a  large  accumulation  of 
serous  fluid  in  the  pericardium.  In  health  the  pericardium  is  simply  lubri- 
cated by  this  fluid-.  It  occurs  som.etimes  as  a  part  of  a  general  dropsy, 
most  frequently  cardiac  dropsy,  more  rarely  in  renal  dropsy.  The  accumu- 
lation is  seldom  large  in  these  cases.  It  is  not  common,  but  is  sufficiently 
so  to  demand  frequent  examination  of  the  heart,  as  it  is  often  overlooked. 
Its  signs  are  the  same  as  those  of  the  inflammatory  effusion. 

Heinopericardiwn,  or  blood  in  the  pericardium,  occurs  only  as  a  result 
of  rupture  of  an  aneurysm  in  the  first  part  of  the  aorta  into  the  pericardial 
sac,  from  rupture  of  the  heart  itself  or  a  wound  of  the  heart.  It  is  rapidh' 
followed  by  shock  and  death.  Its  physical  signs  are  those  of  effusion. 
Cancer  of  the  pericardium  may  be  associated  with  blood  effusion.  It  may 
also  be  caused  by  tuberculosis  of  the  pericardium. 

Pneiwiopericardimn,  or  gas  in  the  pericardial  sac,  is  a  rare  condition, 
analagous  to  the  much  more  common  one  of  pneumothorax.  As  in  pneumo- 
thorax, the  presence  of  air  implies  also  the  presence  of  liquid,  and  that, 
usually,  pus.  It  is  produced  Uy  similar  causes,  such  as  perforation  into  an 
air-containing  space  like  the  lungs  or  esophagus.  Such  perforation  is 
usually  traumatic.  Decomposition  of  pericardial  exudate  or  morbid  growth, 
it  is  said,  may  also  produce  it. 

Symptoms. — Its  symptoms  are  pain  and  pericardial  embarrassment, 
but  the  physical  signs  are  most  distinctive,  especially  those  of  auscultation. 
To  inspection  there  is  prominence  of  the  precordium,  with  indistinctness  or 
obliteration  of  apex-beat,  restored  by  the  patient's  bending  forward.  Per- 
cussion furnishes  dullness  over  the  lower  portion  of  the  cardiac  area  and 
tympanv  above  it,  the  position  of  both  being  altered  by  change  in  position 
of  the  bodv.  To  auscultation  the  heart-sounds  assume  a  striking  metallic 
character,   being   audible   even   at   a   distance    from    the   body.     A   similar 

*  "American  Journal  of  the  Medical  Sciences,"  December,  1897. 


ACUTE  ENDOCARDITIS.  567 

metallic  character  is  given  even  to  a  friction  sound,  if  it  is  present,  as  it 
■often  is. 

Diagnosis. — The  diagnosis  of  this  condition  requires  differentiation 
from  the  effect  of  an  air-dilated  stomach  on  the  heart-sounds,  or  rarely  of 
a  phthisical  cavity  or  pneuinothorax.  All  doubt  in  the  case  of  the  stomach 
is  removed  by  filling  it  with  water.  The  associated  symptoms  of  the  other 
conditions  make  a  mistake  unlikely. 

Treatment  is  scarcely  available,  except  in  case  of  external  injury,  when 
operation  may  be  of  service. 

Tuberculous  Pericarditis  presents  nothing  peculiar  in  its  symptoms 
or  signs  as  already  described. 

Morbid  Growths  of  the  Pericardium  are  rarely  diagnosticated  before 
•death. 


DISEASES  OF  THE  ENDOCARDIUM. 

ACUTE  ENDOCARDITIS. 

Synonym. — Valvulitis. 

Definition. — Endocarditis  in  both  its  acute  and  chronic  forms  is  an 
inflammation  for  the  most  part  confined  to  the  valves;  for  such  inflammation, 
therefore,  valvulitis  is  a  more  correct  term.  The  lining  of  the  cavity  of 
the  heart  is,  however,  sometimes  affected  in  acute  endocarditis,  especially  in 
the  more  severe  cases,  when  it  is  known  as  mural  endocarditis.  It  is  usually 
in  the  apex  of  the  left  ventricle  that  such  inflammation  occurs. 

Etiology. — All  cases  of  acute  endocarditis  in  the  light  of  modern 
studies  must  be  regarded  as  infectious — that  is,  as  due  to  a  specific  poison 
commonly  associated  with  some  disease  which  is  regarded  as  the  cause  of 
the  endocarditis.  Acute  rheumatism  is  the  best  recognized  and  most  fre- 
quent of  these.  Upon  this  follow  closely  the  infectious  fevers,  with  their 
various  specific  organisms  or  their  toxic  products.  In  the  disease  which 
is  acknowledged  to  be  the  most  common  cause — acute  articular  rheumatism — 
no  causing  organism  has  as  yet  been  found. 

There  is,  however,  a  great  difference  in  the  severity  of  different  cases 
of  acute  endocarditis,  and  the  disease  is  easily  separable  into  two  classes, 
from  one  of  which  recovery  almost  always  takes  place  up  to  a  certain 
point,  leaving  often  a  degree  of  valvular  defect  known  as  chronic  endo- 
carditis, while  the  other  is  invariably  fatal.  The  first,  or  milder,  of  these 
classes  was  for  a  time  ascribed  to  some  specific  non-organized  agency,  even 
after  the  more  severe  and  fatal  form  was  recognized  as  infectious,  whence 
arose  the  terms  simple  endocarditis  on  the  one  hand,  and  infectious,  ulcer- 
tive,  malignant,  or  mycotic  on  the  other. 

In  attempting  to  explain  why  at  one  time  the  simple  form  and  at 
another  the  virulent  form  of  endocarditis  arises,  it  may  be  stated  that  the 
toxins  generated  by  the  less  virulent  bacteria  pave  the  way  for  the  operation 
of  the  virulent  streptococcus  and  staphylococcus  pyogenes,  the  pneumococcus, 
the  gonococcus,  and  other  organisms  which  are  found  in  the  morbid 
products  of  malignant  endocarditis.  It  is  not  unreasonable  to  suppose  that 
the  former  produce  the  simple  form  of  endocarditis,  while  the  co-operation 


568  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

of  the  septic  bacteria  named  is  necessary  to  produce  the  mahgnant  variety. 
On  the  other  hand,  it  may  be  not  so  much  the  specific  organism  as  the  con- 
stitutional or  local  peculiarities  of  the  individual  on  whom  the  disease  is  en- 
grafted— the  natv:re  of  the  soil,  as  it  were. 

The  Mild  or   Simple   Form   of  Acute   Endocarditis. 

Synonym. — Warty  or  Vcrrucosc  Endocarditis. 

Etiology. — zA.lmost  any  one  of  the  recognized  infectious  diseases  may 
become  a  cause  of  simple  endocarditis.  Acute  articular  rheumatism  is,  how- 
ever, the  most  frequent  cause,  20  per  cent,  of  all  cases  being  ascribed  to  it. 
After  this  comes  chorea.  Indeed,  William  Osier,  who  has  made  the  sub- 
ject a  special  study,  says :  "  There  is  no  disease  in  which,  postmortem, 
acute  endocarditis  has  been  so  frequently  found."  Vegetations  were  found 
on  the  valves  in  sixty-two  out  of  seventy-three  fatal  cases  of  chorea  col- 
lected by  him.  This  fact  has  suggested  even  a  microbic  origin  of  chorea, 
which  is  sustained  by  other  features  in  the  history  of  the  disease,  but  not 
by  actual  demonstration.  In  the  absence  of  such  demonstration,  chorea  must 
be  regarded  in  the  light  of  a  predisposing  cause.  Scarlet  fever,  pneumonia, 
tuberculosis,  and  peliosis  rheumatica  are  not  infrequent  predisposing  causes ; 
less  frequently  are  tonsillitis,  diphtheria,  erysipelas,  smallpox,  and  typhoid 
fever.  Endocarditis  also  super^^enes  as  a  complication  of  Bright's  disease. 
Even  in  these  cases  bacteria  are  found  in  the  vegetations.  Cachectic  states, 
such  as  are  caused  by  tuberculosis  and  cancer,  also  seem  to  favor  the  develop- 
ment of  acute  endocarditis.  Finally,  chronic  valvulitis  is  a  predisposing 
condition  to  simple  acute  endocarditis  as  well  as  to  the  malignant  form, 
being  often  complicated  by  acute  attacks,  whence  the  term  "  recurring  "  en- 
docarditis. 

Morbid  Anatomy. — The  left  side  of  the  heart  is  more  frequently  in- 
volved, and  in  this  the  mitral  leaflets  first,  in  at  least  half  of  all  cases ;  next 
the  aortic  cusps ;  then,  in  the  right  heart,  the  tricuspid  valve,  and  finally 
the  pulmonary  valve.  In  embryonic  life,  in  which  acute  endocarditis  also 
occurs,  the  right  side  of  the  heart  and  the  tricuspid  valve  are  most  frequently 
affected,  accounting  thus  for  certain  congenital  valvular  defects. 

The  type  of  the  morbid  change  on  the  valves  in  simple  endocarditis  is 
so  constantly  a  product  warty  or  fungous  in  appearance  that  the  term  warty 
or  verrucose  endocarditis  is  often  applied  to  this  form.  On  the  auricular 
surface  of  the  mitral,  and  the  ventricular  surface  of  the  aortic  valves,  at  the 
line  of  their  contact  during  closure, — ?'.  c,  1-25  to  1-12  inch  (i  to  2  mm.) 
back  of  the  valve  edge, — granular  and  warty  excrescences  make  their  ap- 
pearance. These  rise  1-12  to  1-8  inch  (2  to  3  mm.)  above  the  surface  and 
extend  a  variable  extent  along  the  valve.  They  soon  become  capped  with 
fibrin,  often  abundantly,  and  thus  a  vegetation  is  formed.  The  vegetation 
begins  in  a  proliferation  of  the  cells  of  the  adventitia  and  of  the  connective 
tissue  of  the  external  laminae  of  the  endocardium.  Thus  formed,  it  is  a 
friable  product,  liable  to  be  broken  off  at  any  time  and  carried  into  the  gen- 
eral circulation  to  a  point  of  lodgment,  where  it  plays  the  role  of  an  embolus. 
In  point  of  fact,  this  accident  does  not  often  happen  in  the  simple  acute 
endocarditis  succeeding  febrile  diseases.  It  occurs  more  frequently  in 
the  acute  endocarditis  engrafted  on  chronic  valvular  disease,  and  in  the 
malignant   form.     More   frequently  the  vegetation  undergoes   organization 


ACUTE  ENDOCARDITIS.  569 

and  contraction,  and  the  valve  is  restored  partially  to  its  natural  condition, 
leaving  a  simple  sclerotic  thickening,  which  is  especially  prone  to  become 
the  starting-point  of  new  processes.  But  not  every  aortic  murmur  in  the 
course  of  rheumatism  implies  endocarditis,  as  the  condition  of  the  blood 
predisposes  to  a  hemic  murmur ;  nor  every  murmur  at  the  apex,  because 
the  state  of  the  muscle  predisposes  to  imperfect  closure  of  the  auriculo- 
veritricular  orifice.  Unless  there  has  been  previous  valvular  disease,  there  is 
no  enlargement  of  the  heart  in  acute  endocarditis. 

Symptoms. — These  are  often  masked  by  those  of  the  previous  disease, 
and  sometimes  overlooked,  the  autopsy  first  disclosing  the  lesion.  There  is 
frequently  noticed,  however,  greater  or  less  embarrassment  of  breathing, 
orthopnea  being  not  infrequent ;  the  pulse  is  much  more  rapid  and  may  be 
irregular,  the  patient  is  restless,  the  countenance  dusky,  while  the  tempera- 
ture is  a  degree  or  two  higher  than  normal.  Altogether,  it  is  plain  that  he 
is  sicker.    Yet  there  is  rarely  acutal  pain,  as  in  pericarditis. 

Physical  Signs. — In  the  first  attacks  of  endocarditis  there  is  no  notable 
enlargement  of  the  cardiac  area  as  determined  by  percussion  or  mspection 
of  seat  of  apex-beat.  Auscultation  may  recognize  a  murmer,  of  which  the 
situation  varies  with  the  valve  involved.  If  the  mitral,  a  murmur  is  heard 
in  this  area,  usually  systolic,  soft,  and  blowing,  at  times  quite  harsh.  Very 
rarely  is  there  a  presystolic  murmur,  though  its  more  frequent  occurrence 
might  be  expected  from  the  nature  and  situation  of  the  lesions  described. 
When  the  lesion  is  at  the  aortic  orifice,  the  murmur  is  heard  in  the  aortic 
area  at  the  second  interspace  at  the  right  edge  of  the  sternum.  It  is  usually 
also  systolic,  but  may  be  diastolic.  But  not  every  murmur  heard  in  acute 
endocarditis  is  due  to  a  valvular  lesion.  Basic  murmurs  also  occur  in  the 
pulmonary  area  to  the  left  of  the  sternum,  which  are  functional  in  nature — 
the  bellows  murmur. 

A  systolic  murmur  in  the  mitral  area  is  not  always  due  to  regurgita- 
tion. The  same  excrescences  which  grow  on  the  valve  leaflets  may  also 
attach  to  the  papillary  muscles  and  chordae  tendinese  as  well.  Alitral  re- 
gurgitation may  also  occur  in  rheumatism  and  in  other  acute  febrile 
diseases  from  myocardial  changes,  as  the  result  of  which  the  basal  part  of  the 
cardiac  muscle  is  enfeebled  and  unable  to  do  its  part  of  the  work  of  closing 
the  mitral  orifice,  and  the  valve  leaflets  are  insufficient  to  complete  it. 
Some  of  the  cases  of  murmur  which  disappear  with  recovery  may  belong 
to  this  category.  It  is  characteristic  of  endocardial  murmurs  to  come  and  go. 
Diagnosis. — This  is  based  almost  entirely  on  the  physical  signs,  as 
no  one  of  the  symptoms  is  pathognomonic.  Nor  are  the  murmurs  always 
to  be  relied  upon,  for  the  reasons  assigned. 

The  distinction  of  the  endocardial  from  the  pericardial  murmur  was 
considered  in  treating  of  pericarditis.  The  more  superficial  situation  of 
the  latter  over  the  body  of  the  heart,  its  to-and-fro  rhythm,  not  connected 
with  the  heart-sounds,  its  failure  to  follow  the  usual  law^s  of  conduction,  and 
the  fact  that  it  is  made  more  pronounced  by  pressure — all  serve  to  distin- 
guish it.  A.  E.  Sansom  calls  attention  to  a  possible  source  of  error  in 
a  pericardial  roughening  at  or  about  the  apex,  especially  in  children,  which 
causes  a  systolic  apical  murmur.  This  should  be  remembered  as  a  possible, 
but  rare,  occurrence. 

Prognosis. — The  subject  of  the  simple  form  of  acute  endocarditis  rarely 
dies,  but  he  is  likely  to  recover  with  a  damaged  heart — in  other  words, 
chronic  valvular  disease  results.     This  is   not,  however,   always  the   case. 


570  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

for  complete  recovery  is  not  impossible.  On  the  other  hand,  some  of  the 
instances  of  complete  recovery  after  mitral  regurgitant  murmur  belong- 
doubtless  to  the  category  described  of  insufficiency  due  to  myocardial  defect 
without  mitral  lesion.  It  should  not  be  concluded,  however,  that  because  a 
murmur  has  disappeared  the  patient  has  certainly  recovered,  since  a  murmur 
due  to  myocarditis  may  be  succeeded  by  another  true  valvular  murmur. 
Finally,  one  acute  attack  from  which  recovery  has  taken  place  is  liable  to 
be  succeeded  by  another  and  another,  so  that,  sooner  or  later,  chronic  valvular 
defects  are  produced. 

Treatment. — The  keynote  of  the  proper  treatment  of  simple  acute 
endocarditis  is  absolute  quiet.  It  is  not  often  that  much  else  is  required. 
A  blister  is  not  of  the  signal  service  here  that  it  is  in  pericarditis,  while  digi- 
talis is  not  indicated  unless  there  is  irregularity,  when  the  dose  should  be 
moderate — only  enough  to  steady  the  heart.  Dyspnea  is  best  treated  by 
sufficient  doses  of  opium  or  morphin,  which  should  not  be  put  off  too  long. 
The  diet  should  be  easily  assimilable  and  liquid  until  convalescence  is 
established. 


The  Severe  or  Malignant  Form   of  Acute   Endocarditis. 
Synonyms. — Ulcerative,  Infections,  Mycotic,  or  Diphtheritic  Endocarditis. 

Definition. — Malignant  endocarditis  is  an  acute  infectious  fever  due  to 
inoculation  of  the  blood  by  a  bacillus  or  its  toxic  products,  and  characterized 
locally  by  a  specific  valvulitis.  It  is  called  primary  when  not  engrafted  on 
some  other  infectious  disease. 

Historical. — It  was  recognized  as  a  separate  form  of  disease  in  1851  by  Senhouse 
Kirkes,  and  further  studied  by  Charcot  and  Velpeau,  in  France,  Virchow  in  Germany, 
and  recently  in  this  country  by  William  Osier,  who  made  it  the  subject  of  his  Gul- 
stonian  Lectures  before  the  Royal  College  of  Physicians,  England,  in  1885.  Its 
mycotic  nature  was  not  suspected  until  after  Koch  discovered  the  bacillus  of  tuber- 
coJosis,  in  1882. 

Etiology. — Malignant  endocarditis  shares  with  the  simple  form  an 
infectious  origin.  No  satisfactory  explanation  has,  however,  been  furnished 
of  its  more  malignant  nature.  Mention  was  made  when  treating  of  the 
simple  variety  of  the  suggestion  sustained  by  the  experiments  of  Wyssoko- 
witch,  Ribbert,  Orth,  and  others,  that  a  state  of  the  blood  due  to  the  toxic 
effect  of  bacteria  may  be  the  cause  of  the  simple  form,  and  that  it  may  afford 
conditions  favorable  for  the  Operation  of  the  more  virulent  bacteria  found 
associated  with  the  malignant  form.  It  is  extrem.ely  doubtful  whether  there 
can  be  a  primary  malignant  endocarditis  without  the  intervention  of  some 
one  of  the  diseases  which  usually  precede  it.  The  presence  of  chronic  val- 
vular defects  affords  the  most  important  predisposing  cause  favoring  the 
action  of  the  causes  of  the  acute  malignant  form.  Goodhart  found  it  in 
61  out  of  69  cases,  and  Osier  in  54  out  of  209.  The  latter  also  found  it 
II  times  at  100  autopsies  of  fatal  cases  of  pneumonia.  Of  the  infectious 
diseases  associated  with  the  malignant  form  of  endocarditis,  pneumonia  is 
the  most  frequent.  The  disease  occurs  also  in  association  with  gonorrhea, 
rheumatism,  peliosis  rheumatica,  pleurisy,  puerperal  fever,  bone  necrosis, 
and  septicemia  from  any  cause.  More  rarely  it  has  been  found  in  connection 
with  meningitis,  smallpox,  diphtheria,  scarlet  fever,  tuberculosis,  and  dysen- 


MALIGNANT  ENDOCARDITIS.  571 

tery.  Most  frequently,  perhaps,  the  micro-organism  is  the  lancet-shaped 
bacillus  of  pneumonia;  after  this,  pus  organisms,  the  streptococcus  and 
staphylococcus. 

Morbid  Anatomy. — As  to  the  acute  cardiac  lesions  associated,  we 
find,  either  alone  or  in  addition  to  the  old  sclerosis,  three  sets — vegetative, 
ulcerative,  and  suppurative.  The  vegetative  are  for  the  most  part  made  up 
of  closely-packed  spherical  micrococci,  more  or  less  commingled  with  small 
fibrin  masses.  The  vegetations  vary  in  size  from  that  of  a  pin's  head  to  that 
of  a  pea,  and  are  reddish-yellow  in  color.  The  seat  of  this  vegetation  be- 
-comes  rapidly  necrotic,  and  breaks  down  into  an  ulcer  which  may  perforate 
the  valve,  with  or  without  previous  protrusion — the  so-called  valvular  aneu- 
rysm. More  rarely  minute  foci  of  pus  are  found  in  the  deeper  tissues  of  the 
valve  leaflets.  The  invasion  is,  however,  not  always  confined  to  the  valves, 
but  may  extend  to  the  mural  endocardium.  Of  the  valves,  the  mitral  is  most 
frequently  involved;  next,  the  aortic;  next,  mitral  and  aortic  jointly;  next, 
the  lining  of  the  heart-wall ;  next,  the  tricuspid ;  and  last,  the  pulmonary 
valve.  In  a  few  instances  the  right  heart  alone  is  invaded.  Other  morbid 
changes  include  the  lesions  of  the  concurrent  affection  and  the  phenomena 
of  embolism  due  to  lodgment  of  fragments  of  the  vegetation.  The  result  of 
the  latter  when  complete  is  a  metastatic  abscess,  though  the  earlier  stages 
of  red  infarction  may  also  be  present. 

The  spleen,  kidney,  skin,  and  even  the  cerebral  cortex  may  be  seats  of 
embolism.  In  addition  to  these,  we  may  also  have  embolism  and  hemor- 
rhagic infarct  occurring  in  the  lungs  from  emboli  starting  in  the  right  heart, 
as  contrasted  with  those  originating  in  the  left  heart  which  lodge  in  the 
systemic  circulation.  The  number  of  em.bolisms  varies  greatly  in  these  cases. 
They  may  be  altogether  absent,  while  they  may  be  counted  by  hundreds,  in 
which  event  they  are,  of  course,  very  small.  The  spleen  is  enlarged  even 
when  not  the  seat  of  embolism,  as  in  other  infectious  diseases. 

Symptoms. — Given  a  pneumonia,  pleurisy,  the  puerperal  process,  or 
any  one  of  the  diseases  named,  with  the  supervention  of  chills,  followed  by 
fever  and  szveats,  this  form  of  heart  disease  should  be  immediately  thought  of 
and  the  organ  carefully  examined  for  the  auscultatory  signs  of  endocarditis. 
In  the  primary  form,  however,  should  this  exist,  we  have  not  even  the 
presence  of  one  of  the  diseases  named  to  suggest  the  occurrence  of  ulcerative 
endocarditis.  In  this  form,  particularly,  the  resemblance  to  intermittent 
fever  seems  at  first  close,  but  a  careful  study  of  the  temperature  chart  from 
day  to  day,  and,  above  all,  utter  failure  of  the  antiperiodic  remedy  to  produce 
any  effect,  will  in  a  short  time  show  that  the  malarial  disease  is  not  present. 
Doubtless,  often  the  malady  under  consideration  has  been  mistaken  for 
intermittent  fever,  and  not  without  reason,  for  many  a  case  of  irregular 
quotidian  and  tertian  fever  presents  similar  symptoms ;  but  the  regular, 
almost  rhythmical,  rise  and  fall  of  temperature,  as  exhibited  in  the  chart  of 
an  intermittent  fever,  is  wanting.  Indeed,  I  think  there  is  no  disease  in 
which  the  extreme  irregularity  in  temperature  reaches  that  of  the  one  under 
consideration,  as  a  careful  study  of  the  appended  temperature  chart  from  a 
ease  of  my  own  in  the  University  Hospital  will  show.  Note  that  the  maxi- 
mum is  reached  at  any  time  of  day  or  night.  Yet  the  temperature  is  not 
always  so  high,  nor  is  the  extreme  range  always  so  great  as  here  indicated. 
The  absence  of  the  plasinodiiim  malar  ice  serves  only  to  distinguish  it  from 
malarial  disease. 

It  always  greatly  aids  the  diagnosis  when  to  chills  and  fever  are  added 


572 


DISEASES  OF  HEART  AXD  BLOOD-VESSELS. 


other  symptoms  suggesting  ciiibolisiii,  which  so  frequently  occurs.  The 
occurrence  of  a  hemiplegia,  pain  in  the  region  of  the  spleen,  with  increased 
dullness  on  percussion,  pain  in  the  region  of  the  kidney  with  hematuria,  or 
a  sudden  blotch  in  the  skin,  of  the  kind  described,  is  of  inestimable  value. 
Rarer  symptoms  of  similar  origin  are  impaired  vision,  from  retinal  hemor- 
rhage, parotitis,  and  'abscess  of  the  parotid  gland.  The  symptoms  are  not 
always  so  pointed  as  detailed,  while  they  may  include  others  not  mentioned. 
The  fever  may  not  be  so  high,  but  it  is  always  present ;  again,  it  may  not 


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Fig.  52. — Temperature  Chart,  Malignant  Endocarditis. 


be  remittent,  but  continuous.  There  may  be  jaundice,  precordial  oppres- 
sion, shortness  of  breath,  while  heart  symptoms  may  be  altogether  absent, 
when  it  is  almost  impossible  to  distinguish  the  disease  from  a  septic  fever 
of  the  ordinary  kind.  The  pulse  and  respirations  are  invariably  accelerated. 
Extreme  embarrassment  of  breathing  is  very  characteristic.  Albuminuria 
and  casts  occur  in  all  forms,  either  as  the  result  of  acute  nephritis  or  of 
renal  embolism. 

A  further  study  of  the   symptoms  of  malignant   endocarditis  permits 


MALIGNANT  ENDOCARDITIS.  573 

their  classification  into  three  groups,  known  as  the  septic  or  pyemic,  the 
typhoid,  and  the  cerebral. 

The  septic  type  occurs  in  connection  with  such  septic  processes  as  ex- 
ternal wounds,  the  puerperal  process,  or  acute  bone  disease  with  necrosis. 
The  symptoms  added  are  rigor,  irregular  fever,  sweats,  and  exhaustion. 
Yet  these  are  only  the  symptoms  characteristic  of  pyemia.  In  fact,  it  is  a 
pyemia ;  and  the  term  arterial  pyemia,  suggested  by  Wilkes,  is  a  good  one, 
because  the  pyemic  abscesses  result  from  emboli,  starting  in  the  left  heart 
and  lodging  in  arteries.  The  endocarditis  constitutes  the  distinctive  feature 
of  the  disease.  The  resemblance  to  intermittent  fever  here  exists  also,  and 
a  quotidian  or  double  tertian  type  may  be  simulated.  It  is  in  this  form 
especially  that  leukocytosis  occurs,  determined  by  a  blood  count. 

The  symptoms  of  the  typhoid  type  are  even  more  characteristic.  We 
tneet  here,  too,  the  same  prostration,  irregular  temperature,  and  sweating; 
rigor  is  less  frequent,  and  the  onset  is  more  gradual.  There  are  delirium, 
drowsiness,  often  diarrhea,  with  distention  of  the  abdomen  and  tenderness 
in  the  right  iliac  region,  to  which  a  rash  may  also  be  added,  which,  though 
not  identical  with  that  of  typhoid  fever,  is,  nevertheless,  similar  to  it.  The 
tongue  is  dry  and  brown,  and  sordes  collects  about  the  teeth.  The  tem- 
perature is  remittent,  like  that  of  typhoid,  reaching  103°  F.  to  104°  F.  (39.4° 
C.  to  40°  C.)  and  even  higher.  Here  again  the  heart  symptoms  may  be 
overlooked. 

Still  another  group  is  the  cerebral,  in  which  the  symptoms  simulate 
meningitis,  basilar  or  cerebrospinal,  with  acute  delirium  as  the  distinctive 
feature. 

Physical  Signs. — If  there  is  anything  peculiar  about  the  physical  signs, 
it  is  their  want  of  definiteness.  When  murmurs  are  present,  it  is  often 
difficult  to  locate  or  time  them  precisely.  They  often  vary  from  day  to  day. 
They  may  occur  at  both  base  and  apex,  and  with  reason,  for  both  sets  of 
valves  may  be  and  often  are  involved.  The  superaddition  of  pericarditis 
adds  a  further  source  of  confusion  in  the  friction  sound  superadded.  If 
chrowic  valvular  disease  exists,  its  signs  are  also  present,  including  those  of 
hypertrophy. 

Complications. — As  to  complications,  these  are  mainly  the  original  car- 
diac disease  or  the  diseases  the  specific  organisms  of  which  most  frequently 
cause  the  virulent  inflammation.  Pericarditis  and  pleurisy  are  frequent 
complications  in  the  strict  sense  of  the  term ;  there  may  also  be  meningitis. 
Acute  nephritis,  the  result  of  sepsis  and  quite  independent  of  embolism, 
may  be  present,  with  its  characteristic  symptoms,  albuminuria,  blood  casts, 
and  free  blood-corpuscles.  Gastro-intestinal  derangements  not  of  embolic 
origin  are  sometimes  conspicuous.     Diarrhea  may  be  especially  troublesome. 

Diagnosis. — This  is  not  always  easy  at  first.  A  few  days'  study  of 
the  temperature,  with  its  extreme  fluctuations,  the  rigors,  and  the  super- 
vening sweats,  should  at  once  lead  to  suspicion,  and  these,  if  continued, 
point  only  to  this  disease.  If  one  would  always  remember  the  possibility 
of  the  occurrence  of  malignant  endocarditis  in  connection  with  the  diseases 
named,  it  would  be  less  frequently  overlooked.  The  fever  is  a  septic  one  in 
all  cases,  the  heart  symptoms  adding  the  peculiarity.  In  true  typhoid  fever 
there  is  always  splenic  enlargement  and  often  parotitis,  so  that  the  presence 
of  these  symptoms  naturally  suggests  that  disease,  and  an  erroneous  diag- 
nosis is  not  inexcusable.  It  is  said  that  splenic  enlargement  is  not  so 
marked  as  in  typhoid  fever,  and  that  there  is  commonly  more  tenderness  in 


574  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

ulcerative  endocarditis.  This  may  be  true  in  some  cases,  and  not  in  others. 
So  far  as  I  know  the  Widal  test  has  not  been  made  in  a  case  of  ulcerative 
endocarditis. 

Rheumatic  fever  often  more  closely  resembles  malignant  endocarditis, 
with  its  high,  irregular  fever,  and  copious  sweats,  while  confusion  is  further 
contributed  to  by  the  fact  that  endocarditis  is  one  of  the  most  frequent 
complications  of  rheumatism,  the  malignant  form  being,  however,  more  in- 
frequent than  the  simple.  But  recurring  rigors  are  not  usual  in  rheumatism. 
The  joint  symptoms  of  rheumatism  are  conspicuous  at  an  early  stage  of  the 
disease ;  there  is  no  enlargement  of  the  spleen,  nor  symptom  ascribable  to 
embolism,  unless  secondary  to  endocarditis.  The  essential  identity  of 
ordinary  pyemia  and  malignant  endocarditis  has  been  mentioned,  and  only 
the  endocarditis  and  its  consequences  distinguish  the  disease  from  ordinary 
septic  fever. 

It  must  not  be  forgotten  that  the  simple  and  severe  forms  are  not 
separated  by  any  sharp  line.  The  crucial  diagnostic  test  is  a  bacteriological 
examination  of  the  blood. 

Prognosis. — The  prognosis  is  always  unfavorable,  though  ulcerative 
endocarditis  may  be  prolonged  for  many  weeks  and  even  months.  Usually, 
however,  five  or  six  weeks  measure  its  course,  while  some  cases  are  of 
shorter  duration.     Eberth  reports  a  case  fatal  in  two  days. 

Treatment. — Treatment  heretofore  has  availed  little.  There  seems 
reason  to  believe  antistreptococcus  serum  may  be  of  service,  and  several 
cases  of  cure  are  reported.  Twenty  c.  c.  may  be  injected  daily.  It  seems 
quite  harmless.  The  patient  should  be  kept  at  rest.  Remedies  should  be 
restorative  and  supporting — quinin,  stimulants,  digitalis.  Nourishing  food 
is  indicated.  The  high  temperature  may  be  treated  by  sponging  or  by  an 
ice-cap,  or  by  Leiter's  coils  applied  to  the  thorax  or  abdomen ;  but  high  tem- 
perature is  seldom  of  so  long  duration  as  to  require  special  treatment. 


CHRONIC  VALVULAR  DEFECTS. 

Synonyms. — Chronic  Endocarditis ;  Chronic  Valvular  Disease. 

Definition, — Permanent  alterations  in  the  structures  about  the  cardiac 
orifices,  producing  incompetency,  narrowing,  or  other  deviations  from  the 
normal. 

Etiology. — The  majority  of  chronic  valvular  defects  are  the  consequence 
of  endocarditis,  acute  or  chronic.  It  may  be  that  the  very  first  attack  of 
acute  inflammation  has  left  the  valve  leaflets  in  so  sclerotic  a  condition  that 
they  readily  become  the  seat  of  the  subsequent  changes  which  constitute  the 
chronic  disease,  or  that  several  attacks  may  be  necessary  before  a  permanent 
effect  is  produced.  On  the  other  hand,  we  must  acknowledge,  too,  a  chronic 
valvulitis,  in  which  valvular  defect  is  brought  about  gradually  without  the 
intervention  of  acute  inflammation.  This  process  is  analogous  to  chronic 
endarteritis,  consisting  in  hyperplasia  with  fatty  (atheromatous)  and  cal- 
careous degeneration  of  the  new  tissue.  In  fact,  a  chronic  endarteritis  may 
spread  from  the  aorta  to  the  aortic  valves.  These  slowly  induced  inflamma- 
tions are  variously  caused.  The  rheumatic  poison  may  cause  them,  as  it  does 
the  acute  forms.  Alcoholic  indulgence  and  intemperate  eating,  whether  by 
the  direct  irritation  of  the  substances  taken  into  the  blood  o'  through  the 


CHRONIC  VALVULAR  DEFECTS.  575, 

poison  of  gout  engendered  by  their  use,  are  frequent  causes.  Another  cause 
is  prolonged  muscular  strain,  producing  overtension  of  the  valve  leaflets. 
This  operates  in  laborers  who  do  much  heavy  lifting,  and  sometimes  in 
athletes.  Especially  potent  is  it  when,  as  is  often  the  case,  hard  muscular 
work  is  associated  with  overeating  and  drinking.  To  these,  syphilis  also 
often  contributes  a  factor  in  some  unknown  way.  Under  all  of  these  latter 
circumstances  it  is  the  aortic  cusps  which  suffer  most. 

Morbid  Anatomy. — The  anatomical  condition  of  the  defective  valves  is 
made  up  of  five  separate  factors,  each  of  which  may  enter  more  or  less  into 
the  lesion.  This  is  true  both  of  the  auriculo-ventricular  and  semilunar 
valves.     These  conditions  are  : 

(i)  Thickening.  (2)  Retraction.  (3)  Adhesion.  (4)  Calcification. 
(5)  Atheroma,  either  alone  or  associated  with  calcification. 

1.  Thickening  is  the  immediate  result  of  an  overgrowth  of  connective 
tissue.  The  slighter  degrees  are  seen  along  the  bases  of  the  aortic  cusps  and 
at  the  line  of  contact  in  closure  of  the  mitral  leaflets.  Such  degrees  do  not 
necessarily  impair  the  function  of  the  valves.  More  advanced  stages  produce 
a  distinct  thickening  and  sclerosis  of  the  whole  of  each  aortic  cusp  and  mitral 
leaflet. 

2.  Retraction  or  curling  is  the  result  of  shrinkage  of  this  hyperplastic 
tissue.  The  three  aortic  cusps  are  often  reefed  back  and  fixed,  although  the 
very  edge  of  the  valve  may  still  remam  movable.  In  the  case  of  the  mitral 
valve,  the  tendinous  attachments  of  the  papillary  muscles  often  contract  and 
draw  the  valves  into  the  left  ventricle,  producing  a  permanent  funnel-like 
extension  analogous  to  that  which  takes  place  in  physiological  closure  of  the 
mitral  orifice. 

3.  Adhesions  unite  the  valve  leaflets,  increasing  their  fixedness  and 
rigidity,  interfering  with  complete  opening  and  closure.  The  right  and  pos- 
terior aortic  cusps  are  most  frequently  united.  Most  serious  is  the  effect  of 
union  of  the  mitral  leaflets,  which  sometimes  results  in  a  reduction  of  the 
orifice  to  a  mere  slit  or  buttonhole-like  opening — the  buttonhole  mitral  orifice. 

4.  Calcification  or  limy  infiltration  of  the  valves  thus  united  may  succeed 
in  various  degrees,  producing  in  extreme  cases  firm,  bony  rings  which  further 
diminish  the  mobility  of  the  valves.  In  mild  degrees  there  are  formed 
splinter-like  projections  into  the  substance  of  the  valve  which  also  interfere 
with  complete  closure  and  opening ;  at  other  times  there  may  be  simple  mar- 
ginal deposits  which  impede  the  function  of  the  valves  only  slightly  or  not 
at  all. 

5.  Atheroma,  or  fattty  degeneration,  is  also  often  found  in  the  shape  of 
3'ellow  spots  on  the  surface  of  the  valves  and  at  the  marginal  attachments  of 
the  aortic  cusp,  without  producing  insufficiency. 

Still  another  form  of  lesion  found  at  necropsy  is  rupture  of  a  leaflet,  the 
result  of  strain.  This  is  perhaps  not  possible  with  a  sound  valve,  while  one 
weakened  by  the  morbid  states  described  may  give  way.  The  physiological 
result  is  insufficiency,  while  the  lumen  of  the  orifice  during  systole  is  not 
encroached  upon.  Such  an  accident  is  not  infrequent  in  acute  ulcerative  endo- 
carditis in  consequence  of  erosion  and  partial  destruction  of  the  valve. 

Insufficiency  of  the  aortic  orifice  at  the  time  of  life  at  which  it  is  most 
common — say  middle  age — is  favore(^  by  a  gradual  widening  of  this  orifice 
from  4-5  inch  (20  mm.)  at  birth  to  a  possible  2  4-5  inches  (70  mm.)  at  eighty 
years. 

Congenital  defects  are  relatively  common  to  the  right  side  of  the  heart. 


576  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

which  is  the  subject  also  of  inflammations  during  intra-uterine  life.  The 
changes  resulting  from  the  latter  are  of  the  nature  of  fusions.  Such  defects 
.also  occur  rarely  on  the  left  side ;  most  rarely  in  the  mitral  valve. 

Mitral  Insufficiency  or  Incompetency. 

Occurrence  and  Mechanism. — This  is  the  most  frequent  of  the  uncom- 
bined  forms  of  valvular  disease.  The  valve  leaks.  The  blood  flows  back- 
Avard  during  systole  from  the  left  ventricle  to  the  left  auricle.  The  distended 
auricle,  first  attempting  to  resist  the  backward  flow,  hypertrophies  but  eventu- 
ally dilates,  and  the  blood  is  crowded  backward  into  the  lungs,  which  become 
■engorged.  The  right  ventricle,  in  its  efforts  to  push  the  blood  through  the 
engorged  lungs,  hypertrophies,  and  the  pulmonary  factor  of  the  second  sound 
becomes  louder  and  sharply  accentuated.  The  compensating  effect  of  the 
hypertrophied  right  ventricle  for  a  time  arrests  the  mischief.  At  this  stage, 
perhaps,  begins  the  hypertrophy  of  the  left  ventricle,  which  in  all  cases  of 
mitral  insufficiency  presents  itself  sooner  or  later,  although  at  first  the  double 
•outlet  for  the  blood  from  the  ventricle  would  seem  to  demand  less  strength  of 
the  left  ventricle.  The  right  ventricle,  however,  in  its  hypertrophied  state, 
delivers  more  blood  through  the  lungs  to  the  left  ventricle,  which  demands 
more  power  to  drive  it  on,  hypertrophy  results,  and  thus  compensation  is  for 
a  time  longer  maintained.  Sooner  or  later  the  right  ventricle  dilates,  the 
tricuspid  valve  becomes  insufficient,  the  blood  regurgitates  into  the  right 
auricle  and  thence  into  the  great  veins  of  the  neck.  The  valves  of  these  ulti- 
mately yield,  the  jugular  pulse  appears,  and  the  general  venous  system  is 
engorged. 

Incompetency  of  the  cardiac  valves  is  often  brought  about  by  dilatation 
of  the  ventricles  and  the  great  vessels  leading  from  the  heart,  the  valve 
leaflets  themselves  remaining  intact.  Such  relative  insufficiency  affects  most 
frequently  the  auriculo-ventricular  valves,  and,  as  a  consequence,  the  latter 
are  not  "  sufficient  "  to  stretch  across  their  respective  orifices  and  close  them. 
Less  commonly  the  semilunar  valves  are  similarly  deficient ;  more  frequently 
the  aortic  in  dilatation  of  the  aorta ;  and  more  rarely  also  the  pulmonary  valve 
when  that  vessel  is  dilated.  It  should  be  said  of  auriculo-ventricular  insuffi- 
ciency of  this  kind  that  it  is  found  more  frequently  in  the  autopsy-room  than 
recognized  clinically,  for  it  does  not  always  cause  a  murmur. 

Etiology. — Endocarditis,  acute  or  chronic,  is  the  most  frequent  initial 
cause  of  mitral  insufficiency. 

Symptoms. — Often  there  are  no  symptoms,  because  for  a  considerable 
length  of  time  compensation  kfeeps  pace  wath  the  development  of  the  disease 
unless  the  latter  be  sudden,  as  by  rupture  of  a  valve  leaflet.  The  first  thing 
noticeable  is  usually  shortness  of  breath  on  exertion,  the  so-called  cardiac 
asthma.  With  this  is  soon  associated  palpitation,  or  "  beating  "  of  the  heart, 
which  increases  and  abates  pari  passu  with  the  dyspnea.  Next  is  irregularity 
of  the  heart's  action^  This  is  the  beginning  of  waning  compensanuii,  of 
which  the  immediate  result  is  congestion  of  the  lungs.  Dyspnea  is  now  per- 
manent. Thence  the  engorgement  extends  to  the  right  ventricle  and  venous 
side  of  the  circulation,  the  pressure  in  the  arteries  being  proportionately  less. 
The  lung  engorgement  invites  frequent  attacks  of  bronchitis,  excites  cough 
and  increases  dyspnea.  Orthopnea  is  frequent  at  this  stage,  and  the  patient 
can  only  rest  sitting  in  a  chair.  There  is  sometimes  blood-stained  expectora- 
tion, in  which  may  be  found  alveolar  epithelium  dotted  with  pigment  granules. 


CHRONIC  VALVULAR  DEFECTS.  577 

Along  with  this,  or  before  it,  the  liver  becomes  congested,  enlarged,  and 
tender;  the  mucous  membrane  of  the  stomach  also  becomes  congested,  caus- 
ing nausea  and  indigestion.  The  hepatic  enlargement  is  sometimes  very 
great,  and  I  have  known  it  to  be  mistaken  for  cancer  of  the  organ.  The  liver 
is  often  the  seat  of  pulsation,  and  as  often  a  jugular  pulse  is  seen.  Both  signs 
are  pathognomonic  of  mitral  regurgitation.  Later,  this  enlarged  liver  may 
return  to  its  normal  state  or  contract  still  further,  constituting  the  so-called 
red  atrophy.  In  advanced  stages  the  kidneys  also  become  passively  con- 
gested, the  urine  is  scanty  and  its  specific  gravity  high,  while  there  are  copious 
.deposits  of  urates.  It  contains  a  small  quantity  of  albumin  and  there  may 
be  hyaline  tube-casts,  rarely  even  a  few  blood  discs.  As  a  secondary  result  of 
hepatic  engorgement  only  there  may  also  be  enlargement  of  the  spleen. 

Concurrent,  or  succeeding  on  failing  compensation,  comes  edema  or 
dropsy,  the  direct  result  of  venous  engorgement  and  the  filtration  of  the  liquid 
elements  of  the  blood  into  the  subcutaneous  connective  tissue  of  the  body — 
first  of  the  feet  and  legs,  then  of  the  trunk,  face,  and  upper  extremities,  and, 
finally,  into  the  pleural  and  peritoneal  cavities,  causing  various  degrees  of 
inconvenience.  Effusion  into  the  pleural  sacs  may  occur  before  there  is  any 
tendency  to  dropsy  elsewhere.  Allusion  has  been  made  to  the  studies  of  J. 
Dutton  Steele  on  this  subject  on  page  548.  Dr.  Steele  does  not,  of  course, 
deny  the  eflfect  of  concurrent  conditions,  such  as  diaphragmatic  pleurisy, 
hepatitis,  and  the  like. 

Nose-bleed  is  a  symptom  sometimes  seen  in  this  disease.  It  is  a  natural 
result  of  the  venous  congestion. 

Physical  Signs. — Inspection  discovers  the  apex-beat  to  the  left  of  its 
normal  position  in  the  fifth  interspace,  or  perhaps  a  little  lower  down.  It 
may  be  in  the  line  of  the  nipple  or  even  beyond  it,  more  forcible  and  diffuse 
than  in  health.  The  outward  dislocation  of  the  apex-beat  is  due  to  the 
enlargement  of  the  two  ventricles.  In  thin  persons  an  auricular  impulse 
may  be  seen  to  the  left  of  the  pulmonic  area  in  the  second  interspace,  and  may 
"be  presystolic  and  active  for  the  auricle — that  is,  produced  when  the  auricle 
contracts ;  or  systolic  and  passive  for  the  auricle — that  is,  caused  by  a  filling 
■of  the  auricle  by  regurgitation  from  the  ventricle  during  the  latter's  systole. 
In  young  persons  a  bulging  precordium  may  be  looked  for  in  the  second  and 
third  interspaces  to  the  left  of  the  sternum ;  also  to  the  left  of  the  lower  part 
of  the  sternum  from  hypertrophy  of  the  right  ventricle.  In  advanced  stages 
there  is  a  jugular  pulse,  which  is  also  pathognomonic  of  tricuspid  regurgi- 
tation. 

On  palpation  the  apex-beat  is  found  more  forcible  than  normal,  at  least 
while  compensation  is  maintained,  and  there  may  be  a  pulsation  near  the 
ensiform  cartilage,  caused  by  the  systole  of  the  enlarged  right  ventricle.  As 
compensation  wanes  the  apex-beat  becomes  weaker  and  irregular.  Some- 
times an  intermittent  systolic  thrill  is  felt  in  the  fourth  interspace  in  the  left 
mammillary  line.     Very  rarely  is  there  a  systolic  thrill  at  the  apex. 

The  radial  pulse  in  the  early  stage  is  comparatively  unaltered.  Later, 
it  becomes  frequent  and  irregular  in  volume.  Appended  (Fig.  53)  is  a 
sphygmogram  of  the  pulse  in  advanced  mitral  insufficiency.  It  is  of  the  type 
of  the  pulsus  parvus  irregularis. 

Percussion  finds  enlargement  of, both  the  relative  and  absolute  areas  of 
dullness,  upward  in  the  direction  of  the  left  auricle,  downward  to  the  left  and 
also  to  the  right,  the  right  border  of  the  heart  extending  at  times  beyond  the 
right  border  of  the  sternum. 

37 


5/8  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

Auscultation  recognizes  a  systolic  murmur  in  the  mitral  area,  conducted 
with  various  degrees  of  loudness  into  the  left  axilla  and  under  the  angle  of 
the  scapula.  This  direction  of  its  conduction  is  the  distinctive  feature  of  this 
murmur.  It  is  usually  soft,  but  occasionally  rough,  more  rarely  musical. 
Richard  C.  Cabot  says  that  musical  murmurs  are  heard  more  frequently  at  the 


Fig-  53- — Tracing  of  Pulse  of  Mitral  Insufficiency. 

mitral  valve  in  regurgitation  than  at  any  other  valve.  A  fading  mitral  systolic 
murmur  generally  means  failing  compensation,  and  when  compensation  is 
completely  gone  it  is  substituted  by  incomplete  valvular  sounds,  great  irregu- 
larity, gallop  rhythm,  labored  breathing,  and  all  the  signs  of  pulmonary  con- 
gestion. It  is  also  sometimes  heard  distinctly  to  the  left  of  the  pulmonic 
cartilage,  and  rarely  over  the  entire  precordium.  Not  always  loud  enough 
to  be  easily  heard,  it  may  be  brought  out  by  exertion  on  the  part  of  the  patient. 

The  second  sound  of  the  heart  is  heard  sharply  accentuated  at  the  pul- 
monary area  until  the  tricuspid  valve  fails,  when  the  accentuation  fades  away. 
The  aortic  second  sound  is  less  strong,  corresponding  with  the  smaller  degree 
of  hypertrophy  of  the  left  ventricle. 

Differential  Diagnosis. — The  mitral  regurgitation  murmur  is  not  usually 
difficult  of  recognition  through  the  features  which  have  been  described.  A 
functional  murmur  is  rarely  heard  at  the  apex.  Should  it  happen  that  it  is, 
it  will  not  be  conducted  as  is  the  organic  mitral  systolic  murmur,  and  it  is  not 
heard  behind  and  below  the  angle  of  the  scapula.  Aortic  roughening  pro- 
duces a  murmur  heard  at  the  same  time  as  the  mitral  systolic,  and  may  also 
be  propagated  to  the  apex,  but  the  position  of  greatest  intensity  is  the  second 
interspace  to  the  right  of  the  sternum  and  the  murmur  is  transmitted  loudly 
into  the  great  vessels  of  the  neck,  which  is  never  the  case  with  the  mitral 
systolic  murmur.  The  tricuspid  systolic  murmur  occurs  at  the  same  time,  but 
its  point  of  greatest  intensity  is  at  the  ensiform  cartilage ;  it  is  not  commonly 
a  loud  murmur  and  is  more  apt  to  be  observed  by  the  mitral  regurgitant 
murmur  than  it  is  likely  to  obscure  the  latter. 

Mitral  Stenosis. 

Occurrence  and  Mechanism. — This  lesion  occurs  as  an  uncombined  or 
simple  form  of  valvular  disease  in  young  persons,  especially  women,  but  is 
more  commonly  combined  with  mitral  insufficiency.  Seventy-six  per  cent, 
of  all  cases  are  said  to  occur  in  the  female  sex.  In  the  simple  fonn  the  orifice 
is  stenosed,  and  the  blood  is  restrained  from  passing  freely  into  the  left  ven- 
tricle. It  is  backed  into  the  left  auricle,  the  lungs,  right  ventricle,  and  gen- 
eral venous  circulation,  but  the  left  ventricle  is  not  hypertrophied  in  simple 
mitral  obstruction  because  no  extra  muscular  demand  is  made  on  it,  while 
hypertrophy  of  the  left  auricle  is  one  of  its  most  characteristic  signs.  Theo- 
retically, the  left  ventricle  should  even  atrophy  from  diminished  function. 
Practically  this  does  not  occur,  but  the  absence  of  the  enlargement  is  of  great 
diagnostic  value.  Excellent  compensation  is  often  maintained  in  mitral 
stenosis  for  many  years. 


CHRONIC  VALVULAR  DEFECTS.  579 

Pure  stenosis  without  regurgitation  is  possible  if  the  mitral  valve  leaflets 
are  fused  without  retraction,  so  as  to  form  the  funnel-shaped  opening  already 
described.  In  these  cases  a  postmortem  demonstration  of  insufficiency  by 
means  of  the  hydrostatic  test  is  scarcely  possible.  Less  frequently  the  mitral 
orifice  viewed  from  above  is  a  mere  slit, — Corrigan's  buttonhole  contraction, 
— straight  or  slightly  crescentic,  in  a  smooth  septum  formed  by  fusion  and 
contraction  of  the  valve  leaflets  and  tendinous  cords.  In  some  cases  cal- 
careous infiltration  is  added,  and  in  a  few  rare  instances  uratic  deposits  are 
found.  The  ratio  of  buttonhole  mitral  stenosis  to  the  funnel-shaped  orifice 
~ varies  with  different  observers — i  to  10  by  A.  E.  Sansom,  i  to  13  by  Hayden, 
I  to  46  by  Hilton  Fagge. 

Etiology. — Most  frequently  mitral  stenosis  is  the  result  of  endocarditis, 
acute  or  chronic,  but  it  may  in  rare  cases  be  congenital.  In  these  cases,  of 
which  a  number  have  been  collected  by  Bedford  Fenwick,  the  stenosis  is  sec- 
ondary to  narrowing  of  the  tricuspid  orifice,  thus  explained :  A  small  quan- 
tity only  of  blood  being  allowed  to  pass  into  the  right  ventricle  and  lungs,  a 
diminished  supply  is  sent  to  the  left  heart,  whence  both  its  cavities  and 
orifices  are  reduced  in  size.     No  functional  disorder  can  cause  mitral  stenosis. 

Symptoms. — These,  often  delayed  by  compensation,  as  in  mitral  insuffi- 
ciency, are  the  same  as  in  that  lesion.  In  consequence  of  this  commonness 
of  symptoms  the  diagnosis  of  mitral  stenosis  is  based  largely  on  the  physical 
signs. 

Physical  Signs. — Mitral  stenosis  may  exist  for  many  years  without  giv- 
ing rise  to  physical  signs.  Inspection  consistently  with  what  would  be 
expected  in  absence  of  hypertrophy  of  the  left  ventricle,  recognizes  little  or 
no  displacement  of  the  apex  in  pure  stenosis.  If  there  is  any,  it  is  due  to  the 
hypertrophy  of  the  right  ventricle,  which  pushes  the  apex  toward  the  left 
rather  than  downward  and  to  the  left.  Nor  is  the  true  apex-beat  increased 
in  force,  though  there  may  be  strong  epigastric  pulsation  because  of  hyper- 
trophy of  the  right  ventricle,  and  in  persons  with  thin  chest-walls  there  may 
be  an  impulse  in  the  third  and  fourth  interspaces  to  the  left  of  the  sternum 
while  compensation  is  maintained.  A  left  auricular  impulse,  presystolic,  may 
be  noted  in  the  second  interspace  to  the  left  of  the  sternum,  for  the  same  rea- 
son as  in  mitral  regurgitation.  A  jugular  pulse  may  also  be  present  if  there 
is  tricuspid  regurgitation.  A  bulging  precordium  is  possible  only  from 
great  enlargement  of  the  right  ventricle  and  is  not  often  seen.  In  children 
the  lower  sternum  and  fifth  and  sixth  left  costal  cartilages  may  be  prominent 
from  this  cause. 

Palpation  discerns  that  the  apex-beat  is  without  undue  force,  but  it  may 
be  diffuse,  and  an  impulse  may  be  felt  in  the  epigastrium,  the  situation  of  the 
apex  of  the  right  ventricle.  The  most  marked  feature  recognized  by  palpa- 
tion is  the  presy^stolic  thrill  at  the  apex,  differing  in  this  respect  from  the  rare 
systolic  thrill  of  mitral  insufficiency.  It  is  usually  best  felt  in  the  fourth  or 
fifth  interspace,  within  the  nipple-line.  It  is  similar  in  rhythm  to  the  pre- 
systolic murmur,  but  may  be  present  without  it.  It  is  often  absent.  It  is 
pathognomonic  of  mitral  stenosis. 

In  moderate  degrees  of  stenosis  the  pulse  is  not  altered ;  in  high  degrees 
it  is  small,  from  want  of  blood  and  left  ventricular  power.  Irregularity,  like 
that  of  mitral  regurgitation,  is  charaoteristic  of  advanced  stages.  Two  trac- 
ings from  cases  of  mitral  stenosis  are  introduced  in  the  text. 

Percussion  recognizes  cardiac  enlargement  in  the  direction  of  the  left 
auricle  and  right  ventricle,  but  not  of  the  left  ventricle  in  pure  mitral  stenosis. 


58o  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

Auscultation  may  not  recognize  a  murmur  in  every  case  of  mitral 
stenosis  because  of  the  feebleness  of  the  auricular  contraction,  especially 
toward  the  end  of  life,  when  compensation  has  failed  and  there  is  not  the  force 
of  contraction  sufificient  to  throw  the  blood  stream  into  audible  vibration. 
Most  characteristic  is  the  abruptly  terminating  presystolic  murmur,  confined 
for  the  most  part  to  the  mitral  area  to  the  inner  side  of  the  apex-beat,  though 
it  may  be  conveyed  upward,  and  it  is  even  heard  posteriorly,  though  rarely. 
It  is  true  that  the  presytolic  murmur  is  heard  in  atypical  situations,  espe- 
cially in  the  axilla  and  below  the  angle  of  the  scapula,  more  frequently  than 
has  commonly  been  supposed.* 

The  presystolic  murnutr  of  mitral  stenosis  is  a  diastolic  murmur  occur- 
ring at  the  end  of  diastole  of  the  ventricle,  because  it  is  at  this  time  that  the 
auricular  systole  takes  place,  giving  the  propulsive  force  necessary  to  produce 
the  audible  vibration.  It  is  a  loud,  rough,  vibratory  murmur  terminating 
suddenly  with  the  first  sound,  sharp  and  ringing  and  coincident  with  the  pre- 
systolic thrill.  The  murmur  terminates  with  the  impulse,  and  as  the  two  are 
not  always  easily  separable,  the  former  is  commonly  more  readily  distin- 
guished by  its  qualities  than  by  its  time.  It  is  often  followed  by  a  "  thump- 
ing "  first  sound,  which,  in  consequence  of  this  character,  is  sometimes  mis- 
taken for  a  second  sound.  As  the  disease  advances  it  may  occupy  the  entire 
period  of  diastole.  In  such  cases  there  is  sometiines  a  short  pause  between 
the  beginning  or  diastolic  part  and  the  terminal  or  presystolic  part  of  the 
murmur.  In  the  last  stage  the  murmur  may  disappear  altogether,  leaving 
only  the  snapping  first  sound. 

Differential  Diagnosis. — The  murmur  of  mitral  stenosis  ought  not  to 
be  confounded  with  the  murmur  of  aortic  regurgitation,  for  the  latter  is  heard 
loudest  in  a  different  situation,  but  moreover  there  is  enormous  hypertrophy 
of  the  left  ventricle,  which  is  wanting  in  mitral  stenosis.  The  time  of  tri- 
cuspid stenosis  is  identical  with  that  of  mitral  stenosis,  but  it  is  heard  in  a 
different  part  of  the  precordium — in  the  epigastrium.  Tricuspid  stenosis  is, 
however,  a  very  rare  lesion.  Much  more  reasonably  might  the  murmur  of 
mitral  stenosis  be  confounded  with  the  so-called  Flijit  inurnuir.     This  mur- 


Fig.  54. — Tracing  of  Pulse  in  Mitral  Stenosis. 

mur  is  heard  at  the  apex,  at  the  same  site  as  the  presystolic,  and  may  be 
similar  in  quality.  It  occurs  in  high  degrees  of  dilatation  of  the  ventricle, 
and  is  due  to  the  fact,  according  to  the  late  Austin  Flint,  Sr.,  that  in  such 
dilatation  the  mitral  leaflets  cannot,  during  diastole,  be  kept  back  against  the 
ventricular  wall,  but  remain  in  the  blood  current,  throwing  the  latter  into 
audible  vibration.  It  may  be  said  of  the  Flint  murmur  that  it  is  never  as 
intense  as  the  mitral  presystolic  murmur.  Otherwise  the  acoustic  qualities 
are  similar.     The  snapping  first  sound  and  systolic  shock  are  also  apt  to  be 

*  See  an  excellent, well-illustrated  paper  on  this  subject  bj'  J.  P.  C.  Griffith  in  the  "Transactions 
of  the  Association  of  American  Physicians,"  1895. 


CHRONIC  VALVULAR  DEFECTS.  581 

modified  or  absent.  But  the  other  signs  of  aortic  regurgitation  most  heip  us 
to  a  diagnosis. 

A  rumbHng  sound  succeeding  a  pericarditis  in  children,  referred  to  espe- 
cially by  Broadbent  and  Rosenbach,  has  occasioned  error,  but  this,  too,  is 
said  to  be  unaccompanied  by  accentuation  of  the  first  sound  at  the  apex.  It 
is  a  transient  murmur  often  succeeded  by  recover}-. 

These  sources  of  error  are  well  illustrated  by  the  observations  of  Phear,* 
who  investigated  46  cases  of  presystolic  murmur  in  which  no  mitral  lesion 
was  found  at  autopsy.  In  17  of  these  there  was  aortic  regurgitation;  in  20 
■of  these  there  was  adherent  pericardium ;  in  9  nothing  more  than  dilatation  of 
the  left  ventricle  was  found.  In  none  was  the  snapping  first  sound,  so  com- 
mon in  mitral  stenosis,  recorded  during  life. 

Not  infrequently  the  presystolic  murmur  is  associated  with  a  mitral  sys- 
tolic or  regurgitant  murmur,  usually  soft  and  not  very  loud,  though  some- 
times it  is  distinct  and  is  well  transmitted  into  the  axilla. 

The  pulse  is  small,  as  would  be  expected  from  the  small  volume  of  blood 
ejected  from  the  ventricle,  but  may  be  quite  regular,  as  seen  in  the 
sphymograms.  Alore  frequently  it  is  irregular.  Sometimes  there  is  a 
rhythmical  failure  of  an  alternate  heart-beat  to  reach  the  wrist,  while  the 
sphygmogram  will  show  a  small  rise  between  two  higher  ones  constituting 
the  pulsus  higeminus. 

On  account  of  the  difficulties  mentioned,  while  the  presystolic  murmur 
is  a  valuable  sign  of  mitral  stenosis,  it  should  not  be  alone  relied  upon  for 
diagnosis,  but  should  be  taken  in  connection  with  other  signs.  Tricuspid 
stenosis  may  be  associated  with  mitral  stenosis  or  insufficiency,  or  both. 
With  the  loss  of  compensation  the  presystolic  murmur  disappears  together 
with  the  thrill,  and  there  remains  only  the  sharp,  ringing  normal  first  sound. 

Accentuation  of  the  second  sound  is  marked,  but  confined  to  the  pul- 
monary area,  because  there  is  no  hypertrophy  of  the  left  ventricle.  The 
second  sound  may  also  be  duplicated,  because  of  the  want  of  synchronousness 
in  the  closure  of  the  aortic  and  the  pulmonary  valves.  Dr.  Sansom  regards 
this  reduplication  as  only  a  seeming  one  of  the  second  sound.  He  regards  it 
rather  as  the  normal  second  sound  followed  by  another  sound  due  to  a  sudden 
tension  of  the  mitral  valve  itself.  He  also  says  it  occurs  in  at  least  one-third 
of  all  cases  of  mitral  stenosis,  and  is  rare  in  other  cardiac  conditions.  The 
accentuation  of  the  pulmonary  second  sound  also  disappears  with  the  enfeeb- 
ling of  the  contraction  of  the  right  ventricle. 

In  slight  degrees  of  mitral  stenosis  the  second  sound  is  heard  at  the  apex, 
but  as  the  lesion  becomes  more  serious  the  second  sound  becomes  fainter  and 
eventually  inaudible,  though  markedly  accentuated  in  the  pulmonic  area. 

The  physical  signs  of  mitral  stenosis  are  more  changeable  and  fleeting 
than  those  of  any  other  valvular  disease  of  the  heart. 

Dr.  Sansom  lays  great  stress  on  the  evidence  of  the  cardiograph  in  the 
diagnosis  of  mitral  stenosis,  which  enables  one  to  judge  of  the  relative  length 
of  systole  and  diastole.  In  stenosis  the  diastole  may  be  greatly  prolonged, 
or  the  diastolic  intervals  vary  greatly  in  duration.  In  mitral  regurgitation, 
on  the  other  hand,  a  short  interval  only  separates  the  systoles. 

Patients  with  mitral  stenosis  are  subject  to  attacks  of  recurring  valvu- 
litis, with  consequent  embolism  in  different  parts  of  the  body.  Embolism  is 
a  frequent  complication  of  mitral  stenosis.     Pulmonary  tuberculosis,  quite 

*  "Lancet,"  September  21,  1895. 


582  DISEASES  OE  HEART  AXD  BLOOD-VESSELS. 

infrequently  associated  with  valvular  heart  disease,  is  found  more  often  in 
association  with  mitral  stenosis  than  anv  other  form. 


Mitral    Insufficiency    and    Stenosis. 

Occurrence. — More  common  than  mitral  stenosis  as  an  uncombined 
lesion  is  stenosis  associated  with  insufficiency,  in  which  case  we  have  the 
double  mitral  murmur,  sometimes  with  difficulty  divisible  into  its  two  parts. 
Extreme  irregularity  of  rhythm  and  pulse,  with  frequency  and  smallness  of 
the  latter,  conspicuous  thrill,  marked  right-sided  hypertrophy,  and  sharply 
accentuated  pulmonic  sound  are  characteristic  of  advanced  stages.  The 
presence  of  hypertrophy  of  the  left  ventricle  points  to  associated  mitral 
insufficiency  and  stenosis.  Whence  this  combined  lesion  exists,  mitral  insuffi- 
ciency is  said  to  usually  precede. 


Aortic  Insufficiency  or  Incompetency. 

Occurrence  and  Mechanism. — By  aortic  insufficiency  is  meant  an 
abnormal  dilatation  of  the  aortic  orifice.  This  is  the  most  serious  and 
irremediable  of  the  valvular  diseases  of  the  heart  commonly  met.  Next  in 
frequency  to  mitral  incompetency,  much  more  frequent  than  aortic  stenosis, 
with  which  it  more  often  coexists,  it  is  a  disease  of  men  rather  than  women, 
commonly  adults  at  or  before  middle  life.  The  w-idth  of  the  aortic  orifice 
increases  from  birthi  to  old  age,  while  the  valve  cusps  tend  to  shrivel,  so  that 
conditions  favorable  to  incompetency  coexist.  It  includes  30  to  50  per  cent, 
of  all  cases  of  chronic  valvular  disease.  It  is  more  frequently  associated  wath 
arterial  sclerosis  and  less  frequently  the  result  of  rheumatic  endocarditis, 
though  it  may  be  thus  caused.  It  is  the  lesion  most  frequently  followed  by 
sudden  death.  When  it  exists,  the  aortic  valves  are  incompetent  to  close  the 
aortic  orifice,  either  on  account  of  the  large  size  of  the  latter  or  of  disease  of 
the  valve  segments  themselves,  and  the  blood  flows  backward  into  the  left 
ventricle  during  diastole.  The  ventricle,  seeking  to  restore  the  balance, 
redoubles  its  energy  and  hypertrophies.  The  blood  is  thus  driven  into  the 
aorta  with  great  force,  swelling  the  arteries  to  an  extreme  fullness,  which, 
however,  falls  promptly  away,  because  of  the  backward  flow  into  the  ven- 
tricle at  the  same  time  with  the  forward  movement  into  arteries  and  capil- 
laries. This  sudden  falling  away  of  the  pulse,  from  extreme  distention  to 
collapse,  is  very  characteristic  of  this  form  of  valvular  disease,  and  is  called 
the  "  trip-hammer  "  or  "  water-hammer  "  pulse,  also  Corrigan  pulse.  To  the 
casual  observer  it  may  even  be  visible  in  the  exposed  arteries,  such  as  the 
carotid,  temporal,  and  radial,  while  the  aortic  beat,  ordinarily  beyond  reach 
in  the  suprasternal  notch,  may  be  felt  in  this  situation. 

The  abrupt  jerking  impulse  with  sudden  recoil  is  easily  recognized  by 
the  finger  on  the  pulse,  which,  however,  fails  to  find  the  pulse  as  strong  and 
hard  as  would  be  expected  from  its  appearance.  On  the  other  hand,  it  is  soft 
and  receding.  It  is  commonly  regular.  A  tracing  of  this  pulse  is  seen  in 
Figure  55.  It  is  the  typical  pulsus  celer  ef  alius.  A  frequent  and  irregular 
pulse  is  much  more  serious  in  aortic  valve  disease  than  in  mitral  disease. 
Sclerotic  changes  in  the  arterial  zivlls  are  not  uncommon  in  aortic 
incompetency. 


CHRONIC  VALVULAR  DEFECTS.  583 

The  product  of  this  defect  is  the  largest  heart  met  in  morbid  anatomy, 
the  left  auricle  and  right  ventricle  often  sharing  in  the  enlargement.  From 
its  size  the  heart  is  called  the  bovine  heart.  It  may  weigh  as  much  as  thirty- 
five  ounces  (1050  gm.),  and  has  attained  a  weight  of  fifty  ounces  (1500  gm.) 
or  more.  The  cavities  are  enlarged  and  the  walls  are  thickened,  so  that  it 
furnishes  an  instance  of  eccentric  hypertrophy.  There  may  be  ultimate 
dilatation  of  the  arch  of  the  aorta  from  the  constant  pounding  of  the  blood 
against  it  in  systole,  while  the  carotids  may  be  seen  throbbing  in  the  throat. 

The  gradual  enlargement  of  the  ventricle  may  ultimately  cause  the  mitral 
valve  to  yield.  Compensation  is  still  maintained  for  a  time  by  hypertrophy 
of  the  left  auricle,  which  -also  yields  after  a  time,  becoming  dilated  and  allow- 
ing the  blood  to  engorge  the  lung.  Hypertrophy  of  the  right  ventricle  then 
comes  to  the  rescue  for  a  time.     Sooner  or  later  it,  too,  yields,  dilates,  the 


Fig-  55- — Tracings  of  Pulse  of  Aortic  Regurgitation. 

tricuspid  valve  weakens,  and  finally  gives  way,  allowing  the  blood  to  flow 
back  into  the  venous  side  of  the  circulation,  producing  engorgement  of  the 
liver,  stomach,  kidneys,  general  dropsy — the  train  of  symptoms  described 
under  mitral  regurgitation. 

Etiology. — Causes  of  insufficiency  in  addition  to  those  considered  under 
the  general  etiology  of  valvular  disease  are  congenital  malformations,  includ- 
ing fusion  of  two  leaflets,  commonly  those  behind  which  the  coronary  arteries 
come  off.  Such  fused  leaflets  are  especially  prone  to  valvulitis  and  its  conse- 
quences. Aortic  insufficiency  is  quite  often  caused  by  dilatation  and 
aneurysm  of  the  ascending  aorta,  giving  rise  to  relative  insufficiency. 

Symptoms. — Like  all  other  forms  of  valvular  heart  disease,  aortic 
incompetency  may  be  compensated  for  a  long  time,  and  elude  detection  for  a 
corresponding  time.  Indeed,  full  compensation  is  said  by  some  to  be  most 
usual  in  this  form  of  valvular  disease.  Both  dropsy  and  dyspnea  are  char- 
acteristically absent  until  compensation  ceases,  which  is  never  the  case  until 
the  mitral  valve  begins  to  yield.  Then,  however,  both  appear  and  may  be 
very  distressing.  An  especially  frequent  symptom  is  dissiness  with  faint- 
ness,  particularly  on  rising  quickly.  Palpitation  ensues  on  slight  exertion, 
and  this  effect  is  in  marked  contrast  to  the  comfort  of  the  patient  when  quiet, 
when  the  pulse  may  be  slow  and  breathing  regular.  In  advanced  cases,  on 
the  other  hand,  the  patient  complains  of  a  constant  "  beating  "  or  pulsation 
all  over  the  body,  especially  in  the  head,  which  is  exceedingly  unpleasant. 


584  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

The  patient  is  very  apt  to  be  troubled  in  ]iis  sleep  and  to  dream,  probably 
because  of  disturbed  circulation  in  the  brain.  Even  permanent  mental  symp- 
toms may  result  from  this  cause,  including  insanity  and  suicidal  tendency. 
Lesser  degrees  are  irritability  and  peevishness,  though  these  are  not  confined 
to  this  form  of  heart  disease.  Precordial  pain,  present  also  in  stenosis,  is 
frequent  in  this  form  of  valvular  disease.  It  may  be  a  dull  ache  with  a  sense 
of  constriction  of  the  chest,  or  sharp  and  radiating  down  the  arms,  particularly 
the  left,  as  in  angina  pectoris,  which  condition  itself  is  also  common.  With 
the  yielding  of  the  mitral  valve  and  loss  of  compensation  come  the  symptoms 
of  mitral  disease  already  described. 

As  previously  stated,  this  is  the  form  of  valvular  disease  in  v,-hich  sudden 
death  is  most  frequent.  It  has  overtaken  many  a  victim  in  the  course  of  his 
daily  vocation  and  without  warning,  though  it  is  most  apt  to  be  induced  by 
some  slight  overexertion  or  mental  excitement.  The  cause  of  such  sudden 
death  is  probably  interruption  of  the  circulation  in  the  coronary  arteries. 
This  may  be  brought  about  in  one  of  two  ways.  These  arteries,  in  common 
with  others,  are  especially  disposed  to  endarteritis  and  resulting  sclerosis  and 
atheroma,  a  condition  which  constantly  invites  thrombosis  and  obstruction  to 
the  circulation ;  or  it  may  be  due  to  embarrassed  circulation  in  these  vessels,,, 
caused  by  the  aortic  regurgitation,  for  even  if  the  blood  enters  the  coronary 
arteries  during  systole,  it  must  still  receive  in  health  some  further  supply  in 
the  recoil  of  the  blood  on  the  closed  semilunar  valves,  which  cannot  take  place 
when  the  valves  are  incompetent.  On  this  variety,  too,  supervenes  not  infre- 
quently acute  infectious  endocarditis  of  the  grave  type,  with  the  train  of 
symptoms  and  the  sequelae  described.  Embolism  in  various  organs  is  also  a 
complication  independent  of  the  acute  involvement. 

Physical  Signs. — Inspection  often  discerns  the  prominent  left  precor- 
dium,  with  the  apex-beat  lowered  and  to  the  left,  and  the  visible  pulsation  far 
beyond  the  normal  situation  of  the  apex,  all  confirmed  by  palpation.  Palpa- 
tion also  recognizes  at  times  a  diastolic  thrill  over  the  base,  in  the  carotids 
and  subclavians,  and  sometimes  in  the  aorta  at  the  suprasternal  notch.  This 
is,  however,  much  rarer  in  aortic  regurgitation  than  the  systolic  thrill  in 
stenosis.  The  Corrigan  pulse  may  also  be  felt,  but  is  much  more  strikingly 
manifested  in  the  sphygmogram.  A  capillary  pulse  is  also  sometimes  demon- 
strable in  the  skin  and  mucous  membrane.  This  may  be  observed  by  draw- 
ing a  pencil  lightly  across  the  skin  of  the  cheek  or  forehead ;  and  on  the 
muc®us  membrane  of  the  everted  lower  lip  by  pressing  a  glass  microscope 
slide  against  it.  It  may  often  be  w^ell  studied  around  the  lunula  of  the  finger- 
nail. Pulsation  in  the  retinal  arteries  may  be  recognized  by  the  ophthalmo- 
scope. Pulsation  may  even  be  ^en  in  the  uvula  as  originally  pointed  out  by 
F.  Miiller  in  1889,  by  Schlesinger  *  the  next  year  and  recently  by  David 
Riesman.f 

Percussion  discloses  increased  dullness  to  the  left  and  downward,  and 
also,  sometimes  in  advanced  cases,  upward  to  the  left  of  the  sternum,  owing 
to  hypertrophy  of  the  left  auricle,  as  w^ell  as -to  the  enlargement  of  the 
ventricle  upward. 

Auscultation  recognizes  a  diastolic  murmur,  long,  loud,  and  blowing  in 
quality,  usually  harsher  than  the  aortic  obstructive  murmur.  It  may  or  may 
not  replace  the  second  sound  of  the  heart.  It  is  well  heard  in  the  aortic  area, 
but  its  seat  of  maximum  intensity  is  commonly  to  the  left  of  the  second  inter- 

*  "  Wiener  klin,  Wochenschrift,"  October  4,  1900. 
t  "American  jMedicine,"  June  15,  igoi. 


CHRONIC  VALVULAR  DEFECTS.  585 

space,  near  the  midsternum,  sometimes  as  low  as  the  fourth  left  costal  car- 
tilage, and  even  at  the  ensiform  cartilage.  The  murmur  is  naturally  trans- 
mitted downward  toward  the  ensiform  cartilage  or  along  the  left  edge  of  the 
sternum.  Hence  it  may  be  mistaken  for  the  murmur  of  tricuspid  disease, 
but  this,  be  it  remembered,  is  unaccompanied  by  hypertrophy  of  the  left  ven- 
tricle. It  is  sometimes  also  well  conducted  toward  the  apex  which  is  in  the 
direction  of  the  regurgitating  column,  but  it  is  not  conducted  in  the  direc- 
tion of  the  great  vessels  of  the  neck,  at  least  with  any  loudness.  In  this  con- 
dition also  occurs  the  Flint  murmur,  described  under  mitral  stenosis.  This 
rnurmur  is  additional  to  the  distinctive  diastolic  murmur  (see  p.  580).  The 
aortic  regurgitant  murmur  is  probably  the  most  widely  conducted  of  all  car- 
diac murmurs. 

Auscultation  of  the  vessels  furnishes  interesting  information  in  aortic 
insufficiency.  It  is  well  known  that  if  the  stethoscope  be  placed  as  lightly  as 
possible  over  the  carotid  artery  of  a  healthy  person,  two  sounds  are  usually 
audible,  corresponding  to  the  expansion  and  contraction  of  the  artery.  Of 
these  the  latter  is  simply  the  second  aortic  sound  conducted  into  the  carotid. 
It  is  probable  also  that  the  first  sound  corresponding  with  the  arterial  expan- 
sion is  produced  by  vibrations  of  the  arterial  wall  induced  by  the  blood  driven 
into  it  from  the  ventricle.  The  second  arterial  sound  is  greatly  diminished 
in  intensity  or  even  absent  in  aortic  incompetency,  since  the  valve  remains 
open.  The  aortic  diastolic  murmur  is  sometimes  faintly  transmitted  into 
the  carotid,  while  a  short,  rough,  systolic  murmur  is  sometimes  heard  in  the 
same  vessel.  A  valvular  sound  may  also  be  heard  in  smaller  arteries,  such  as 
the  femoral,  the  brachial,  and  often  the  radial,  the  ulnar,  and  even  the  palmar 
arch  and  dorsalis  pedis,  by  pressing  lightly  with  the  stethoscope,  rendered 
more  intense  by  strong  pressure.  Then  there  is  Traube's  double  sound,  in  the 
femoral  and  popliteal  arteries  quite  often  heard.  The  sounds  are  such  that 
the  two  follow  each  other  closely,  so  that  the  first  seems  preparatory  to  the 
second,  or  they  are  separated  by  a  longer  interval,  like  the  two  sounds  of  the 
hesrt.  No  indisputable  explanation  of  these  sounds  has  been  suggested. 
The  first  femoral  sound  is  ascribed  to  a  sudden  filling  of  the  unusually  empty 
artery,  and  Traube  explained  the  first  of  his  sounds  in  this  way,  while  he 
explained  the  second  by  sudden  relaxation  of  this  tension.  Friedreich 
pointed  out  that  a  similar  double  sound  could  be  heard  in  the  femoral  vein 
in  tricuspid  insufficiency,  which  he  ascribed  to  tension  of  the  valves  of  the 
vein.  It  is  claimed  that  the  double  sound  is  heard  in  other  diseases  of  the 
heart,  especially  mitral  stenosis,  and  even  in  aneurysm,  but  it  is  acknowl- 
edged to  be  most  frequent  in  aortic  incompetency.  Finally,  there  is 
Durosies's  sign,  a.  murmur  produced  by  pressure  with  the  stethoscope  upon 
the  femoral  artery,  sometimes  heard  in  aortic  insufficiency.  Duroziez's  sign 
will  be  more  easily  understood  when  it  is  remembered  that  a  murmur  may 
be  produced  by  pressure  with  the  stethoscope  on  any  artery  of  the  caliber  of 
the  carotid.  The  murmur  occurs  during  the  expansion  or  diastole.  During 
the  collapse  or  systole  of  the  artery,  on  the  other  hand,  nO'  murmur  can  be 
thus  produced  in  health.  In  aortic  regurgitation,  however,  this  is  possible, 
and  it  is  the  second  murmur  thus  produced  which  is  Duroziez's  sign.  It 
is  said  that  this  sign  dies  out  as  compensation  fails.  T.  Clifford  Allbutt 
does  not  consider  Duroziez's  sign  peculiar  to  aortic  regurgitation,  though 
Vierordt  says  it  is.  A  right  degree  of  pressure,  tO'  be  determined  by  prac- 
tice, is  necessary,  and  the  artery  on  which  it  is  obtained  is  usually  the 
femoral. 


586  DISEASE  OF  HEART  AXD  BLOOD-VESSELS. 

Aortic    Stenosis. 

Occurrence  and  Mechanism. — By  aortic  stenosis  is  meant  a  narrow- 
ing of  the  aortic  orifice.  Pure  and  uncompHcated  aortic  stenosis  is  probably 
the  rarest  of  the  valvular  lesions.  Writers  have  been  led  into  error  because 
the  presence  of  an  aortic  systolic  murmur  has  been  interpreted  as  meaning 
stenosis,  where  it  has  been  produced  by  simple  roughening  of  the  valves  or 
beyond  them.  Richard  C.  Cabot  says  that  out  of  250  autopsies  made  at  the 
^Massachusetts  General  Hospital,  there  was  not  one  of  uncomplicated  aortic 
stenosis.  Stenosis  is  said  to  be  relative  when  there  is  a  normal  orifice  while 
the  aorta  is  dilated  beyond  it.  It  occurs  in  older  persons,  and  the  older  the 
person,  the  more  likely  are  there  to  be  calcareous  deposits  causing  it.  It 
may  be  congenital.  When  uncombined  with  insufficiency,  it  is  the  least 
dangerous  of  the  various  forms  of  valvular  disease.  The  narrowed  orifice 
prevents  the  free  discharge  of  blood  from  the  left  ventricle  into  the  aorta. 
The  ventricle  attempts  to  overcome  this,  and  its  walls  hypertrophy  in  propor- 
tion to  the  degree  of  resistance,  and  often  for  a  long  time  compensate  for  the 
obstruction — until  dilatation  occurs,  when  the  danger  really  begins.  The 
hypertrophy  thus  induced,  usually  of  the  simple  form,  is  only  second  in 
degree  to  that  produced  by  incompetency. 

Symptoms. — The  symptoms  of  aortic  stenosis  may  be  long  deferred, 
so  long  as  compensation  is  maintained,  and  when  they  do  occur,  they  are 
usually  those  of  a  deficient  supply  of  blood  to  the  brain  and  heart  itself — 
viz.,  dizziness  and  fainting.  Succeeding  exertion  there  is  apt  to  be  a  sense 
of  constriction  or  oppression  and  even  pain  in  the  precordium,  which  may 
develop  into  the  severe  pain  of  a  true  angina  pectoris. 

Physical  Signs. — Inspection  and  palpation  recognize  usually  a  forcible 
apex-beat  outside  of  its  normal  site,  and  at  varying  distances,  in  accordance 
with  the  degree  of  hypertrophy.  Some  describe  the  apex-beat  as  without 
force  and  indistinct.     Broadbent  savs  it  is  "  a  well-defined  and  deliberate 


Fig.  56. — Pulse-tracing  of  Aortic  Stenosis. — Anacrotic  Curve. 

push  of  no  great  violence."  Palpation  often  perceives  a  thrill  of  great 
intensity  with  each  beat  of  the  heart,  more  marked  when  dilated  hypertrophy 
is  established.  A  bulging  of  the  precordium  may  also  be  present,  though 
less  often  than  in  incompetency. 

The  pulse  is  the  pulsus  parvus  et  tardus,  slow  in  reaching  its  maximum 
volume,  which  is  small.  It  is  frequent,  but  regular,  contrasting  in  the  latter 
respect  with  the  pulse  of  mitral  disease.  It  is  sometimes  infrequent,  pidsus 
rams.     Figure  56  is  a  sphygmogram. 

Percussion  elicits  dullness  downward  and  laterally  toward  the  left, 
since,  as  a  rule,  the  enlargement  is  confined  to  the  left  ventricle.  There  may, 
however,  be  slight  enlargement  upward  to  the  left  of  the  sternum  if  hyper- 
trophy of  the  left  auricle  is  added. 

Auscultation  discloses  a  systolic  basic  murmur,  loudest  at  the  aortic 
area, — second  interspace  at  the  right  of  the  sternum, — conducted  distinctly 
into  the  carotids,  and  even  sometimes  along  the  course  of  the  aorta,  behmd 
and  to  the  left  of  the  vertebral  column,  into  the  popliteals  and  dorsal  arteries 


CHRONIC   VALVULAR   DEFECTS.  587 

of  the  feet.  It  is  not,  however,  confined  to  the  aortic  area,  but  may  be 
heard  over  the  entire  precordium.  It  is  usually  rough,  at  least  until  com- 
pensation fails,  but  may  be  soft  and  musical.  It  may  be  heard  even  at  a 
distance  from  the  chest.  It  is  late  systolic,  as  a  rule,  following  the  apex- 
impulse,  often  at  an  appreciable  interval.  It  is  made  louder  by  exercise. 
The  aortk  factor  of  the  second  sound  is  very  feeble,  or  not  at  all  heard,  if 
the  constriction  be  quite  marked,  because  of  the  feeble  recoil,  the  necessary 
result  of  the  small  amount  of  blood  in  the  aorta.  The  first  sound  is  normal, 
somewhat  louder  and  more  prolonged  than  natural,  because  of  the  powerful 
contraction  of  the  left  ventricle. 

Roughness  of  the  aorta,  dilatation,  and  narrowing  of  the  vessel,  how- 
ever caused,  may  also  produce  a  systolic  murmur;  so  may  roughness 
within  the  ventricle  in  the  course  of  the  outgoing  column  of  blood.  But 
these  causes  have  a  less  positive  efifect  upon  the  substance  of  the  heart — 
that  is,  do  not  produce  as  marked  hypertrophy  of  the  left  ventricle.  Nor 
do  these  causes  interfere  with  the  production  of  a  normal  second  sound, 
except,  perhaps,  dilatation,  which  in  that  event  is  accompanied  by  an  aortic 
regurgitant  murmur.  From  this  it  follows  that  the  important  point  to  re- 
member in  diagnosis  is  that  an  aortic  systolic  murmur  by  no  means  always 
indicates  aortic  stenosis.  So,  also,  anemic  or  hemic  murmurs,  which  are 
always  systolic  and  for  the  most  part  basic,  may  simulate  aortic  systolic 
murmurs  but  these  occur  in  young,  delicate  persons  of  both  sexes,  are 
often  intermittent  and  without  other  efifect  on  the  muscular  heart,  while 
they  are  also  unaccompanied  by  thrill.  There  may  be  roughness,  too,  in. 
the  pulmonary  artery,  which  can  be  localized  to  the  left  of  the  sternum. 

Stenosis  of  the  aortic  orifice  is  very  apt  to  be  associated  with  insuffi- 
ciency, the  same  rigidity  and  adhesion  which  prevent  complete  patulousness 
of  the  orifice  preventing  also  complete  closure. 

Differential  Diagnosis. — The  signs  which  distinguish  aortic  stenosis 
from  aortic  roughening  are  not  many.  In  aortic  stenosis  the  pulse  would 
naturally  be  small  as  contrasted  with  that  of  simple  roughening  or  dilatation 
of  the  aorta.  A  systolic  thrill  is  more  characteristic  of  aortic  stenosis.  It 
may  be  felt  at  the  base  and  apex,  and  rarely  at  the  apex  alone.  From  the 
last  may  be  inferred  that  the  cusp  nearest  the  mitral  leaflets  is  involved. 

Aortic  Stenosis  and  Insufficiency. 

Occurrence. — This  double  lesion  is  a  comparatively  frequent  one;  in- 
deed, it  is  commonly- reg'arded  as- the- next- in -frequency  after  mitral  insuffi- 
ciency, and  therefore  more  frequent  than  either  aortic  insufficiency  or  aortic 
stenosis  alone.  It  occasions  a  double  basic  murmur,  systolic  and  diastolic, 
and  is  also  a  grave  condition,  giving  rise  to  the  same  dangers  as  aortic 
regurgitation,  and  the  same  enormous  hypertrophy  of  the  left  ventricle. 

Diagnosis. — The  diagnosis  of  this  condition  requires  special  mention, 
"because  it  not  infrequently  happens  that  it  is  mistaken  for  aneurysm  of  the 
arch  of  the  aorta,  which  is  associated  with  a  similar  double  murmur  of  which 
the  systolic  element  is  due  to  the  roughness  of  the  aorta  and  aneurysmal 
walls,  and  of  which  the  diastolic  is  a  sign  of  relative  insufficiency  due  to 
dilatation  of  the  aorta.  The  distinctive  differences  between  the  two  condi- 
tions will  be  given  in  treating  aneurysm  of  the  arch  of  the  aorta. 


588  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 


Tricuspid  Insufficiency  or  Incompetency. 

Occurrence  and  Mechanism. — Tricuspid  regurgitation  as  a  primary 
condition  is  extremely  rare,  and,  when  present,  is  probably  the  result  of  an 
endocarditis  during  fetal  life,  endocarditis  at  this  period  being  more  prone  to 
attack  the  right  than  the  left  side.  Endocarditis  involving  the  tricuspid 
valve  may,  however,  also  occur  in  children — according  to  Byrom  Bramwell,''' 
more  commonly  than  has  been  supposed.  Infectious  or  ulcerative  endocarditis, 
also  affects  the  tricuspid  valve — according  to  Osier,  in  19  out  of  238  cases. 
More  frequently  tricuspid  regurgitation  is  the  result  of  a  relative  insuf- 
ficiency, one  of  the  terminal  events  of  mitral  disease,  the  tricuspid  orifice 
yielding  with  the  dilatation  of  the  right  ventricle,  which  takes  place  sooner 
or  later,  consequent  upon  the  resistance  to  the  movement  of  the  blood 
through  the  engorged  lungs.  It  is  also  one  of  the  possible  sequelae  of 
emphysema  of  the  lungs  and  long-standing  fibroid  phthisis  or  chronic  bron- 
chitis, succeeding,  too,  a  primary  hypertrophy  of  the  right  ventricle,  due  to 
these  causes. 

Thus,  out  of  405  autopsies  at  Guy's  Hospital  in  which  evidence  of 
tricuspid  regurgitation  was  found,  271,  or  two-thirds,  resulted  from  mitral 
disease,  68  from  myocardial  degeneration,  55  ,from  pulmonary  disease, 
bronchitis,  emphysema,  and  cirrhosis  of  the  lung.  The  effects  of  tricuspid 
insufficiency  growing  out  of  the  venous  obstruction  have  been  detailed  on 
page  576. 

Tricuspid  insufficiency  succeeding  upon  mitral  insufficiency  is  not  al- 
ways accompanied  by  an  audible  murmur.  It  is  evident  that  every  case  of 
mitral  regurgitation  associated  with  dropsy  must  be  attended  with  tricuspid 
regurgitation.  Very  few  of  the  cases  above  referred  to  had  been  diagnosed 
during  life,  and  in  all  of  them  the  valve  was  itself  healthy,  but  insufficient 
to  close  the  dilated  orifice. 

Symptoms. — These  are  those  described  when  treating  of  mitral  disease 
after  the  stage  of  tricuspid  regurgitation  has  been  reached,  dropsy  more 
or  less  general,  engorgement  of  the  stomach,  liver,  and  kidneys,  an  enlarged,, 
tender,  pulsating  liver,  and  a  jugular  pulse.  The  last  two  symptoms  are  re- 
garded as  pathognomonic. 

Jugular  pulse  is  often  more  forcible  in  the  right  than  in  the  left  jugular. 
There  is  also  cyanosis,  dyspnea,  and  pulmonary  edema.  The  jugular  pulse 
is  systolic  in  time,  and  does  not  appear  until  the  valves  situated  at  the  open- 
ing of  the  internal  jugulars  into  the  innominate  veins  yield.  These  give  way 
first  on  the  right  side,  because  the  course  of  the  right  innominate  is  straighter 
and  communication  is  more  direct.  So  long  as  the  valve  above  the  bulbus 
jugularis  is  closed,  the  pulse  is  confined  to  the  bulb,  but  with  the  yielding 
of  this  valve  the  pulse  becomes  general  throughout  the  vein.-  It  is  sometimes 
difficult  to  distinguish  a  true  jugular  pulse  from  the  "  physiological  "  or 
"  false  "  jugular  pulse,  which  may  sometimes  be  seen  in  health  and  whenever 
the  venous  system  is  overfull.  Pressure  on  the  vein  above  the  valves  will 
cause  the  false  pulse  to  disappear,  while  the  true  pulse,  coming  from  the 
right  ventricle,  will  remain.  The  physiological  or  false  jugular  pulse  alter- 
nates with  the  ventricular  systole  and  corresponds  with  the  auricular  systole, 
while  the  true  jugular  coincides  with  the  systole  of  the  ventricles. 

Physical  Signs. — In  primary  tricuspid  disease  with  regurgitation,  in- 

*  "  Amer.  Jour.  Med.  Sci.,"  April,  1886,  p.  419. 


CHRONIC  VALVULAR  DEFECTS.  589 

spection  and  palpation  reveal  an  apex-beat  diffused  toward  the  ensiform 
cartilage  and  the  epigastrium.  Percussion  detects  enlargement  toward  the 
right  edge  of  the  sternum,  due  to  hypertrophy  of  the  right  ventricle,  which 
occurs  for  the  same  reason  as  hypertrophy  of  the  left  ventricle  in  mitral 
insufficiency. 

To  auscultation  the  systolic  murmur  thus  engendered  is  invariably 
feeble,  and  is  heard  almost  solely  in  the  tricuspid  area,  just  above  and  to 
the  left  of  the  ensiform  cartilage.  Occasionally  only  is  the  second  pul- 
monic sound  accentuated.  There  should  be  no  confounding  of  this  mur- 
mur with  that  of  aortic  regurgitation  conducted  toward  the  same  situation, 
but  different  in  time,  nor  with  that  of  mitral  regurgitation  heard  at  no  great 
distance,  for  the  reasons  already  given.  To  these  must  be  added  a  dift'er- 
ence  in  quality  and  pitch  between  the  tricuspid  and  the  mitral  murmur,  not 
always,  however,  manifest. 

Tricuspid  Stenosis. 

Occurrence. — Tricuspid  stenosis  is  a  rarer  condition,  but  it  may  be  an 
acquired  one  in  association  with  left-sided  heart  disease  as  the  result  of 
rheumatic  endocarditis,  and  of  unknown  causes.  Ninety  per  cent,  of  cases 
are  associated  with  mitral  stenosis.  It  is  much  more  frequent  in  women, 
fully  80  per  cent,  of  all  cases  being  in  women.  As  in  endocarditis  of  the 
left  side,  there  are  thickening,  adhesion,  narrowing. 

A  presystolic  tricuspid  murmur  pointing  to  stenosis,  in  a  case  obsen^ed 
by  Gardner,  w-as  found  due  to  a  growth  from  the  endocardium  of  the  right 
auricle,  so  placed  as  to  fall  over  the  tricuspid  orifice  in  the  manner  of  a  ball 
valve.  Fred.  C.  Shattuck  has  met  one  instance  of  tricuspid  stenosis  with 
mitral  stenosis  and  regurgitation,  along  with  adherent  pericardium,  hepatic 
cirrhosis,  and  slightly  granular  kidney,  as  determined  by  autopsy.  In  this 
case  there  was  a  presystolic  tricuspid  murmur  observed  for  three  years  be- 
fore death. 

Physical  Signs. — Simple  uncomplicated  tricuspid  stenosis  would  be 
recognized  from  the  presence  of  a  presystolic  murmur  and  thrill,  best  heard 
in  the  tricuspid  area,  unaccompanied  by  hypertrophy  of  the  right  A-entricle. 
When  associated  with  left-sided  heart  disease,  the  diagnosis  is  seldom  made, 
because  the  murmur  is  masked  by  the  coincident  mitral  presystolic  nuiruinr. 
In  a  very  few  cases  only  is  it  confined  to  this  valve.  Frequently  there  is 
no  murmur.     Percussion  shows  dullness  to  the  right  of  the  sternum. 

Congenital  stenosis  of  the  tricuspid  orifice  occurs,  but  is  usually  asso- 
ciated with  defects  of  other  valves,  which  early  cause  death. 

Other  symptoms  are  cyanosis  of  the  face  and  lips  and,  in  the  later  stages, 
extreme  and  obstinate  dropsy. 

PULMOXARY  IXSUFFICIEXCY  OR  IXCOMPETEXCY. 

Occurrence. — Simple  pulmonary  regurgitation  is  rarely  seen.  It  may, 
however,  exist  as  a  congenital  defect  (fusion  of  two  segments),  and  the 
pulmonary  valve  has  been  found  involved  in  ulcerative  valvulitis. 

Physical  Signs. — It  is  easy  from  what  has  gone  before  to  deduce  the 
physical  signs  which  are  to  be  expected — a  diastolic  murmur  heard  in  the 
pulmonic  area,  hypertrophy  of  the  right  ventricle,  later  jugular  pulse,  venous 
congestion,  and  cyanosis.     The  diastolic  mmrmur  may  be  confounded  wath 


590  DISEASES  OF  HEART  AXD  BLOOD-VESSELS. 

that  of  aortic  insufficiency,  but  the  latter  is  accompanied  with  hypertrophy 
of  the  left  ventricle,  with  Corrigan  pulse  and  capillary  pulse.  A  few  cases 
are  related  in  which  a  diastolic  murmur  has  been  found  associated  with 
defects  in  the  pulmonar}-  valves — in  one,  warty,  which  might  have  been 
the  result  of  infectious  endocarditis.  All  others  are  congenital.  Among 
them  is  aneurysmal  dilatation.  Such  was  a  case  reported  to  the  Pathological 
Society  of  Philadelphia  by  Edw^ard  T.  Bruen  (see  "  Transactions  "  for 
1883). 

Pulmonary  Stenosis. 

Occurrence. — The  great  majority  of  systolic  murmurs  heard  at  the  pul- 
monary orifice  are  functional.  Pulmonary  stenosis,  though  very  rare,  may, 
however,  exist,  in  which  case  it  is  far  more  likely  to  be  congenital  from 
arrested  development,  although  intra-uterine  endocarditis  may  also  cause  it. 
So,  also,  may  infectious  endocarditis,  and  in  rare  instances,  atheroma.  I  well 
remember  a  case  of  malignant  endocarditis  with  a  pulmonary  systolic  mur- 
mur in  which  I  was  led  from  a  correct  diagnosis,  because  I  thought  that  such 
murmurs  are  so  invariably  functional  that  it  w^as  scarcely  worth  while  to 
consider  the  probability  of  an  organic  lesion.  The  autopsy  disclosed  a  val- 
vulitis of  the  pulmonar}'  valve.  Since  then  I  have  met  other  cases.  The 
valve  leaflets  are  apt  to  be  fused.  When  the  lesion  is  congenital,  it  is  com- 
monly associated  with  patency  of  the  foramen  of  Botal  or  foramen  ovale, 
together  wnth  imperfect  ventricular  septum  and  tricuspid  stenosis. 

Physical  Signs. — Pulmonary  stenosis  should  furnish  a  systolic  munnur 
in  the  pulmonary  area,  to  the  left  of  the  sternum.  The  murmur  may  even 
be  heard  behind,  between  the  shoulders,  and  it  may  be  rough.  It  is  accom- 
panied by  hypertrophy  of  the  right  ventricle.  There  may  be  a  basic  thrill, 
as  in  aortic  obstruction,  but  the  pulse  is  uninfluenced.  Compensation  may 
be  set  up  by  means  of  a  patulous  foramen  ovale,  an  open  ductus  arteriosus,  or 
interventricular  communication.  The  invariable  presence  of  cyanosis  due  to 
venous  obstruction  and  of  attacks  of  dyspnea  complete  the  picture  and  aid 
greatly  in  the  diagnosis.  Anemic  murmurs  at  the  same  time  and  place  are 
unaccompanied  by  cyanosis. 

Walshe  has  described  a  case  of  death  from  thrombosis  of  the  pulmonary 
artery  in  which  he  heard  a  pulmonary  systolic  murmur  before  the  end  came. 

Congenital  Defects. 

Congenital  defects  in  the  cardiac  valves  and  orifices  deserve  a  passing 
notice.  They  may  be  the  result  of  endocarditis  during  fetal  life  or  of 
arrest  of  development.  Their  most  frequent  seat  is  the  right  heart,  and  the 
most  frequent  form  is  stenosis  of  the  puhnonary  orifice,  the  effects  and  signs 
of  which  have  already  been  considered.  Another  is  a  permanently  patulous 
foramen  ovale ;  or  there  may  be  a  defect  of  the  septum  of  the  ventricles, 
or  a  communication  between  the  aorta  and  pulmonary  artery, — a  persistent 
ductus  arteriosus, — or  between  the  aorta  and  the  vena  cava  or  aorta  and  right 
auricle.  All  of  these  intercommunications  produce  murmurs  difficult  to 
separate,  and  it  is,  after  all,  by  attention  to  the  general  condition  that  the 
defect  is  recognized.  The  patient  is  a  child  of  arrested  development,  more 
or  less  permanently  cyanosed,  with  continued  embarrassed  breathing — all 
of  these  are  conditions  which  point  to  the  congenital  defect.     If  there  be 


CHRONIC  VALVULAR  DEFECTS.  591 

added  to  these  a  persistent  loud  murmur  at  the  base  of  the  heart  without 
other  signs  or  symptoms  of  valvular  disease,  this  may  be  due  to  congenital 
defect. 

In  addition  to  these,  there  are  a  large  number  of  defects  of  develop- 
ment which  are  rather  pathological  curiosities  than  of  clinical  interest. 
Among  these  may  be  mentioned  acardia,  or  absence  of  heart,  met  in  the 
monstrosity  thus  named ;  double  heart,  sometimes  present  in  high  degrees 
of  fetal  defect ;  dextrocardia,  in  which  the  heart  is  on  the  right  side,  alone 
or  with  other  viscera.  In  ectopia  cordis,  or  dislocation,  which  is  associated 
with  fission  of  the  chest-wall  and  of  the  abdomen,  the  heart  may  be  in  the 
cervical,  pectoral,  or  abdominal  regions.  Then  there  are  anomalies  of  the 
cardiac  septa,  of  which  the  patulous  foramen  ovale  is  the  most  frequent, 
various  in  degree.  Next  is  a  small  defect  in  the  upper  part  of  the  septum, 
between  the  ventricles,  in  what  is  known  as  the  "  undefended  "  space,  or  just 
anterior  to  it.  A  6fcuspid  state  of  the  semilunar  valves,  from  fusion  of 
cusps,  is  often  met — most  frequently  of  the  aorta.  The  combined  valve  is 
more  liable  to  sclerotic  change.  Finally,  there  is  fenestration  of  the  semi- 
lunar cusps. 

Relative  Frequency  of  Valvular  Defects. — The  order  of  frequency 
of  the  various  valvular  defects  is  not  entirely  agreed  upon.  As  to  one, 
however,  there  seems  to  be  universal  concurrence,  and  that  is  that  mitral 
regurgitation  is  the  most  frequent.  After  this,  however,  statistics  differ. 
Thus,  of  the  older  authors,  W.  H.  Walshe  presents  the  following  order  of 
frequency  for  the  single  or  simple  murmurs  : 

I.  Mitral  incompetency.  2.  Aortic  stenosis.  3.  Aortic  incompetency. 
4.  Mitral  stenosis.  5.  Tricuspid  incompetency.  6.  Pulmonary  stenosis. 
7.  Tricuspid  stenosis.  8.  Pulmonary  incompetency.  Presumably,  this  list 
is  based  upon  necropsy  records. 

This  order,  in  the  light  of  modern  studies,  must  be  corrected,  except 
as  to  mitral  incompetency.  Frederick  J.  Smith,  analyzing  the  registers  and 
postmortem  records  of  the  London  hospitals  for  eleven  years, — 1877-87, — 
and  taking  the  fatal  cases  only,  arrived  at  the  following  order : 

1.  Mitral  incompetency. 

2.  Mitral  stenosis.  )    r\s:  ^-     u  1   r 

...  ^  )■  Ui  practically  equal  frequency. 

3.  Aortic  incompetency,     j  ^      -1  -1         ./ 

4.  Aortic  stenosis. 

5.  Tricuspid  stenosis. 
To  these  we  may  add : 

6.  Tricuspid  incompetency. 

7.  Pulmonary  stenosis. 

8.  Pulmonary  incompetency. 

It  is  evident  that  the  older  observers  mistook  the  aortic  systolic  murmur 
to  mean  aortic  stenosis,  when  roughening  only  of  some  kind  was  present. 

Out  of  705  cases,  Smith  found  26,  or  3.38  per  cent.,  of  mitral  stenosis, 
and  25,  or  3.25  per  cent.,  of  aortic  regurgitation ;  so  it  cannot  be  said  there 
is  any  practical  difference  in  the  relative  frequency  of  these  two  lesions. 
Von  Leube  says  that,  after  mitral  incompetency,  aortic  incompetency  is 
the  most  frequent,  and  this  is  my  experience.  Smith's  statistics,  being 
recent  and  based,  as  they  are,  upon  the  examination  of  registers  and 
autopsy  records,  are  probably  nearly  correct,  but  these  two  lesions  approxi- 
mate in  frequency.     Such  are  to  be  distinguished  from  those  based  on 


592  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

observation  at  the  bedside,  regardless  of  autopsy.  Such  observation  cer- 
tainly fails  to  detect  all  cases  of  mitral  stenosis. 

Of  "  double  "  initnnurs  heard  at  one  orifice,  those  of  mitral  stenosis 
and  insufficiency  are  more  numerous  than  aortic  stenosis  and  insufficiency, 
wom^n  being  the  most  frequent  subjects.  It  should  be  mentioned,  however, 
that  George  S.  Middleton,  in  a  clinical  study  of  150  cases  of  chronic  valvular 
disease  at  the  out-patient  department  of  the  Royal  Glasgow  Infirmary,  found 
a  much  larger  number — 22  per  cent. — of  the  double  aortic  lesions,  as  against 
Dr.  Smith's  4  per  cent. ;  also,  that  Walshe  makes  the  double  aortic  lesion 
the  second  in  frequency  of  all  valvular  diseases.  I  am  inclined  to  agree  with 
the  latter  statement. 

Associated  or  Combined  Valvular  Lesions. — These  terms  are  applied 
when  two  valves  are  diseased  at  the  same  time — a  very  frequent  occurrence.* 
The  valves  which  are  most  frequently  jointly  affected  are,  of  course,  the 
aortic  and  mitral,  then  the  mitral  and  tricuspid,  then  the  aortic,  mitral,  and 
tricuspid.  Aortic  disease  of  either  kind  is  more  frequently  associated  with 
mitral  incompetency  than  mitral  stenosis,  because  the  former  is,  sooner  or 
later,  a  result  of  the  aortic  disease,  while  mitral  stenosis  arises  by  a  sepa- 
rate process.  The  very  careful  analysis  by  Frederick  J.  Smith  referred  to 
furnishes  the  following  order,  which  is  not  far  from  correct : 

1.  Aortic  incompetency  and  stenosis;  mitral  incompetency. 

2.  Aortic  stenosis  and  mitral  incompetency. 

3.  Aortic  incompetency  and  mitral  incompetency. 

There  is  less  than  one  per  cent,  difference  in  the  frequency  of  2  and  3. 

4.  Aortic  incompetency  and  stenosis,  with  mitral  stenosis  and  incom- 

petency. 

5.  Mitral  incompetency  and  tricuspid  incompetency. 

6.  Aortic   incompetency   and   stenosis,   with   mitral   incompetency,   tri- 

cuspid incompetency. 

Too  much  reliance  must  not  be  placed  on  the  order  of  combined  mur- 
murs, as  after  i  the  arrangement  is  not  altogether  what  would  be  expected 
from  a  consideration  of  the  natural  sequence.  In  children,  it  is  said,  the 
most  frequent  combination  is  aortic  incompetency  and  mitral  incompetency. 
One  would  expect  this  to  be  the  case  with  adults  also. 

The  diagnosis  of  these  combinations  is  based  upon  the  quality  and 
situation  of  the  murmurs  and  their  conduction. 

Prognosis  of  Chronic  Valvular  Disease. — Possible  positive  statements 
as  to  the  prognosis  in  chron[c  valvular  disease  are  few,  so  uncertain  is  it 
and  so  many  circumstances  influence  it.  Undoubtedly,  valvular  disease 
often  exists  where  the  subject  is  totally  free  from  symptoms,  and  therefore 
quite  unconscious  of  it.  Yet  such  subject  is  not  free  from  danger.  On 
the  other  hand,  fifteen,  twenty,  thirty,  and  even  forty  years  pass  over  such 
cases  without  inconvenience,  compensation  being  easily  maintained.  Such 
cases  are  usually  of  mitral  incompetency  or  stenosis,  or  both.  Much  de- 
pends upon  the  life  led  by  the  patient — whether  one  of  ease  and  quiet,  associ- 
ated with  proper  food  and  clothing  and  without  dissipation.  Even  when 
such  disease  occasions  symptoms,  the  same  measures  may  hold  them  in 
abeyance  for  a  long  time,  and  occasional   judicious  medication  may  raise 

_  *  Dr.  Sansom  has  sug-Rested  that  the  term  "combined"  be  retained  for  two  murmurs  at  one 
orifice,  commonly  known  as  "  double  "  murmurs— an  unfortunate  suggestion,  as  it  will  be  sure  to 
give  rise  to  confusion,  while  the  term  double  is  easily  understood. 


CHRONIC  VALVULAR  DEFECTS.  593 

the  patient  from  a  serious  condition  to  one  of  comfort.  It  is  astonishing 
with  what  Httle  disturbance  women  with  these  affections  sometimes  bear 
children.  Of  the  lesions  at  the  mitral  orifice,  incompetency  is  usually  most 
easily  compensated,  then  combined  stenosis  and  incompetency,  and  finally 
stenosis  only;  but  even  the  last  exists  at  times  without  subjective  symptoms 
in  persons  who  have  worked  hard.  After  all,  the  prospect  of  life  must  be 
judged  from  the  symptoms  in  each  case.  The  compensation  which  is  ob- 
tained by  extreme  hypertrophy  and  apex  displacement  is  tottering.  An  ad- 
ditional danger  in  mitral  disease,  especially  mitral  stenosis,  is  that  of  em- 
Ijolism.  Recurring  attacks  of  rheumatism  not  only  increase  the  latter  dan- 
ger, but  augment  the  valvular  defect.  The  supervention  of  dropsy  and 
dyspnea  indicate  failing  compensation,  and  though  they  may  be  overcome, 
it  is  with  increasing  difficulty  at  each  recurrence. 

Aortic  incompetency  is  a  much  graver  condition.  It  is  this  valvular 
disease  in  which  sudden  death  overtakes  the  patient.  Yet  it,  too,  may  be 
compensated  for  years.  Much  here  depends  upon  the  state  of  the  arteries, 
the  danger  being  increased  when  associated  with  sclerosis  or  atheroma,  for 
these  conditions  are  likely  to  affect  the  root  of  the  aorta  and  the  valves, 
and  especially  the  coronary  arteries.  Any  obstruction  in  these,  as  already 
stated,  may  be  the  cause  of  sudden  death.  Angina  pectoris  indicates  a 
diseased  condition  of  the  coronary  arteries,  which  may  at  any  time  be  fol- 
lowed by  complete  obstruction  and  sudden  death.  Overdistention,  such  as 
takes  place  during  exertion,  may  be  too  much  for  a  fatty  heart  already  dilated, 
and  becomes  also  a  cause  of  sudden  death. 

The  most  unfavorable  of  all  forms  of  cardiac  valvular  disease  is  tri- 
cuspid regurgitation,  which  occasions  obstinate  dropsy  and  dyspnea. 

Chronic  valvular  disease  is  regarded  as  much  more  serious  in  young 
children,  say  those  under  ten  years  of  age ;  this,  in  spite  of  the  fact  that 
many  conditions  favorable  to  compensation  are  present,  such  as  integrity 
of  heart  muscle  and  vascular  supply.  Notwithstanding  this,  the  valve 
lesion  is  apt  to  increase.  On  the  other  hand,  there  is  a  popular  notion, 
which  physicians  are  disposed  to  encourage,  that  a  child  may  outgrow  a 
heart  disease  under  favorable  circumstances,  such  as  abundance  of  good 
food  and  protection  against  exposure  and  overwork.  This  may  be  true,  but 
it  is  more  likely  that  compensation  is  established  with  the  growth  and  de- 
velopment of  the  organ.  That  the  apparent  event  does  sometimes  occur,  I 
can  attest.  Congenital  defects  in  the  heart  are  apt  to  destroy  the  lives  of 
children  the  first  few  years  of  their  existence. 

Finally,  almost  any  serious  illness,  especially  when  involving  the  lung, 
increases  the  danger  to  the  life  of  the  subject  of  cardiac  disease,  while 
mitral  disease,  and  especially  mitral  stenosis,  invites  pulmonary  congestion 
and  inflammations. 

Treatment  of  Chronic  Valvular  Diseases  of  the  Heart. — i.  Prophy- 
laxis. There  can  be  no  doubt  that  the  number  of  cases  of  chronic  valvular 
disease  may  be  decreased  by  a  careful  treatment  of  the  diseases  which  ex- 
cite them  or  favor  their  occurrence,  especially  acute  rheumatism.  The  stu- 
dent is  referred  to  a  valuable  monograph  by  R.  Caton,  M.  D.,  on  "  The 
Prevention  of  Valvular  Disease  of  the  Heart."  *  This  author  emphasizes 
especially  ( i )  the  importance  of  rest  awd  a  minimum  of  exertion  of  all  kinds 
for  the  rheumatic  patient;   (2)   stimulation  of  the  trophic  centers  by  small 

*  London,  C.  J.  Clay  &  Sons,  igoo. 
38 


594  DISEASES  OE  HEART  AND  BLOOD-VESSELS. 

blisters  in  the  neighborhood  of  the  affected  joints  and  in  front  and  in  the 
axilla,  preferably  in  front  between  the  clavicle  of  the  nipple  on  both  sides, 
with  a  view  to  stimulating  vasomotor  nerves;  (3)  treatment  by  absorbents, 
including  the  iodid  of  sodium  and  mercury.  The  rest  and  quiet  should  be 
prolonged  long  after  the  symptoms  of  pain  and  fever  have  subsided,  and  a 
second  attack  of  rheumatism  should  especially  be  guarded  against,  as  an 
apparently  cured  endocarditis  is  sure  to  be  followed  by  another  attack. 

2.  Remedial  Measures. — Since  there  are  certain  points  in  the  treatment 
of  disease  of  the  cardiac  valves  which  are  the  same  for  the  different  orifices, 
I  shall  consider  first  such  measures  as  are  thus  common,  referring  more 
especially  to  mitral  and  aortic  disease. 

In  the  first  place,  it  is  well  known  that  there  exist  chronic  valvular 
defects  at  either  of  these  orifices  which  give  rise  to  no  symptoms  whatever 
and  are  often  accidentally  discovered.  From  the  standpoint  generally  con- 
ceded, that  such  defects  themselves  are  irremediable,  it  is  clear  that,  in  the 
absence  of  symptoms,  medicinal  treatment  is  quite  unnecessary.  On  the 
other  hand,  it  is  a  happy  circumstance  when  the  subjects  of  such  lesions 
are  made  aware  of  their  presence,  because  they  are  enabled  so  to  regulate 
their  mode  of  life  as  to  prevent  harmful  consequences,  either  symptomatic- 
ally  or  organically.  Such  persons  should  avoid  overexercise  and  excite- 
ment. Running  or  even  walking  rapidly,  hurriedly  ascending  stairs,  ex- 
tremes of  passion  of  all  kinds,  and  especially  of  anger,  should  be  avoided, 
as  should  also  exposure  and  irregular  living.  In  a  higher  grade  of  involve- 
ment of  either  orifice,  the  same  treatment  is  demanded  in  a  more  imperative 
manner,  since  its  omission  results  in  a  loss  of  compensation,  manifested  by 
dyspnea,  palpitation,  and  precordial  distress. 

In  a  still  more  advanced  degree  of  interference  with  normal  functions 
the  treatment  becomes  different  with  the  seat  of  the  lesion.  Let  us  first 
consider  lesions  of  the  mitral  valve,  and  first  the  most  common  of  all  forms — 
mitral  regurgitation.  We  have  seen  that  the  blood  flows  back  into  the 
left  auricle  during  systole  of  the  ventricle,  at  a  time  when  all  communication 
between  these  cavities  should  be  cut  off  and  the  movement  of  the  blood 
should  be  forward  only.  Averted  for  a  time  by  hypertrophy  of  the  left 
auricle,  engorgement  of  the  lungs  ultimately  results,  with  defective  aeration 
of  blood,  and  consequent  shortness  of  breath.  This  effect  is  at  first  counter- 
acted by  the  increased  effort  of  the  right  ventricle,  whence  its  hypertrophy, 
with  sharp  accentuation  of  the  pulmonary  second  sound. 

So  long  as  compensation  is  thus  maintained  there  is  probably  no  sign 
of  embarrassed  breathing,  iri^^egularity,  precordial  oppression,  or  digestive 
derangement ;  but  as  soon  as  compensation  begins  to  fail,  in  consequence 
of  a  suspension  of  the  conditions  which  co-operate  to  help  it,  or  of  a  slight 
yielding  of  the  heart  muscle,  assistance  is  demanded.  The  heart  tonics,  of 
which  digitalis  is  the  type,  are  the  agents  pre-eminent  for  this  purpose. 
That  they  operate  by  directly  increasing  the  force  of  the  right  ventricle 
and  left  auricle,  and  thus  contribute  to  the  compensation,  can  scarcely  be 
doubted;  but  that  they  help  also  to  make  the  closure  of  the  mitral  orifice 
more  complete  by  forcibly  increasing  the  contraction  of  the  left  ventricle 
seems  also  reasonably  sure,  since  the  experiments  of  Ludwig  and  Hesse 
have  made  it  so  plain  that  this  can  occur.  They  have  shown  that  the 
mechanism  for  closing  the  mitral  orifice  does  not  reside  in  the  valve  alone, 
but  that  the  surrounding  muscles  of  the  ventricle  have  an  active  share,  not 
only  in  floating  up  the  valve  curtains,  but  in  reducing  also  the  size  of  the 


CHROXIC  VALVULAR  DEFECTS.  595 

opening  which  these  valve  curtains  have  to  close.  This  is,  of  course,  less 
applicable  in  chronic  valvular  conditions  where  there  is  stiffness  from  cal- 
careous change,  than  where  regurgitation  results  from  simple  feebleness  of 
muscle  in  anemia  and  after  the  infectious  fevers. 

The  effect  required  of  this  class  of  drugs  varies  with  the  degree  of 
obstruction  to  be  overcome,  and  the  doses  var)^  accordingly.  Very  often 
the  heart  requires  but  little  steadying  to  enable  it  to  accomplish  the  desired 
end,  and  moderate  doses — such  as  five  minims  (0.3  c.  c.)  of  the  tincture  of 
digitalis  once  in  six  or  eight  hours — suffice.  On  the  other  hand,  it  is  a  mis- 
take to  give  too  small  a  dose,  and  too  great  timidity  often  results  in  failure. 
Doses  of  from  ten  to  fifteen  minims  (0.6  to  i  c.  c.)  of  the  tincture  of  digi- 
talis every  four  hours,  and  corresponding  doses  of  the  other  preparations, 
are  often  necessary  and  sometimes  produce  magical  effects.  The  irregular 
and  halting  pulse  becomes  regular,  the  dropped  beat  is  again  taken  up,  the 
dusky  lips  become  pink,  the  scanty  urine  is  increased,  the  shortness  of 
breath  disappears,  and  calmness  and  quiet  succeed  distress  and  restlessness. 
As  soon,  however,  as  the  desired  effect  is  produced,  the  dose  should  be 
lowered.  Digitalis  is  a  remedy  always  better  intermitted  to  obtain  its  best 
effects,  and  a  remedy,  too,  which,  having  once  excited  nausea,  is  thereafter 
badly  borne. 

The  same  principles  apply  to  the  management  of  the  still  more  serious 
engorgements  of  the  venous  system  which  succeed  upon  tricuspid  insuffi- 
ciency, and  produce  dropsies  and  serous  effusions.  This  engorgement  is 
also  relieved  by  the  use  of  purgatives,  and  as  the  portal  area,  including  the 
liver  itself  and  the  stomach,  is  especially  involved,  mercurial  purgatives  are 
especially  indicated.  From  five  to  ten  grains  (0.32  to  0.65  gm.)  of  blue 
mass  at  bedtime,  followed  by  a  saline  in  the  morning,  relieve  the  congestion, 
and  with  it  the  nausea  and  indisposition  to  take  food  which  attend  it.  Such 
remedies  may  be  resorted  to  occasionally.  Sometimes  the  continued  use 
of  small  doses  for  a  long  time — say  1-2  to  one  grain  (0.03  to  0.065  gm.) 
of  blue  mass  three  times  a  day — is  more  efficient.  It  is  generally  recog- 
nized that  digitalis  produces  also  contraction  of  the  arterioles,  and  that 
through  this,  in  connection  with  the  forcible  systole,  the  arterial  pressure  is 
increased.  This  effect  is  desirable  and  useful  in  the  early  stages  of  mitral 
regurgitation,  before  tricuspid  regurgitation  and  dropsy  have  set  in.  Later 
in  the  disease,  however,  when  dropsy  has  set  in,  this  effect  militates  against 
the  diuretic  action  which  is  so  much  needed.  The  manner  in  which  this 
may  be  overcome  will  be  described  later. 

As  to  the  relative  value  of  the  different  preparations  of  digitalis :  While 
testimony  is  generally  favorable  to  the  infusion  as  the  most  efficient  remedy, 
yet,  on  account  of  convenience  and  accessibility,  the  tincture  is  most  fre- 
quently used.  I  am  inclined  to  believe  that  the  greater  apparent  efficiency 
of  the  infusion  is  partly  due  to  the  fact  that  it  is  generally  given  in  larger 
doses.  Thus,  a  tablespoonful,  or  1-2  ounce  (15  c.  c),  is  not  an  infrequent 
dose  of  the  infusion,  while  ten  minims  (0.6  c.  c. ),  or  twenty  drops,  of  the 
tincture  and  one  grain  (0.066  gm.)  of  the  powder  are  not  often  exceeded. 
When  it  is  remembered  that  1-2  ounce  (15  c.  c.)  of  the  infusion,  as  made  by 
the  United  States  Pharmacopeia,  represents  nearly  three  grains  (0.19  gm.) 
of  the  powder,  or  twenty  minims  (1.2  c.  c.)  of  the  tincture,  one  may  under- 
stand why  it  is  more  efficient.  It  is  true,  however,  that  the  infusion  is  some- 
times better  borne  by  the  stomach  than  equivalent  doses  of  the  tincture.  It 
mav  be  that  the  cinnamon  water  with  which  it  is  made  has  this  effect.     All 


596  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

preparations  of  digitalis  thus  far  mentioned  are  more  or  less  uncertain,  and 
I  purpose  to  use  hereafter  more  of  the  so-called  "  normal  liquid,"  which,  if 
correctly  represented,  must  be  a  constant  preparation.  Each  minim  repre- 
sents one  grain  of  the  drug,  and  hence  the  proper  dose  is  easily  determined. 

Of  remedies  which  may  be  substituted  for  digitalis,  strophanthus 
should  be  first  mentioned,  not  that  it  is  always  the  best.  It  was  at  one  time 
thought  that  strophanthus  might  have  all  the  effects  of  digitalis  on  the  left 
ventricle  without  the  contracting  effect  on  the  arterioles.  This  expectation 
was  not,  however,  realized  by  clinicians,  but  it  is  a  fair  substitute  for  digitalis 
in  about  the  same  dose.  It  is  better  borne  by  the  stomach,  as  a  rule,  than 
digitalis. 

Caffein  is  an  admirable  heart  tonic  in  mitral  regurgitation.  I  do  not 
give  less  than  three  grains  (0.2  gm.)  at  a  dose,  but  seldom  give  more,  every 
four  to  six  hours.  When  caffein  has  been  given  in  full  doses  for  some 
time,  it  may  produce  mental  symptoms  quite  characteristic,  consisting  in 
hallucinations  not  unlike  those  of  delirium  tremens,  the  patient  imagining 
there  are  persons,  animals,  and  other  objects  about  him,  and  he  is  some- 
times difficult  to  control.  These  symptoms,  however,  cease  immediately 
when  the  drug  is  discontinued.  Another  effect  of  caffein  which  sometimes 
interferes  with  its  usefulness  is  insomnia. 

Spartein  sulphate  is  another  heart  tonic  which  I  have  come  to  value 
very  highly,  especially  when  a  diuretic  effect  is  desired.  The  dose  should 
never  be  less  than  1-4  grain  (0.016  gm.),  increased  to  1-2  grain  (0.032  gm.), 
four,  five,  and  six  times  a  day.  I  am  sure  many  have  been  disappointed  in 
spartein  because  they  have  given  too  small  a  dose.  Broom  itself,  in  the 
shape  of  an  infusion  or  "  tea,"  is  a  popular  and  efficient  remedy,  less  well 
borne  by  the  stomach  than  its  active  principle,  spartein.  Spartein  and 
broom  are  more  commonly  used  as  diuretics,  and  will  be  again  referred  to 
in  the  treatment  of  the  dropsy  of  Bright's  disease. 

In  the  much  rarer  disease  of  simple  mitral  stenosis,  compensation  is  even 
easier  and  longer  maintained  by  nature's  own  resources  than  in  mitral 
regurgitation.  Here,  for  evident  reasons,  there  is  no  tendency  to  dilatation 
or  hypertrophy  of  the  left  ventricle.  On  the  other  hand,  hypertrophy  of 
the  left  auricle  becomes  a  conspicuous  condition,  succeeded  by  hypertrophy 
of  the  right  ventricle,  for  the  same  reason  as  in  mitral  regurgitation.  Espe- 
cially easy  is  it  to  maintain  compensation  if  the  narrowing  is  not  too  great 
and  if  there  is  a  well-preserved  left  auricle  and  a  strong  right  ventricle.  If, 
however,  the  mitral  narrowing  is  extreme,  it  is  plain  that  the  pulmonary 
engorgement  will  become  greater  if  we  increase  the  force  of  the  right  ven- 
tricle. Much  more  cautious  must  we  be,  therefore,  in  the  use  of  digitalis. 
Much  more  important  under  these  circumstances  is  relief  to  the  pulmonary 
congestion,  which  in  turn  will  relieve  the  right  heart  tension.  Blood-letting 
is  the  most  direct  method  of  accomplishing  this,  and  in  severe  cases  associated 
with  great  dyspnea  and  cyanosis  it  may  be  practiced.  For  the  same  pur- 
pose, aconite  is  sometimes  of  advantage  in  these  cases,  in  small  doses,  say 
one  minim  or  i  1-2  minims  (0.06  to  0.09  c.  c.)  every  two  hours  or  every  hour, 
watching  its  effect.  It  is  possible  that  it  is  through  a  somewhat  similar 
action  that  convallaria  majalis — a  remedy  in  which  most  observers  have  been 
disappointed — has  been  found  useful  by  Dr.  Sansom  *  in  mitral  stenosis,  and 
also  by  French  physicians.     By  these  observers  it  has  been  found  diuretic, 

*  "  The  Treatment  of  Some  of  the  Forms  of  Valvular  Disease  of  the  Heart,"  Lettsomian  Lectures, 
second  edition,  with  corrections,  London,  1886. 


CHRONIC  VALVULAR  DEFECTS.  597 

increasing  the  twenty-four  hours'  urine  to  85  and  even  to  115  ounces  (2550  to 
3450  c.  c),  reducing  the  pulse  rate,  regulating  irregularity,  and  improving 
the  breathing,  even  when  accompanied  by  tricuspid  regurgitation.  The  doses 
given  are  from  ten  to  twenty  minims  (0.6  to  1.2  c.  c.)  of  the  tincture  three 
times  a  day,  and  it  may  with  advantage  be  associated  wdth  caffein.  The 
French  physicians  give  the  extract  in  doses  of  from  one  gram  to  i  1-2  grams 
a  dav — /.  c,  fifteen  to  twenty  grains  (i  to  1.3  gm.).  Veratria  may  be  used 
under  the  same  circumstances.  More  effectual  than  either  of  these  remedies 
to  relieve  pulmonary  congestion  is  purging,  sometimes  blood-letting,  and 
repeated  small  bleedings  are  often  of  great  advantage  in  this  form  of  chronic 
valvular  disease. 

The  principles  governing  the  treatment  of  combined  mitral  regurgitation 
and  stenosis  are  rather  those  of  mitral  regurgitation  than  of  mitral  stenosis. 

And  what  shall  be  the  treatment  of  pure  aortic  disease?  It  wdll  be 
remembered  that  both  aortic  obstruction  and  regurgitation  give  rise  to  hyper- 
trophy of  the  left  ventricle,  and  that  this  is  compensatory  in  purpose.  For  a 
time  this  is  quite  sufficient  to  ward  off  any  unpleasant  symptoms,  and  for  a 
still  longer  time  when  associated  with  a  quiet  life.,  the  absence  of  excitement, 
of  exposure,  and  privation.  High  degrees  of  h3'pertrophy  are  accompanied 
with  a  powerful  systolic  impulse,  a  symptom  which  is  of  itself  often  a  source 
of  great  discomfort.  Shall  we,  then,  give  heart  tonics  which  increase  the 
force  of  this  thumping  blow?  Certainly  not.  Shall  w^e  give  aconite  or 
veratrum  viride,  which  slow  the  heart  and  diminish  the  force  of  its  stroke? 
Yes,  at  times  these  remedies  are  very  useful.  W^henever,  as  the  result  of 
overexertion  or  undue  excitement  or  gastric  derangement,  the  heart  is  turbu- 
lently  overactive,  and  even  irregular  in  its  rhythm,  then  I  have  often  seen 
aconite  in  small  doses — say  one  minim  (0.06  c.  c),  or  two  drops,  repeated 
every  half  hour  or  hour  under  close  observation — act  happily,  especially  when 
combined  with  bromid  of  potassium,  say  fifteen  grains  (i  gm.).  The 
tincture  of  veratrum  viride  may  be  given  in  slightly  larger  doses.  As  soon, 
however,  as  this  period  is  past,  the  aconite  should  be  omitted.  Even  in  mitral 
regurgitation  I  have  seen  aconite  act  most  happily  under  these  circumstances. 

We  want  also  in  this  condition  remedies  which  will  help  to  maintain  the 
integrity  of  the  heart  muscle.  Such  are  strychnin,  iron  in  small  doses, 
arsenic,  and  nutritious,  easily  assimilable  food.  Especially  useful  are  well- 
ventilated  living-  and  sleeping-rooms,  wholesome  outdoor  life,  with  moderate, 
deliberate  muscular  exercise.  Like  all  other  muscles,  the  heart  is  strength- 
ened by  judicious  exercise.  In  the  light  of  this  fact  even  the  mountain- 
climbing  advocated  by  Oertel  is  not  so  irrational  and  dangerous  as  it  seems 
at  first  thought.  Very  cautious  and  gradually  increased  exercise  is  doubtless 
intended.  On  the  other  hand,  so  much  judgment  is  required  in  the  applica- 
tion of  this  treatment  that  it  is  perhaps  better  honored  in  the  breach  than  in 
the  observance. 

Such  measures  as  those  described  tend  to  ward  off  the  next  stage,  for 
sooner  or  later  the  integrity  of  the  muscle  of  the  ventricle  yields,  dilatation  is 
added  to  hypertrophy,  the  auriculo-ventricular  orifice  enlarges,  and  w^e  have 
mitral  regurgitation.     Then  the  treatment  becomes  that  for  mitral  disease. 

The  treatment  for  aortic  regurgitation  and  of  aortic  stenosis  with 
regurgitation  is  similar  to  that  of  aortic  stenosis. 

Treatment  of  Dyspnea. — As  the  dyspnea  is  primarily  the  result  of  defi- 
cient blood  aeration  in  the  congested  lungs,  the  same  remedies  which  force 
the  blood  through  these  organs,  and  thus  relieve  the  congestion,  tend  also  to 


598  DISEASES  OF  HEART  AXD  BLOOD-VESSELS. 

relieve  the  dyspnea,  and  often  do  so.  When  the  dyspnea  persists,  it  is  fre- 
quently caused  by  efifusions  into  the  pleural  cavity,  which  are  most  promptly 
and  successfully  removed  by  tapping,  although  a  blister  may  also  answer  the 
purpose.  Repeated  tapping  may  be  necessary.  Dyspnea  not  thus  relieved 
demands  an  opiate,  and  of  opiates  under  these  circumstances,  morphin  is  the 
best.  One-fourth  of  a  grain  (0.0165  gm. )  at  bedtime,  by  the  mouth  or  hypo- 
dermically,  gives  unspeakable  comfort.  Hoffmann's  anodyne,  given  in  fluid 
dram  doses  (3.  5  c  c),  will  sometimes  relieve  the  milder  degrees,  and  should 
perhaps  be  tried  first,  as  it  is  always  desirable  to  put  ofif  the  use  of  morphin 
as  long  as  possible.  Paraldehyd  may  be  substituted  for  Hoffmann's  anodyne 
in  the  same  doses.  Chloralamid  is  even  a  better  remedy  in  thirty-grain  (2 
gm.)  doses.  Sulphonal  may  be  tried  in  full  doses  of  fifteen  to  thirty  grains 
(i  to  2  gm.).  Trional  in  the  same  doses  is  a  similar  drug.  So  is- thermol. 
None  of  these  is  an  anodyne.  They  are  simple  hypnotics,  and  cannot  be 
expected  to  take  the  place  of  morphin.  though  they  may  be  tried  at  first.  All 
the  coal-tar  products  are  more  soluble  in  hot  liquids,  of  which  milk  is  a  typical 
form.  Inhalations  of  oxygen  should  not  be  forgotten  as  sometimes  giving 
signal  relief  in  dyspnea. 

Treatment  of  Dropsy. — In  like  manner  the  measures  that  relieve  the  con- 
gestion and  dyspnea  tend  also  to  relieve  the  dropsy,  but  special  means  are 
also  necessary.  Here  it  is  that  full  doses  of  digitalis  are  especially  indicated, 
and  at  closer  intervals — every  three  hours. 

But  these  measures  are  often  insufficient.  They  may  be  materially 
aided  by  restricting  the  ingestion  of  liquids.  With  the  tissues  water-logged 
and  secretion  insufficient,  it  is  plain  that  copious  liquid  ingestion  only  in- 
creases the  difficulty.  I  am  speaking  now  of  cases  in  which  there  is  general 
dropsy  which  resists  the  ordinary  treatment.  The  principle  of  the  ^Matthew 
Hay  method  is  correct,  but  in  practice  it  is  limited,  because,  with  an  already 
congested  stomach,  solids  cannot  be  digested  without  an  admixture  of  liquid, 
and  further  embarrassment  results  from  the  effort  to  dissolve  them  and  from 
the  presence  of  undigested  residue.  Therefore  it  is  better  to  omit  solid  food 
altogether  and  reduce  the  liquid  to  a  minimum  that  will  sustain  life — not 
more  than  three  ounces  every  two  hours,  and  that  only  during  the  wakirg 
hours.  To  this  may  be  added  the  use  of  purgatives.  While  diuretics  some- 
times fail  us,  we  can  always  secure  an  effect  from  purgatives.  A  daily  morn- 
ing dose  of  Epsom  salts  or  Rochelle  salts  or  compound  jalap  powder  is  given. 
Then,  when  action  of  the  bowels  begins,  full  doses  of  digitalis,  caffein,  or 
spartein,  associated  with  nitro-glycerin,  are  almost  sure  to  be  followed  by 
copious  diuresis :  and  when  diuresis  starts  in  in  these  cases,  it  is  astonishing 
what  quantities  of  urine  are  passed.  The  association  of  nitroglycerin  with 
digitalis  at  this  stage  may  be  helpful.  The  object  of  nitroglycerin  is  to  dilate 
the  renal  artery  and  allow  more  blood  to  pass  through  the  kidney:  i-ioo  to 
1-50  grain  (0.00065  to  0.0013  gm.)  may  be  given  as  often  as  the  digitalis 
and  simultaneously.  One  need  not  be  afraid  of  this  drug.  I  have  given  this 
dose  every  two  hours  for  twenty-four  hours  or  more  at  a  time.  Elimination 
by  the  bowels  and  kidneys  being  simultaneously  stimulated,  the  sucking  up  of 
the  interstitial  fluid  is  greatly  favored  and  often  rapidly  brought  about.  If 
these  measures  be  associated  with  paracentesis  of  the  chest,  which  may  be 
required,  the  diuresis  set  up  is  often  enorm.ous,  while  the  swelling  rapidly 
declines.  As  diuresis  is  established  or  hunger  sets  in  the  quantity  of  milk 
allowed  may  be  increased,  and  when  the  dropsy  has  entirely  disappeared,  a 
cautious  return  to  solid  food  mav  be  permitted. 


HYPERTROPHY  AND  DILATATION.  599 

A  time-honored  remedy  in  the  treatment  of  cardiac  dropsy  which  should 
not  be  overlooked  is  the  combination  of  calomel,  squills,  and  digitalis,  in 
doses  of  1-2  grain  (0.03  gm.)  of  the  first  and  one  grain  (0.065  grn-)  of  the 
second  and  third  every  three  or  four  hours ;  this  is  most  happy  in  its  results. 
Still  another  remedy  sometimes  very  efficient  in  this  form  of  dropsy  is  theo- 
bromin.  It  is  obtained  from  cacao,  and  is  chemically  closely  allied  to 
caffein,  the  latter  being  trimethyl-xanthin,  while  theobromin  is  dimethyl' 
xanthin.  Like  cafifein,  theobromin  is  a  renal  diuretic  as  well  as  a  heart 
tonic.  The  dose  I  have  found  most  satisfactory  is  forty-five  grains  (3  gms.) 
in  the  twenty-four  hours,  coiiveniently  divided  into  doses  of  7  1-2  grains  (.5 
gm.)  every  three  hours,  which,  allowing  for  necessary  interruptions,  results 
in  the  administration  of  at  least  forty-five  grains  in  this  period.  On  the  other 
hand,  diuretin,  which  is  supposed  to  contain  50  per  cent,  of  soluble  theo- 
bromin in  combination  with  salicylate  of  sodium,  I  have  found  of  little  or 
no  use  in  any  form  of  dropsy. 

Treatment  of  Irregularity  of  Heart  Action  and  Palpitation. — For  these 
symptoms,  in  addition  to  the  cardiac  tonics  mentioned,  belladonna  is  also  a 
useful  remedy.  It  may  be  combined  with  digitalis.  A  good  belladonna 
plaster  placed  over  the  palpitating  heart  is  one  of  the  most  efficient  agents  in 
subduing  it.  Nitroglycerin  is  often  very  useful  to  the  same  end;  i-ioo 
grain  (0.00065  gi^i-))  rapidly  increased  to  1-50  grain  (0.0013  gm.).  every 
four  hours  or  oftener,  is  the  proper  dose.  It  may  also  be  combined  with  digi- 
talis, as  previously  directed.  Cardiac  pain  is  also  sometimes  relieved  by  the 
same  remedy. 

For  further  treatment  of  dropsy  see  section  on  Bright's  disease.  Sec 
also  treatment  of  cardiac  dilatation  by  the  Schott  treatment  and  Nauheim 
baths. 


DISEASES  OF  THE  MYOCARDIUM. 

The  heart  is  subject  to  alterations  in  its  muscular  substance  independent 
of  valvular  defect.  Simple  hypertrophy,  dilatation,  fatty  infiltration,  and 
fatty  metamorphosis  or  true  fatty  degeneration,  and  atrophy  are  the  most 
important.  Myositis,  abscess,  and  aneurysm  of  the  walls  of  the  heart  are 
such  rare  conditions  that  they  need  only  be  mentioned  in  passing,  especially 
as  there  is  no  way  to  recognize  them  before  death. 


HYPERTROPHY  AND  DILATATION— ATROPHY. 

Definition. — Some  vagueness  exists  in  the  application  of  these  terms. 
The  word  enlargement  may  be  applied  with  its  literal  meaning  to  any  increase 
of  size,  whether  hypertrophy  or  dilatation.  Hypertrophy  should  be  limited 
to  indicate  such  enlargement  as  is  associated  with  increased  thickness  of  the 
v^alls,  with  or  without  increase  in  the  size  of  the  cardiac  cavities.  When  such 
increased  thickness  is  associated  with  a  cavity  of  normal  size,  it  is  known  as 
simple  hypertrophy.  More  frequently  the  cavity  is  also  enlarged,  producing 
eccentric  hypertrophy,  also  known  as  jjypertrophy  with  dilatation,  but  I  pre- 
fer to  retain  the  term  dilatation  for  pathological  states.  Hypertrophy  is 
physiological.  The  term  concentric  hypertrophy  was  applied  to  a  condition 
in  which  thickening  is  associated  with  reduction  in  the  size  of  the  cavity,  but 


6oo  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

it  is  now  conceded  that  such  condition  is  a  postmortem  product  and  does  not 
exist  antemortem.  Even  simple  hypertrophy  is  more  infrequent  in  the  post- 
mortem room  than  is  supposed.  When  the  left  or  right  ventricle  alone  is 
affected,  the  hypertrophy  may  be  simple  or  eccentric ;  when  there  is  general 
hypertrophy,  it  is  always  eccentric.  All  true  hypertrophies  are  numerical — 
that  is,  there  is  an  actual  increase  in  the  number  of  muscular  fasciculi,  due 
partly  to  a  fission  of  previously  existing  fibers  and  partly  to  a  new  formation 
of  fibers. 

The  word  dilatation  is  applied  to  conditions  in  which  the  cavities  are 
enlarged  without  corresponding  thickening  of  the  walls.  Usually  there  is 
attenuation  of  the  walls.  The  latter  is  the  typical  condition.  Dilatation 
implies  fatty  degeneration,  for  it  is  through  intermediate  degeneration  that 
the  muscular  fasciculi  waste  and  ultimately  disappear,  producing  thinning. 

Hypertrophy  more  frequently  affects  the  left  ventricle,  dilatation  the 
left  auricle  and  right  ventricle,  but  the  whole  heart  may  be  involved  by  one 
or  the  other  condition. 

Hypertrophy  of  the  Heart. 

Etiology. — Hypertrophy  implies  an  overgrowth  of  muscular  tissue,  and 
is  naturally  the  result  of  extra  work,  increased  effort  to  overcome  increased 
resistance,  whatever  its  cause.  The  term  idiopathic  hypertrophy  is  applied 
to  such  hypertrophy  associated  with  no  abnormality  in  the  valves  and  no 
cause  external  to  the  heart  exciting  it  to  overaction.  Hypertrophy  without 
valvular  disease  involves  the  left  ventricle  more  frequently,  but  may  involve 
both  cavities,  and  even  the  right  ventricle  alone. 

The  resistance  needed  to  excite  increased  action  may  be  from  within  or 
from  without,  or  due  to  nervous  influence.  Resistance  from  within  is  occa- 
sioned by  obstruction  to  the  outflow  of  blood  from  the  heart,  or  to  increased 
intravascular  pressure. 

Such  obstruction  is  offered  in  the  case  of  the  left  ventricle  by  aortic 
stenosis,  congenital  narrowing,  aortic  insufficiency,  and  mitral  insufficiency. 
Increased  intravascular  pressure  is  caused  by  endarteritis  and  resulting 
sclerotic  changes  in  the  vessel-walls  and  by  aneurysm ;  by  contraction  stimu- 
lated by  the  irritation  of  toxic  substances  in  the  blood,  such  as  accumulate  in 
Bright's  disease,  or  as  the  result  of  overeating  or  excessive  drinking,  espe- 
cially of  large  quantities  of  beer ;  finally,  by  excessive  physical  exertion.  All 
these  are,  therefore,  causes  of  hypertrophy  of  the  left  ventricle. 

External  obstruction  to  the  contraction  of  the  left  ventricle  is  found  in 
pericardial  adhesions  and  myoc'&rditis.  Such  hypertrophy  is  always  eccen- 
tric. Hypertrophy  of  the  left  ventricle  from  nervous  influence  is  seen  in 
exophthalmic  goiter  and  allied  conditions,  and  in  long-continued  palpitation. 
Constant  mental  excitement  is  a  possible  cause. 

In  the  case  of  the  right  ventricle,  internal  resistance  is  produced  by  pul- 
monary congestion  due  to  mitral  regurgitation  or  to  mitral  stenosis,  to  nar- 
rowing of  the  same  vessel  or  branches,  such  as  occurs  in  pulmonary  emphy- 
sema. Valvular  lesions  of  the  right  side  of  the  heart  produce  hypertrophy  of 
the  right  ventricle,  just  as  those  of  the  left  cause  it  to  hypertrophy.  The 
greater  infrequency  of  these  lesions  and  their  frequent  development  in  ntero 
are  to  be  remembered.  Pericardial  adhesions  also  constitute  a  cause  of 
external  resistance  to  contraction  of  the  right  ventricle. 

Auricular  hypertrophy  is  always  eccentric — that  is,  while  the  walls  are 


HYPERTROPHY  AND  DILATATION.  6oi 

thickened,  the  cavities  are  also  dilated.  Hypertrophy  of  the  left  auricle  is 
usually  caused  by  stenosis  of  the  mitral  orifice,  and  to  a  less  degree  is  a  result 
also  of  regurgitation  of  the  blood  in  incompetency  of  the  mitral  valve.  Hyper- 
trophy of  the  right  auricle  might  also  be  expected  as  a  consequence  of 
regurgitation  of  blood  from  the  right  ventricle  to  the  right  auricle,  but  the 
resistance  to  the  further  backward  flow  into  the  veins  is  so  much  less  than  on 
the  left  side  of  the  heart  that  hypertrophy  is  correspondingly  less  frequent. 
In  like  manner,  even  if  stenosis  of  the  tricuspid  orifice  is  present,  the  same 
conditions  prevent  any  marked  degree  of  hypertrophy  of  the  right  auricle. 

In  all  cases  of  hypertrophy  due  to  disease  of  the  valves  it  is  likely  that  a 
certain  amount  of  distention  of  the  heart  cavity  by  blood  precedes  the  mus- 
cular growth. 

Morbid  Anatomy. — The  hypertrophied  heart  is  altered  in  its  weight, 
dimensions,  and  shape.  The  adult  heart  weighs  in  health,  in  the  male  fifty 
to  sixty  years  old,  about  335  grams  (11.8  ounces)  ;  in  the  female,  295  grams 
(10.44  ounces).  The  average  thickness  of  the  wall  of  the  lefc  ventricle  in 
health  is  from  5-8  to  2-3  inch  (1.6  to  1.7  cm.)  ;  of  the  right  ventricle,  1-6  to 
1-4  inch  (0.4  to  0.6  cm.)  ;  of  the  left  auricle,  1-8  inch  (3  mm.)  ;  the  right 
auricle,  1-12  inch  (2  mm.). 

Hearts  exceeding  these  weights  and  measurements  are,  therefore,  hyper- 
trophied. Measurements  should  be  made  before  rigor  mortis  sets  in  or  after 
it  has  passed  away.  The  latter  may  be  favored  by  soaking  the  heart  in  water. 
Commonly,  the  hypertrophied  heart  does  not  exceed  25  ounces  (750  grn.), 
though  hearts  weighing  48  and  53  ounces  (1440  to  1590  gm.)  have  been 
noticed. 

The  shape  of  the  heart  varies :  in  left  ventricular  hypertrophy  it  is  elon- 
gated to  the  left  and  lies  more  horizontally,  while  the  conical  shape  is  less 
marked  ;  when  both  ventricles  are  hypertrophied,  the  heart  is  round.  In  mitral 
stenosis  with  hypertrophy  of  the  left  auricle  and  right  ventricle  it  is  also 
quadrate,  the  right  ventricle  occupying  the  chief  bulk  of  the  organ,  while  the 
left  ventricle  recedes  behind  it. 

Symptoms. — Hypertrophy,  being  a  process  of  compensation,  is  not  at 
first  attended  by  any  symptoms.  It  is  the  result  of  a  generous  conservative 
efifort  of  nature,  by  means  of  which  symptoms  are  averted.  But  unlike  the 
hypertrophy  of  the  muscles  of  the  blacksmith's  arm,  it  tends  ultimately  to 
degeneration,  and  thus  becomes  the  initial  link  in  a  chain  of  evil  which  is  well 
stated  by  J.  G.  Adami :  *  "  In  the  first  place,  it  leads  to  an  increased  nutri- 
tion of  the  walls  of  the  arteries;  increased  nutrition  leads  to  increased  con- 
nective-tissue growth  of  the  walls ;  increased  fibrous  tissue  of  the  walls  leads 
tO'  contraction  and  increased  rigidity  of  those  walls ;  the  increased  rigidity 
leads  tO'  increased  resistance  to  the  passage  of  the  blood  current.  The 
increased  resistance  requires  increased  propulsive  power  on  the  part  of  the 
ventricular  muscle — that  is  to  say,  increased  work ;  the  increased  work  of 
the  heart  leads  to  overgrowth  and  hypertrophy  (myocarditis),  and  with  this, 
heightened  blood  pressure  and  further  increased  nutrition  of  the  walls,  and 
now,  at  last,  the  stage  is  reached,  this  vicious  circle  continuing,  in  which 
either  the  vessel  walls  give  way  or  the  heart."  From  this  standpoint 
increased  blood  pressure  alone  is  sufficient  to  explain  the  anatomical  changes 
— i.  e.,  the  arterial  sclerosis,  atheroma,  and  fibroid  thickening  so  constantly 
seen  in  valves  and  heart-walls  without  calling  in  chronic  inflammation  or 

*  "Notes  upon  Cardiac  Hypertrophy,"  "Montreal  Medical  Journal,"   May,  1895. 


6o2  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

specific  agency.  Certain  it  is  that  the  two  conditions  react  on  each  other, 
and  it  is  more  than  likely  that  the  former  (increased  blood  pressure)  may 
produce  the  latter  (chronic  inflammation)  de  novo,  and  many  otherwise 
unexplained  facts  are  rendered  clear. 

When  reactive  effect  sets  in,  we  begin  to  have  symptoms  which  are  at 
first  intermittent,  brought  about  only  by  some  temporary  cause  which  excites 
the  heart,  such  as  exercise,  mental  emotion,  fatigue,  mental  or  physical, 
tobacco,  or  alcohol.  There  is  a  feeling  of  vague  discomfort  about  the  heart, 
seldom  amounting  to  pain,  sometimes  increased  when  the  patient  lies  on  the 
left  side.  To  this  may  be  added  palpitation,  a  consciousness  of  the  beating 
of  the  arteries  in  the  head,  dizziness,  headache,  ringing  in  the  ears,  flushes 
or  flashes  of  light,  and  a  tendency  to  hemorrhage  of  the  nose. 

Physical  Signs. — While  symptoms  other  than  physical  signs  may  be 
wanting,  the  latter  are  present  from  the  beginning,  increasing  with  the  dura- 
tion of  the  hypertrophy. 

In  hypertrophy  of  the  left  ventricle  inspection  and  palpation  furnish 
much  the  same  information  as  in  hypertrophy  of  the  left  ventricle  from  val- 
vular disease — an  apex-beat  lower  and  to  the  left,  strong  and  diffuse.  The 
radial  pulse  is  strong  and  tense,  the  carotids  pulsate  visibly,  and  the  auscul- 
tated vessel  sounds  are  loud  and  distinct.  Percussion  shows  enlargement  to 
the  left  and  downward.  To  auscultation  there  is  nd  murmur,  but  a  distinctive 
intensification  of  the  aortic  second  sound  is  noticed,  sometimes  ringing,  quite 
characteristic,  and  itself  of  great  diagnostic  value.  It  may  be  reduplicated. 
The  first  sound,  while  louder,  is  also  duller,  more  prolonged  and  diffuse,  some- 
times suggesting  a  systolic  murmur  not  present.     It  may  also  be  reduplicated. 

In  hypertrophy  of  the  right  ventricle  the  signs  of  enlargement  are  toward 
the  right  edge  of  the  sternum  and  beyond,  also  without  murmur,  but  with 
sharp  accentuation  of  the  second  sound  in  the  pulmonary  area  to  the  left  of 
the  sternum.  The  apex-beat  is  also  displaced  outward,  but  not  downward ; 
pulsation  may  be  distinct  in  the  lower  sternal  or  epigastric  region  or  between 
the  ensiform  cartilage  and  the  seventh  rib.  In  persons  with  thin  chest-walls 
an  impulse  may  be  seen  in  the  third  and  fourth  right  interspaces.  The  pulse 
at  the  wrist  is  small,  unless  there  be  associated  hypertrophy  of  the  left 
ventricle. 

Diagnosis. — In  view  of  the  fact  that  hypertrophy  is  a  part  of  the  mor- 
bid anatomy  of  chronic  valvular  defect,  we  need  concern  ourselves  only  with 
the  so-called  idiopathic  hypertrophy.  The  resemblance  to  hypertrophy  may 
arise  from  pericardial  effusion,  circumscribed  pleuritic  effusion,  aneurysm,  or 
mediastinal  tumor  in  the  neighborhood  of  a  normal  heart,  the  latter  espe- 
cially if  it  push  the  heart  forward.  A  normal  heart  may  appear  enlarged  to 
percussion  when  it  is  uncovered  by  a  lung  retracted  from  any  cause,  as  cir- 
rhosis of  that  organ.  Simple  palpitation  of  the  heart  may  be  mistaken  for 
hypertrophy. 

In  all  cases  the  situation  of  the  apex-beat  is  a  valuable  criterion,  because, 
although  its  position  may  be  changed  in  pleuritic  effusion  and  pericardial 
effusion,  it  is  in  the  opposite  direction  from  that  in  hypertrophy,  while  the 
impulse  is  feeble  instead  of  being  strong.  Aneurysm  and  mediastinal  tumor 
will  certainly  furnish  some  of  the  signs  peculiar  to  them,  and  thus  permit  a 
distinction.  Simple  palpitation  is  without  the  percussion  signs  of  enlarge- 
ment of  the  heart.  Under  none  of  the  circumstances  named  will  its  situation 
be  altered. 

Hypertrophy  may  be  obscured  if  the  heart  is  overlapped  by  an  emphy- 


HYPERTROPHY  AND  DILATATION.  603 

sematous  lung.  This  is  partly  the  case  in  hypertrophy  of  the  right  ventricle, 
which  is  often  associated  with  emphysema  of  the  lungs.  In  such  cases  the 
pulse  does  not  help,  but  rather  tends  to  mislead,  because  it  is  small  in  hyper- 
trophy of  the  right  ventricle. 

Prognosis. — When  associated  with  valvular  disease,  the  prognosis  is 
that  of  the  disease  itself,  against  which  hypertrophy  is,  for  a  time,  a  pro- 
tection, counterbalancing  the  growing  defect  of  the  valve  until  the  nutrition 
of  the  heart  begins  to  be  impaired  and  dilatation  replaces  hypertrophy  with 
loss  of  compensation.  The  latter  may  be  sudden,  though  it  may  be  delayed 
for  a  time  by  treatment.  While  such  malnutrition  may  be  of  local  origin, — 
that  is,  resident  in  the  heart  muscle  itself, — it  may  be  due  to  general  causes 
also,  as  general  illness,  hardship  and  exposure,  overexertion,  fatiguing  occu- 
pation, insufficient  food,  and  the  like.  When  it  is  the  result  of  endarteritis 
and  aneurysm,  the  termination  comes  with  the  rupture  of  the  vessel  or  of  the 
aneurysm. 

In  the  so-called  idiopathic  forms  due  to  toxic  substances  in  the  blood 
d^.nger  does  not  threaten  until  sclerotic  changes  are  established  in  the  blood- 
vessel walls. 

Treatment. — ^This  embraces  that  of  the  causal  condition  and  of  measures 
to  reduce  overaction. 

Dilatation  of  the  Heart. 
Synonym. — Fatty  Degeneration  of  the  Heart. 

Definition, —  This  has  already  been  defined  on  page  600,  so  far  as  the 
state  of  the  chambers  is  concerned.  Dilated  heart  is  of  two  kinds :  first, 
acute  dilatation ;  and,  second,  chronic  dilatation,  or  dilatation  accompanied 
by  fatty  degeneration.  Of  the  latter,  two  varieties  exist :  ( i )  Those  succeed- 
ing valvular  disease;  (2)  those  succeeding  hypertrophy  due  to  muscular 
effort,  especially  when  associated  with  alcoholic  intemperance  and  other  forms 
of  dissipation.  Acute  dilatation  may  be  unassociated  with  structural  change, 
except  as  to  mechanical  arrangement  of  the  muscular  elements.  Cloudy 
swelling  may  be  present.     The  latter  is  associated  with  fatty  change. 

Etiology. — Chronic  dilatation  is  the  last  stage  in  a  valvular  disease  the 
result  of  failing  nutrition.  The  conditions  under  which  this  manifests  itself 
have  been  described.  Acute  dilatation  is  the  result  of  prolonged  muscular 
effort,  such  as  occurs  in  rowing,  running,  and  mountain-climbing.  Moderate 
degrees  of  distention  occur  with  any  decided  muscular  effort.  The  more 
marked  degrees  capable  of  mischievous  consequences  are  the  result  of  pro- 
longed severe  muscular  exertion.  The  effect  of  moderate,  well-regulated 
exercise  on  the  heart,  known  as  training,  by  which  endurance  is  developed, 
is  to  produce  eccentric  hypertrophy,  or  hypertrophy  with  dilatation,  which  is 
not  dilatation  in  the  sense  under  consideration — enlargement  of  the  cavity 
with  thinning  of  the  walls.  The  right  heart  is  the  seat  of  such  dilatation. 
In  overexertion  the  harmful  effect  of  excessive  acute  strain  is  averted  for  a 
time  by  the  safety-valve  action  of  the  tricuspid  valve,  permitting  a  regurgita- 
tion of  blood  into  the  right  auricle.  Dilatation  has  exceeded  its  physiological 
limit  when  the  cavity  is  no  longer  able  to  empty  itself  of  blood,  ^^l^ile 
moderate  degrees  of  acute  dilatation  may  be  recovered  from,  either  rapidly 
or  slowly,  dilatation  may  be  carried  to  degrees  at  which  recovery  is  impos- 
sible and  death  results.  Such  results  have  followed  rowing  and  mountain- 
climbinsf. 


6o4  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

The  so-called  irritable  heart,  to  which  attention  was  first  called  by  J.  M. 
Da  Costa  in  a  graphic  description  based  on  a  study  of  the  cases  of  soldiers  in 
the  American  War  of  the  Rebellion,  is  an  example  of  an  abnormally  dilated 
heart,  a  heart  in  which  compensation  has  failed.  Another  example  of  the 
idiopathic  hypertrophy  already  referred  to  is  seen  in  those  persons  w'ho, 
through  hard  work,  acquire  muscular  strength  and  at  the  same  time,  through 
alcoholic  indulgence,  become  obese.  Such  are  the  drivers  of  beer-wagons 
and  workers  in  breweries  where  an  unlimited  amount  of  beer  is  allowed — 
as  much  as  twenty  liters  (as  many  quarts)  a  day.  After  a  while,  in  these 
hearts  compensation  is  lost  and  the  symptoms  of  dilated  heart  follow.  Sud- 
den dilatation  may  happen  to  hearts  whose  muscular  substance  is  degener- 
ated, though  seemingly  hypertrophied,  as  in  chronic  Bright's  disease,  where 
overexertion  often  brings  on  dilatation.  In  a  few  instances  in  malignant  forms 
of  the  infectious  diseases,  such  as  scarlet  fever  and  diphtheria,  the  nutrition  of 
the  heart  may  be  so  rapidly  impaired  by  the  toxic  agency  which  causes  the 
disease  that  dilatation  occurs  with  very  little  or  no  undue  intravascular 
pressure.  All  these  belong  to  the  second  category,  that  of  chronic  or  slow 
dilatation. 

Symptoms. — The  symptoms  of  "  heart  strain  ''  are  sudden  pain  in  the 
region  of  the  heart  or  epigastrium,  shortness  of  breath,  and  rapid,  feeble 
action  of  the  heart.  If  it  be  not  immediately  fatal,  the  symptoms  may  pass 
ofif,  but  are  renewed  on  the  slightest  exertion.  In  the  acute  cases  described 
as  due  to  the  toxic  causes  of  infectious  disease,  sudden  death  may  be  the  only 
s)'mptom.  In  some  cases  it  may  be  preceded  or  not  by  very  brief  precordial 
distress.  Less  serious  degrees  may  be  associated  with  faintness  or  palpita- 
tion on  exertion,  extreme  feebleness  of  the  heart's  action,  and  dyspnea.  It 
is  rather  characteristic  for  these  symptoms  to  pass  away  wdien  the  patient  is 
at  rest,  to  be  renewed  on  the  slightest  exertion. 

Symptoms  growing  out  of  dilatation  of  the  heart,  going  also  to  make 
up  the  sum  of  those  constituting  chronic  valvular  disease  with  failure  of 
compensation,  are  general  venoits  congestion,  dropsy,  feeble,  frequent,  and 
irregular  radial  pulse — rarely,  on  the  other  hand,  a  sloiv  pulse.  The  former 
may  be  due  to  impaired  pneumogastric  inhibition  the  result  of  anemia  of  the 
brain,  the  latter  to  scanty  nutrition  and  a  loss  of  irritability  of  heart  muscle. 
To  anemia  especially  affecting  the  medulla  oblongata  may  be  ascribed  Cheyne- 
Stokes  breathing,  also  a  symptom  of  the  terminal  stage  of  the  disease.  To  it 
may  be  ascribed,  too,  S3-mptoms  simulating  apoplexy,  vs^hich  characterize  the 
slower  dying  in  some  of  these  cases.  Palpitation,  angina  pectoris,  and 
dyspnea — cardiac  asthma,  with  syncopal  attacks,  coldness,  and  slow  pulse 
(thirty  to  forty) — are  all  symptoms  more  or  less  associated  with  dilatation  of 
the  heart.  It  is  further  characteristic  of  these  symptoms  of  dilatation  that 
they  are  often  not  transient  or  amenable  to  treatment  by  the  usual  heart  tonics, 
of  which  digitalis  is  the  type. 

In  some  instances,  especially  in  the  dilated  heart  of  pernicious  anemia, 
there  may  be  a  full,  strong,  and  regular  pulse. 

High-colored,  scanty  urine  of  high  specific  gravity,  sometimes  contain- 
ing hyaline  casts  and  blood  discs,  also  result  from  cardiac  dilatation. 

Physical  Signs. — When  the  termination  is  not  immediate,  physical  signs 
may  be  recognized.  To  inspection  the  impulse,  if  visible,  may  be  diffused 
over  a  wide  area,  but  is  feeble  and  fluttering,  a  point  of  greatest  intensity  or 
an  apex-beat  being  often  wanting.  At  times  it  is  found  higher  up  and  to  the 
left  of  its  normal  position.      If  the  right  heart  is  chiefly  involved,  the  beat. 


HYPERTROPHY  AND  DILATATION.  605 

as  far  as  caused  by  the  left  apex,  is  completely  wanting,  while  an  impulse 
may  be  felt  below  or  to  the  right  of  the  ensiform  cartilage,  as  well  as  a  wavy 
impulse  in  the  fourth,  fifth,  and  sixth  interspaces  to  the  left  of  the  sternum.  A 
pulsation  may  be  seen  in  the  second  left  interspace,  which,  while  sometimes 
presystolic,  is  commonly  systolic.  In  the  latter  event  it  may  be  a  further 
expansion  of  an  already  dilated  auricle  by  blood  regurgitating  during  systole 
of  the  left  ventricle ;  or  if  presystolic,  it  may  be  the  pulse  of  auricular  systole. 
Such  at  least  are  possible  explanations.  The  fact  that  at  autopsies,  even  in 
extreme  dilatation,  the  left  auricle  is  found  so  far  back  from  the  thoracic  wall 
■as  to  be  scarcely  able  to  beat  against  the  second  interspace,  does  not  preclude 
the  possibility  of  this  during  life.  In  dilatation  of  the  right  auricle,  on  the 
other  hand,  there  is  sometimes  seen  an  impulse  in  the  third  interspace  on  the 
right  side  which  is  clearly  systolic  and  due  to  regurgitation  from  the  right 
ventricle  during  its  systole.  The  pulsating  symptoms  described  in  this  para- 
graph are  commonly  seen  only  in  persons  with  thin  chest-walls. 

To  percussion  there  should  be  increased  dullness  to  the  right  and  down- 
ward toward  the  epigastrium  or  to  the  left  beyond  the  normal  line,  though 
these  boundaries  may  be  obscured  by  an  emphysematous  lung.  The  results 
•of  aiiscultation  are  greatly  influenced  by  complications.  If  cardiac  murmurs 
are  present,  they  may  obscure  all  else.  On  the  other  hand,  previous  murmurs 
may  disappear.  The  typical  sounds  are  found  in  the  dilatation  following 
idiopathic  hypertrophy.  The  impulse  is  feebly  heard  as  well  as  felt ;  the  first 
sound  is  feeble  but  pure — that  is,  shorter  and  more  like  the  second,  lacking, 
as  it  does,  the  muscular  element.  It  may  be  scarcely  audible,  even  in  the 
absence  of  murmurs.  It  is  sometimes  reduplicated  because  of  asynchrony  in 
the  action  in  the  two  halves  of  the  heart.  Sometimes  there  is  a  loud  systolic 
murmur  at  the  apex,  due  to  relative  insufficiency  of  the  mitral  valve,  the  true 
nature  of  which  becomes  apparent  only  in  the  event  of  its  disappearance.  The 
second  pulmonic  sound  may  remain  sharp  if  there  is  dilatation  only  of  the 
left  ventricle  and  there  is  compensatory  hypertrophy  of  the  right ;  feeble  if  the 
right  ventricle  is  involved.  Finally,  there  is  intermittent  and  irregular  action ; 
at  times  the  characteristic  gallop  rhythm/^  which  is  almost  pathognomonic  of 
dilatation,  is  present.     The  pulse  is  very  rapid  and  feeble. 

Diagnosis. — An  acknowledged  difficult  matter  at  times  is  the  dis- 
tinction of  pericarditis  zvith  effusion  from  the  dilated  heart.  Whether  in- 
spection furnishes  any  information,  depends  mainly  upon  the  stoutness  or 
leanness  of  the  patient.  In  the  stout  person  nothing  is  recognizable  in 
either  condition.  In  the  thin-chested  the  impulse  is  visible  and  wave-like 
in  dilatation ;  it  is  not  visible,  or  barely  so,  in  pericardial  effusion.  The 
same  is  true  of  palpation,  except  that,  if  the  patient  leans  forward,  the 
impulse  may  be  felt  in  pericarditis. 

Percussion  affords  the  miost  valuable  information.  If  it  brings  out 
the  well-known  triangular  shape  of  dullness,  with  the  apex  toward  the  inner 
€nd  of  the  left  clavicle,  and  the  base  in  the  fifth  or  sixth  interspace,  espe- 
cially in  the  absence  of  a  cardiac  impulse,  there  must  be  pericardial  effusion. 
To  auscultation,  while  the  heart-sounds  have  lost  their  characteristic  sharp- 
ness, they  still  contrast  with  the  distant  and  muffled  sounds  in  pericardial 
effusion.  Especially  if  there  is  left  any  of  the  original  hypertrophy,  the 
second  sound  will  retain  some  of  its  sharpness,  while,  if  there  happens  to 
have  been  valvular  disease,  the  murmurs  remain  to  help  us. 

*For  explanation  of  gallop  rhythm  see  Barth  and  Roger,  "Traite  Pratique  d' Auscultation." 
"Thirteenth  Edition,  Paris,  i8g8,  p.  352. 


6o6  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

Bamberger's  sign,  described  on  p.  561,  must  be  sought  for  in  evidence 
of  pericardial  effusion.  There  may  be  encroachment  on  the  lung  in  dila- 
tation, but  it  is  very  much  less  in  dilatation  than  in  pericarditis  with  effusion. 
This  encroachment  in  the  case  of  dilatation  does  not  give  rise  to  Skodaic 
resonance  in  the  axilla.  While  there  is  shortness  of  breath  in  both,  it  is 
less  pronounced  in  dilatation  and  more  influenced  by  exertion,  being  less 
while  the  patient  is  quiet. 

Prognosis. — This  is  ultimately  fatal;  in  fact,  the  stage  of  dilatation  is 
the  stage  in  which  remedies  become  unavailing.  At  the  same  time,  marvel- 
ous results  sometimes  follow  treatment.  I, have  seen  general  anasarca  with 
effusions  in  the  serous  cavities  disappear  when  least  expected,  so  that  one  is 
never  justified  in  giving  an  unqualifiedly  unfavorable  prognosis. 

Treatment. — This  is  essentially  that  of  valvular  heart  disease.  Rest 
is  even  more  important,  while  the  heart  tonics  are,  of  course,  indicated. 
Strychnin  is  an  important  remedy,  and  in  dangerous  stages  may  be  given 
hypodermically  in  1-30  grain  (0.0022  gm.)  doses  every  three  or  four  hours 
or  oftener  for  a  short  time.  Digitalis  in  7.5  minims  (0.5  c.  c.)  or  Merck's 
German  digitalin,  in  doses  of  i-io  to  1-2  grain  (1.0066  to  0.033  g"^-)»  ^^^y  ^^ 
given  under  like  circumstances.  Suitable  nutritious  food  and,  if  the  patient 
survives  the  primary  danger,  well-regulated  exercise,  are  indicated.  A  timely 
blood-letting  may  save  life  if  the  signs  of  engorgement  of  the  right  ven- 
tricle are  present — intense  dyspnea,  lividity. 

It  is  in  this  condition  that  the  Schott  or  Nauheim  treatment  is  especially 
useful.  It  consists  in  the  use  of  the  carbonated  saline  baths  at  Bad  Nauheim, 
associated  with  special  exercises  called  "  resistance  "  movements,  originated 
by  the  brothers  Schott.  Fortunately,  artificial  baths  may  be  substituted 
for  the  natural  baths,  or  the  treatment  would  have  limited  application. 
Ignoring  for  the  present  the  rationale  of  the  action  of  these  baths,  their 
therapeutic  efficacy  is  undoubted.  The  waters  at  Nauheim  have  a  tempera- 
ture ranging  from  82°  F.  (27°  C.)  to  95°  F.  (35°  C).  Their  important 
constituents  are  chlorid  of  sodium  and  chlorid  of  calcium. 

The  baths  may  be  imitated  at  home  by  dissolving  chlorid  of  sodium  and 
chlorid  of  calcium  in  water,  to  which  carbonic  acid  is  added  by  decomposing" 
bicarbonate  of  potassium  by  hydrochloric  acid.  Dr.  K.  N.  B.  Camac  has 
calculated  the  required  quantities  of  salt  to  each  forty  gallons  of  water 
for  six  different  strengths  of  the  baths.  In  the  baths  I  recommend  I  have 
adopted  the  proportions  of  sodium  chlorid  and  calcium  chlorid  calculated 
by  Camac,  but  have  slightly  modified  the  proportions  of  carbonic-acid-form- 
ing constituents,  making  three^  strengths  of  the  latter,  after  the  method 
recommended  by  Bezley  Thorne,  of  London  : 

Bath  No.  I  :  Sodium  chlorid,  4  pounds  ;  calcium  chlorid,  6  ounces. 

Bath  No.  2  :  Sodium  chlorid,  5  pounds  :  calcium  chlorid,  8  ounces. 

Bath  No.  3  :  Sodium  chlorid,  6  pounds  ;  calcium  chlorid,  10  ounces. 

Bath  No.  4 :  Sodium  chlorid,  7  pounds  ;  calcium  chlorid,  10  ounces  ;  sodium 
bicarbonate,  1-2  pound  ;  HCl  (25  per  cent.),  12  ounces. 

Bath  No.  5  :  Sodium  chlorid,  9  pounds;  calcium  chlorid,  11  ounces;  sodium 
bicarbonate,  i  pound  ;  HCl,  i  1-2  pounds. 

Bath  No.  6  :  Sodium  chlorid,  10  pounds  ;  calcium  chlorid,  12  ounces  ;  sodium 
bicarbonate,  2  pounds  ;  HCl,  3  pounds. 

I  rarely  use  anything  beyond  No.  4  bath. 

The  alkali  should  always  be  slightly  in  excess,  unless  a  porcelain  or 
paper  tub  is  used. 

In  preparing  the  bath,  the  salts,  including  the  right  proportion  of  bi- 


HYPERTROPHY  AND  DILATATION.  607 

carbonate  of  sodium,  are  dissolved  in  the  water.  The  bottle  containing 
the  hydrochloric  acid  is  inverted  and  lowered  until  its  mouth  is  below  the 
surface,  when  the  stopper  is  withdrawn  and  the  bottle  moved  about  so  as 
to  diffuse  the  acid  as  uniformly  as  possible  through  the  water.  In  this  way 
the  bath  is  made  ready  in  a  few  minutes.  The  carbonic  acid  is  the  most 
unsatisfactory  feature  of  the  artificial  bath,  since  it  is  rapidly  dissipated,  and 
produces  only  feebly  the  effect  of  the  acid  in  the  natural  baths.  Hence  the 
patient  should  be  promptly  put  into  the  bath  after  the  HCl  is  added,  lest 
the  CO,  is  lost  before  he  can  get  the  effect  of  it.  My  plan  has  been  to  give 
-^the  baths  on  alternate  days,  using  the  weaker  until  its  effects  are  exhausted, 
then  passing  on  to  Nos.  3  and  4  in  the  same  manner.  Nos.  5  and  6  are 
not  often  called  for.* 

As  already  stated,  the  baths  are  most  efficient  in  cardiac  disease,  but 
they  are  also  useful  in  renal  affections.  Their  immediate  effect  is  a  dimin- 
ished pulse-rate,  intensified  heart-sounds,  diminished  breathing-rate,  while 
the  dilated  heart  is  reduced  in  size — under  favorable  circumstances  to 
almost  its  natural  limits.  The  effect  is  also  to  increase  the  action  of  the 
kidneys  and  that  of  the  skin.  These  effects  are  apparent  in  a  free  flow  of 
urine,  which  may  continue  for  days  and  weeks.  Metabolic  changes  are 
accelerated  and  improved ;  the  deep-seated  organs,  especially  the  liver  and 
pelvic  viscera,  are  relieved  of  congestion ;  while  the  heart,  relieved  of  its 
burden,  and  contracting  strongly,  derives  from  its  improved  coronary  circu- 
lation material  for  the  repair  of  weakened  and  damaged  tissue. 

I  find  in  my  experience  that  it  is  more  satisfactory  to  give  the  baths 
on  alternate  days  until  about  fifteen  or  twenty  baths  are  taken,  gradually 
passing  from  the  weaker  to  the  greater  strengths,  and  gradually  reducing 
the  temperature  from  95°  F.  (35°  C.)  to  82°  F.  {2y°  C). 

The  exercises  are  not  so  easily  described  as  shown  by  actual  practice, 
but  briefly  they  may  be  said  to  include  every  reasonable  movement  of  the 
arms  and  legs,  gently  resisted  by  opposite  pressure  exerted  by  the  phy- 
sician or  attendant.  Thus,  there  is  flexion  of  the  arms  on  the  forearm, 
carrying  the  arms  forward  until  the  palms  are  apposed,  then  backward 
from  this  position  until  they  are  in  a  line,  and  raising  them  from  the  sides 
upward  until  they  touch  the  sides  of  the  head.  There  are  also  radial  move- 
ments of  the  arms  alongside  of  the  head,  etc. — in  all,  nineteen  movements. 
Similar  movements  are  made  with  the  legs,  including  flexion  and  extension 
at  the  knee-,  ankle-,  and  hip-joints.  They  include  also  lateral  and  twisting 
movements  of  the  trunk. 

The  exercises  are  not  commenced  until  some  very  positive  effect  of 
the  baths  is  secured,  when  they  are  associated  with  the  baths  or  substituted 
after  the  latter  are  discontinued.  The  effects  of  these  gymnastics  are 
described  as  identical  with  those  of  the  baths.  The  extremities  become 
warm,  the  breathing  is  deepened,  the  sense  of  oppression  is  relieved,  the 
pulse  becomes  slower,  the  dilated  heart  area  reduced.  Even  the  liver, 
which  is  so  often  enlarged  in  heart  disease  as  a  result  of  passive  congestion, 
is  said  to  be  reduced  in  size. 

*  I  have  had  constructed  for  use  at  the  Hospital  of  the  Universitj'  of  Pennsylvania  an  apparatus 
for  introducing  carbonic  acid  into  the  water  of  the  bath,  after  a  device  suggested  by  Dr.  Smitheman, 
when  a  student  of  medicine.  ' 


6o8  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 


Atrophy  of  the  Heart — Brown  Atrophy. 

Definition. — Atrophy  of  the  heart  is  the  opposite  state  to  hypertroph}' 
— viz.,  a  reduction  in  the  muscular  substance,  with  a  corresponding  reduc- 
tion in  the  size  of  the  cavities.  It  is  associated  with  pigmentation,  hence 
the  term  brown  atrophy.  It  is  Hmited  cHnically,  being  confined  to  the  sub- 
jects of  wasting  diseases,  Hke  phthisis  puhiionahs  and  carcinoma.  It  is  the 
special  result  of  senile  marasmus.  It  is  occasionally  associated  with  chronic 
valvular  disease.  The  muscular  fasciculi  undergo  molecular  death,  the 
organ  wastes,  and  is  symmetrically  reduced.  It  is  dark  red-brown  in  color 
and  firm  in  consistence.  By  the  microscope  is  recognized  a  peculiar  ar- 
rangement of  pigment  granules  about  the  nuclei  and  between  the  primitive 
fibrillse.  The  source  of  the  pigment  is  not  precisely  known.  It  may  be  the 
coloring  matter  of  the  muscle,  or  directly  derived  from  the  blood. 

The  diagnosis  of  such  condition  can  only  be  based  on  a  diminution  in 
the  normal  area  of  cardiac  percussion  dullness  associated  with  feeble  pulse, 
and  the  long-continued  presence  of  the  causal  disease.  Reduced  area  of 
cardiac  dullness  must  be  unassociated  with  emphysema  of  the  lungs  or  other 
causes  which  may  diminish  cardiac  dullness  by  covering  up  the  heart. 

The  treatment  is  that  of  the  causal  disease. 


DEGENERATIONS  OF  THE  CARDIAC  MUSCLE. 

The  heart  muscle  is  subject  to  parenchymatous  degeneration,  to  fatty 
degeneration,  to  fatty  infiltration,  to  amyloid  degeneration,  to  the  hyaline 
transformation  of  Zenker,  to  calcareous  degeneration,  and  to  the  changes 
known  as  brown  atrophy  and  yellow  atrophy. 

Parenchymatous  or  Albuminoid  Degeneration  (Cloudy  Swell- 
ing).— This  is  a  change  in  which  the  sarcous  substance  is  converted  into 
granular  matter  of  albuminoid  composition,  which  produces  also  more  or 
less  indistinctness  in  the  striated  appearance  of  the  fasciculi.  The  albu- 
minoid composition  of  the  product  is  attested  by  its  solubility  in  acetic 
acid,  and  its  insolubility  in  ether.  The  general  effect  is  one  of  softening 
and  flaccidity. 

It  is  ascribed  to  some  toxic  agency,  and  occurs  most  frequently  in  the 
infectious  fevers — typhoid  fever,  typhus  fever,  scarlet  fever,  diphtheria,  and 
the  like.  It  was  at  one  time  considered  a  consequence  of  high  tempera- 
ture, but  this  view  is  no  longer  held.  It  is  believed  also  to  be,  at  times,  at 
least,  the  first  stage  of  fatty  degeneration,  or  to  precede  fatty  degeneration. 
It  is  certainly  at  times  associated  with  it.  Cloudy  swelling  may  disappear 
and  the  muscle  resume  its  natural  histology. 

Fatty  Degeneration  or  Fatty  Metamorphosis. — In  this  change, 
also  sometimes  known  as  yellozv  atrophy,  the  sarcous  substance  of  the  mus- 
cular fasciculi  is  directly  converted  into  globular  fat,  as  contrasted  with 
the  condition  of  fatty  infiltration,  in  which  the  fat  is  deposited  between  the 
fasciculi.  The  little  fat  drops — and  they  are  very  minute,  as  a  rule — are 
seen  in  rows  parallel  to  the  fibrillse  of  the  fasciculus,  and  all   transverse 


DEGENERATIONS    OF    THE   MYOCARDIUM.  609 

striation  has  disappeared.  As  intimated,  the  cause  of  such  degeneration  is 
an  interference  with  the  proper  nutrition  of  the  heart-muscle. 

It  may  be  general,  when  it  has  its  most  frequent  expression  in  the 
dilated  heart  which  succeeds  upon  hypertrophy,  involving  the  walls  of  one 
or  more  cavities.  It  is  also  a  result  of  the  impaired  nutrition  of  old  age,  of 
the  grave  infectious  diseases,  and  of  cachectic  states  generally — such,  for  ex- 
ample, as  pernicious  anemia.  In  the  infective  diseases  and  cachexias  it  may 
be  associated  with  parenchymatous  degeneration  or  succeed  upon  it.  It  is 
also  a  result  of  the  action  of  certain  poisons,  as  phosphorus  and  arsenic, 
.the  effects  of  which  may  extend  to  other  muscular  organs.  Under  these 
circumstances,  the  heart  is  generally  enlarged  (dilated),  flabby,  and  relaxed, 
of  a  light  yellow  or  yellowish-brown  color,  and  very  friable,  permitting  the 
finger  to  be  easily  poked  through  it.  The  papillary  muscles  and  the  tra- 
beculae  in  the  left  ventricle  may  be  the  seat  of  circumscribed  fatty  degen- 
eration, and  be  dotted  and  streaked  with  yellow,  fatty  matter.  Unlike 
parenchymatous  degeneration,  fatty  degeneration,  when  once  established,  is 
considered  irremediable. 

Fatty  degeneration  of  the  heart  may  also  be  circiimscrihed  in  small  foci 
variously  distributed.  Thus,  it  may  be  confined  to  the  superficial  or  sub- 
pericardial  layers,  when  it  is  especially  the  result  of  pericarditis.  Or  there 
may  be  numerous  pinhead-sized  foci  in  the  subendocardial  layer  in  cases  of 
extreme  dilatation. 

Finally,  there  may  be  a  single  focus  in  the  substance  of  the  left  ven- 
tricle or  the  septum,  due  to  total  obstruction  of  one  of  the  branches  of  the 
coronary  artery,  usually  the  anterior,  by  a  thrombus  or  embolus.  The 
product  is  an  area  of  fatty  degeneration  known  also  as  anemic  necrosis,  or 
white  infarct.  In  the  early  stage  the  infarction  is  brownish-yellow  or 
hemorrhagic.  Minutely  examined,  the  muscular  fasciculi  are  without  nuclei, 
and  later  they  break  up  into  a  cheesy  detritus.  The  infarct  is  not  always 
thus  made  of  fatty  debris,  but  may  present  a  hyaline  appearance.  It  may 
be  the  seat  of  rupture,  and  thus  cause  hemorrhage  into  the  pericardium,  and 
immediate  death. 

Diagnosis. — The  diagnosis  of  fatty  degeneration,  so  far  as  recogniz- 
able, is  that  of  dilatation,  slight  degrees  and  circumscribed  fatty  degeneration 
being  unrecognizable,  while  considerable  areas  of  partial  degeneration  may 
also  exist  without  exhibiting  symptoms.  In  fact,  the  presence  of  some 
dilatation  of  the  cardiac  cavities  seems  to  be  necessary  to  the  production 
of  symptoms — the  feeble  pulse,  palpitation,  and  dyspnea  being  symptoms 
of  the  dilatation,  rather  than  the  fatty  degeneration. 

Prognosis. — This  is  grave.  It  is  impossible  to  restore  the  degener- 
ated muscular  substance  to  its  natural  structure.  With  degeneration  estab- 
lished death  is  liable  to  occur  suddenly,  and  remedies  which  avail  with  an 
integral  organ  are  useless  here. 

Treatment. — This  embraces  that  of  cardiac  dilatation.  Acute  attacks 
should  be  met  by  stimulants,  of  which  alcohol,  aromatic  spirit  of  ammonia, 
and  digitalis  are  the  type.  Strychnin  is  also  indicated,  and  may  be  used 
hypodermically. 

Fatty  Infiltration  or  Fatty  Overgrowth. — Strictly  speaking,  this  con- 
dition is  not  a  degeneration  of  the  heart  muscle,  though  it  leads  ulti- 
mately to  fatty  metamorphosis.  It  is  the  cor  adiposum  of  the  older  authors, 
and  differs  from  fatty  metamorphosis  in  that  the  fat  is  infiltrated  between  the 
muscular  fasciculi.     In  the  true  cor  adiposum,  the  fat  extends  deep  into  the 

39 


6io  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

substance  of  the  muscle,  sometimes  as  far  as  the  endocardium.  It  covers 
also  the  outside  of  the  heart,  at  times  so  completely  that  the  true  muscular 
structure  is  invisible.  This  infiltration  sooner  or  later  interferes  with  the 
proper  nutrition  of  the  muscular  substance,  a  true  fatty  degeneration  results, 
with  its  symptoms,  so  far  as  any  are  manifested,  and  becomes  ultimately 
also  a  cause  of  death. 

The  fatty  infiltrated  heart  is  commonly  a  part  of  general  obesity,  and 
occurs,  therefore,  at  a  time  of  life  when  this  is  usual, — that  is,  between  the 
ages  of  forty  and  seventy  years, — and  is  more  than  twice  as  frequent  in 
men  as  in  women. 

The  condition  is  inferred  from  the  presence  of  extreme  obesity  asso- 
ciated with  signs  of  cardiac  weakness. 

The  treatment  is  that  of  obesity. 

Amyloid  infiltration  invades  the  heart  as  it  does  other  organs,  at- 
tacking the  blood-vessels  and  intermuscular  connective  tissue.  Zenker's 
hyaline  transformation  attacks,  on  the  other  hand,  the  muscular  fasciculi, 
causing  them  to  appear  swollen  and  transparent,  and  the  striae  to  be  indis- 
tinct or  absent. 

Calcareous  infiltration  is  a  rare  condition,  in  which  the  muscular  fas- 
ciculi are  infiltrated  with  lime  salts. 


MYOCARDITIS. 

Chronic  Myocarditis  or  Fibromyocarditis. 

Synonyms. — Fibroid  Degeneration  of  the  Myocardium;  Fibroid  Heart; 
Fibrous  Myocarditis;  Interstitial  Myocarditis;  Indurated  Degeneration; 
Myodegeneration ;  Sclerosis  of  the  Coronary  Arteries. 

Definition. —  A  condition  of  the  cardiac  muscle  in  which  there  is  more 
or  less  substitution  of  the  normal  substance  by  fibroid  tissue,  either  localized 
in  patches  or  diffused  throughout  the  organ.  It  is  analagous  to  fatty  infil- 
tration. 

Etiology  and  Pathology. — The  condition  is  not,  strictly  speaking,  in- 
flammatory, the  patches  representing  transformed  areas  of  anemic  necrosis, 
due  to  obstructive  disease  of  the  coronary  arteries  and  branches.  The  dis- 
ease in  the  coronary  arteries  is  endarteritis,  resulting  in  arteriosclerosis.  It 
not  only  diminishes  the  blood  supply,  but  it  causes  degeneration  of  the  mus- 
cular fasciculi,  and  their  substitution  by  fibrous  tissue.  Only  in  the  event 
of  such  diminished  supply  do  the  changes  occur.  Hence  it  is  that  arterio- 
sclerosis of  the  coronary  arteries  is  not  always  followed  by  fibroid  change. 
The  causes  of  arteriosclerosis  of  the  coronary  arteries,  which  in  its  turn 
gives  rise  to  the  fibroid  change,  are  those  of  endarteritis  elsewhere.  They 
include  all  the  causes  which  produce  idiopathic  hypertrophy  (p.  603).  The 
tendency  to  arteriosclerosis  is  often  hereditary.  It  is  a  disease  also  which 
seldom  occurs  prior  to  middle  life,  though  sometimes  seen  surprisingly 
early.  It  might  be  said  that  it  is  natural  to  old  age — one  of  its  evolutional 
terminations.  In  pure,  uncomplicated  cases  the  valves  are  normal,  while  the 
muscle,  on  examination,  is  found  dotted  with  white,  shining  areas  present  in 
varying  numbers.  Minutely  examined,  these  are  found  made  up  of  pure  or 
partly  fibroid  tissue,  the  muscular  fasciculi  being  correspondingly  destroyed. 


MYOCARDITIS.  6ii 

They  are  seated  for  the  most  part  in  the  left  ventricle  toward  the  apex  and  in 
the  anterior  zvall,  though  they  may  be  found  elsewhere.  They  may  often  be 
seen  from  the  endocardial  or  pericardial  surface  as  cicatricial-like  depressions. 
Sometimes  there  is  a  single  large  patch  known  as  a  Hbroid  patch.  The 
papillary  muscles  may  exhibit  the  same  fibroid  change. 

The  fibroid  change  may  also  be  associated  with  valvular  disease,  the 
mechanical  impediment  to  the  movement  of  blood  in  these  conditions  being 
the  cause  of  a  chronic  venous  congestion,  which  results  in  a  fibroid  infiltra- 
tion ;  or  the  valvulitis  may  give  rise  to  embolism  of  the  coronary  arteries  or 
branches,  thus  cutting  off  nutrition.  From  the  cardiac  thrombosis  which 
sometimes  results  there  may  arise  cerebral,  renal,  and  pulmonary  embolism. 
Long-standing  emphysema  of  the  lungs  results  in  similar  congestion ;  so 
does  obstruction  of  the  pulmonary  artery  from  any  cause. 

A  further  result  of  the  fibroid  change  is  dilatation  of  a  part  or  of  the 
whole  of  one  of  the  heart  cavities,  producing  in  the  former  instance  what  is 
known  as  cardiac  aneurysm.  Fibrosis  may  also  be  associated  with  hyper- 
trophy without  valvular  disease,  though  the  recognition  of  such  combination 
before  death  must  be  a  matter  of  inference,  based  on  the  presence  of  arterio- 
sclerosis elsewhere  and  of  the  causes  of  such  hypertrophy. 

Symptoms. — Slight  degrees  of  fibroid  change  occasion  no  symptoms, 
while  autopsies  even  disclose  advanced  stages  of  indurative  myocarditis 
which  were  not  suspected.  In  consequence  of  the  frequent  association,  too, 
of  endocarditis  and  pericarditis,  the  symptoms  of  these  diseases  are  often 
combined  and  mask  the  distinctive  symptoms  of  the  fibroid  change.  Un- 
masked, the  symptoms  are,  in  a  word,  those  of  dilatation  of  the  heart,  in- 
cluding dyspnea,  often  so  severe  that  the  patient  cannot  lie  down.  With 
this  may  be  associated  Cheyne-Stokes  breathing,  commonly  occurring  during 
sleep.  There  may  be  palpitation,  with  small,  frequent,  and  irregular  pulse, 
or  the  pulse  may  be  unnaturally  slow.  There  is  precordial  oppression,  with 
attacks  of  faint ness,  and,  finally,  venous  stasis  with  cyanosis,  general  edema, 
congestion  of  the  liver,  stomach,  and  kidneys,  feeble  digestion,  scanty  urine, 
and  albuminuria.  These  symptoms  may  set  in  gradually  or  suddenly.  On 
such  a  heart,  digitalis  and  other  heart  tonics  are  often  without  effect.  A 
persistently  slow  pulse  should  be  mentioned  as  an  occasional  symptom. 
Angina  pectoris  is  also  a  symptom  of  indurative  myocarditis,  though  it  also 
occurs  in  other  cardiac  diseases,  especially  aortic  stenosis.  It  will  be  de- 
scribed when  treating  of  neuroses  of  the  heart.  The  same  symptoms  may 
aris^  from  fatty  heart. 

A  very  interesting  train  of  nervous  symptoms  may  arise,  due  to  changed 
local  distribution  of  blood  in  the  brain,  partly  due  to  feeble  cardiac  action 
and  partly  to  stenosis  of  the  basilar  vessels.  They  may  include  brief  un- 
consciousness and  various  degrees  of  paralysis,  and  anesthesia  resembling 
the  symptoms  of  cerebral  embolism. 

Physical  Signs. — Physical  examination  recognizes  a  feeble  impulse, 
often  scarcely  appreciable,  and,  on  percussion,  either  enlargement  of  the 
heart — dilatation — or  the  reverse.  The  first  sound  lacks  its  muscular  element, 
and  is  more  like  the  second — more  purely  valvular,  and  therefore  short. 
Both  sounds  maintain  for  a  time  considerable  distinctness,  but  ultimately 
grow  feeble.  Occasionally  there  maA-  be  a  mitral  murmur,  which  may  be 
functional  and  transitory  or  permanent.  Such  murmur  is  explained  by  the 
experiments  of  Ludwig  and  Hesse,  already  alluded  to,  and  more  recentiv 
confirmed   bv   Krehl.     These   go  to   show   that   a   certain   integrity   of   the 


6i2  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

muscles  about  the  mitral  orifice  or  of  the  papillary  muscles  is  necessary  to 
a  complete  closure  of  the  latter.  Such  integrity  is  impaired  by  myocarditis, 
and  the  resulting  murmur  increases  the  difficulty  of  diagnosis.  There  is, 
however,  usually  absence  of  accentuation  of  the  pulmonic  second  sound 
characteristic  of  mitral  regurgitation,  though  this  may  also  be  relatively 
present  if  the  right  ventricle  happens  to  be  less  severely  involved  than  the 
left.  The  second  sound  is  also  sometimes  reduplicated.  The  mitral  mur- 
mur in  the  fibroid  heart  is  more  variable  and  more  subject  to  intermissions 
than  that  of  mitral  regurgitation.  The  sudden  addition  of  a  mitral  systolic 
murmur  in  a  fibroid  heart  previously  without  murmur  may  also  indicate 
a  lacerated  valve. 

Diagnosis. — This  is  often  difficult,  requiring  the  opportunity  of  pro- 
longed study  of  the  case  for  an  accurate  diagnosis.  For  the  most  part,  we 
are  compelled  to  rely  on  the  absence  of  the  symptom.s  and  signs  of  valvular 
disease,  and  the  presence  of  the  symptoms  of  dilatation,  the  evidences  of 
arteriosclerosis  elsewhere,  a  persistently  slow  pulse,  angina  pectoris,  the 
history  of  syphilis  and  of  other  causes,  together  with  the  age  of  the  patient. 
When  the  fibroid  condition  is  associated  with  murmurs,  the  diagnosis  is  still 
more  difficult,  and  must,  indeed,  be  a  matter  of  probability,  if  even  suggested, 
so  much  more  likely  are  the  signs  to  be  interpreted  as  those  of  valvular 
disease,  with  which,  however,  the  fibrosis  may  be  associated.  The  presence 
of  radial  sclerosis  is  strongly  confirmatory,  but  not  essential. 

Prognosis. — This  is  grave,  or,  to  say  the  least,  uncertain.  Associated 
as  it  is  with  sclerosis  and  narrowing  of  the  coronary  arteries  or  branches, 
complete  obstruction  is  liable  to  occur  at  any  time,  producing  sudden  death. 
On  the  other  hand,  the  patient  may  live  for  many  years  with  the  heart  the 
seat  of  considerable  fibroid  change. 

Treatment. — ^This  must  mainly  consist  in  treating  the  causes,  and  in 
a  proper  hygienic  management.  Habits  of  overeating  and  excessive  drink- 
ing should  be  overcome.  The  avoidance  of  overexertion,  associated  with 
just  sufficient  exercise  to  develop  the  heart  healthfully,  should  be  observed. 
Outdoor  life  and  a  proper  hygiene  of  the  skin  and  body  by  bathing  and 
massage  are  important. 

Drugs  which  will  remove  the  diseased  condition  of  the  coronary  arteries 
and  fibroid  overgrowth  probably  do  not  exist.  Still,  the  reputation  of 
iodid  of  potassium  as  a  remover  of  fibroid  overgrowth  and  for  the  cure  of 
svphilitic  disease  should  be  availed  of.  The  iodid  is  also  serviceable  in  pro- 
ducing vascular  dilatation  and  facilitating  the  movement  of  the  blood.  For 
the  symptoms  of  stasis  and  hgart  weakness,  of  dyspnea  and  of  angina  pec- 
toris, the  treatment  is  the  same  as  that  for  these  conditions  under  other 
circumstances.  The  judicious  use  of  digitalis  is  indicated,  and  may  accom- 
plish much.     Nitroglycerin  may  be  associated  with  advantage  or  used  alone. 


Acute  Suppurative  Myocarditis. 
Synonym. — Abscess  of  the  Heart. 

This  is  a  rare  condition.  It  is  always  metastatic  or  pyemic  in  origin, 
in  association  with  puerperal  fever,  malignant  endocarditis,  or  other  septic 
processes.     It  may  occur  in  the  septum,  as  well  as  the  outer  ventricular  walls. 

As  such  it  is  not  recognizable  before  death,  and  is  commonly  discovered 


MYOCARDITIS.  613 

at  autopsies.  It  may,  however,  rupture  into  the  heart  cavities,  causing 
other  metastatic  abscesses,  or  into  the  pericardium,  causing  septic  pericarditis 
and  early  fatal  termination. 

Aneurysm  of  the  Heart. 

This  is  a  term  given  to  two  conditions : 

1.  A  saccular  projection  from  the  ventricular  surface  of  a  sigmoid  or 
cuspid  leaflet,  where  the  valve  is  weakened  by  ulceration  through  one  of 
the  lamellse,  the  intravascular  or  intracardiac  pressure  furnishing  the  dis- 
tending force.  It  is  much  more  common  in  the  aortic  segments.  The  sac- 
cule may  ultimately  perforate,  causing  laceration  of  the  valve. 

2.  Projection  outward  of  a  circumscribed  portion  of  the  muscular  wall, 
which  has  been  weakened  by  the  fibroid  patch  or  by  an  injury  to  the  wall. 
Here,  naturally,  the  left  ventricle,  too,  suffers,  and  near  the  apex  in  more 
than  half  the  cases.  The  resulting  pullulation  varies  in  size  from  2-5  inch  ( i 
cm.)  or  less  to  dimensions  equal  to  those  of  the  heart  itself.  The  aneurysm 
may  be  sacculated  or  partitioned  and  even  multiple. 

There  are  no  symptoms  by  which  the  condition  may  be  recognized 
with  any  degree  of  probability.  It  may  also  terminate  fatally  by  rupture 
into  the  pericardium. 

Rupture  of  the  Heart. 

Rupture  of  the  normally  integral  heart  muscle  does  not  occur.  It  is 
only  when  weakened  by  disease  that  such  an  event  is  possible.  Fatty  meta- 
morphosis furnishes  the  most  frequent  predisposing  condition.  The  soften- 
ing due  to  obstruction  of  a  branch  of  the  coronary  arter}^,  as  already 
described  on  page  610,  and  known  as  massive  softening,  is  the  most  frequent 
cause  of  heart  rupture,  but  the  fibroid  change,  abscess,  or  ulceration  are  all 
conditions  which  at  times  precede  rupture.  Morbid  growths  in  the  heart- 
wall,  such  as  gummy  tumor  and  carcinoma,  are  also  possible  causes. 

These  preliminary  conditions  presupposed,  any  unusual  strain  is  suf- 
ficient to  produce  rupture,  though  this  is  not  always  necessary,  especially 
in  the  case  of  the  white  infarct,  where  the  degeneration  is  so  great  as  to 
admit  rupture  with  the  ordinary  pressure.  It  is  naturally  an  event  of  the 
second  and  third  half-centuries  of  life. 

The  anterior  portion  of  the  left  ventricular-wall  near  the  septum  is  the 
favorite  seat.  Rupture  is  rarely  recognized  before  death,  which  usually 
follows  in  the  course  of  a  few  hours.  The  symptoms  are  precordial  pain, 
a  sense  of  oppression,  dyspnea,  pulselessness,  and  collapse.  There  may  be 
enlargement  of  the  cardiac  area  of  dullness,  owing  to  filling  up  of  the  peri- 
cardial sac. 


6i4  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

NEUROSES  OF  THE  HEART. 

NERVOUS  PALPITATION. 

Definition. — By  this  is  meant  an  unnaturally  frequent,  regular,  or 
irregular  beating  of  the  heart,  of  which  the  patient  is  uncomfortably  con- 
scious, but  which  is  unattended  by  any  physical  evidence  of  organic  disease 
of  the  organ.  This  does  not  mean  that  there  may  not  be  functional  or  acci- 
dental murmurs,  because  these  are  especially  prone  to  be  present  in  the 
different  varieties  of  anemia  which  are  commonly  associated  with  palpita- 
tion. Such  murmurs  are  always,  however,  systolic,  a  diastolic  murmur 
always  indicating  organic  disease.  Palpitation,  or  uncomfortable  heart- 
beating,  also  occurs  in  connection  with  organic  disease  of  the  heart,  but  this 
is  not  nervous  palpitation. 

Etiology, — There  are  numerous  causes  of  palpitation.  In  the  first 
place,  it  is  much  more  frequent  in  women  than  in  men.  Again,  it  is  prone 
to  occur  at  the  time  of  puberty  in  girls,  and  at  the  menstrual  period  and 
climacteric  in  women.  Anemia  is  at  once  a  predisposing  and  an  exciting 
cause ;  indigestion  is  a  very  frequent  causal  agent.  Mental  emotion,  in- 
cluding fright,  anxiety,  and  grief,  diseases  of  the  uterus  and  stomach,  the 
exhaustion  of  protracted  illness,  sexual  excesses,  overwork,  the  abuse  of 
alcohol,  tobacco,  tea,  and  coffee,  are  all  active  etiological  elements.  The 
"  irritable  heart  "  described  by  Da  Costa,  based  on  observations  made  on 
soldiers  in  the  late  War  of  the  Rebellion  in  America,  has  for  its  most  strik- 
ing symptom  palpitation ;  yet  this  dare  not  be  called  nervous  palpitation, 
as  dilatation  of  the  heart  was  probably  here  present.  Overwork  and  excite- 
ment were  its  chief  causes,  abetted  by  exhaustion  from  illness. 

Symptoms. — The  "  beating  "  referred  to  is,  of  course,  the  chief  symp- 
tom. It  varies  greatly,  however,  in  degree  and  duration.  At  times  there 
is  a  mere  fluttering,  lasting  for  a  few  minutes.  At  other  times  the  pulse- 
rate  may  reach  i6o  or  more  and  be  scarcely  countable.  When  the  character 
last  described  is  attained,  and  continues  for  a  variable  time  of  hours  to  days, 
but  finally  ceasing,  the  term  paroxysmal  tachycardia  is  applied.  The  rapid 
heart-action  is  sometimes  associated  with  a  sense  of  weakness  or  "  gone- 
ness "  in  the  epigastrium,  and  sometimes  with  natisea.  The  face  is  usually 
pale,  but  is  sometimes  flushed.  The  physical  signs  usually  add  nothing  to 
the  undue  beating  noted  on  auscultation,  though,  as  already  mentioned, 
there  may  be  functional  murmurs  systolic  in  time  at  the  base  of  the  heart, 
more  rarely  at  the  apex.  The  normal  heart-sounds  may  be  somewhat 
sharper  and  clearer,  or  they  may  be  more  blurred. 

Diagnosis. — The  only  two  conditions  with  which  nervous  palpitation 
may  be  confounded  are  myocarditis  and  fatty  degeneration  of  the  heart  and 
dilatation,  the  symptoms  of  which,  it  will  be  remembered,  are  similar.  The 
nervous  affection  is,  however,  a  less  serious  affection,  characterized  by 
intermissions  during  which  the  heart  is  quiet.  Its  subjects  are  also  of  the 
anemic  nervous  type,  whose  history  greatly  aids  the  diagnosis,  and  they 
are  commonly  younger, 

.  Treatment, — This   is  by   rest,   nerve   sedatives,   and   a  suitable   moral 
treatment  of  encouraging  words  and  a  confident  manner.     A  few  drops  of 


TACHYCARDIA  AND  BRADYCARDIA.  615 

tincture  of  digitalis,  with  a  few  more  grains  of  sodium  bromid,  repeated 
every  hour,  may  be  useful.  When  the  patient  is  weak  and  anemic,  he  should 
be  built  up  and  strengthened  by  iron,  quinin,  and  strychnin. 


TACHYCARDIA  AND  BRADYCARDIA. 

Paroxysmal  Tachycardia. — This  term  is  applied  to  conditions  of  the 
heart  in  which,  without  evident  cause,  there  appears  paroxysmally  an 
inordinate  increase  in  the  number  of  heart-beats  a  minute,  of  which  also 
the  patient  is  conscious.  The  number  of  beats  may  reach  200  or  more. 
The  paroxysm  may  last  for  a  few  minutes  only,  or  for  hours.  The  inter- 
vals between  two  attacks  vary  greatly,  and  their  recurrence  may  extend 
over  many  years. 

Bradycardia;  Brachycardia ;  Sloiv  Heart. — The  term  bradycardia  is 
applied  to  urmatural  slowness  of  pulse.  It  is  to  be  remembered,  how- 
ever, that  some  healthy  persons  naturally  have  a  slow  pulse,  as  others  have 
one  whose  rate  is  more  rapid  than  the  typical  y2.  A  rate  of  from  50  to  5o 
is  not  unusual.  It  may  even  be  slower,  as  in  the  case  of  a  patient  of  mine 
whose  habitual  pulse  for  many  years  of  my  observation  was  from  36  to  40. 
I  do  not  know,  however,  what  it  was  in  youth.  Of  abnormally  infrequent 
rates,  cases  with  20  beats  are  reported,  some  even  at  12,  9,  and  7.  These 
instances  of  extremely  slow  rate  are  apt  to  be  associated  with  fibroid  heart, 
and  there  can  be  no  doubt  that  the  nervous  condition  is  often  confounded 
with  the  organic  one. 

In  the  study  of  an  apparently  slow  pulse,  care  must  be  taken  that  the 
actual  count  is  based  on  a  corresponding  heart-rate,  for  it  sometimes  hap- 
pens that  in^  consequence  of  the  weakness  of  an  alternate  systole  the  heart- 
beat does  not  reach  the  wrist. 

Bradycardia  occurs  under  a  variety  of  conditions,  which  have  been 
carefully  collected  by  Riegel.     They  include  the  following : 

1.  Convalescence  from  acute  fevers,  such  as  typhoid,  pneumonia,  diph- 
theria, acute  rheumatism,  and  the  like. 

2.  Diseases  of  the  digestive  apparatus,  especially  dyspepsia,  but  also 
ulcer  and  cancer  of  the  stomach. 

3.  Rarely  in  diseases  of  the  respiratory  system. 

4.  Diseases  of  the  circulatory  system,  more  frequently  those  involving 
the  muscular  structure  of  the  heart,  and  associated  with  deficient  nutritive 
supply,  especially  conditions  succeeding  obstruction  to  the  coronary  artery. 

5.  In  nephritis. 

6.  From  the  action  of  toxic  agents,  including  the  uremic  poison,  lead, 
alcohol,  coffee,  and  digitalis. 

7.  Certain  diseases  of  the  nervous  S3'stem,  including  apoplexy,  brain 
tumors,  especially  those  involving  the  medulla  and  cervical  cord.  (To 
these  may  be  added  epilepsy  and  catalepsy. — Author.) 

8.  Finally,  affections  of  the  skin  and  sexual  organs. 

Explanation  of  Tachycardia  and  Bradycardia. — The  rationale  of  the 
production  of  tachycardia  and  bradycardia  has  excited  much  discussion  and 
cannot  be  said  to  be  settled.  The  heart's  action  is  accelerated  by  stimulating 
the  accelerator  branch  of  the  sympathetic  or  by  paralysis  of  the  inhibitory 
root  of  the  pneumogastric,  and  slowed  by  stimulation  of  the  latter,  directly 
or  reflexly.     Direct  stimulation  of  the  latter  is  caused  by  pressure  on  its  root. 


6i6  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

which  may  be  exerted  through  the  cerebrospinal  fluid,  which  in  turn  may  be 
excited  by  brain  tumor,  hemorrhage,  and  meningitis  of  the  dura  or  pia.. 
Such  irritation  may  be  caused  by  toxic  constituents  of  the  blood,  as  in  uremia. 

Increased  arterial  pressure — such,  for  example,  as  occurs  in  acute 
nephritis — is  said  also  to  produce  cerebral  vagus  irritation.  On  the  other 
hand,  such  slowing  is  not  maintained  if  the  arterial  tension  is  kept  up,  as  in 
chronic  Bright's  disease  and  arterial  sclerosis.  Under  such  circumstances 
the  excitability  of  the  penumogastric  center  may  be  said  to  be  exhausted. 
Deficient  nourishment  to  the  heart  substance,  such  as  is  caused  by  atheroma 
and  obstruction  of  the  coronary  artery,  leads  also  to  a  slow  pulse.  Refiexly, 
the  pneumogastric  may  be  stimulated  by  diseases  of  the  abdominal  organs — 
as,  for  example,  the  stomach,  bowels,  and  peritoneum.  The  effect  of  disease 
of  the  muscular  substance  of  the  heart  in  reducing  its  rate  has  often  been 
mentioned  in  the  foregoing  section.  On  the  other  hand,  poisons  and  high 
temperature  increase  the  pulse-rate.  In  this  way  the  infectious  diseases  may 
produce  acceleration.  Other  poisons  slow  the  pulse,  possibly  by  acting  on 
the  nerve  endings  in  the  heart.  Such  are  the  salts  of  the  biliary  acids  and 
the  uremic  poison,  whatever  it  may  be. 

It  is  well  known  that  in  the  course  of  acute  infectious  diseases,  especially 
typhoid  fever,  slowing  of  the  pulse  occurs  at  times  very  strikingly.  This  is 
not  uncommon  in  the  beginning  of  convalescence.  It  has  been  observed  also 
in  typhus  fever,  in  croupous  pneumonia,  erj'sipelas,  diphtheria,  and  measles. 
I  have  met  it  as  slow  as  i8  in  typhoid  fever.  In  explanation  of  this  phe- 
nomenon one  may  suppose  a  lesion  of  the  cardiac  ganglia  by  the  toxic  sub- 
stances circulating  with  the  blood,  or  a  consequent  weakness  of  the  heart 
muscle  due  to  the  long  continued  fever.* 

His  and  Romberg,  in  their  studies  on  the  innervation  of  the  heart,  were 
led  to  believe  that  the  cardiac  ganglia  are  sensory  in  function  and  that  they 
share  the  increased  sensitiveness  of  the  entire  nervous  system,  variously 
caused,  and  thence  reflexly  may  excite  the  violent  cardiac  action  of  tachy 
cardia.  Not  unlike  this  is  the  explanation  of  H.  C.  Wood,  who  suggests  that 
the  paroxysms  of  tachycardia  are  due  to  "  discharging  lesions  "  affecting  the 
centers  of  the  accelerator  nerves.  In  some  one  of  these  views,  perhaps,  must 
be  sought  the  required  explanation.  On  the  other  hand,  anesthesia  of  the 
cardiac  ganglia,  however  induced,  would  be  expected  to  have  the  opposite 
effect  of  a  bradycardia.  By  recalling  these  facts  many  of  the  cases  of  brady- 
cardia may  be  explained. 


IRREGULAR   PULSE. 

Synonym. — Arrhythmia. 

Description  of  the  Different  Varieties,  Peculiarities,  and  Explana- 
tion.— The  simplest  form  of  irregular  heart  is  that  in  which  there  is  an  occa- 
sional drop  or  intermission  in  the  beat,  while  the  pulse  in  the  intervals  is  per- 
fectlv  regular.  This  may  occur  once  only  in  twenty  or  more  beats,  and  from 
this  rate  mav  increase  until  it  happens  once  in  six  or  four  beats,  or  it  may  be 
every  second  or  third  beat ;  or  the  pulse  may  be  altogether  irregular — arrhyth- 
mical.    A  striking  feature  of  even  the  simplest  form  of  intermittent  pulse  or 

*  See  a  very  full  paper  "  Ueber  Bradycardia,"  by  Dr.  F.  Grob,  "  Deutsches  Archiv  fur  klinische 
Medicin,"  vol.  xxii.,  1888,  p.  574. 


IRREGULAR  PULSE.  617 

heart  is  that  the  omitted  beat  is  commonly  recognized  by  the  patient  himself, 
and  often  it  becomes  a  matter  of  intense  annoyance  to  him.  Here,  again,  it 
is  quite  important  to  decide  whether  the  dropped  beat  at  the  wrist  is  the  con- 
sequence of  an  omitted  systole  recognized  by  absence  of  the  first  sound  in 
the  auscultated  heart,  or  whether  it  is  a  simple  weak  systole  which  does  not 
send  the  pulse  to  the  radial  artery  at  the  wrist.  It  is  more  apt  to  be  the 
former,  if  the  patient  recognizes  it.  It  may  be  constant  or  occur  at  regular 
intervals  or  only  occasionally. 

In  the  latter  event  it  may  be  associated  with  some  such  disturbing  cause  as 
dyspepsia  and,  especially,  flatulence.  It  follows  the  use  of  tea,  coffee,  or 
tobacco,  and  is  in  rather  frequent  association  with  chronic  gout.  It  follows 
also  mental  shock,  and  is  especially  prone  to  occur  in  nervous,  hysterical  per- 
sons. The  intermittent  pulse  thus  occurring  is  vaguely  ascribed  to  nervous 
influences,  and  nothing  more  definite  can  at  present  be  confidently  suggested 
for  its  causation.  It  may  be  due  to  some  influences  of  the  causes  named  on 
the  cardiac  ganglia  of  the  sympathetic  nerve.  It  is  probably  at  times  directly 
due  to  organic  changes  in  the  heart  muscle,  especially  in  fatty  degeneration, 
in  which  event  it  is  a  more  serious  symptom. 

It  is  characteristic  of  the  more  purely  functional  variety  of  intermittent 
pulse  that  it  may  be  removed  by  exercise  or  excitement,  while  it  often  dis- 
appears during  pyrexia.  On  the  other  hand,  the  effect  of  exertion  on  the 
intermittent  pulse  of  fatty  heart  is  to  increase  the  intermission  or  convert  it 
into  an  irregularity. 

The  irregular  pulse  is  indicated  by  its  name.  It  is  associated  with  a 
corresponding  degree  of  irregularity  of  the  heart's  action,  the  highest  degree 
of  which  is  known  as  delirium  cordis.  This  irregularity  varies  also,  may  be 
habitual  or  occasional,  and  produced  by  the  same  causes  as  intermission.  It 
may  also  be  induced  by  temporary  or  permanent  derangements  of  the  respira- 
tory organs  through  changes  in  pressure  on  the  large  arteries  in  the  chest. 
This,  be  it  noted,  is  not  an  influence  on  the  heart.  Irregularity  of  the  pulse 
and  heart  is  a  distinctive  symptom  of  mitral  insufficiency.  This  is  very  rea- 
sonably ascribed  by  W.  H.  Broadbent  not  to  nervous  influence,  but  to  varia- 
tions in  pressure  due  to  traction  of  the  lungs  during  the  inspiratory  act  on  the 
cavities  of  the  heart.  This  is  favored  by  the  thin,  flabby,  and  feebly  resisting 
walls  of  a  dilated  auricle,  incapable  of  resisting  variations  of  external  pressure. 
In  mitral  stenosis,  though  the  auricle  is  dilated,  the  narrow  auriculo-ven- 
tricular  orifice  prevents  the  disturbing  efifect  of  the  varying  pressure  of  the 
respiratory  movements. 

In  like  manner  may  be  explained  the  pulsus  bigeminus  and  trigeminus, 
also  common  in  mitral  disease,  more  especially  mitral  stenosis.  In  these  two 
and  three  beats  follow  each  other  in  rapid  succession,  separated  by  a  longer 
interval.  The  pulsus  paradoxus  of  Kussmaul,  in  which  the  beats  during 
inspiration  are  more  frequent,  but  less  full  than  during  expiration,  may  also 
be  explained  in  this  way,  occurring  as  it  does  in  weak  heart,  chronic  peri- 
carditis, and  other  conditions  in  which  the  normal  relation  of  respiration  to 
the  heart's  dilatation  and  contraction  is  interfered  with. 

Other  modifications  of  the  cardiac  rhythm  are  the  gallop  rhythm  and 
embryocardia.  The  former  consists  of  three  sounds,  and  is  so  called  because 
it  resembles  the  footfall  of  a  horsre  in  canter.  It  occurs  especially  in  the 
hypertrophy  which  accompanies  interstitial  nephritis  with  arteriosclerosis,  and 
in  fatty  dilated  heart.  It  is  variously  ascribed  to  an  ( i)  abnormal  "  clacking," 
produced  by  the  contraction  of  a  hypertrophied  auricle,  preceding  the  ven- 


6i8  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

tricular  shock  (Charcelay)  ;  (2)  to  a  presystolic  impulse  which  immediately 
precedes  the  precordial  shock;  (3)  to  the  contraction  of  a  hypertrophied 
auricle  and  powerful  tension  of  the  ventricular  wall  produced  by  the  rushing 
of  the  column  of  blood  into  the  ventricles  in  connection  with  the  elastic  resist- 
ance due  to  the  muscular  tonicity  of  the  hypertrophied  wall  (Potain)  ;  (4.) 
Cuffer  and  Barbillion  suggest,  in  explanation  of  the  variety  occurring  in  the 
feeble  myocardium  of  ataxic  fevers  and  dilatation,  that  the  ventricular  con- 
traction and  consequently  the  first  sound  is  broken  into  two  parts  succeeding 
the  precordial  shock.*  Emhryocardia,  first  described  by  Stokes,  is  a  condi- 
tion in  which  the  first  sound  is  shortened,  and  therefore  more  like  the  second, 
the  resultant  being  a  sound  similar  to  that  of  the  fetal  heart.  It  occurs  espe- 
cially in  the  latter  stages  of  dilated  heart,  in  which  the  muscular  element  of 
the  first  sound  has  become  lost  because  of  weakness  and  the  sound  is  purely 
valvular. 

The  dicrotic  pulse  is  a  double  beat,  and  is  foand  in  every  normal  sphyg- 
mogram.  It  is  the  effect  of  the  elastic  recoil  of  the  overdistended  aorta  on 
the  contained  blood  immediately  succeeding  the  closure  of  the  aortic  valve, 
and  is  shown  at  /  in  the  catacrotic  or  descending  portion  of  the  normal  sphyg- 


Fig.  57- — Showing  Normal  Pulse-tracing. 

mogram  appended.  It  is  preceded  by  the  aortic  notch  e;  this  by  the  tidal 
wave  d  and  the  percussion  wave  b,  the  apex  of  the  curve.  Only  when  exag- 
gerated is  it  felt  by  the  fingers.  It  may  occur  abnormally  wherever  there  are 
a  forcible  systole  and  unobstructed  arterioles,  especially  in  aortic  regurgita- 
tion, and  although  here  the  incompetent  aortic  valves  do  not  furnish  the  requi- 
site resistance,  this  is  furnished  by  the  full  ventricle  behind  them,  so  that 
while  the  dicrotic  factor  may  be  delayed,  it  is  marked  when  it  occurs.  This 
is  seen  in  the  sphygmogram  on  page  583.  It  occurs  also  in  anemia  after 
venesection,  the  necessary  atony  of  the  arterial  system  being  thus  produced; 
after  the  administration  of  amyl  nitrite  and  nitroglycerin ;  also  in  uncompen- 
sated mitral  regurgitation,  when  the  emptiness  of  the  arterial  system  is  pro- 
duced in  a  dififerent  way — that  is,  by  diminishing  the  amount  of  blood  which 
enters  the  aorta  with  each  systole. 

Another  variety  of  double  beat  is  the  ptilus  bisferiens,  most  frequently 
noticed  in  aortic  stenosis,  but  also  in  senile  degeneration  of  the  arteries. 
This  resembles  the  dicrotic  pulse,  though  quite  different  in  its  etiology.  In 
it  the  second  beat  is  a  reinforcement  near  its  close  of  a  prolonged  systole. 
Under  these  circumstances  the  dicrotic  wave  will  be  absent. 

Mention  should  be  made  in  passing  of  the  anacrotic  pulse,  though  this  is 

*  For  an  elaboration  of  these  and  further  explanations  see  Barth  and  Roger,  "  Traite  Pratique 
■d'Ausctiltation,"  thirteenth  edition,  Paris,  1898. 


IRREGULAR  PULSE. 


619 


not  appreciable  to  the  finger.  It  is  similar  to  the  pulsus  bisferiens.  An  ana- 
crotic pulse-wave  is  one  in  which  a  more  or  less  marked  notch  occurs  in  the 
ascending  limb,  as  in  Figure  59.  It  is  the  pulse  of  high  arterial  tension,  and 
occurs  when  the  arteries  are  rigid  and  do  not  expand  promptly  to  receive  the 
contents  of  the  ventricle  during  systole.  The  walls  yield  slowly,  the  pressure 
is  prolonged,  broadens  the  top  of  the  sphygmogram,  and  throws  the  highest 
part  of  the  tracing  toward  the  end  of  the  systole  and  nearer  the  dicrotic 


Fig.  58. — Pulsus  Bisferiens  (Broadbent). 

wave,  which  is  usually  ill  developed.  So,  too,  the  percussion  wave  is  prac- 
tically abolished  and  the  tidal  wave  forms  the  apex  of  the  curve.  The  pulse 
of  prolonged  arterial  tension  is  produced  by  anything  which  resists  the  motion 
of  the  blood  through  the  capillaries  and  arterioles,  and  such  causes  are  numer- 
ous. Chronic  renal  disease,  especially  interstitial  nephritis,  is  one  of  them ; 
so  are  gout,  lead  poisoning,  constipation,  atheroma,  or  calcification  of  the 
arterial  walls.  The  anacrotic  pulse  is  also  produced  in  aortic  stenosis,  where 
it  is  of  diagnostic  value. 

Treatment    of    Palpitation,    Tachycardia,    and    Arrhythmia. — 
It  is  of  the  greatest  importance  that  the  cause  of  nervous  palpitation  should  be 


Fig-  59- — Anacrotic  Pulse-Curves — Pulse  of  High  Arterial  Tension. 
{Landois  and  Sterling) 


ascertained,  for  with  its  removal  recovery  may  be  expected.  Indigestion, 
distant  causes  of  reflex  irritation,  such  as  uterine  and  ovarian  disease  in 
women,  anemia,  chlorosis,  and  the  like  should  be  carefully  sought  and  elimi- 
nated by  a  proper  treatment.  During  an  attack  the  strictest  quiet  should  be 
enjoined,  and  the  patient  should  be  kept  in  the  recumbent  posture.  It  is 
much  more  important  that  this  should  be  done  than  that  heart  tonics  or  heart 
sedatives  should  be  administered.  Yet  at  this  time  it  may  be  helpful  to  give 
small  doses  of  digitalis,  frequently  repeated,  say  three  to  five  minims  (0.18  to 


620  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

0.3  c.  c),  or  five  to  ten  drops,  every  hour,  combined  with  the  bromids  in  ten- 
to  fifteen-grain  (0.66  to  i  gm.)  doses,  or  aconite  and  veratrum  viride  in  one- 
minim  (0.06  c.  c.)  doses  as  often.  When  the  palpitation  is  prolonged,  a  bella- 
donna plaster  may  be  applied  to  the  heart,  or  cold  may  be  applied  over  the 
cardiac  region. 

The  treatment  of  an  attack  of  tachycardia  is  similar.  Every  conceivable 
remedy  has  been  tried  by  those  subject  to  these  attacks  and  their  advisers,  with 
results  apparently  satisfactory  at  one  time  and  totally  disappointing  at  another. 
In  one  remarkable  case,  a  dear  medical  friend  of  my  own,  a  glass  of  ice-water 
rapidly  drunk  almost  always  stopped  a  paroxysm.  I  have  seen  this  eflfect  in 
his  case  follow  in  a  few  minutes.  This  remedy  he  arrived  at  after  fifty  years' 
trial  of  everything  he  could  think  of.  Bradycardia  is  perhaps  best  left  alone, 
unless  some  evident,  easily  removable  cause  be  found. 

As  to  treatment  between  attacks,  the  continuous  use  of  strychnin  may 
be  expected  to  be  useful.  It  should  be  combined  with  iron  and  quinin  in 
moderate  doses.  A  very  elegant  and  convenient  preparation  is  the  elixir  of 
iron,  quinin,  and  strychnin  of  the  U.  S.  P.  On  the  other  hand, 
strychnin  sometimes  causes  nervousness.  The  dose  must  be  regulated 
to  avoid  this.  The  tincture  of  nux  vomica  has  been  commended 
as  especially  suitable  in  these  cases,  given  in  ascending  doses  until 
thirty  minims  (2  c.  c.)or  more  are  reached.  Outdoor  life  and  exercise,  walk- 
ing, riding,  cycling  if  not  too  violent,  and  mountain-climbing,  all  con- 
tribute to  improve  the  general  health  and  strengthen  the  heart  at  the  same 
time.  Cold  bathing  is  one  of  the  best  measures  for  the  same  purpose,  either 
at  home  or  at  the  seaside. 

The  same  principles  of  treatment  apply  to  intermittent  heart  and 
arrhythmia.  When  these  are  the  result  of  organic  cardiac  disease,  their  treat- 
ment is  that  of  the  disease.  In  the  treatment  of  the  simple  slow  pulse  any 
cause  of  pneumogastric  irritation  should  be  sought  for  and  removed,  such  as 
dyspeptic  states,  torpor  of  the  liver,  poisoning  with  retained  bile  salts,  and  the 
like.  In  the  absence,  however,  of  certain  knowledge  of  the  presence  of  such 
cause,  the  condition  is  best  left  alone,  as  treatment  under  such  circumstances 
may  do  more  harm  than  good. 


ANGINA  PECTORIS,  OR  STENOCARDIA. 

Definition. —  An  affection  of  the  heart  characterized  by  intense  par- 
oxysmal pain,  at  first  usually  substernal,  extending  thence  down  the  arms^ 
especially  the  left,  and  up  into  the  neck.  It  is  a  symptom  rather  than  a  dis- 
ease, as  it  is  commonly  associated  with  some  recognizable  organic  change  in 
the  heart  or  great  vessels,  though  not  always  the  same  change.  Often,  how- 
ever, such  change  cannot  be  found,  and  it  may  be  that  in  rare  instances  it  is 
a  purely  functional  state. 

Etiology. — The  immediate  cause  of  angina  pectoris  is  deficient  cardiac 
nutrition,  however  induced.  It  may  be  on  account  of  obstructive  disease  of 
the  coronary  arteries,  aortic  stenosis  or  insufficiency,  pressure  by  a  tumor  or 
other  cause,  dilatation  or  enlargement  of  the  heart  beyond  the  capacity  of  the 
coronary  arteries  to  nourish,  or  any  cause  which  produces  cardiac  ischemia. 
Adhesive  pericarditis  may  act  in  this  way.  It  may  be  that  the  excessive  use 
of  tobacco,  which  has  been  accredited  with  the  direct  effect  of  causing  angina, 
may  operate  in  this  way.     The  exciting  cause  of  the  attack  is  usually  some 


ANGIXA  PECTORIS,  OR  STEXOCARDIA.  621 

overexertion  or  mental  emotion  calling  for  some  additional  effort  from  an 
already  crippled  ischemic  heart.  These  events  after  a  meal  are  more  apt  to 
produce  this  effect  because  a  full  stomach  encroaches  on  the  heart.  Thus, 
the  taking  of  food  alone,  even  in  moderate  amount,  may  excite  an  attack. 
Still  more,  excessive  eating  and  indigestion,  however  caused,  become  excit- 
ing causes. 

It  must  be  admitted  that  all  explanations  of  the  pain  are  purely  specu- 
lative, for  though  total  obstruction  of  the  coronary  arteries  experimentally 
produced  is  followed  by  death,  pain  has  not  been  found  an  associated  symp- 
tom. On  the  other  hand,  the  pain  which  succeeds  the  obstruction  of  an 
artery,  leading  to  gangrene  of  a  part,  as  the  leg,  is  precisely  analogous  to  the 
anginose  pain  which  succeeds  obstruction  of  the  coronary  arteries,  while  the 
results  of  experimental  closure  of  these  arteries  have  their  parallel  in  recog- 
nized cases  of  angina  sine  dolorc.  Again,  neuralgic  pain  of  the  ordinary 
kind  occurs  in  a  nerve  which  is  badly  nourished.  ]May  one  not  explain  the 
pain  of  angina  in  the  same  way,  since  a  defective  nutrition  is  the  one  acknowl- 
edged condition  of  angina?  ^Mention  should  be  made  of  the  view  recently 
announced  by  Clifford  Allbutt*  that  the  agonizing  pain  and  dread  char- 
acteristic of  angina  pectoris  may  be  produced  by  an  acute  aortitis. 

Angina  pectoris  is  a  disease  of  adults,  and  of  men  rather  than  women, 
and  though  it  may  happen  in  early  life,  80  per  cent,  of  all  cases  occur  after  the 
fortieth  year. 

Morbid  Anatomy. — Atheroma  of  the  coronary  arteries  is  the  most  con- 
stant anatomical  change  found  associated  with  angina  pectoris.  It  is  well 
known,  also,  that  obstruction  of  these  arteries  experimentally  produced  results 
fatally,  though  such  death  is  not  attended  by  the  pain  of  angina.  On  the 
other  hand,  many  cases  of  advanced  sclerosis  of  the  coronary  arteries  occur 
without  angina.  In  these  it  must  be  concluded  that  the  nutrition  of  the  heart 
has  not  seriously  suffered.  The  other  associated  conditions  named  in  con- 
sidering the  etiology  must  also  be  regarded  as  a  part  of  the  morbid  anatomy. 
A  fair  estimate  of  the  frequency  of  such  associations  may  be  obtained  from 
W.  H.  Walshe's  statement  that  in  every  one  of  twenty-four  cases  he  exam- 
ined during  life  distinct  signs  of  changes  in  the  heart,  the  aorta,  or  in  both 
coexisted;  The  testimony  of  G.  W.  Balfour  and  P.  W.  Latham  is  similar. 
Acute  aortitis  has  been  found.  (See  Clifford  Allbutt's  paper  previously 
mentioned.) 

Symptoms. — The  cardinal  symptom  is  agonizing  pain — pain  beginning 
beneath  the  sternum  in  the  region  of  the  heart,  extending  up  into  the  neck, 
sometimes  the  jaws,  and  down  the  arms,  especially  the  left,  following  the  dis- 
tribution of  the  ulnar  nerve.  Associated  with  this  are  shortness  of  breath, 
precordial  oppression,  and  a  sense  of  impending  dissolution.  The  pulse  is 
often  strikingly  natural,  though  it  is  also  at  times  unnaturally  small,  frequent, 
and  irregular.  The  pain  is  often  associated  with  a  numbness  or  tingling  in 
the  fingers  or  over  the  cardiac  region.  There  are  usually  extreme  pallor  and 
an  agony  of  expression  which  are  not  soon  forgotten.  The  skin  is  pale  or 
ashen  gray,  and  often  the  perspiration  stands  out  in  huge  beads.  This  ashen- 
gray  color  of  the  skin  is  not  confined  to  the  period  of  the  paroxysm.  It  is. 
in  my  experience,  quite  a  characteristic  symptom,  and  when  associated  with 
atheromatous  arteries,  is  of  diagnostic  value.  The  duration  of  the  paroxysm 
varies  from  a  few  seconds  to  a  half  hour.     At  the  end  of  this  time,  or  earlier, 


*"Ang-ina  Pectoris,"  by   Clifford  Allbutt,  M.  D.,  "Philadelphia  :Med.  Jour.."  vol.  v.,  June  30, 
:i89o,  p.  1464. 


622  DISEASES  OF  HEART  AXD  BLOOD-J'ESSELS. 

the  patient  either  passes  out  of  the  attack  or  dies  in  it.  The  paroxysms  occur 
at  widely  different  intervals,  sometimes  once  in  a  few  months,  sometimes 
oftener,  and  sometimes  at  intervals  of  a  year  or  more.  Xeither  are  they 
always  so  painful  as  described,  and  it  is  more  than  likely  that  the  slighter 
attacks  of  cardiac  pain  associated  with  aortic  stenosis  and  sometimes  with 
aneurysm  are  of  the  same  nature. 

Diagnosis. — The  only  condition  with  which  true  angina  pectoris  is  liable 
to  be  confounded  is  the  hysterical  form  known  as  psciido-aiigiiia.  It  is  not 
often,  however,  that  practical  difficulty  occurs  in  separating  the  two  condi- 
tions. The  hysterical  form  is  more  common  in  younger  women,  in  nervous 
and  hysterical  persons,  than  the  true  form,  and  is  associated  with  other  ner- 
vous symptoms.  In  all  instances  careful  examination  should  be  made  of  the 
vascular  system  with  a  view  to  detecting  alterations  in  it,  such  as  arterial 
sclerosis  and  enlargement  of  the  heart.  These  will  generally  be  found  in 
some  one  of  their  modes  of  manifestation  in  true  angina.  In  false  angina, 
as  in  other  manifestations  of  hysteria,  there  is  something  indescribable  which 
will  guide  the  experienced  physician  aright.  In  cases  of  doubt  the  patient 
should  have  the  benefit  of  it. 

Intercostal  neuralgia  in  the  neighborhood  of  the  heart  resembles  the 
pain  of  angina  somewhat.  It  is,  however,  more  circumscribed.  It  does  not 
radiate  into  the  neck  and  arms,  and  the  heart  and  blood-vessels  are  normal. 
The  pain  is  not  so  severe,  and  the  anxious  expression  of  the  face  is 
wanting. 

The  Adams-Stokes  Syndrome  may  be  here  alluded  to.  It  is  a  condition 
allied  to  true  angina  which  may  or  may  not,  however,  be  associated  with  it. 
It  was  first  described. by  Robert  Adams  of  Dublin  in  1827*  and  later  more 
fully  by  Stokes  in  i846.t 

The  syndrome  consists  of  vertigo  with  repeated  apoplectic  or  syncopal 
seizures  with  unconsciousness,  usually  preceded  for  a  few  days  by  hebetude 
and  a  loss  of  memory;  slow  pulse — permanently  slow,  but  slower  at  the  time 
of  the  attacks.  These  were  the  symptoms  in  Adams'  case.  Stokes  suggested 
the  name  false  or  pseudo-apoplexy,  laid  stress  on  the  syncopal  character  of 
the  attacks,  their  frequency,  the  absence  of  paralysis,  and  the  good  effect  of  a 
stimulating  rather  than  a  depleting  plan  of  treatment.  Both  Adams  and 
Stokes'  patients  were  sixty-eight  years  of  age. 

There  is  myocardial  change,  fatty  or  fibroid,  and  the  visible  arteries,  espe- 
cially the  radials  and  temporals,  are  sclerotic. 

Slowness  of  heart-rate  and  vertigo  are  distinctive  symptoms.  The 
former  may  fall  to  40.  30,  20,  or  even  10  and  5.  The  slowness  must  be  of 
the  heart's  action  and  not  of  the  pulse.  The  latter  may  be  only  20,  while 
the  heart-rate  may  be  40,  because  the  intermediate  pulse  does  not  reach  the 
radial,  producing  in  sphymogram  the  so-called  bigeminal  pulse. 

Prognosis. — True  angina  is  a  very  grave  condition  because,  although 
fully  three-fourths  of  all  persons  attacked  recover  from  the  first  paroxysm, 
sooner  or  later  a  fatal  ending  may  be  expected,  and  no  one  knows  what  attack 
is  going  to  be  the  last.  In  some  instances  paroxysms  recur  at  inten-als  of 
considerable  length  throughout  a  lifetime,  while  in  others  the  first  proves 
fatal.  G.  W.  Balfour  mentions  the  case  of  an  old  gentleman  who  had  a  final 
fatal  attack  after  an  interval  of  ten  years,  in  which  he  had  enjoyed  excellent 
health.     ]\Iany  instnces  of  death  in  the  first  paroxysms  are  reported. 

*  "Dublin  Hospital  Reports,"  vol.  iv..  1827. 

+  "  Observations  on   Some    Cases    of    Permanently    Slow    Pulse."     "Dublin    Quarterly    Jour- 
nal," 1846. 


ANGINA  PECTORIS,  OR  STENOCARDIA.  623 

Treatment. — Treatment  naturally  resolves  itself  into  that  of  the  par- 
oxysm and  that  for  prevention  or  cure.  For  the  first,  morphin  is  the  most 
efficient  remedy,  and  if  at  hand,  should  be  used  hypodermically  in  not  less 
than  1-4-grain  (0.016  gm.)  doses  for  an  adult,  combined  with  atropin. 
Nitrite  of  amyl  has  come  to  be  an  acknowledged  remedy,  first  suggested  by 
Lauder  Brunton.  A  few  drops  may  be  placed  upon  a  handkerchief  or  on 
cotton  and  inhaled,  or,  more  conveniently,  pearls  of  glass  filled  with  the 
nitrite  are  crushed  in  a  handkerchief.  The  pearls  recommend  themselves 
further  because  they  can  be  conveniently  carried,  and  it  is  desirable  that  per- 
sons subject  to  angina  pectoris  should  always  have  the  drug  at  hand.  Chloro- 
form may  also  be  used  instead  of  nitrite  of  amyl,  if  more  convenient.  Nitro- 
glycerin is  used  for  the  same  purpose  in  doses  of  i- 100  to  1-50  grain  (0.00065 
to  0.0013  gm.)  at  short  intervals,  say  15  minutes.  Counterirritation  should  be 
simultaneously  applied.  The  ordinary  mustard  plaster  is  a  most  convenient 
and  efficient  measure  for  the  purpose. 

Prophylaxis  is  exceedingly  important,  and  is  best  accomplished  by  avoid- 
ing the  exciting  causes  commonly  responsible  for  the  paroxysms — overexer- 
tion, overeating,  and  mental  excitement.  The  patient  subject  to  angina 
should  never  hurry  or  get  into  a  passion  or  become  excited  in  any  way.  The 
use  of  all  indigestible  articles  of  food  should  be  carefully  avoided.  Nitro- 
glycerin is  sometimes  efficient  as  a  prophylactic  as  well  as  for  the  paroxysm 
in  the  same  doses  once  in  four  hours  or  oftener.  The  alcoholic  solution,  of 
such  strength  that  one  minim  represents  i-ioo  grain  (0.0006  gm.),  is  the  best 
preparation.  Nitrite  of  sodium  may  be  used  in  from  three  to  five-grain 
(0.1944  to  0.32  gm.)  doses.  Other  remedies  recommended  with  a  view  to 
averting  the  attack  are  arsenic,  nitrate  of  silver,  the  bromids,  and  especially 
iodid  of  potassium,  the  long-continued  use  of  full  doses  of  which  has  appar- 
ently sufficed  to  prevent  the  recurrence  of  attacks  previously  present.  Its 
efifect  in  this  disease  is  comparable  to  that  produced  by  it  in  aneurysm.  As 
heart  tonics,  arsenic  and  strychnin  in  doses  of  1-50  to  1-25  grain  (0.0012  to 
0.024  gm.)  should  be  given.  While  sudden  exertion  and  overexertion  are  to 
be  avoided,  carefully  graduated  exercise  is  to  be  recommended,  for  like  all 
organs,  the  heart  is  strengthened  and  invigorated  by  exercise  properly  regu- 
lated. When  moderate  exertion,  if  borne  at  all,  brings  on  an  attack,  even 
this  should  be  avoided. 

Could  we  correct  the  faulty  nutrition  of  the  heart  we  could  hope  for  a 
cure,  and  though  this  may  be  impossible,  we  may  do  that  which  promotes  it. 
Angina  pectoris  is  one  of  the  conditions  in  which  the  Nauheim  hot  bath  may 
be  expected  to  be  beneficial.  So  it  might,  so  far  as  the  hot  baths  are  used, 
but  the  cold  bath  in  any  form  is  harmful.  Iodid  of  potassium  should  be  used 
with  the  same  end  in  view  as  in  arteriosclerosis. 

The  treatment  of  hysterical  or  pseudo-angina  is  that  of  hysteria  under 
other  circumstances. 


624  DISEASES  OF  HEART  AXD  BLOOD-VESSELS 

DISEASES  OF  THE   BLOOD-VESSELS. 

ARTERIOSCLEROSIS. 

Syxoxyms. — Endarteritis    chronica    deformans:    Atheroma  of    the    Blood- 
vessels; Artcriocapillary  Fibrosis. 

Definition. — A  disease  chiefly  of  arteries,  consisting  of  inflammation 
first  of  the  intinia,  but  extending  also  to  the  media  and  adventitia. 

Etiology. — There  is  a  tendency  to  atheronia  in  the  arteries  of  the  old,  as 
an  evolution  process  quite  independent  of  exciting  causes.  This  tendency 
also  varies  greatly  in  different  families,  being  very  strong  in  some  and  absent 
in  others.  'Men  are  decidedly  more  liable  than  women.  There  are,  how- 
ever, many  exciting  causes,  among  which  are  overeating  and  drinking,  with 
consequent  accumulation  of  irritating  matters  in  the  blood,  syphilis,  the  gouty 
poison,  and  lead.  Chronic  Bright"s  disease  is  especially  frequently  suc- 
ceeded by  it ;  more  rarely  acute  articular  rheumatism..  In  the  latter  the  rheu- 
matic poison  is  probably  the  responsible  agent;  and  in  Bright's  disease  it  may 
be  retained  excrementitious  matter.  Two  classes  of  cases  may,  however,  be 
associated  with  Bright's  disease,  in  one  of  which  the  arteriosclerosis  is  general 
and  primary,  causing  interstitial  nephritis,  and  in  the  other  it  is  secondary, 
the  result  of  the  Bright's  disease.  One  set  of  observers  regard  all  cases  of 
interstitial  nephritis  as  secondary.  Among  these  the  late  Sir  William  Gull 
and  Henry  D.  Sutton,  of  England,  and  Arthur  \'.  ^leigs,  of  Philadelphia,  have 
been  conspicuous  by  their  v.-ritings.  Still  another  cause  of  arteriosclerosis 
is  increased  arterial  tension  due  to  prolonged  muscular  exertion. 

Morbid  Anatomy, — The  aorta  is  the  most  frequent  and  conspicuous 
seat  of  the  changes  ascribed  to  chronic  endarteritis,  but  the  carotids,  sub- 
clavians,  brachials,  radials,  and  ulnars,  the  iliacs,  femorals,  and  especially 
the  arteries  of  the  brain  and  coronary  arteries  of  the  heart,  are  frequentl> 
involved.  The  arteries  to  viscera,  like  the  stomach  and  liver,  are  rarely 
affected,  while  the  pulmonary  arteries  take  an  intermediate  place.  On  the 
other  hand,  the  latter  are  sometimes  invaded  to  the  exclusion  of  the  aorta. 
Whatever  invites  high  tension  in  the  lesser  circulation  tends  to  produce 
sclerosis  in  these  vessels.  The  portal  vein  may  also  be  invaded.  The  super- 
ficial arteries  thus  affected  are  easily  recognized.  They  are  tortuous,  stand 
out  conspicuously,  and  feel  hard  to  the  finger,  under  which  they  may  be  made 
to  roll.  These  features  are  often  recognizable  in  the  temporals  and  less 
plainly  in  the  radials.  The  smaller  arteries  and  veins  with  transparent  walls, 
especially  in  the  brain,  exhibit  to  the  naked  eye  white  patches  which  are  the 
seat  of  the  atheroma.  On  slitting  them  open,  the  inner  surface  of  these  and 
other  arteries  will  be  found  to  have  lost  its  natural  smoothness,  to  be  rough 
and  uneven,  while  the  lumen  is  more  or  less  encroached  upon. 

^Minutely  examined,  the  appearances  vary  with  the  stage.  The  first 
stage  is  that  of  cellular  infiltration,  represented  by  the  translucent  yellowish 
areas  of  intima  thickened  to  three  or  four  times  its  natural  thickness.  Later 
these  young  cells  are  in  part  converted  into  connective  tissue,  causing  the 
primary  hardness  of  the  vessel-walls.  In  the  second  stage  the  cells  of  the 
connective  tissue  and  the  surface  cells  of  the  intima  undergo  fatty  degenera- 
tion, and  the  intercellular  substance  liquefies.     In  the  third  stage,  which  is 


ARTERIOSCLEROSIS.  625 

not  reached  in  the  smaller  arteries,  or,  indeed,  usually  in  those  below  the  aorta, 
there  occurs  a  further  liquefaction  with  the  formation  of  the  so-called  athero- 
matous abscess,  whose  contents  are  not  pus,  but  the  well-known  atherom- 
pulp,  representing  the  debris  of  fattily  degenerated  cells,  including  fat  drops 
and  cholesterin  crystals.  Alongside  of  the  atheromatous  patches  appear  also 
plates  or  scales  of  calcareous  infiltration  of  the  intima,  produced  by  a  deposit 
of  lime  salts  in  the  intercellular  substance  of  the  deeper  layers.  The  athero- 
matous abscess  sometimes  undermines  the  intima,  forming  sinuous  cavities, 
and  after  evacuation  there  results  the  atheromatous  ulcer.  Both  the  limy 
^  plates  and  ulcers  furnish  inequalities  which  favor  thrombosis.  In  the  later 
stages  of  the  more  diffuse  form  of  arteriosclerosis,  especially  studied  by  Coun- 
cilman, the  media  or  muscular  coat  and  the  adventitia  are  also  invaded,  the 
former  mainly  by  atrophic  changes,  alongside  of  which,  at  times,  is  a  homo- 
geneous hyaline  infiltration.  In  this  form  the  capillary  walls  are  also  thick- 
ened, especially  those  of  the  glomeruli  of  the  kidneys,  in  some  of  which  the 
vessels  become  obliterated. 

A  calcareous  infiltration  of  the  muscular  coat  without  previous  inflam- 
mation may  be  found  in  old  age  in  arteries  like  the  radial,  crural,  and  tem- 
poral. Still  another  primary  degeneration  is  the  fatty  erosin  of  Virchow, 
extending  through  the  intima  and  media  as  a  transverse  fissure  thought  to 
be  the  starting-point  at  times  of  dissecting  aneurysm. 

The  effect  of  these  changes  is  to  produce  rigidity  and  narrowing  of  the 
vessel,  a  loss  of  the  propulsive  power  residing  in  the  elastic  coat,  a  slowing 
of  the  current,  and  increased  intravascular  pressure.  These  events  tax  the 
compensating  power  of  the  left  ventricle,  which  therefore  hypertrophies. 
This  hypertrophy  keeps  up  so  long  as  its  nutrition  is  maintained. 

But  another  effect  of  obstructed  circulation  is  defective  local  nutrition, 
some  of  the  consequences  of  which  have  already  been  considered  in  the  study 
of  the  fibroid  heart.  Similar  interstitial  overgrowth  and  contraction  may  be 
met  in  the  kidney  and  have  been  referred  to.  Localized  softening  of  the  brain 
also  succeeds  upon  atheroma,  though  this  event  is  usually  preceded  by  throm- 
botic obstruction  favored  by  the  sclerosis.  A  more  frequent  accident  to  the 
brain  is  rupture  of  one  of  these  atheromatous  vessels,  succeeded  by  the  symp- 
toms of  apoplexy  and  hemiplegia.  Such  rupture  may  be  preceded  by  an 
aneurysmal  dilatation.  Finally,  aneurysm  of  the  larger  vessels  has  for  its 
almost  indispensable  condition,  except  in  traumatic  cases,  atheroma  of  the 
dilated  vessel.  Both  events — the  primary  atheroma  and  the  subsequent  dila- 
tation— are  favored  by  the  increased  intravascular  pressure. 

Symptoms. — Superficial  vessels  in  a  state  of  atheroma  are  easily  de-  . 
tected  by  their  dilated,  tortuous,  pulsating  appearance  in  the  temples,  while 
in  other  situations,  as  at  the  wrist,  antebrachial  and  popliteal  spaces,  they  may 
be  recognized  more  or  less  by  the  touch.  Distinction  should  be  made  between 
simple  increase  of  tension  and  thickening  of  vessel-walls,  though  the  two  are 
constantly  associated.  The  vessel  in  both  instances  is  hard  and  requires  some 
force  to  compress  it,  and  between  beats  it  is  still  full  and  can  be  rolled  under 
the  finger,  but  the  artery  with  the  thickened  wall,  if  firmly  enough  compressed 
to  obliterate  the  blood  current,  can  still  be  felt  beyond  the  seat  of  compression. 
In  many  instances,  on  the  other  hand,  the  changes  escape  detection  until  a  fatal 
apoplexy  gives  notice  of  their  presence.  In  most  of  these  cases,  however,  if 
attention  had  been  directed  to  the  patient,  the  previously  described  condition 
of  the  arteries  would  probably  have  been  recognized,  while  a  certain  degree  of 
hypertrophy  of  the  left  ventricle  would  also,  perhaps,  have  been  detected.     It 

40 


626  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

does  not  follow,  however,  that  the  absence  of  atheroma  in  one  place  implies  its 
absence  in  another,  since  fatal  rupture  of  an  artery  in  the  brain  has  occurred 
when  there  has  been  no  sign  cd  sclerosis  in  the  radials.  Prolonged  h3'per- 
trophy  and  the  increased  tension  incident  to  it  may  produce  atheroma,  or  the 
two  may  be  the  result  of  the  same  cause — as,  for  example,  contracted  kidney. 

Cardiac  hypertrophy  is  not  always  demonstrable  to  percussion,  as  the 
enlarged  heart  may  be  covered  by  an  emphysematous  lung,  also  often  present 
in  the  aged,  in  whom  atheroma  is  most  prone  to  occur.  On  the  other  hand, 
the  usual  sharp  accentuation  of  the  a(irtic  second  sound  is  present  if  the  hyper- 
trophy has  not  given  way  to  dilatation  or  fibroid  induration.  Cardiac  mur- 
murs do  not  occur  unless  the  atheroma  invades  the  valves  to  produce  insuffi- 
ciency, stenosis,  or  roughening  of  the  aortic  orifice  or  aotta  near  the  orifice. 
This  is  not  so  very  rare  in  old  persons,  apart  from  the  relative  insufficiency 
due  to  aortic  dilatation. 

For  the  reasons  mentioned,  the  pulse  is  prolonged,  hard,  and  tense, — 
the  pulsus  tardus, — while  its  sphygmogram  is  very  characteristic :  a  slow, 
oblique  ascent,  a  broad  top ;  a  slow  descent  and  absence  of  the  dicrotic  rise, 
which  in  the  normal  state  depends  on  an  elasticity  absent  in  the  diseased  vessel. 
Owing  to  the  same  slow  transmission  of  the  pulse-wave  the  pulse  is  some- 


Fig.  60. — Sphygmogram  of  an  Atheromatous  Vessel — The  Pulsus  Tardus. 

times  retarded  at  the  wrist,  while  the  rate  is  also  slow.  At  other  times  it  is 
frequent  and  irregular,  especially  toward  the  end  of  life  when  the  heart 
begins  to  fail. 

The  arcus  senilis  is  often  an  associate  of  arteriosclerosis,  and  strongly 
confirmatory  of  its  presence. 

One  of  the  most  annoying  consequences  of  atheroma  of  the  blood-vessels 
of  the  brain  is  dizziness  or  vertigo,. and  this  symptom,  when  present  in  the 
aged,  is  very  apt  to  be  caused  by  it. 

The  consequences  of  atheroma  of  vessels  of  the  lower  extremities  include 
muscidar  zveakness,  stiffness,  and  a  tottering  gait.  In  extreme  cases  gan- 
grene of  the  lower  extremities  may  result  from  obstruction  to  their  arteries 
due  to  thrombosis' invited  by  the  atheroma.  Such  termination  is  not  very 
rare  in  contracted  kidney. 

With  the  supervention  hi  cardiac  dilatation  and  heart  failure  there 
appear  paralysis,  precordial  oppression  on  slight  exertion,  dyspnea,  edema, 
pulmonary  congestion,  scanty  urine,  aggravated  vertigo,  angina  pectoris — in 
a  word,  all  the  symptoms  of  chronic  heart  disease.  Finally,  other  symptoms 
are  those  of  the  morbid  states  it  causes — /.  e.,  apoplexy,  contracted  or  senile 
kidney,  atheroma  of  the  coronary  artery  and  its  consequences. 

Treatment.— Treatment  is  mainly  the  removal  of  conditions  causing  it, 
such  as  too  free  living,  gout,  lead  poisoning,  and  syphilis ;  together  with  rest 
and  quiet,  the  avoidance  of  ^excitement,  also  the  free  use  of  diluent  drinks 
and  aperients  to  lower  the  arterial  tension,  a  slight  increase  of  which  is  often 
the  last  straw  required  to  produce  an  apoplexy.  The  iodid  of  potassium  is 
highly  recommended  by  G.  W.  Balfour  as  a  vascular  stimulant  in  the  sense 
that  it  promotes  the  flow  of  blood  through  the  vessels  and  lowers  the  blood 


ANEURYSM.  627 

pressure.  As  such,  it  ought  to  be  useful  in  arterial  sclerosis  and  probably  is. 
Moderate  doses  should  be  continued  a  long  time.  In  conjunction  with  this 
the  usual  cardiac  tonics  should  be  employed  with  a  view  to  promoting  a  proper 
circulation  of  the  blood. 

ANEURYSM.  !' 

Definition. — An  aneurysm  is  a  more  or  less  circumscribed  dilatation  of 
a  blood-vessel.  Aneurysm  is  known  as  true  or  false.  A  true  aneurysm  is  one 
in  which,  at  the  outset,  all  three  coats  of  the  blood-vessel  share  in  the  dilata- 
tion, though  one  or  two  may  disappear  later  in  the  course  of  its  growth.  A 
false  aneurysm,  on  the  other  hand,  starts  at  the  outset  with  a  laceration  of  one 
of  the  coats. 

1.  True  aneurysm  may  be  saccular,  fusiform  or  spindle-shaped,  cylin- 
drical and  cirsoid.  The  "  cirsoid  "  or  varicose  aneurysm  is  one  in  which  a 
blood-vessel — one  of  medium  size — and  its  branches  are  irregularly  dilated 
and  contorted  like  a  varicose  vein,  whence  the  name  "  variax,"  a  dilated  vein. 
The  "  invaginating  "  aneurysm  is  a  rare  form  of  cylindrical  aneurysm,  in 
which  the  cylindrical  sac  overlaps  at  either  or  both  ends  the  main  trunk  of  the 
artery  involved.  Saccular  and  fusiform  aneurysms  are  for  the  most  part  fre- 
quent. The  "  neck  "  of  an  aneurysm  is  a  constricted  portion  by  which  a  sac- 
cular aneurysm  is  attached  to  the  main  trunk. 

2.  False  aneurysm  includes  two  varieties,  traumatic  and  dissecting. 

(a)  Traumatic  aneurysm.  In  traumatic  aneurysm  the  initial  event  is 
some  injury  from  without  to  one  or  more  of  the  coats  of  the  vessels,  as  the 
result  of  which  the  resistance  to  intravascular  pressure  is  diminished  and  a 
protrusion  of  the  intima  through  the  yielding  media  takes  place,  the  latter 
being  the  most  passive  of  all  the  coats.  The  simplest  illustration  of  this  form 
of  aneurysm  is  the  antebrachial  aneurysm  caused  by  accidental  wounding  of 
the  brachial  artery  in  venesection  of  the  median  vein.  The  blood  pushes  out 
the  intima  and  antebrachial  fascia  and  forms  a  sac  communicating  with  the 
artery  through  the  wound. 

A  second  form  is  the  aneurysmal  varix  or  anastomotic  aneurysm,  in  which 
the  blood  from  the  wounded  artery  passes  directly  into  the  adjacent  vein 
through  the  wound  made  at  the  same  time,  causing  a  dilatation  of  the  vein. 
This  is  resisted  by  the  valves,  which,  however,  give  way  to  the  extent  of  two, 
three,  and  even  more  pairs  before  the  current  is  successfully  resisted. 

(b)  Dissecting  aneurysm.  This  involves  the  aorta,  in  which,  in  conse- 
quence of  a  perforation  through  the  intima  and  media,  the  blood  dissects 
between  them  and  the  adventitia.  The  initial  slit  is  found  most  frequently 
in  the  inner  and  posterior  portion,  about  one  inch  (2.5  cm.)  above  the  semi- 
lunar valves.  The  blood  may  dissect  from  this  point  around  the  arch  of  the 
aorta,  even  as  low  as  the  diaphragm,  before  it  returns  to  the  lumen  of  the 
vessel.  Even  the  visceral  pericardium  has  been  thus  separated  by  an 
aneurysm  which  projects  into  the  pericardium,  rupturing  finally  into  the  peri- 
cardial sac. 

Etiology. — The  aneurysm  most  frequently  encountered  by  the  physi- 
cian is  the  saccular  and  fusiform  form.  Its  most  frequent  essential  cause 
is  endarteritis  and  its  consequences,  including  the  more  acute  stage  of 
cellular  infiltration,  as  well  as  atheroma.  The  coats  thus  weakened  yield 
to  the  intravascular  pressure.  The  intima  is  capable  of  a  considerable 
degree  of  expansion  without  rupture,  while  the  media  is  entirely  passive 


628  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

and  yields  very  soon  to  the  distending  force.  The  adventitia  alone  seeks 
to  guard  the  sac  against  rupture  by  reactive  overgrowth.  The  causes  of 
endarteritis,  already  discussed,  such  as  syphilis,  alcohol,  and  other  toxic 
substances  variously  introduced  into  the  blood,  are  responsible  for  the  more 
usual  forms  of  arteriosclerosis  which  furnish  the  initial  lesion  of  aneurysm. 
But  weakening  of  the  coats  is  caused  also  in  the  smaller  vessels  by  emboli, 
after  the  lodgment  of  which  the  proximal  part  of  the  vessel  often  becomes 
dilated.  Such  embolus  may  excite  an  endarteritis,  or  may  occasion  direct 
violence  to  the  vessel-walls  if  it  be  hard  or  sharp,  as  is  often  the  case  with 
a  fragment  of  a  calcified  valve.  Muscular  compression  exerted  by  muscles 
in  certain  situations  may  also  produce  it.  Such  may  be  the  origin  of  pop- 
liteal aneurysms  so  frequent  in  footmen,  who  maintain  a  rigidly  erect  posi- 
tion. Finally,  disturbances  of  innervation  are  considered  capable  of  causing 
dilatation,  and  to  such  influence  are  ascribed  the  varicose  aneurysms  of 
the  arteries  of  the  scalp,  of  the  temporal,  and  of  the  popliteal. 

Aneurysm   of  the   Thoracic  Aorta. 

ThoracicT  aneurysm  occurs  in  the  arch  of  the  aorta,  in  its  ascending 
transverse  and  descending  portions,  and  in  the  .thoracic  aorta  below  the 
arch.  Such  aneurysm  may  but  slightly  exceed  the  normal  caliber  of  the 
vessel,  or  it  may  be  six  inches  (12  cm.)  or  more  in  diameter. 

The  greater  frequency  of  aneurysm  in  the  male  sex  and  during  early 
middle  life  is  recognized.  To  the  pre-existing  conditions  of  atheroma  there 
may  be  added  the  effect  of  extreme  exertion  in  lifting,  or  muscular  strain 
of  any  kind,  the  effect  of  which  is  always  to  increase  intravascular  pressure. 
Partly  because  they  are  points  of  least  resistance,  and  partly  because  they 
are  in  the  line  of  successive  impingement  of  the  whirling  blood  stream, 
there  are  certain  points  of  selection  in  the  aorta  which  are  quite  constantly 
seats  for  beginning  aneurysm.  These  are  shown  in  the  appended  illustra- 
tion. 

The  first  point  (i)  of  election  is  the  beginning  of  the  aorta  directly 
behind  the  trunk  of  the  pulmonary  artery.  Aneurysm  originating  there 
may  produce  early  hypertrophy  of  the  right  ventricle  because  of  the  resist- 
ance to  the  outward  flow  of  the  blood  through  this  vessel,  a  basic  murmur 
in  the  pulmonary  area,  relative  insufficiency  of  the  tricuspid  valve  and  venous 
pulse,  with  a  possible  ultimate  perforation  into  the  pericardium  or  pulmonary 
artery.  The  second  point  (2)  is  the  favorite  seat  of  aneurysm  of  the  ascend- 
ing limb  of  the  arch,  behind^the  sternum,  at  the  manubrio-gladiolar  junc- 
tion, at  which  place  it  often  bores  its  way  through  the  sternum  as  a  saccu- 
lated aneurysm,  which  may  finally  burst  through  the  external  integument. 
The  third  seat  (3)  is  at  the  convexity  of  the  arch  toward  the  apex  of  the 
right  lung.  The  pleural  cavity  at  this  point  is  soon  obliterated  by  adhesive 
inflammation,  through  which  the  aneurysm  bores  its  way,  rupturing  into  the 
bronchioles  of  the  apex  of  the  lung,  producing  fatal  hemoptysis.  The 
fourth  (4)  is  between  the  innominate  and  left  carotid  at  the  apex  of  the  arch 
behind  the  trachea.  It  may  perforate  into  the  trachea  before  attaining  very 
large  size.  The  fifth  position  (5)  is  posterior  in  the  descending  limb  of  the 
arch,  between  the  left  subclavian  and  the  isthmus  of  the  aorta  to  the  left  of 
the  vertebral  column.  The  aneurysm  here  is  more  commonly  a  cylindrical 
dilatation.  It  may  also  rupture  into  the  larynx.  The  remaining  aneurysms 
of  the  aorta  all  point  more  or  less  toward  the  vertebrae,  but  the  greater  resist- 


ANEURYSM. 


629 


ance  to  their  formation  in  that  direction  favors  lateral  development.  Ulti- 
mately they  rupture,  with  hemorrhage  into  the  pleural  or  abdominal  cavity. 
As  much  as  seven  pounds  (3.17  kilos.)  of  blood  have  been  found  in  the 
pleural  cavity  after  a  fatal  hemorrhage.  Aneurysms  of  the  thoracic  aorta 
lying  close  upon  the  diaphragm  may  bore  their  way  between  the  trunk  mus- 
cles behind,  attaining  often  large  size  without  perforation. 

Symptoms  of  Thoracic  Aneurysm. — Apart  from  the  physical  signs, 
the  most  important  of  the  symptoms  due  to  thoracic  aneurysm  are  the  result  of 
pressure  of  the  growing  aneurysm,  hence  they  are  called  pressure  symptoms. 

The  first  of  these  is  pain,  which  may  be  sharp  and  acute  when  nerves 
are  directly  involved,  or  dull  and  boring  when  the  result  of  pressure  on  bone. 
In  the  latter  case,  too,  it  is  localized;  in  the  former  it  may  extend  all  over 


Fig.  61. — Showing  Sites  of  Election  for  Aneurysms  in  the  Aorta — {after  Rindfieisch). 

a,  b.    Line  of  impingement  of  the  whirling  blood  current — the  continuous  line  is  sup- 
posed to  be  on  the  anterior  surface  of  the  aorta,  the  dotted  line  on  the  posterior. 

the  chest  and  down  the  arms,  simulating  angina  pectoris.  It  may  be  uni- 
lateral. It  may  occur  in  aneurysm  of  any  part  of  the  arch,  but  is  more 
frequent  in  that  of  the  ascending  limb. 

Shortness  of  breath,  especially  on  exertion,  is  a  frequent  S3'mptom.  It 
may  be  due  to  pressure  of  the  aneurysm  on  the  trachea,  or  on  a  bronchus, 
especially  the  left.  Dyspnea  may  be  increased  on  changing  position. 
Dysphagia  from  pressure  of  the  tumor  on  the  esophagus  is  a  frequent 
symptom,  especially  in  aneurysm  of  the  descending  aorta,  anywhere  in  the 
thorax.  Such  pressure  may  be  strikingly  demonstrated  by  Schnell's* 
method  of  introducing  into  the  esophagus  a  stomach-tube,  of  which  the 
lower  end  is  closed,  attaching  to  the  outer  end  a  glass  tube,  and  filling  the 


*  "  Miinch.  med.  Woch.,"  xxxvi.,  "  Der  Diagnose  des  Aneurysma  der  Aorta  descendens." 


630  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

whole  with  water,  and  watching  the  rise  and  fall  of  the  water  in  the  glass 
tube,  corresponding  to  the  pulsation. 

Cough  and  alicrations  in  the  voice  are  important  symptoms.  The  latter 
include  hoarseness,  aphonia,  and  stridor.  Some  of  these  symptoms  may 
be  produced  by  direct  pressure  on  the  trachea  itself,  others  by  pressure  upon 
the  left  recurrent  laryngeal  nerve.  A  stridulous  voice,  unaccompanied 
by  dysphagia  or  aphonia,  was  early  pointed  out  by  Thomas  Jolliffe  Tufnell 
as  indicating  that  the  pressure  is  on  the  right  side  of  the  trachea  and  does 
not  affect  the  esophagus  or  recurrent  laryngeal  nerve.  Cough  may  be 
caused  by  tracheal  pressure  or  by  a  resulting  tracheo-bronchitis  with  copious 
thin  or  mucous  expectoration,  sometimes  bloody.  It  is  often  brassy  in 
character. 

On  the  other  hand,  hoarseness,  aphonia  and  various  degrees  of  paralysis 
of  the  vocal  cord  are  due  to  paralysis  of  the  recurrent  laryngeal  nerve,  com- 
monly the  left,  which  passes  around  the  arch  of  the  aorta  and  is,  therefore, 
more  likely  to  be  involved  than  the  right.  The  paralytic  phenomena  may 
be  present  without  other  laryngeal  symptoms,  hence  any  alteration  of  voice 
in  a  person  exhibiting  palpitation  or  dyspnea  calls  for  a  laryngoscopic  exami- 
nation. When  paralysis  is  total,  such  examination  may  show  little  alteration 
in  the  position  of  the  vocal  cords  in  ordinary  breathing,  or  the  left  may  be 
a  little  nearer  the  median  line.  On  deep  inspiration  the  right  vocal  cord  is 
well  abducted,  the  left  remaining  quiescent  in  the  so-called  cadaveric  po- 
sition, midway  between  that  of  inspiration  and  phonation.  The  attempt  at 
pJwjiation  is  more  or  less  abortive.  During  it,  the  right  vocal  cord  may 
go  to  the  median  line,  leaving  a  small  opening  between  it  and  the  motion- 
less left  cord,  or  it  may  even  cross  the  line  to  its  paralyzed  neighbor. 

Partial  recurrent  paralysis  results  if  only  the  twigs  distributed  to  the 
abductor  muscle — /.  e.,  the  posterior  crico-thyroid — are  involved  in  the 
pressure.  There  ensues  gradually  a  permanent  shortening  or  "  paralytic 
contracture  "  of  the  antagonistic  orfductors  of  the  same  side,  and  the  affected 
cord  is  drawn  by  this  into  a  position  of  constant  phonation — that  is,  to  the 
median  line.  The  result  is  that  the  voice  may  be  entirely  natural,  the 
paralyzed  cord  being  in  the  position  of  adduction,  while  its  tension  is  mainly 
regulated  by  the  external  branch  of  the  superior  laryngeal  nerve,  which  is 
uninfluenced  in  aortic  aneurysm.*  In  these  cases  quiet  breathing  is  also 
unimpeded. 

These  phenomena  imply,  of  course,  a  destructive  lesion,  a  wasting  of  the 
nerve,  the  result  of  pressure,  which  may  be  preceded  by  a  primary  neuritis. 
Such  neuritis  and  resulting  irritation  of  the  entire  pneumogastric  may  ac- 
count for  certain  attacks  of  extreme  dyspnea  sometimes  experienced  by  sub- 
jects of  aortic  aneurysm.  Associated  with  the  neural  degeneration  is  also 
found  atrophy  of  the  left  abductor  muscle,  the  crico-arytenoid,  while  the 
adductors  remain  nearly  intact.  Constant  dyspnea  is  more  likely  to  be  due 
to  direct  compression  of  the  trachea. 

Other  nerves  may  also  be  compressed,  especially  the  intercostal,  vagus, 
and  sympathetic.  By  compression  of  the  intercostal  nerves,  pain  may  be 
caused :  of  the  vagus,  vomiting :  and  of  the  sympathetic,  inequality  of  the 
pupils  and  unilateral  sweating.  I  remember  well  a  very  stubborn  case  of 
intercostal  neuralgia  in  my  own  practice  which  turned  out  to  be  caused  by 
aneurysm  of  the  descending  aorta,  confirmed  by  autopsy. 

*  For  the  muscles  involved  see  Diseases  of  the  Larynx. 


ANEURYSM.  631 

Then,  there  is  the  tracheal  tugging  of  aneurysm  first  described  by  Sur- 
geon-Major OHver,  and  further  studied  by  Ross  and  McDonnell,  in  Canada.* 
It  is  generally  indorsed  by  English  clinicians  as  a  valuable  sign.  Recently 
Frankel,  from  the  German  side,  confirms  the  importance  of  this  symptom. f 
This  is  a  dragging  downward  of  the  larynx  with  each  systole  of  the  heart. 
In  Ewart's  method  the  patient  sits  with  his  mouth  closed,  his  head  well  bent 
backward,  steadied  against  the  chest  of  the  examiner,  standing  behind  him. 
The  trachea  is  drawn  up  gently  by  inserting  the  ends  of  the  fingers  under 
the  edge  of  the  cricoid  cartilage,  when  with  each  impulse  the  larynx  is  felt 
to  be  pulled  downward.  Oliver  directs,  with  the  patient  in  the  upright 
position,  the  mouth  closed,  and  chin  elevated,  grasping  the  cricoid  cartilage 
between  the  fingers  and  the  thuriib  and  pressing  it  steadily  upward,  when,  if 
aneurysm  exists,  the  pulsation  of  the  aorta  will  be  distinctly  felt.  It  is  said 
that  it  may  be  the  sole  sign  of  aneurysm,  and  a  sign,  also,  that  the  position 
of  the  aneurysm  is  such  as  to  involve  the  posterior  aspect  of  the  arch — 4  in 
Fig.  61.  It  should  be  a  distinct  tug  downward,  as  light  degrees  of  tracheal 
tugging  are  found  in  healthy  persons.  Cardarelli's  sign  of  lateral  movement 
of  the  larynx  is  similar,  with  an  obvious  difference.  It  is  said  never  to  be 
present  in  aneurysm  of  the  innominate. 

J.  N.  Hall  called  attention  |  to  a  sign  of  aneurysm  not  previously  de- 
scribed, which  he  calls  tracheal  shock,  consisting  in  a  distinct  sharp  impulse, 
diastolic  in  time,  transmitted  through  the  aneurysm  to  the  trachea  just  after 
the  tracheal  tug,  when  the  latter  is  present. 

Alteration  in  the  pulse  in  distal  arteries  is  also  a  sign  of  considerable 
diagnostic  value.  It  is  chiefly  when  the  aneurysm  involves  the  origin  of 
blood-vessels  leading  to  those  arteries,  as  the  innominate  on  the  right  and 
the  carotid  or  subclavian  on  the  left.  If  the  right  radial  pulse  is  enfeebled 
or  delayed,  the  aneurysm  will  be  on  the  right,  involving  the  origin  of  the 
innominate ;  if  the  left  radial  is  influenced,  the  aneurysm  is  probably  in  the 
neighborhood  of  the  left  subclavian.  Great  care  should  be  taken  in  the 
examination,  and  it  should  be  made  from  the  center  to  the  periphery — that 
is,  the  carotids,  the  subclavians,  the  brachials,  and  the  radials  should  be  suc- 
cessively examined,  as  recommended  by  Sansom.  These  effects  are  variously 
produced.  Thus,  the  aneurysm  may  narrow  or  distort  the  orifice  of  the 
blood-vessel  by  traction  on  it ;  or  there  may  be  atheromatous  change  in 
the  branch  vessel  analogous  to  that  in  the  aorta  itself,  which  may  cause 
narrowing  of  the  orifice,  while  the  possibility  of  this,  in  the  absence  of 
aneurysm,  is  also  to  be  remembered ;  or  the  aneurysmal  sac  may  act  as  the 
elastic  air-chamber  in  a  pump,  diminishing  thus  the  pulsatile  force  in  the 
vessel  and  branches  beyond.  It  is  particularly  in  the  arteries  of  the  lower 
extremities,  by  aneurysm  of  the  descending  thoracic  and  abdominal  aorta, 
that  this  air-chamber  effect  is  seen,  and  the  pulse,  even  in  the  abdominal 
aorta  and  its  branches,  has  been  thus  obliterated  by  a  large  thoracic  aneu- 
rysm. Capillary  pulse  is  occasionally  present,  and  is  probably  favored  by 
the  recoil  of  the  blood  into  the  aneurysmal  sac. 

Pressure  of  the  aneurysm  on  a  bronchus  may  lead  to  retention  of  secre- 
tion and  fetid  bronchitis  and  bronchiectasis,  and  favor  the  inoculation  of 
tubercular  phthisis,  thus  accounting  for  the  frequent  association  of  tubercu- 
losis of  the  lungs  and  aneurysm.         ^ 


*  "  London  Lancet,"  i8qi. 

t  "  Centralbl.  f.  innere'Med.,"  August  5,  iSqq. 

$  "  Amer.  Jour,  of  the  Med.  Sci.,"  January,  1901. 


632  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

Spitting  of  blood  is  an  occasional  symptom,  which  may  be  the  fore- 
runner of  larger  and  more  dangerous  hemorrhage. 

Still  rarer  is  pressure  on  the  thoracic  duct,  causing  emaciation.  Though 
this  symptom  is  more  frequently  due  to  mediastinal  tumor. 

Physical  Signs. — Inspection  does  not  always  discover  changes,  but  if 
the  sac  grows  outwardly,  sooner  or  later  a  swelling  makes  its  appearance, 
to  the  right  of  the  sternum  if  in  the  ascending  limb,  possibly  raising  a  rib 
or  the  end  of  the  clavicle ;  above  and  behind  the  sternum  if  in  the  transverse 
portion,  raising  the  manubrium  or  boring  its  way  through  it;  and  to  the 
left  of  the  sternum  if  in  the  descending  limb  of  the  arch.  As  the  tumor  pro- 
trudes, the  skin  becomes  smooth,  shining,  and  tense  over  it,  and  may  be- 
come gangrenous  previous  to  rupture.  Such  a  tumor  may  pulsate  or 
not.  The  aneurysm  is,  as  it  were,  a  rudimental  heart,  dilating  in  all  direc- 
tions with  every  jet  of  blood  that  is  shot  into  it,  and  contracting  on  the  with- 
drawal of  the  intravascular  pressure  so  long  as  any  elasticity  remains. 
Should  this  property  be  lost,  either  as  the  result  of  calcification  or  the  lining 
of  the  sac  with  successive  layers  of  coagulum,  such  dilatation  becomes 
impossible,  and  pulsation  does  not  occur.  The  pulsation  is,  however,  of 
great  importance  in  the  diagnosis.  When  present,  it  is  synchronous  with 
the  systole  of  the  ventricles.  The  heart  itself  is  sometimes  displaced  down- 
ward, as  seen  from  the  lowering  of  the  apex  sometimes  as  low  as  the  sixth 
interspace  and  outside  the  mammillary  line.  Less  frequent  is  hypertrophy 
of  the  left  ventricle,  and  when  present,  not  so  extreme  as  in  aortic  valve 
disease. 

If  the  aneurysmal  tumor  press  upon  the  great  veins  of  the  neck,  there 
may  be  venous  engorgement  and  edema  on  one  side  of  the  neck  or  both, 
according  as  the  innominate  of  one  side  only  is  compressed  or  the  descend- 
ing cava  itself.  The  aneurysm  may  rarely  rupture  into  the  descending  cava, 
resulting  in  a  form  of  varicose  aneurysm,  producing,  in  addition  to  the  ordi- 
nary signs  of  aneurysm,  sudden  distention  of  the  veins  in  the  upper  half  of  the 
body,  edema  of  the  face,  hands,  and  arms,  cyanosis,  systolic  venous  pulse, 
and  purring  thrill. 

Palpation  also  appreciates  the  impulse  of  the  aneurysm  if  it  is  visible, 
and  sometimes  when  it  is  not  visible.  This  beating  is  peculiar,  being  expan- 
sile, and  differs  thus  from  the  rising  of  a  tumor  over  a  pulsating  blood- 
vessel. Sometimes  there  is  a  double  beat,  the  second  and  weaker  being  the 
usual  recoil  following  closure  of  the  aortic  valves.  A  thrill  is  also  often 
felt,  a  vibration  in  the  walls  of  the  sac  caused  by  the  whirl  of  the  blood  in 
it.  It  is  by  no  means,  however,  invariable,  and  it  may  come  and  go.  Very 
great  tenderness  is  sometimes  present  over  the  seat  of  the  protruding 
aneurysm.  Palpation  may  also  recognize  the  "  diastolic  shock,"  or  recoil 
blow  of  the  aneurysm  on  the  closed  aortic  valve,  if  this  be  competent — to 
be  again  referred  to. 

Percussion  over  the  swelling  of  an  aneurysm  invariably  elicits  impaired 
resonance,  varying  greatly  in  degree  and  extent.  On  the  other  hand,  the 
adjacent  lung  may  be  compressed,  producing  an  area  of  dullness  beyond 
the  tumor  itself.  The  dullness  is  usually  in  the  right  upper  intercostal 
spaces,  especially  if  the  aneurysm  is  in  the  ascending  limb  of  the  arch. 
Aneurysms  in  the  transverse  portion  produce  dullness  in  the  middle  line 
under  the  manubrium  and  toward  the  left  of  the  sternum,  while  aneurysms 
of  the  descending  part  may  produce  dullness  in  the  left  interscapular  and 
scapular    regions    posteriorly.      Sometimes    the    impairment    of    resonance 


ANEURYSM.  633 

precedes    the    pulsation,    though    such    dullness    is    of    uncertain    signifi- 
cance. 

Auscultation  is  no  exception,  as  compared  with  the  other  modes  of 
physical  investigation,  as  to  the  inconstancy  of  its  information,  sometimes 
furnishing  the  most  distinctive  signs,  while  at  other  times  it  is  totally 
negative. 

The  murmur  of  bruit  heard  over  an  aneurysm  varies.  Sometimes  but 
one  murmur  is  produced — systolic,  corresponding  with  the  first  sound  over 
the  ventricles,  but  more  intense  ;  more  rarely  it  is  diastolic  only.  Not  infre- 
quently there  is  a  combined  or  double  murmur,  both  systolic  and  diastolic, 
the  first  intense  and  prolonged,  the  second  fainter  and  shorter.  It  varies 
greatly,  being  sometimes  rough,  sometimes  soft,  and  sometimes  musical. 
The  murmur  is  not  infrequently  absent.  The  mechanism  of  these  sounds  is 
not  settled.  The  systolic  is  most  easily  explained.  There  can  be  little 
doubt  that  it  is  produced  by  the  inequalities  which  meet  the  entrance  of  the 
blood  into  the  sac.  When  the  aneurysm  is  at  the  beginning  of  the  aorta, 
the  diastolic  murmur  will  probably  be  an  aortic  regurgitant  murmur,  due  to 
relative  insufficiency  of  the  aortic  valves.  When  the  aneurysm  is  distant 
from  the  aortic  orifice,  the  diastolic  murmur  may  be  due  to  the  recoil  of 
the  distended  sac,  propelling  the  blood  through  the  outlet  with  additional 
force,  or  the  whirling  of  the  blood  through  the  sac.  Rarely  in  these  distant 
situations  there  is  a  diastolic  murmur  only,  probably  thus  caused. 

A  much  more  constant  symptom  is  an  accentuated  aortic  second  sound, 
which  is,  in  fact,  rarely  absent  in  aneurysm  of  the  arch  where  the  aortic 
valves  are  intact  and  which  constitutes  the  so-called  diastolic  shock.  It  is 
an  exaggeration  of  the  second  sound,  recognizable  by  the  ear  and  due  to 
the  elastic  recoil  of  the  aneurysmal  sac.  "  It  is  the  shock  of  the  second 
sound  that  is  heard  and  the  recoil  that  is  felt."  It  is  not  always  present, 
and  requires  a  sound  aortic  valve  to  produce  it  in  its  most  marked  degree. 
Sir  Douglas  Powell  holds  that  it  is  best  studied  with  the  wooden  stethoscope, 
and  that  the  binaural  fails  to  observe  it.  Ernest  Sansom  considers  it  best 
investigated  by  the  ear  direct,  with  only  a  slight  intervening  chest  covering. 
It  may  be  accompanied  by  or  replaced  by  the  diastolic  murmur  referred 
to.  It  is  rarely,  if  ever,  present  with  mediastinal  growths,  even  when  they 
perforate  the  sternum  and  produce  pulsation.  J.  N.  Hall  *  calls  attention 
to  what  he  names  tracheal  shock  in  aneurysm — a  communication  of  the 
diastolic  shock  to  the  trachea. 

Occasionally  a  peculiar  zvhiifiiig  interruption  of  the  breath-sounds  may 
be  heard  bv  the  stethoscope  or  ear  placed  near  the  open  mouth,  due  to 
the  expansile  pulsation  of  the  aneurysm.  Similarly  caused  is  Dnimniond's 
sign,  produced  by  having  the  patient  take  a  full  inspiration  and  allowing  the 
air  to  pass  out  slowly  through  one  nostril,  the  other  being  compressed  by 
the  finger,  while  the  clinician  listens  with  the  stethoscope  over  the  manu- 
brium. Perez's  sign  is  a  creaking  sound  heard  when  auscultating  over  the 
sternum  when  the  patient  raises  and  lowers  the  arm.  It  is  caused  by  traction 
on  adhesions,  which  may  have  formed  in  the  anterior  mediastinum  in  cases 
of  aneurvsm  of  the  first  and  second  parts  of  the  aorta.  Glasgow's  sign  is 
a  systolic  thud  audible  by  the  stethoscope  in  the  brachial  or  similar  large 
artery  like  that  heard  in  aortic  regurgitation.  S cheek's  sign  is  a  momentary' 
disappearance  of  the  systolic  murmur,  accompanied  by  severe  pain,  pro- 
duced by  pressing  over  the  crural  arteries  of  the  two  sides.  It  is  an  experi- 
ment not  altogether  without  danger,  as  death  occurred  in  one  instance  on^ 

*  "Tracheal  Diastolic  Shock  in  the  Diagnosis  of  Aortic  Aneurj-sm,"  "  Amer.  Jour,  of  the  Med. 
Sci.,"  vol.   cxix.,  1900,  p.  10. 


634  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

practicing  it.     Enlargement  of  the  tumor  mass  may  also  arise  by  the  pressure 
on  the  crurals.* 

But  any  one  or  all  of  these  signs  may  be  wanting.  Particularly  is  this 
the  case  where  the  aneurysm  occurs  just  after  the  aorta  has  left  the  heart. 
The  most  valuable  is  the  pulsation  distinct  and  separate  from  that  of  the 
heart,  or,  as  grapliically  put  by  Da  Costa,  "  what  is  more  essential  is  to  find 
two  points  of  pulsation  in  the  chest — two  hearts,  apparently  each  with  its 
own  distinct  beat,  its  own  distinct  sounds."  f 

The  X-ray  has  been  brought  to  bear  on  the  diagnosis  of  aneurysm,  and 
commonly  a  distinct  demonstration  of  the  tumor  can  be  made,  both  by  the 
fluoroscope  and  skiagraphy,  but  it  is  scarcely  available  to  the  practicing 
physician,  because  of  the  costliness  of  the  apparatus. 

Is  it  possible  to  determine  the  portion  of  the  aorta  involved  by  aneurysm  ? 
Yes,  with  a  certain  degree  of  probability : 

In  aneurysm  of  the  Ascending  Aorta  there  is  more  apt  to  be  pain  like 
that  of  angina  pectoris,  dyspnea,  dullness  to  the  right  of  the  manubrium 
sterni  from  the  second  intercostal  space  upward,  pulsation  in  the  same 
region,  displacement  of  the  heart  downward  and  to  the  left,  delayed  pulse  in 
the  peripheral  arteries  as  contrasted  with  the  heart's  impulse,  compression 
svmptoms  involving  the  sympathetic  and  the  area  of  the  superior  cava,  pres- 
sure upon  the  pulmonary  artery  producing  a  pulmonic  systolic  murmur, 
with  hypertrophy  and  dilatation  of  the  right  ventricle  if  the  aneurysm  com- 
press the  pulmonary  artery. 

Aneurysm  of  the  Transverse  Part  of  the  Arch  furnishes  more  par- 
ticularly pulsation  in  the  fossa  jiignlaris,  dullness  on  percussion  over  the 
manubrium  and  to  its  left  in  the  first  intercostal  space,  with  possible  narrow- 
ing of  the  orifices  of  the  innominate,  the  left  carotid,  or  left  subclavian,  and 
resulting  inequality  of  the  pulse  in  the.  head  and  arm,  pressure  on  the  left 
innominate  vein,  with  resulting  congestion  and  edema  of  the  left  half  of  the 
neck  and  head.  It  is  when  in  this  situation  that  aneurysm  compresses  the 
left  recurrent  laryngeal  nerve  and  causes  paralysis  of  the  left  vocal  cord, 
presses  on  the  trachea,  with  resulting  stridor  and  cough,  and  on  the  left 
bronchus,  producing  inspiratory  dyspnea. 

In  aneurysm  of  the  Descending  Limb  of  the  Arch  of  the  x\orta  J 
we  look  for  the  pulsation  posteriorly  to  the  left  of  the  vertebral  column 
opposite  the  angle  of  the  scapula  or  below.  The  bruit  is  faint  or  absent. 
In  the  thoracic  aorta  below  the  arc,  in  consequence  of  the  air-chamber  effect, 
we  may  find  smallness  of  the  crural  pulse  as  contrasted  with  the  radial, 
and  symptoms  of  pressure  upon  the  left  lower  azygos  or  hemiazygos  vein — 
i.  e.,  edema  of  the  upper  part  of  the  abdomen  and  pleuritic  effusion:  also 
pressure  on  the  esophagus  and  left  bronchus.  The  intercostal  nerves  may 
be  compressed,  producing  intense  pain  in  the  course  of  their  distribution,  the 
vertebral  column  may  also  be  eroded,  the  spinal  canal  opened,  and  the  cord 
compressed,  with  resulting  paraplegia.  If  the  aneurysm  project  forward, 
which  is  rarely  the  case,  it  may  press  upon  and  displace  the  heart,  causing 
palpitation,  or  it  may  also  compress  the  esophagus,  causing  painful  degluti- 
tion.    It  sometimes  ulcerates  and  breaks  into  the  esophagus.     Obscure  symp- 

*  "  Reitraar  zur  Casuistik  und  Symptomatologie  des  Aorten  Aneurismen,"  "  Berl.  klin.  Wochen- 
schr."  XV    1878. 

t  Da  Costa,  "  Medical  Diagnosis,"  eighth  ed.,  1835.  P-  5o7- 

J  The  descending  part  of  the  arch  of  the  aorta  is  somewhat  arbitrarily  terminated  by  anatomists 
at  the  lower  end  of  the  fifth  dorsal  vertebra,  below  which  it  is  called  the  descending  thoracic  aorta, 
■which  terminates  at  the  opening  of  the  diaphragm  in  front  of  the  last  dorsal  vertebra,  below  which 
it  is  the  abdominal  aorta.  The  symptoms  of  aneurysm  of  the  descending  part  of  the  arch  and  the 
descending  thoracic  aorta  do  not'differ  wideU-. 


ANEURYSM.  635 

toms  of  this  variety  of  aneurysm  may  exist  for  a  long  time  before  a  tumor 
shows  itself  posteriorly  between  the  shoulders,  which  is  unmistakable  at 
this  late  stage. 

Aneurysm  of  the  Abdominal  Aorta  furnishes  a  pulsating  tumor  to 
the  left  of  the  vertebral  column,  to  the  left  and  above  the  umbilicus.  The 
bifurcation  of  the  aorta  takes  place  on  the  fourth  lumbar  vertebra,  which 
point  corresponds  to  the  umbilicus.  Sometimes  a  thrill  may  be  felt  and  a 
systolic  murmur  heard,  rarely  a  double  murmur.  Here,  too,  the  smallness 
of  the  crural  pulses,  as  contrasted  with  the  heart's  impulse  and  the  radial 
pulse,  may  be  observed,  while  in  some,  cases  the  crural  pulses  disappear 
altogether.  The  symptoms  vary  somewhat,  according  as  the  aneurysm 
grows  backward  or  toward  the  front.  In  the  former  case  pain  is  also  a 
striking  symptom,  and  may  be  of  two  kinds,  a  fixed  and  constant  pain  in 
the  back,  caused  by  the  pressure  of  the  tumor  on  the  solar  plexus  and 
splanchnic  nerves,  or  a  sharp  lancinating  pain  radiating  along  the  branches 
of  the  compressed  lumbar  nerves,  whence  pain  in  the  loins,  testes,  hypo- 
gastrium,  and  in  the  lower  limb,  usually  of  the  left  side.  If  the  sac 
grows  anteriorly,  gastro-intestinal  symptoms  may  be  present,  such  as 
vomiting,  gastralgia,  diarrhea,  and  even  symptoms  of  obstruction.  Paui 
is  also  present,  but  is  more  likely  to  be  fixed  in  the  loins,  epigastrium, 
or  some  part  of  the  abdomen.  Erosion  of  the  spine  is  much  rarer  in  ab- 
dominal aneurysm  than  in  thoracic.  In  emaciated  persons  the  abdominal 
aorta  sometimes  pulsates  so  plainly  that  one  is  strongly  reminded  of  aneurysm, 
and  I  have  myself  been  misled  by  such  pulsation,  but  under  these  circum- 
stances there  is  absence  of  the  systolic  murmur  and  of  the  alterations 
in  the  pulse  of  the  arteries  of  the  lower  extremity,  and  none  of  the  pain 
described.  Indeed,  evident  abdominal,  pulsation  occurs  far  more  frequently 
without  aneurysm  than  with  it. 

Aneurysm  of  the  Branches  of  the  Abdominal  Aorta. — Of  these, 
aneurysm  of  the  celiac  axis  is  most  often  mentioned  and  diagnosed,  though 
not  always  confirmed  by  the  necropsy.  The  symptoms  may  be  said  to  be 
a  pulsating  epigastric  tumor,  associated  with  pain  in  the  same  neighborhood, 
and  often  vomiting.  The  pain  and  vomiting  may  precede  the  pulsation 
and  tumor  by  some  months.  These  aneurysms  are  sometimes  traumatic,  and 
have  been  referred  to  railroad  accidents  in  which  sudden  and  powerful  com- 
pression has  been  exerted  upon  the  abdomen.  As  intimated,  their  diagno- 
sis is  not  always  easy.  Two  illustrative  cases  have  come  to  my  knowledge. 
In  one,  an  aneurysm  diagnosed  as  being  of  the  celiac  axis  was  at  the 
autopsy  proved  to  be  in  the  abdominal  aorta.  In  another  case  of  supposed 
aneurysm  the  celiac  axis  was  excluded,  and  the  necropsy  disclosed  an 
aneurysm  of  that  axis. 

Aneurysm  of  the  Splenic  Artery  is  sometimes  met.  Ten  cases  have 
been  collected  by  Lebert  out  of  thirty-nine  involving  various  branches  of  the 
abdominal  aorta.  Osier  reports,  in  his  book,  one  in  a  patient  aged  thirty. 
The  aneurysm  was  as  large  as  a  cocoanut,  and  was  found  at  autopsy  between 
the  stomach  above  and  the  transverse  colon  below,  and  extended  to  the  left 
as  far  as  the  level  of  the  navel.  The  sac  contained  densely  laminated  fibrin 
and  had  perforated  the  colon.  The  symptoms  were  a  deep-seated  tumor  in 
the  left  hypochondriac  region,  with  fullness,  which  merged  into  that  of  the 
spleen.  There  was  no  pulsation,  but  a  bruit  was  thought  once  to  have  been 
heard.  The  symotoms  were  vomiting,  epigastric  pain,  occasional  hemate- 
mesis,  and,  finallv,  hemorrhage  from  the  bowels. 


636  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

Aneurysm  of  the  Hepatic  Artery  is  a  rare  lesion,  some  ten  or  twelve 
cases  having  been  recorded.  These  aneurysms  are  not  usually  large,  while 
the  liver  has  been  found  greatly  enlarged. 

Aneurysms  of  the  Superior  Mesenteric  Artery  have  been  found  at 
necropsies. 

Aneurysms  of  the  Renal  Artery  are  more  numerous.  They  are  gen- 
erally small,  but  may  terminate  in  rupture  and  retroperitoneal  hemorrhage. 

Aneurysm  of  the  Innominate  is  especially  indicated  by  its  murmur, 
thrill,  and  impulse  in  the  vicinity  of  the  inner  end  of  the  right  clavicle, 
which  is  sometimes  raised  by  the  resulting  tumor;  also  by  the  comparative 
absence  of  signs  of  pressure  on  the  larynx  or  esophagus.  The  differences 
in  the  right  radial  pulse  alluded  to  are  especially  present  here.  Compres- 
sion of  the  right  subclavian  and  right  carotid  diminishes  the  force  beat  of 
the  innominate  aneurysm,  but  is  without  effect  in  aortic  aneurysm.  Nor  are 
there  percussion  signs  of  enlargement  of  the  aorta. 

If  the  Subclavian  is  involved,  the  signs  are  further  outward,  on  the 
outer  side  of  the  sternocleidomastoid,  while  in  aneurysm  of  the  innominate 
they  are  found  on  the  inner  or  tracheal  side.  To  those  named  may  be 
added  pressure  symptoms  upon  the  subclavian  vein,  producing  swelling  of 
the  arm  and  neck ;  upon  the  right  recurrent  laryngeal,  producing  defective 
speech  and  dyspnea ;  on  the  sympathetic,  producing  contraction  of  the 
pupil,  and  on  the  brachial  plexus  of  nerves,  pain.  Especially  would  these 
signs  point  to  aneurysm  of  the  subclavian  if  the  pulse  of  the  carotids  is  unin- 
fluenced while  the  right  or  left  radial  pulse  is  influenced. 

The  very  rare  .condition  of  aneurysm  of  the  Pulmonary  Artery  may 
produce  a  swelling,  with  the  other  local  symptoms  described,  to  the  left  of 
the  sternum,  in  the  second  interspace.  A  murmur  is  less  constant  and  is 
not  conducted  into  the  vessels  of  the  neck,  while  the  superficial  pressure 
signs  are  more  conspicuous.  There  is  lividity  of  the  face,  with  dropsy,  and 
the  dyspnea  is  naturally  very  great.  There  is  no  cough  or  voice  alter- 
tion.  It  is  to  be  remembered,  however,  that  the  swelling  of  an  aneurysm 
of  the  arch  of  the  aorta  may  extend  to  the  left  of  the  sternum.  Such  an 
aneurysm  may  break  into  the  pulmonary  artery. 

An  aneurysm  of  the  Heart  is  not  recognizable,  though  it  may  be  sus- 
pected if  there  is  bulging  succeeding  the  signs  of  fibroid  disease  of  the  organ. 

Differential  Diagnosis  of  Aneurysm  of  the  Arch. — Further  diagnosis 
distinguishes  aneurysm  of  the  aorta  mainly  from  mediastinal  tumors.  There 
may  be  the  same  percussion  signs,  and  there  is  often  similar  pain ;  there 
is  also  pulsation,  but  instead  of  the  expansile  pulsation  extending  in  all 
directions,  there  is  in  mediastinal  tumor  more  upheaving.  Percussion  dull- 
ness is  more  irregular  in  mediastinal  tumor.  Murmurs  are  not  usual  in 
the  latter.  The  ringing,  or  accentuated  second  sound — diastolic  shock — 
which  may  be  present  in  aneurysm  when  the  aortic  valves  are  intact,  or 
substituted  by  the  diastolic  murmur  when  the  valves  are  incompetent,  is 
absent  in  mediastinal  tumor.  Tracheal  tugging  does  not  occur  in  medias- 
tinal tumor,  nor  do  differences  in  the  pulse  or  changes  in  the  voice.  The 
state  of  the  blood-vessels  usually  associated  with  aneurysm  must  be  ascer- 
tained. Fever  is  often  present  in  mediastinal  tumor ;  very  rarely  in  aneu- 
rysm. A  differential  diagnosis  is  often  impossible,  and  experts  have  held 
opposite  opinions  on  the  same  case.  Should  the  patient  develop  a  cachectic 
state  and  secondary  glandular  enlargements  appear,  presumption  is  in  favor 
of  mediastinal  disease. 


ANEURYSM.  637 

The  resemblance  of  some  of  the  symptoms  of  aneurysm  of  the  ascend- 
ing aorta  to  some  of  those  of  aortic  incompetency  is  very  close.  The  same 
pulsating  aorta,  the  same  double  basic  murmur  with  impaired  resonance  at 
the  right  of  the  sternum,  may  be  present.  I  have  seen  a  case  diagnosed 
as  aortic  regurgitation,  with  stenosis,  in  which  the  autopsy  disclosed 
perfect  semilunar  valves  with,  however,  aneurysm  and  relative  insufficiency, 
which  caused  the  diastolic  murmur.  In  aneurysm  there  is  less  hypertrophy 
of  the  heart  than  in  aortic  valvular  disease.  The  age  of  the  patient,  if 
tinder  forty,  especially  the  history  of  heart  disease  in  early  life,  the  history 
of  rheumatism,  and  the  absence  of  the  causes  of  atheromatous  vessels, 
point  to  valvular  disease.  Though  there  may  be  pulsation  at  the  root 
of  the  neck  in  both,  in  aortic  incompetency  the  same  strong  pulse-beat  ex- 
tends to  the  wrists.  Traube's  double  sound  in  the  femorals  and  popliteals, 
though  possibly  otherwise  caused,  is  still  more  frequently  associated  with 
aortic  incompetency  than  any  other  lesion.  Simple  dilatation  may,  indeed, 
be  present  in  aortic  incompetency,  but  the  pressure  signs  are  wanting. 

A  pulsating  empyema  on  either  side  of  the  upper  sternum  sometimes 
closely  resembles  a  pulsating  aneurysm,  and  the  illusion  is  more  complete 
because  the  pulsation  is  expansile.  I  well  remember  a  case  of  my  own  in 
which  the  pulsation  to  the  left  of  the  sternum  was  so  like  that  of  an  aneurysm 
that  I  hesitated  to  use  the  exploring  needle.  Pulsating  empyemas  are 
generally  further  to  the  left  of  the  sternum  than  aneurysmal  pulsation.  Other 
signs  of  aneurysm  are  also  wanting,  unless  it  be  tenderness,  which  may  be 
present.  A  rare  condition  is  a  narroiving  of  the  aorta  below  the  remains 
of  the  ductus  arteriosus  at  the  junction  of  the  arch  with  the  thoracic  aorta, 
which  produces  small  delayed  pulse  in  the  femorals,  a  thrill  and  murmur 
over  the  upper  part  of  the  sternum,  but  the  extraordinary  enlargement  of 
the  collateral  vessels,  especially  the  mammary  and  epigastric  arteries,  should 
set  the  question  at  rest. 

How  shall  the  symptoms,  which  also  so  much  resemble  those  of  a 
laryngitis,  be  recognized  as  due  to  aneurysm  instead  of  the  latter  affection 
in  the  absence  of  the  physical  signs  of  aneurysm  ? 

In  acute  laryngitis  we  have  often  the  cause — exposure  to  cold — to  help 
tis,  though  in  the  chronic  form  we  have  not.  In  laryngitis  there  is  usually 
m.ore  huskiness  and  less  stridor  in  the  voice,  nor  is  the  cough  so  brassy,  or 
the  voice  so  uniformly  changed ;  it  is  more  likely  to  alternate  with  normal 
voice.  In  aneurysm  the  voice  grows  progressively  weak  until  aphonia  re- 
sults. The  dyspnea  in  aneurysm  is  more  often  attended  with  wheezing, 
and  is  sometimes  relieved  for  a  time  by  coughing.  Stokes  called  attention 
to  the  fact  that  in  aneurysm  the  stridor  of  the  voice  seem.s  to  come  from 
the  notch  of  the  sternum,  rather  than  from  the  larynx  itself.  In  aneurysm 
the  breathing  sounds  are  more  likely  to  differ  in  the  two  lungs.  Then  we 
have  the  laryngoscopic  picture.  There  is  no  swelling  of  the  cords  in  aneu- 
rysm, while  there  may  be  the  paralytic  phenomena  detailed.  Finally,  in 
laryngitis  there  may  be  fever. 

Prognosis. — Aneurysm  is  not  infrequently  found  at  necropsy  with- 
out having  been  suspected.  In  other  cases  the  fatal  termination  is'  the 
first  notification  of  its  presence.  When  an  aneurysm  of  the  aorta  is  so  de- 
veloped as  to  exhibit  its  usual  signs  plainly,  it  is  sooner  or  later  fatal  in 
some  one  of  the  modes  already  described.  To  foretell  in  which  of  the 
directions  pointed  out  perforation  will  occur  depends  upon  the  accuracy 
v/ith  which  diagnosis  of  its  position  can  be  made,  and  such  diagnosis  is  at 


63S  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

best  a  matter  of  probability.  Only  in  cases  in  which  aneurysm  slowly  erodes 
the  anterior  wall  of  the  chest  is  there  a  gradual  termination.  Then  there 
are  sometimes  repeated  small  hemorrhages,  which  gradually  reduce  the 
strength  of  the  patient,  who  finally  dies  of  exhaustion  or  of  an  ultimately 
fatal  large  hemorrhage.  Perforation  into  the  vena  cava,  pulmonary  artery, 
and  right  side  of  the  heart  is  a  rare  termination.  The  course  of  the  disease 
may,  however,  be  prolonged  many  months,  and  if  treatment  is  instituted 
early,  it  may  contribute  to  such  prolongation.'  When  death  does  not  occur 
from  sudden  hemorrhage,  the  symptoms  may  assume  the  type  of  chronic 
heart  disease,  for  which,  indeed,  the  condition  is.  sometimes  mistaken  bv.  the 
untrained  observer.  With  failing  heart,  come  dyspnea,  palpitation,  dropsy, 
and  death. 

Treatment. —  W^e  seek  in  the  treatment  of  aneurysm  to  diminish  intra- 
vascular pressure  and  restore  the  integrity  of  the  vessel.  The  former  mav  be 
accomplished  in  a  degree  by  placing  the  patient  under  conditions  which  will 
avert  the  causes  of  such  increased  intravascular  pressure,  which  is  constantly 
co-operating  with  the  disease  of  the  artery  to  produce  further  dilatation  and 
ultimate  rupture  of  the  blood-vessel.  This  is,  of  course,  best  accomplished 
by  absolute  rest.  It  is  plain  the  less  frequently  the  heart  beats  and  throws 
the  weight  of  its  blood  against  the  weak  blood-vessel,  the  longer  will  that 
blood-vessel  last,  while  it  is  known  to  every  student  that  the  heart  beats 
less  frequently  in  the  sitting  than  in  the  standing  posture,  and  less  in  the 
recumbent  than  in  the  sitting  position.  On  the  other  hand,  it  is  evident  that 
absolute  rest  is  an  impossibility.  Yet  it  may  be  approximated  in  various 
degrees.  It  is  Ir.ipossible  also  to  restore  the  integrity  of  the  vessel,  but  to 
this  end  also  measures  are  suggested  which  have  for  their  immediate  pur- 
pose coagulation  of  the  blood  in  the  vessel  and  obliteration  of  the  sac. 
That  this  sometimes  occurs  numerous  autopsies  also  attest. 

The  method  which  has  met  most  favor  is  that  now  known  as  Tufnell's 
treatment,  though  Valsalva  originally  suggested  a  restricted  diet  and  prac- 
ticed frequent  venesections.  Bellingham  advised  starvation  without  bleed- 
ing. It  was,  however,  revived  by  the  late  T.  Jolliffe  Tufnell  and  modified  by 
W.  G.  Balfour.  Tufnell's  treatment  consists  in  absolute  mental  and  physical 
rest  in  the  recumbent  position,  together  with  a  moderate  dry  diet.  The 
object  of  this  is  to  diminish  the  blood  pressure  and  volume  of  blood,  to 
increase  the  proportion  of  fibrin  in  the  latter,  and  to  promote  its  coagulation. 
The  diet  is  as  follows : 

For  breakfast,  two  ounces  of  bread  and  butter  and  two  ounces  of  milk ; 
for  dinner,  two  or  three  ounces  jof  meat  and  three  or  four  ounces  of  milk  or 
claret ;  for  supper,  two  ounces  of  bread  and  two  ounces  of  milk.  Thus  it 
is  hoped  to  diminish  the  blood  volume  and  reduce  the  pressure  within  the  sac, 
to  render  the  blood  more  fibrinous  and  to  favor  coagulation.  The  addition 
of  iodid  of  potassium  is  Balfour's  modification.  The  proper  maximum  dose  is 
from  five  to  twenty  grains  (0.33  to  1.3  gm.)  three  times  a  day.  An  additional 
effect  of  the  iodid  of  potassium  is  the  relief  it  affords  to  pain.  To  its  efficacy 
in  this  direction  I  think  I  may  add  my  testimony.  It  is  supposed  also  to  act 
by  increasing  secretions,  thus  thickening  the  blood.  Dr.  Balfour  also  claims 
that  it  lowers  the  blood  pressure  by  promoting  the  flow  of  blood  through  the 
arterioles.  It  may  be  expected,  also,  that  cases  of  syphilitic  origin  will  be 
those  especially  benefited,  but  it  is  said  that  experience  does  not  confirm  such 
expectation.  Occasional  small  bleedings  are  said  to  contribute  to  a  favorable 
result.     Evidences  of  improvement  are  reduction  in  the  size  of  the  tumor. 


AXEURYSM.  639 

diminished  force  of  pulsation,  and  relief  of  pain.  It  should  be  kept  up  for 
several  months,  or  as  long  as  the  patient  will  submit  to  it.  It  is  said  to  be 
useful  more  particularly  in  saccular  aneurysm  communicating-  by  a  small 
orifice  with  the  aorta.  It  is  doubtful  whether  it  is  worth  while  to  subject 
a  patient  with  large  aneurysm  communicating  with  the  aorta  by  a  large  orifice 
to  the  inconvenience  of  such  a  treatment,  and  whether  it  may  not  be  better 
to  advise  him  to  live  a  life  as  quiet  as  possible  and  to  await  the  inevitable, 
while  we  relieve  symptoms  as  they  arise,  and  remember  especially  that  iodid 
of  potassium  is  often  one  of  the  best  remedies  for  pain. 

Small  venesections — to  the  amount  of  a  few  ounces — are  also  recom- 
mended for  the  relief  of  pain  in  aneurysm.  Acupuncture  as  a  means  of  secur- 
ing coagulation  and  contraction  of  the  clot  was  suggested  by  Velpeau.  It 
consists  in  placing  an  iron  wire  or  needle  into  the  aneurysm  with  the  hope 
that  the  bl'ood  will  coagulate  on  it.  Filling  the  aneurysm  with  horsehair  or 
fine  zvire  has  been  suggested  for  the  same  purpose.  The  wire  is  introduced 
through  a  hypodermic  needle.  Galvanopuncture,  suggested  by  Loretta,  fur- 
nishes perhaps  the  most  satisfactory  results.  Two  needles  are  introduced 
into  the  sac,  and  a  mild  current  of  electricity  is  passed  through  them.  In  this 
W'ay  a  combined  electrolytic  and  mechanical  effect  is  obtained.  The  intro- 
duction of  astringent  substances,  as  solution  of  acetate  of  lead  or  persulphate 
of  iron,  into  the  ar.eurysm  may  be  mentioned  only  to  be  discouraged,  since 
the  danger  of  producing  embolism  far  exceeds  the  chance  of  benefit.  Liga- 
tion of  the  carotid  or  subclavian,  or  both,  has  also  been  done  for  aneurysm 
of  the  aorta  with  satisfactory  results.  It  is,  however,  a  formidable  opera- 
tion. 

The  latest  method  of  inducing  coagulation  for  the  cure  of  aneurysm  is 
by  the  subcutaneous  injection  of  gelatin,  suggested  by  Lancereaux."^'  Two 
hundred  and  fifty  cubic  centimeters  of  a  solution  of  two  grams  of  gelatin  in 
100  grams  of  saline  solution  are  injected  under  the  skin  of  the  thigh.  This 
is  renewed  at  varying  intervals  from  every  two  to  fifteen  days.  It  has  been 
claimed  that,  as  a  rule,  ten,  fifteen,  or  twenty  injections  produce  complete 
cure.  They  act  by  increasing  the  coagulability  of  the  blood.  Recently,  Pro- 
fessor Shoicesco  of  Bucharest  reported  f  six  cases  treated  in  this  way  with 
good  results  in  five  cases.  On  the  other  hand.  Osier  treated  ten  cases  at  Johns 
Hopkins  Hospital  without  a  single  cure. 

Xo  other  internal  treatment  for  aneurysm  other  than  that  suggested — 
by  iodid  of  potassium — has  ever  be^en  of  any  use.  As  a  part  of  the  medicinal 
treatment  of  thoracic  aneurysm  it  should  be  added  that  where  there  is  violent 
action  of  the  heart,  cardiac  sedatives  are  sometimes  indicated  to  allay  this, 
in  addition,  of  course,  to  the  enjoined  rest.  Among  these  sedatives  we 
include  aconite  and  veratrum  viride  in  extreme  cases,  also  cold  to  the  seat  of 
the  swelling  and  to  the  cardiac  region. 

The  treatment  of  peripheral  aneurysm,  as  of  the  popliteal  and  femoral,  is 
usually  relegated  to  the  surgeon,  who  will  treat  it  by  ligation  or  compression. 
The  injection  of  ergotin  in  the  vicinity  of  the  aneurysm,  as  suggested  by 
Langenbeck,  may  be  tried.  From  two  to  five  grains  (0.132  to  0.33  gm.) 
of  the  aqueous  extract  dissolved  in  water  or  glycerin  are  injected  every  two 
days.  TufnelFs  method  is  also  applied  to  peripheral  aneurysm,  for  which 
indeed,  it  was  originally  recommended. 

The  treatment  of  peripheral  aneurysm  by  compression  has  long  been  an 

*  "The  Lancet."  October  22,  i8or. 

+  "Journal  de  Medicine  Interne,"  July  i,  iSgg. 


640  DISEASES  OF  HEART  AND  BLOOD-VESSELS. 

acknowledged  method  for  the  purpose,  and  though  looked  upon  as  a  surgical 
procedure,  is  as  medical  as  surgical.  The  method  adopted  which  has  been 
most  successful  is  digital  compression,  which  is  exerted  by  relays  of  students 
or  others  available  for  the  purpose.  The  effect  is  that  in  the  course  of  forty- 
eight  hours  coagulation  has  taken  place  and  the  aneurysm  is  cured.  Failing 
in  these  measures,  ligation  is  practiced  in  case  of  the  smaller  arteries,  but  all 
details  of  this  operation  belong  to  the  province  of  surgery. 


SECTION  V. 

DISEASES   OF    THE   BLOOD    AND   BLOOD-MAKING    ORGANS. 

DISEASES   OF  THE   BLOOD. 

THE   MIXUTE   STRUCTURE   OF   THE   BLOOD. 

An  accurate  knowledge  of  the  histology  of  the  blood  has  become  so 
important  to  an  intelligent  study  of  its  diseases  that  a  brief  statement  of  its 
minute  constitution  seems  justified.  It  is  more  especially  since  the  practice 
of  staining  blood  preparations  has  come  into  use  that  our  present  more  inti- 
mate knowledge  has  been  acquired. 

The  red  blood  disc  needed  these  aids  least,  but  it  is  nevertheless  a  more 
interesting  object  thus  studied.  Thus,  when  stained  with  a  solution  of 
orange  G,  contained  in  the  Ehrlich  triple  stain,  it  assumes  a  beautiful  yellow 
or  pale-orange  color.  By  means  of  this  stain  the  expert  observer  may  even 
measure  a  diminution  in  the  amount  of  hemoglobin,  indicated  by  a  diminished 
intensity  of  the  central  coloring.  Only  in  high  degrees  of  loss  of  hemoglobin 
do  the  edges  of  the  cell  become  paler.  Eosin  solutions  stain  the  red  disc 
a  brilliant  red.*  (See  F  in  plate  opposite  p.  662.)  The  average  number  of 
red  discs  in  a  cubic  millimeter  in  the  male  is  5,000,000,  in  the  adult  female 
4,500,000 ;  previous  to  menstruation,  the  number  is  somewhat  larger. 

The  blood  plaques,  though  a  constituent  of  normal  blood,  are  not  ren- 
dered visible  by  staining  They  are  most  readily  demonstrated  by  placing 
a  drop  of  fresh  blood  at  the  edge  of  a  thin  cover  previously  placed  on  the 
slide,  whence  the  blood  is  drawn  in  by  capillary  attraction.  The  plaques  may 
be  recognized  as  dotted  bodies  of  irregular  outline  Jialf  the  diameter  of  a  red 
blood  disc  and  often  coherent.  Fibrin  is  not  stainable,  but  its  delicate  threads 
may  be  seen  after  a  time  in  specimens  prepared  as  previously  directed. 

*  The  student  is  referred  to  works  on  diagnosis  for  technical  methods,  but  it  may  not  be  amiss 
to  add  directions  for  making  and  using  Ehrlich's  triple  stain.    The  formula  is  as  follows  : 

Saturated  aqueous  solution  orange  G,         120-135  c.  c. 

Saturated  aqueous  solution  acid  fuchsin,  80-165  c.  c. 

Saturated  aqueous  solution  methyl-green, 125  c.  c. 

Add— 

Water 300  c.  c. 

Absolute  alcohol, 200  c.  c. 

Glycerin 100  c.  c. 

Or  the  colors  previously  mixed,  constituting  the  Ehrlich-Biondi  or  Ehrlich-Biondi-Heidenheim  pow- 
der, may  be  used  as  follows  : 

Ehrlich-Biondi  powder, 1-70  Sm. 

Acid  fuchsin o-o5  S^- 

Absolute  alcohol,       . 2.00  c.  c. 

Distilled  water 18.00  c.  c. 

To  Sfai'n.— After  cleansing  the  finger  thoroughly  with  soap  and  water  and  alcohol,  it  is  pricked 
with  a  clean  needle  and  a  clean  cover-slip  touched  to  the  blood  as  it  flows  from  the  puncture.  Drop 
this  cover-slip  on  another,  draw  the  two  apart  and  drv  in  the  air.  At  any  time  within  a  few  days  fix 
by  heating  at  2^"  F.  (no"  C.)  for  ten  minutes,  or  bv  p'lacing  in  absolute  alcohol  or  alcohol  and  ether. 
Then  place  for  four  minutes  in  the  Ehrlich  tricolor  mixture.  Drv  and  mount.  Better  success  in  the 
differential  staining  is  obtained,  according  to  Henry  F.  Hewe's,  if  the  specimen  is  washed  after 
treatment  with  the  Ehrlich  tricolor  mixture  and  treated  for  from  one-half  a  second  to  ten  seconds  m 
Loffler's  solution  of  methvlene-blue  rsaturated  alcoholic  solution  of  methylene-blue  30  c.c,  potas- 
sium hydrate— i  :  10.000  solution— 100  c.  CI.  Wash,  dry,  and  mount  in  balsam.  The  second  alkalme 
basic  stain  is  recommended  because  it  completes  the  conditions  necessary  for  acid,  neutral  and 
basic  staining,  the  last  being  furnished  imperfectly  by  Ehrlich's  stain,  which  does  furnish  perfectly 
acid  and  neutral  staining. 

41  641 


642  DISEASES  OF  THE  BLOOD. 

It  is  the  study  of  the  colorless  corpuscle  which  is  most  facihtated  by  the 
staining  process.  By  it  are  differentiated  first  the  different  varieties  of  white 
cells.     They  include  the  following: 

1.  The  Small  Lymphocyte  (C,  plate  opposite  p.  662). — This  consists  of 
a  greenish  blue  nucleus  as  stained  by  the  acid  fuchsin  of  Ehrlich's  triple 
solution.  It  is  about  as  large  as  a  red  disc,  surrounded  by  a  thin,  slightly 
stained,  scarcely  visible  or  even  invisible  ring  of  protoplasm.  The  small 
lymphocyte  is  from  5  to  10  /^in  diameter. 

2.  The  Large  Lymphocyte  or  Large  Mononuclear  Cell. — This  presents 
the  same  characters  as  the  small  lymphocyte,  but  is  larger  and  paler.  Both 
nucleus  and  protoplasm  have  increased  in  size,  but  the  former  more  than  the 
latter.  The  protoplasm  continues  free  of  granules,  as  a  rule,  but  fine  and 
pale  granules  may  be  brought  out  by  intense  basic  stain  like  methylene-blue. 
Between  the  small  and  large  lymphocyte  are  intermediate  forms.  These  cells 
have  a  common  origin  and  represent  different  stages  of  development.  It 
was  formerly  erroneously  supposed  that  the  large  mononuclear  cell  arose 
from  the  spleen  and  the  small  one  from  the  lymph  glands.  The  large 
lymphocyte  may  have  a  diameter  of  13  to  15  //.  Both  large  and  small  cells 
sometimes  show  a  disposition  to  division  of  the  nucleus. 

3.  Transiiional  Leukocytes. — These  differ  from  the  large  mononuclear 
cells  only  in  the  fact  that  the  nucleus  is  indented  or  horseshoe  shaped,  and 
are  a  still  more  mature  cell  than  the  large  lymphocyte.  Its  protoplasm  is 
like  that  of  the  large  mononuclear  leukocyte,  but  neutrophilic.  The  proto- 
plasm of  the  three  varieties  described  is  therefore  quite  similar. 

4.  P olymor phomuclear  or  Polynuclear  Cells.— Thtst  include  three  sub- 
divisions : 

(a)  Polymorphonuclear  Neutrophiles  (B,  plate  opposite  p.  662). — 
These  are  regarded  as  matured  leukocytes.  They  make  up  the  majority  of 
the  white  cells  of  the  blood  and  of  pus.  They  are  large,  possessed  of  an 
irregular  nucleus,  often  bent  or  twisted  into  fantastic  shapes,  which  stain 
a  green  or  greenish-blue  in  Ehrlich's  tricolor  fluid.  Different  parts  of  the 
nucleus  are  variously  distinct,  according  to  the  distance  of  such  parts  from 
the  surface,  and  thus  the  impression  of  a  polynuclear  cell  is  often  produced, 
though  a  multiple  nucleus  is  not  present.  Two  or  more  nuclei  are,  however, 
sometimes  found.  The  cell  is  further  characterized  by  the  presence  within 
the  nucleus  and  the  protoplasm  surrounding  it  of  minute  granules  which 
stain  well  only  in  neutral  solutions  like  Ehrlich's,  whence  the  name  neu- 
trophilic or  £  granules.  In  this  fluid  they  stain  violet  or  purple.  Between 
the  granules  may  be  seen  a  pinkish  matrix.  Occasionally  the  nucleus  of  a 
neutrophile  appears  to  have  a  round  or  oval  nucleolus,  but  this  is  said  to  be 
an  optical  effect  caused  by  the  arrangement  of  the  nucleus  or  point  of  view" 
whence  it  is  seen.  The  presence  of  these  neutrophilic  granules  constitutes 
the  chief  difference  between  this  variety  and  the  three  forms  previously 
described. 

(&)  The  Eosinophiles  (A,  plate  opposite  p.  662). — These  are  also  large 
polymorphonuclear  cells,  slightly  smaller  than  the  neutrophiles,  with  granules 
much  larger,  which  stain  in  acid  stains  such  as  eosin  and  the  acid  fuchsin 
of  Ehrlich's  triple  stain  :  hence  they  are  called  oxyphiles  or  «  granules.  With- 
eosin  they  assume  a  brilliant  pink  color,  with  acid  fuchsin  in  the  Ehrlich- 
Biondi  a  copper  red.  The  nucleus  stains  bluish,  and  there  may  be  more  than 
one.  The  eosinophiles  are  actively  ameboid,  and  are  regarded  as  overmature 
cells,  as  contrasted  with  the  adult  or  mature  neutrophile. 


THE  MINUTE  STRUCTURE  OF  THE  BLOOD.  643 

(c)  The  Basophilic  or  "Mast''  Cell. — Occasionally  is  found  in  normal 
blood  a  polymorphonuclear  cell  whose  granules  either  do  not  come  out  with 
Ehrlich's  fluid  or  appear  as  white  spots.  They  stain,  however,  in  a  basic 
solutioTi  of  the  anilin  dyes, — as,  for  example,  dahlia  in  glacial  acetic  acid 
and  water, — and  are  hence  called  basophilic.  The  large  basophilic  granules 
are  called  y  granules  ;  the  fine,  6  granules.  The  relation  of  the  "  mast  "  cells 
to  the  other  leukocytes  is  not  known. 

The  proportion  of  the  different  varieties  of  colorless  cells  in  normal 
blood  is  approximately  as  follows : 

Small  lymphocytes  (young) 20       to  30     per  cent. 

Large  lymphocytes  (young), 4       to    8 

Polymorphonuclear  neutrophiles  (adult),     .    .  62       to  70  " 

Eosinophiles  (old), 0.5    to    4  " 

Coarsely  Granular  Basophilic  or  "  Mast  "  cells       0.25  to    0.5  " 

These  proportions  are  not  absolute  in  health.  Thus,  in  infancy  the  per- 
centage of  young  cells  represented  by  small  and  large  leukocytes  may  be 
from  40  to  60  per  cent.,  while  the  adult  cells,  or  polymorphonuclear  cells, 
may  be  as  low  as  from  18  to  40  per  cent.  A  similar  ratio  is  at  times  found 
in  conditions  of  debility  without  actual  disease.  The  eosinophiles  are  more 
abundant  in  various  parts  of  the  body,  as  in  the  marrow  of  bones  and  in  the 
thymus  gland,  while  their  number  often  varies  in  an  unexplainable  way  in 
the  blood.  The  total  mean  number  of  leukocytes  in  health  is  6000  per  cubic 
millimeter. 

Cell  Forms  Rarely  or  not  at  all  Found  in  Normal  Blood. — (a)  The 
myelocyte  of  Ehrlich,  or  marrow  cell;  Cornil's  "cellules  medullaires"  (A, 
plate  opposite  p.  662). — Certain  large  leukocytes  twice  or  three  times  as 
large  as  a  red  blood  disc  and  corresponding  in  all  respects  to  the  large 
granular  cells  of  the  bone-marrow  are  thus  named.  They  are  the  variety 
of  leukocyte  most  numerous  in  the  bone-marrow,  in  which  lymphocytes, 
polymorphonuclear  cells,  as  well  as  eosinophiles,  are  also  found.  Their  proto- 
plasmic granules  are  commonly  neutrophilic,  but  occasionally  eosinophilic. 
They  are  recognizable  only  by  the  Ehrlich  staining  methods.  The  nucleus 
stains  pale  in  the  Ehrlich-Biondi  stain,  is  large,  single,  at  times  smooth,  at 
others  irregular,  and  sometimes  showing  a  tendency  to  degeneration. 
Smaller  cells  exhibiting  all  the  characteristic  features  of  true  myelocytes  are 
sometimes  met  associated  with  the  large  variety.  Myelocytes  resemble  the 
large  lymphocytes,  dififering,  however,  in  the  presence  of  granules.  They 
differ  also  from  the  polymorphonuclear  cells  in  the  shape  of  the  nucleus. 
They  may  be  an  intermediate  stage  between  these  last  mentioned  cells. 
Rarely  if  at  all  found  in  normal  blood,  these  cells  are  numerous  in  certain 
varieties  of  leukemia  and  occur  also  in  pernicious  anemia  and  in  some 
infectious  diseases.  There  is  every  reason  to  believe  they  are  the  cells 
originally  described  by  Cornil  as  "  cellules  medullaires." 

(b)  Nucleated  Red  Corpuscles  (D,  plate  opposite  p.  662). — These  are 
red  cells  possessed  of  a  nucleus.  They  are  usually  divided  into  three  classes : 
(a)  Normoblasts,  about  the  size  of  a  normal  red  corpuscle;  (b)  megaloblasts, 
large  and  irregular  cells;  (c)  microblasts,  very  small  cells,  smaller  than  a 
normal  corpuscle. 

These  cells  are  regarded  as  pointing  to  regenerative  change.  The 
normoblast,  representing  an  immature  red  corpuscle,  is  found  normally  in 
the  bone-marrow,  whence  it  may  be  prematurely  ejected  before  it  has 
expelled  its  nucleus.     Its  nucleus  stains  deep  blue,  almost  black  with  the 


644  DISEASES  OF  THE  BLOOD. 

Ehrlich-Biondi  fluid.  It  is  found  in  severe  anemias,  occasionally  in  large 
numbers.  The  megaloblast  is  very  large,  with  a  large  nucleus,  staining  pale 
green  or  a  robin's-egg  blue  with  Ehrlich-Biondi  fluid.  It  is  found  nowhere 
in  the  normal  adult  body,  but  it  does  occur  in  fetal  marrow  and  in  grave 
forms  of  anemia  along  with  the  normoblast.  Ehrlich  regarded  it  as  degen- 
erate, while  the  normoblast  is  regenerate.  The  mkroblast  is  still  smaller 
than  the  normoblast.  It  is  variously  regarded  as  degenerate  and  as  a 
younger  normoblast.  It  is  found  in  the  blood  in  anemias.  Irregular  or 
atypical  forms  are  also  met.  The  smaller  forms  of  nucleated  cells  appear 
in  the  earlier  stages  of  anemia,  the  megaloblasts  and  irregular  forms  in  the 
more  advanced  stages. 

Muller's  *  "blood  dust"  (hemoconien)  is  the  latest  discovered  constit- 
uent of  normal  and  pathological  blood.  It  consists  of  small,  round  colorless 
granules  resembling  the  smallest  fat  drops,  about  1-4  to  i  /x  in  diameter, 
highly  refracting  and  characterized  by  molecular  movement.  According  to 
Stokes  and  Weyforth  f  they  may  be  the  extruded  granules  of  neutrophilic 
and  eosinophilic  leukocytes. 


THE  ANEMIAS. 

Broadly  defined,  anemia  means  "  bad  blood."  It  is  further  subdivided 
into  local  and  general.  The  former  is  known  also  as  ischemia.  Its  special 
consideration  requires  but  brief  treatment  in  a  text-book  of  medicine.  It  is 
illustrated  by  the  pallor  of  the  fainting  person,  and  by  that  interesting  dis- 
ease known  as  Raynaud's  disease,  which  will  be  considered  with  diseases  of 
the  nervous  system. 

By  general  anemia  is  meant  any  state  of  the  blood  in  which  there  is  a 
diminution  of  its  total  bulk,  its  red  corpuscles,  its  hemoglobin — any  one  or 
all  of  these.  The  first  is  the  condition  which  ensues  from  a  large  hemor- 
rhage of  any  kind,  as  from  the  rupturing  of  an  aneurysm,  erosion  of  a  blood- 
vessel, such  as  sometimes  happens  in  ulcer  of  the  stomach  or  in  tubercu- 
losis of  the  lung,  or  from  a  blood-vessel  wounded  in  any  way.  In  all 
instances,  however,  where  the  hemorrhage  is  not  fatal  the  original  bulk  of 
the  blood  is  rapidly  restored  by  the  absorption  of  water  and  salts  from  the 
tissues,  while  the  hemoglobin  and  albumin  remain  deficient  until  they  can 
be  restored  by  suitable  nourishment.  Practically,  therefore,  anemias  resolve 
themselves  for  study  into  conditions  in  which  there  is  a  reduction  in  the 
amount  of  hemoglobin  through  a  diminution  in  the  total  number  of  red 
corpuscles  or  in  the  proportion  of  coloring-matter  in  each  corpuscle,  or  both. 

Anemias  are  further  divided  into  primary  or  essential,  and  secondary 
anemias.  The  former,  strictly  speaking,  should  include  only  those  which 
are  the  direct  result  of  a  defect  in  the  blood-making  apparatus,  while  sec- 
ondary anemias  are  those  due  to  loss  of  blood,  or  some  one  of  its  important 
constituents,  or  from  a  defective  supply  of  blood-making  material.  Richard 
C.  Cabot  defines  primary  anemia  as  an  anemia  "  in  which  the  causal  factors 
are  entirely  unknown  or  are  insufficient  to  cause  so  severe  a  disease."  That 
such  a  definition  has  some  foundation  will  appear  from  the  facts  to  be 
adduced  as  our  study  proceeds. 

*"Centralblatt  f.  allg.  Path.,"  viii.,  i8g6. 

t  "Johns  Hopkins  Hospital  Bulletin,"  December,  1897. 


SECONDARY  OR  SYMPTOMATIC  ANEMIA.  645 

Among  primary  anemias  are  commonly  included  chlorosis,  pernicious 
anemia,  leukocythemia,  lymphatic  anemia  or  Hodgkin's  disease,  and 
splenic  anemia.  It  is  not  conceded  by  all  observers  that  pernicious  anemia 
is  the  result  of  a  defect  in  blood-making.  In  fact,  each  year  adds  more 
evidence  to  show  that  the  conclusion  of  Quincke  and  William  Hunter  that 
it  is  a  hemolysis,  or  disintegration  of  the  red  blood-corpuscles  in  the  circu- 
lation or  certain  parts  of  it,  especially  in  the  liver,  is  the  correct  one.  Par- 
ticularly noteworthy  are  the  studies  of  J.  P.  C.  Griffith  and  C.  W.  Burr,* 
favoring  such  view.  As  the  chain  of  evidence  is  not,  however,  complete,  I 
shall  for  the  present  consider  it  among  the  essential  anemias. 

The  secondar}^  anemias  are  numerous,  including  those  due  to  hemor- 
rhage and  other  drains  of  various  kinds  on  the  economy,  inadequate  food, 
and  defects  in  the  digestive  apparatus ;  also  those  due  to^  the  action  of 
poisons  on  the  blood — the  toxanemias,  including  lead-poisoning  and  uremia. 


SECONDARY   OR   SYMPTOMATIC    ANEMIA. 

This  form  of  anemia  is  the  direct  result  of  trauma,  accidental  hemor- 
rhage, chronic  disease,  or  toxic  agents.  I  may  again  refer  to  the  fact  men- 
tioned in  the  preliminary  remarks  on  the  anemias,  that  reasons  are  being 
found  to  show  that  some,  at  least,  of  the  so-called  essential  anemias  may  be 
due  to  agencies  tending  to  destroy  the  corpuscles,  rather  than  to  diseases  of 
the  blood-making  apparatus.     The  secondary  anemias  include : 

1.  Anemias  Due  to  Hemorrhage,  hozvever  caused. — Traumatic  hemor- 
rhage, postpartum  hemorrhage,  lung  hemorrhage,  and  gastric  and  intestinal 
hemorrhages  comprise  most  of  these ;  ruptured  aneurysms,  purpura,  and  the 
bleeding  habit  furnish  others.  Parasites  invading  the  intestinal  canal  may 
be  causes  of  hemorrhage  and  consequent  anemia.  So  may  parasites  else- 
where, as  the  distoma  hcematohium  in  the  kidney. 

In  non-fatal  hemorrhages  from  these  causes  the  immediate  loss  of  blood 
in  bulk  is  rapidly  made  up  by  the  absorption  of  water  from  the  gastro- 
intestinal tract,  but  a  long  time  is  required,  even  under  favorable  circum- 
stances, before  the  corpuscles  and  hemoglobin  are  restored.  At  other  times 
regeneration  is  quite  rapid,  restoration  being  complete  in  ten  days.  The 
hemoglobin  is  always  rather  more  reduced  than  the  corpuscles,  but  both 
increase  for  a  time  pari  passu,  as  shown  in  the  appended  chart.  The  albu- 
minous constituents  are  more  rapidly  restored. 

2.  Anemias  Due  to  the  Drain  of  Chronic  Disease. — Such  are  chronic 
Bright's  disease,  suppurative  processes,  cancer,  or  prolonged  lactation,  or 
chronic  diarrhea.  In  this  group  belong  the  anemias  of  malaria,  in  which 
the  corpuscle  is  directly  consumed  by  the  plasmodium. 

3.  Anemia  from  Inanition. — This  results  from  starvation,  which  may 
be  the  practical  consequence  of  diseases  which  interfere  with  the  successful 
ingestion  and  assimilation  of  food,  such  as  obstruction  of  the  esophagus 
by  cancer  or  otherwise,  or  chronic  and  prolonged  dyspepsia.  Carcinoma 
of  the  stomacii  may  also  be  included  in  this  group.  The  last  two  groups 
(2  and  3)  overlap. 

Under  these  circumstances,  the  tlood  mass  is  greatly  reduced,  but  it  is 
by  a  reduction  in  the  blood  plasma,  rather  than  in  the  corpuscles,  for  the 

*  "  Pathology  of  Pernicious  Anemia,"  "Transactions  of  the  Association  of  American  Physicians," 
vol.  vi.,  i8qi. 


646 


DISEASES  OF  THE  BLOOD. 


latter,  though  reduced,   are  not  markedly  so,  and  may  even  be  relatively 
increased. 

4.  Toxic  Anemias. — Finally,  there  remain  the  toxic  anemias.  These 
are  the  result  of  the  presence  in  the  blood  of  such  substances  as  lead,  acquired 
by  painters  or  workers  in  lead-paint  factories,  type-setters,  and  type-founders  ; 
also  arsenic  from  dress  fabrics,  wallpaper,  and  furniture  coverings ;  mer- 
cury, and  certain  disease  poisons,  among  which  that  of  chronic  malaria  is 
the  most  conspicuous.  Syphilis  is  also  one  of  these,  producing  what  is  some- 
times known  as  syphilitic  chlorosis.  The  blood-chart  (Fig.  62)  is  from  a 
case  of  syphilis. 


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Fig.  62. — The  Blood  in  Simple  Anemia.     Hemoglobin  Red,  Corpuscles  Black. 
From  a  Case  of  Syphilis. 


In  the  true  toxic  anemias  the  poisonous  substance  acts  directly  upon 
the  red  corpuscles,  destroying  them,  or  perhaps  also  by  increasing  their 
consumption  in  the  ordinary  way. 

Among  the  toxic  anemias  must,  perhaps,  be  included  those  due  to 
unsanitary  surroundings ;  also  those  due  to  infectious  diseases,  the  organisms 
causing  which  generate  toxins.  Among  these  is  the  anemia  of  tuberculosis. 
Similar  products,  generated  by  intestinal  and  other  parasites,  are  responsible 
for  the  anemias  associated  with  them.  Such  intestinal  parasites  are  the 
anchylostoma  duodenale,  bothriocephalus  latus,  and  angiiiluUa  intestinalis. 
The  latter  also  contributes  to  anemia  by  causing  hemorrhage. 

Symptoms. — The  most  commonly  recognized  symptom  of  anemia  is  a 
paleness  of  the  skin,  and  this  is  undoubtedly  present  in  the  vast  majority  of 
cases.  Yet  a  total  reliance  dare  not  be  placed  on  it,  for  it  sometimes  hap- 
pens that  the  skin  and  even  the  lips  are  pale,  and  yet  no  anemia  is  found 


SECOXDARY  OR  SYMPTOMATIC  AXEMIA.  647 

when  the  blood  is  examined.  On  the  other  hand,  the  skin  and  hps  may 
have  a  good  color,  and  yet  anemia  be  actually  present.  Weakness,  faint- 
ness,  and  palpitation  are  also  symptoms.  In  addition  to  these  are  the  blood 
changes,  which  vary  with  the  degree  of  anemia.  Both  corpuscles  and 
hemoglobin  are  reduced,  the  latter  in  somewhat  larger  proportion.  The 
disproportionate  lowering  of  the  hemoglobin  is  explained  by  a  more  than 
natural  paleness  of  the  red  corpuscles.  Their  average  size  is  reduced,  while 
there  is  algo  a  moderate  poikilocytosis.  Nucleated  red  corpuscles  also  make 
their  appearance  soon  after  a  hemorrhage.  The  normoblasts  and  micro- 
blasts  are  the  prevailing  forms.  They  exhibit,  after  staining  with  hema- 
toxylon,  a  deep-blue  nucleus,  while  free  nuclei  are  occasionally  found. 
Microcytes,  megalocytes,  and  poikilocytes  are  present  in  advanced  cases. 

The  colorless  corpuscles  are  moderately  increased,  such  increase  being 
represented  by  the  multinuclear  neutiophiles,  while  the  small  mononuclear 
lymphocytes  are  diminished.  The  leukocytosis  gradually  disappears  with 
•the  return  of  the  blood  to  its  normal  state.  The  presence  of  leukocytes  as 
well  as  of  the  nucleated  corpuscles  is  evidence  of  regenerative  activity.  The 
proportion  of  the  different  varieties  is  nearly  normal.  In  severe  cases  the 
lymphocytes  miay  be  in  excess  and  the  polymorphous  leukocytes  be  reduced. 
Myelocytes  are  exceptionally  present. 

Diagnosis. — In  addition  to  the  blood  changes  more  or  less  common 
to  all  of  these  causes  of  anemia,  the  same  general  symptoms  of  pallor,  lassi- 
tude, debility,  and  faintness  which  characterize  the  essential  anemias  are 
also  present  in  less  degree. 

The  distinctive  feature  of  simple  anemia  is  the  nearly  coequal  reduction 
of  the  hemoglobin  and  corpuscles.  The  history  of  the  case  in  the  presence 
of  one  of  the  causes  named  is  of  itself  sufficient  to  determine  the  diagnosis 
in  many  cases.  The  simple  anemias  are  not  always,  however,  sudden  or 
rapid  in  their  occurrence,  and  a  study  of  the  blood  is  often  necessary  to  clear 
up  a  doubtful  case. 

Treatment. — The  treatment  of  simple  anemia  is  eminently  satisfac- 
tory. The  administration  of  nourishing  food  with  rest  is  followed  by  a  very 
rapid  coequal  rise  in  the  hemoglobin  and  corpuscles,  as  is  beautifully  shown 
in  the  foregoing  chart  (Fig.  62)  made  from  one  of  my  cases  in  the  Philadel- 
phia Hospital.  And  when  to  the  treatment  by  nourishing  food  we  add  the 
use  of  iron,  there  is  nothing  more  to  be  desired.  Full  doses  of  iron  are 
well  borne  in  these  cases,  and  we  have  the  choice  of  almost  any  of  the  prep- 
arations, including  Blaud's  pills  of  the  carbonate,  reduced  iron,  tincture  of 
the  chlorid,  Basham's  mixture,  and  the  vegetable  salts.  Though  full  doses 
are  here  indicated,  it  is  still  unnecessar}-  to  give  the  massive  doses  recom- 
mended by  some,  as  they  are  not  absorbed  and  produce  constipation.  The 
rapidity  of  the  cure  in  some  of  these  is  surprising. 


648  DISEASES  OF  THE  BLOOD. 


THE  PRIMARY  OR  ESSENTIAL  ANEMIAS. 

These  include  chlorosis,  for  the  present  pernicious  anemia,  leukocy- 
themia,  lymphatic  anemia,  or  Hodgkin's  disease,  or  pseudoleukemia,  and 
splenic  anemia. 

I.  CHLOROSIS. 

Synonyms. — Morbus  Tirgineus;  Green  Sickness:  Chloreniia;  Chloranemia. 

Definition. —  An  essential  anemia  most  frequently  met  in  young  women, 
characterized  by  a  very  marked  relative  reduction  in  the  hemoglobin  of 
the  blood. 

Etiology, — As  stated  in  the  definition,  it  is  a  disease  of  women,  and 
especially  of  young  women.  Yet  its  occurrence  is  not  impossible  in  men 
having  the  habits  and  occupations  of  women,  among  whom  Hermann  Eich- 
horst  especially  instances  tailors.  ^Moreover,  while  it  is  especially  a  disease 
of  young  women  from  about  the  age  of  puberty  to  twenty-four  years,  it  is 
also  possible  in  those  who  are  older,  as  well  as  those  who  are  younger.  In 
the  former  it  is  known  as  chlcrosis  tarda,  and  as  siich  is  met  in  women  be- 
tween thirty  and  forty.  Rather  more  frequent  is  its  occurrence  in  children 
who  have  not  reached  the  age  of  puberty.  Niemeyer  held  that  girls  who 
menstruated  at  thirteen  or  fourteen,  in  whom  there  was,  as  yet,  no  develop- 
ment of  pubis  or  breasts,  most  invariably  become  chlorotic.  The  disease 
occurs  the  world  over,  and  is  apt  to  be  recurrent  in  the  same  individual.  It 
is  more  common  in  blondes  than  in  brunettes,  in  the  weak  and  delicate,, 
rather  than  the  strong  and  vigorous.  Yet  this  general  truth  is  not  without 
exception. 

Among  predisposing  causes  are  overwork,  especially  in  closely  confined 
and  ill-ventilated  rooms,  insufficient  nourishment,  exhausting  drains,  such 
as  prolonged  lactation  and  profuse  menstruation.  ^Menstrual  derangement 
is,  however,  also  a  consequence  as  well  as  a  cause.  Sustained  or  repeated 
emotion,  especially  such  as  arises  from  sexual  excitement  and  masturbation,, 
is  a  cause.     Homesickness  and  grief  are  included  among  causes. 

The  frequent  association  of  constipation  with  chlorosis  led  Sir  Andrew 
Clark  to  suggest  that  it  might  really  be  a  copremia.  or  poisoned  blood  due 
to  absorption  from  the  large  bowel  of  poisons  of  the  nature  of  ptomains 
and  leukomains.  Such  poisons  may  readily  interfere  with  the  proper  de- 
velopment of  the  hemoglobin  df  the  blood  disc,  without  in  a  great  degree 
causing  its  destruction.  Similar  is  the  hypothesis  of  Bunge  that  intestinal 
putrefaction  due  to  imperfect  stomach  digestion  is  the  cause  of  chlorosis. 
These  views  explain  what  seems  to  me  a  closer  relation  between  chlorosis 
and  pernicious  anemia  than  has  commonly  been  admitted,  a  relation  con- 
sistent with  the  newer  etiology  of  pernicious  anemia,  as  well  as  with  features 
in  its  clinical  course,  and  with  the  results  of  treatment,  to  which  attention 
will  be  called  when  considering  the  latter  aft'ection. 

Morbid  Anatomy. — Other  than  the  changes  in  the  blood,  to  be  con- 
sidered under  symptoms,  there  is  no  essential  miorbid  anatomy  in  chlorosis. 
Many  years  ago  Mrchow  pointed  out  an  imperfect  development  of  the 
circulatory  apparatus  as  more  or  less  characteristic — that  the  heart  was 
small,  the  right  ventricle  sometimes  dilated,  the  aorta  and  its  larger  branches 


CHLOROSIS.  649 

were  poorly  developed  and  thin-walled.  Such  a  condition,  when  present,, 
is  probably  an  accidental  coincidence.  There  is  no  enlargement  of  the 
spleen  or  lymphatic  glands.  Imperfect  development  of  the  uterus  and 
Other  genitalia  has  been  noticed.  The  rarity  of  fatal  termination  in  chlorosis 
may  limit  our  knowledge  of  the  morbid  anatomy,  uncertain  at  best. 

Symptoms. — Of  these,  the  blood  changes  may  be  regarded  as  funda- 
mental, though  not  absolutely  constant.  They  consist  in  a  decided  reduc- 
tion in  the  hemoglobin,  with  a  moderate  oligocythemia,  or  reduction  in  the 
number  of  red  corpuscles.  Thus,  the  hemoglobin  value  of  each  red  disc 
is  diminished.  The  usual  range  may  be  put  at  from  3,500,000  to  little  less 
than  normal.  Thus,  Thayer,  in  63  consecutive  cases  in  Osier's  clinic, 
found  the  average  4,096,544,  or  over  80  per  cent.,  and  Lembeck  found  the 
maximum  in  one  of  15  cases  to  be  but  3,600,000.  In  a  few  instances,  how- 
ever, in  cases  of  acknowledged  chlorosis,  there  has  been  found  a  more 
decided  reduction  in  the  erythrocytes.  One  has  been  reported  in  which 
they  were  reduced  as  low  as  1,190,000  in  a  cubic  millimeter. 

The  hemoglobin,  on  the  other  hand,  is  much  reduced,  the  average  of 
Thayer's  cases  referred  to  being  42.3  per  cent.,  which  may  be  regarded  as 
a  fair  average.  This  disproportionate  fall  in  the  hemoglobin,  while  not 
invariable,  remains,  however,  a  tolerably  constant  feature,  producing  some- 
times a  recognizable  diminished  intensity  of  color  when  the  blood  is  seen 
en  masse.  Along  with  the  lowering  of  hemoglobin,  as  would  be  expected,, 
since  it  is  a  constituent  of  the  hemoglobin,  the  iron  of  the  blood  falls.  An 
increase  of  alkalescence,  announced  by  Graeber  *  as  a  constant  symptom,, 
has  not  been  found  by  Kraus  f  in  his  more  exact  methods  of  testing.  In- 
creased coagulability  of  the  blood  has  been  observed. 

As  to  remaining  changes,  the  red  corpuscles  may  be  altered  in  shape 
to  a  moderate  extent,  constituting  a  small  degree  of  poikilocytosis,  a  term 
suggested  by  Quincke,  or  they  may  be  larger  than  in  health,  when  they 
are  known  as  megalocytes.  More  frequent  is  an  undue  reduction  in  size  of 
the  corpuscles — a  microcytosis.  The  red  discs  are  sometimes  appreciably 
paler  than  in  health.  A  very  slight  degree  of  leukocytosis  may  be  rarely 
present,  an  average  of  8467  in  Thayer's  counts,  as  contrasted  with  a  mean 
normal  of  6000  in  cubic  millimeter,  while  the  blood  plaques  in  severe  cases, 
may  also  be  increased.  Nucleated  red  corpuscles  are  sometimes  met,  espe- 
cially in  the  later  stages,  represented  by  the  smaller  forms  (microblasts) 
which  sometimes  appear  in  crops.  In  this  stage  the  corpuscles  may  assume 
irregular  shapes.     Myelocytes  have  rarely  been  met. 

While  the  blood  alterations  in  chlorosis  are  scarcely  distinctive  enough 
to  be  considered  diagnostic,  the  other  symptoms  help  greatly  to  the  forma- 
tion of  a  correct  conclusion.  The  patient  is  almost  invariably  a  girl,  gen- 
erally between  sixteen  and  twenty,  who,  although  she  may  have  been  over- 
worked, does  not  seem  badly  nourished ;  certainly  she  is  not  emaciated. 
There  is  often  derangement  of  menstruation,  and  sometimes  the  girl  is 
hysterical. 

Most  striking,  though  not  invariable,  is  a  peculiar  pallor,  often  exhibit- 
ing a  yellowish-green  tinge,  extending  to  the  lips,  and  especially  the  mucous 
membranes,  and  which  is  responsible  for  one  of  the  names  of  the  affection — 
green  sickness.  The  patient  is  extr^iely  weak,  especially  on  exertion,  and 
short  of  breath.     She  is  subject  to  vertigo,  palpitation  of  the  heart,  and  even 

*  "Zur  klin.  Diag-nostik  d.  Blutkrankheiten,"  Leipsic,  1888. 
t  "Zeitschrift  f.  Heilkunde,"  Bd.  ii. 


650 


DISEASES  OF  THE  BLOOD. 


irregularity  of  the  heart's  action.  Physical  examination  will  sometimes  dis- 
cover functional  cardiac  murmurs ;  also  a  systolic  murmur  at  the  apex, 
ascribed  by  Balfour  to  a  relative  insufficiency  of  the  mitral  value  due  to  dila- 
tation of  the  left  ventricle.  Rarely,  a  compensatory  hypertrophy  of  the  left 
ventricle  has  been  noticed,  but  never  actual  valvular  disease.  Sometimes  a 
bruit  dc   diable,   or   humming-top  murmur,   may  be   heard   over  the   right 


130% 

vm 

40^ 


6.000.000 


2,000,000 


200.000 


120JS 
lOOS 


NORMAL  NO. 


CORPUSCLES. 


Red  Corpuscles — Black. 


Hemoglobin — Red.  Colorless  Corpuscles— Blue. 

Fig.  63. — Blood  in  Chlorosis. 


jugular.  Epigastric  pain  is  also  a  symptom  at  times.  It  must  not  be  for- 
gotten that  a  chlorosis  late  in  life,  or  chlorosis  tarda,  does  sometimes  occur. 
Fever  is  not  rarely  present.  On  the  other  hand,  the  hands  and  feet  are 
often  cold. 

Diagnosis. — The  diagnosis  is  based  chiefly  upon  the  age  and  sex  of 
the  patient,  the  peculiar  greenish-yellow  color,  the  paleness  of  the  lips,  and 
the   decidedly   diminished   hemoglobin,   unaccompanied,   as    a    rule,    with   a 


CHLOROSIS.  651 

proportionate  reduction  in  the  number  of  erythrocytes.  The  same  lost  nor- 
mal ratio  between  the  hemoglobin  and  the  corpuscles  is  also  a  characteristic 
of  lead-poisoning,  which  has,  however,  superadded  its  own  characteristic 
symptoms,  and  is  almost  restricted  to  adult  males. 

The  epigastric  pain  mentioned  as  occurring  in  chlorosis  resembles  that 
more  common  in  nicer  of  the  stomach.  The  anemia  which  so  constantly 
attends  ulcer  of  the  stomach,  often  in  a  high  degree,  is,  however,  different 
from  that  of  chlorosis,  there  being  a  proportionate  decline  in  the  number 
of  the  erythrocytes  and  their  coloring-matter.  At  least,  the  reduction  is 
.not  so  widely  disproportionate  as  in  chlorosis.  It  dare  not  be  said,  as  it  once 
was,  that  there  is  subacidity,  as  a  rule,  in  the  gastric  fluid  in  chlorosis,  nor 
is  there  motor  deficiency. 

A  not  infrequent  error  of  diagnosis  in  connection  with  chlorosis  is  the 
mistaking  of  it  for  a  "  decline,"  a  pulmonary  consumption,  which  it  resembles 
in  the  pallor,  the  feebleness,  and  shortness  of  breath  of  the  patient.  The 
absence  of  emaciation,  of  cough,  and  of  the  physical  signs  of  consumption 
exclude  that  disease.  On  the  other  hand,  evidences  of  tuberculosis  should 
always  be  sought  where  the  symptoms  of  chlorosis  prevail.  Latent  cancer 
is  also  sometimes  responsible  for  similar  symptoms. 

Most  frequently  chlorosis  is  confounded  with  secondary  anemia,  and 
with  reason.  Close  observation  will  recognize  in  chlorosis  the  yellowish 
tinge  of  the  skin  and  mucous  membranes,  while  the  sclerotic  remains  white 
or  bluish.  The  most  constant  dift'erence  is  in  the  reduction  of  hemoglobin, 
which  is  disproportionately  large  in  chlorosis.  Leukocytosis  is  less  frequent 
in  chlorosis ;  so  are  nucleated  red  cells.  In  advanced  degrees  of  chlorosis 
the  blood  approaches  nearer  that  of  pernicious  anemia,  in  which,  however, 
the  blood  coagulates  more  slowly.  The  question  whether  a  chlorosis  will  be 
transformed  into  that  more  serious  variety  of  anemia  known  as  pernicious 
anemia  has  been  raised.  This  seems  not  impossible.  If  the  view  of  Sir 
Andrew  Clark  be  accepted,  that  chlorosis  may  result  from  the  absorption 
of  poisonous  substances  from  the  larger  bowel,  and  if  pernicious  anemia 
be  due  to  the  absorption  of  more  intense  poisons  from  the  small  intestine, 
the  difference  is  only  one  of  degree.  Both  are  characterized  by  defects  in 
the  cellular  constituents  of  the  blood.  In  the  one,  chlorosis,  the  coloring- 
matter  is  chiefly  wanting,  although  associated  with  this  is  usually  found  a 
small  degree  of  morphological  defect.  In  pernicious  anemia  both  cell- 
shapes  and  coloring-matter  are  defective.  In  both  diseases  the  oxygen- 
carrying  office  of  the  blood  is  interfered  with,  and  thus  important  vital 
processes  are  embarrassed,  the  total  suspension  of  which  must  be  fatal. 

Prognosis. — The  prognosis  is  nearly  always  favorable  when  the  disease 
is  recognized  and  the  proper  treatment  instituted.  There  are  few  results 
more  satisfactory  in  therapeutics  than  those  of  a  properly  treated  case  of 
chlorosis.  Time  is,  however,  required,  and  too  rapid  a  cure  must  not  be 
promised,  several  months  and  even  longer  being  sometimes  required. 

Treatment. — The  treatment  is  pre-eminently  by  iron,  and  it  matters 
not  very  much  what  preparation  is  used.  The  tincture  of  the  chlorid  well 
diluted  is  probably  the  most  easily  assimilable,  but  the  carbonate,  in  the 
shape  of  Blaud's  pill,  made  by  a  double  decomposition  between  the  carbonate 
of  potassium  and  the  sulphate  of  iron,  maintains  its  popularity,  one  to 
five  grains  (0.06  to  0.2  gm.)  being  given  at  a  dose  three  times  a  day. 
Reduced  iron  or  one  of  the  vegetable  salts  may  be  given.  Much  larger 
doses  are  sometimes  given,  as  much  as  45  grains  (3  gms.)   a  day.     I  have 


652  ■  DISEASES  OF  THE  BLOOD. 

many  times  said  that  iron  is  given  in  too  large  doses  in  the  majority  of  cases 
for  which  it  is  prescribed.  Most  of  it  is  unabsorbed,  and  therefore  wasted. 
Nay,  worse,  that  which  is  unabsorbed  locks  up  the  intestinal  secretions  by 
its  astringency,  produces  headache,  and  makes  the  patient  otherwise  uncom- 
fortable. But  chlorosis  is  one  of  the  few  diseases  in  which  large  doses  of 
iron  are  well  borne.  The  reason  is  plain.  It  is  the  iron-holding  constituent 
of  the  blood  which  is  wanting,  and  the  iron  is  needed  to  replace  it.  The 
blood  is,  as  it  were,  hungry  for  it.  Next  to  iron  comes  arsenic.  The  effi- 
ciency of  iron  is  greatly  aided  by  union  with  arsenic,  which  should  be  given 
in  increasing  doses,  bvit  short  of  toxic  effect. 

Hydrochloric  acid  in  full  doses,  originally  suggested  by  Zander  on  the 
ground  of  supposed  deficiency  of  this  acid  in  the  digestive  fluid  in  chlorosis, 
is  useful  also  in  promoting  the  solubility  of  iron,  as  well  as  for  its  tonic 
and  antiseptic  properties. 

But  to  give  these  drugs  is  not  alone  sufficient.  Rest  in  bed,  at  first 
continuous,  is  imperative  to  secure  a  rapid  result,  and  this  must  be  associated 
with  an  abundance  of  good  food.  Daily  massage,  except  during  menstru- 
ation, is  also  a  useful  adjuvant.  There  is  no  condition  in  which  the  so-called 
"  rest  cure  "  is  more  efficient  than  in  chlorosis.  With  a  return  of  color  to 
the  lips,  or,  better,  with  the  growing  increase  in  the  hemoglobin  as  meas- 
ured by  the  hemoglobinometer,  the  patient  should  be  permitted  to  be  out 
of  bed  at  first  from  a  half-hour  to  an  hour  only,  but  this  should  be  gradually 
increased  until  she  is  up  most  of  the  day.  For  a  long  time,  however, 
fatigue  should  be  avoided.  To  those  who  can  afford  it,  a  residence  at  the 
seaside  materially  aids  convalescence.  Indeed,  I  know  of  no  condition  so 
rapidly  improved  at  the  proper  time  by  sea  air  as  chlorosis.  To  the  poor,  a 
well-regulated  hospital  treatment  is  a  boon  for  which  there  is  scarcely  a 
substitute. 


11.  PROGRESSIVE  PERNICIOUS  ANEMIA. 

Synonyms. — Idiopathic  Anemia;  Pernicious  Anemia. 

A  second  variety  of  essential  anemia  is  pernicious  or  idiopathic  anemia,, 
originally  described  by  Addison  in  1855  in  his  celebrated  paper  on  "  Dis- 
eases of  the  Suprarenal  Capsules."  Interest  in  the  subject  was  revived  by 
Biermer  in  1868,  and  since  then  it  has  been  thoroughly  studied  anatomically 
and  clinically.  It  is,  however,  still  the  least  understood  of  all  the  anemias. 
Fortunately,  it  is  an  infrequent^disease. 

Definition. — Pernicious  anemia  is  an  anemia  in  which  the  red  cor- 
puscles have  been  destroyed  and  reduced  in  number,  along  with  a  reduction 
of  the  hemoglobin,  while  the  ratio  of  the  latter  to  the  remaining  corpuscles 
is  one  of  excess. 

Etiology. — The  etiology  of  pernicious  anemia  is  very  obscure.  Preg- 
nancy seems  to  be  in  some  way  responsible  for  a  certain  number  of  cases. 
Such  a  condition,  associated  with  the  puerperal  state  and  with  functional  dis- 
ease of  the  uterus,  was  first  described  by  Walter  Channing  *  in  1842.  The 
symptoms  described  by  him  are  evidently  those  of  pernicious  anemia,  though 
he  called  the  condition   simply  "  anhemia."     A.   Gusserow  f  published,   in 

*  "New  England  Quarterly  Jour,  of  Medicine  and  Surgery,"  Boston,  1842-43. 

+  "Ueber  hochgradigste  Anamie  bei  Schwangerer,"  "Archiv  fiir  Gynakologie,"  Berlin,  1871. 


PROGRESSIVE  PERNICIOUS  ANEMIA. 


653 


1871,  a  number  of  cases  in  pregnant  women.  It  has  also  followed  lactation. 
Other  causes  are  cited,  such  as  atrophy  of  the  stomach,  early  noted  by  Flint 
and  Fenwick,  profound  and  long-continued  gastro-intestinal  disease,  and 
intestinal  parasites,  especially  the  anchylostomum  duodenale  and  bothrio- 
cephalus  latus,  which  undoubtedly  produce  symptoms  clinically  indistin- 
guishable from  the  general  anemia  which  Addison  characterized  as  "  oc- 
curring without  anv  discoverable  cause  whatever — cases  in  which  there 
had  been  no  previous  loss  of  blood,  no  exhausting  diarrhea,  no  chlorosis, 
no  purpura,  no  renal,  splenic,  miasmatic,  glandular,  strumous,  or  malignant 
disease."  I  have  already  expressed  my  partiality  toward  the  view  of  Quincke 
and  others,  who  ascribe  the  state  of  the  blood  to  a  hemolysis,  in  proof  of 
which  they  point  to  the  enormous  accumulation  of  iron  in  the  liver  noted 
"by  Quincke  in  1876  and  confirmed  by  Rosenstein  in  1877.  To  these,  Wil- 
liam Hunter  added  a  pathological  increase  of  the  urobilin  in  the  urine. 
In  a  noteworthy  paper,  Griffith  and  Burr  take  the  same  view.*  Figs.  64 
and  65  are  from  Griffith  and  Burr's  paper,  and  show  the  deposit  of  iron  in 


Fig.  64 — Liver  Lobules  in  a  Case  of  Pernicious  Anemia,  Showing  Distribution 
of  Iron  Pigment — {after  Griffith  and  Burr). 

the  liver  cells  demonstrated  by  ferro-cyanid  of  potassium.  Such  a  hemol- 
ysis is  most  satisfactorily  explained  on  the  supposition  of  absorption  from 
the  intestine  or  elsewhere  of  poisonous  products  engendered  under  any  of 
the  circumstances  named.  Among  these  may  be  included  the  products  of 
imperfect  digestion,  such  as  may  be  expected  to  arise  when  there  is  atrophy 
of  the  gastric  tubules. 

The  disease  is  widespread,  being  quite  common  in  this  country.  It 
affects  mostly  those  past  middle  age,  but  children  also  have  it,  and  Griffith 
mentions  ten  cases  occurring  under  twelve.     It  is  more  frequent  in  males. 

Symptoms. — The  approach  of  the  symptoms  of  pernicious  anemia  is 
most  insidious,  beginning  with  a  gradual  progressive  zveakness.  What  is 
first  interpreted  as  a  causeless  weariness  or  languor  grows  slowly  into  an 
extreme  debility,  with  faintness  on  the  slightest  exertion,  and  thence  into  a 
state  of  thorough  muscular  weakness,  which  ultimately  prostrates  the  pa- 
tient, and  he  is  too  weak  to  rise  from  bed.     To  this  succeeds  a  state  of 


*  Loc.  cit. 


654 


DISEASES  OF  THE  BLOOD. 


mental  hebetude  and  bodily  torpor.  Yet  there  is  no  euiaciation.  The  body 
bulk  is  well  preserved.  The  skin  acquires  gradually  a  lemon-yellow  hue,  and 
sometimes  an  actual  jaundice,  whence  the  disease  has  been  mistaken  for  the 
slower  form  of  yellow  atrophy  of  the  liver,  a  mistake  not  altogether  unsus- 
tained  bv  other  symptoms.  In  fact,  the  jaundice  is  similarly  caused.  It  is 
probably  a  hematogenous  jaundice,  a  matter  of  blood  disintegration,  al- 
though it  has  also  been  ascribed  to  defective  cell  action  on  the  part  of  the 
liver.  The  mucous  membranes,  on  the  other  hand,  are  blanched,  as  may 
be  noticed  in  the  lips,  gums,  and  mouth. 

Cardiovascular  symptoms  are  especially  conspicuous  in  progressive  per- 
nicious anemia.  Hemic  murmurs,  visibly  pulsating  and  throbbing  arteries, 
even  pulsating  veins,  have  been  noticed.     The  large,  but  soft,  jerky  pulse. 


Fig.  65. — Cells  from  Liver  in  Pernicious  Anemia,  More  Highly  Magnified,  Showing 
Position  of  the  Iron  Pigment  within  them — {after  Griffith  and  Burr). 


resembling  that  of  aortic  regurgitation,  w^as  mentioned  by  Addison.  The 
capillary  pulse  is  also  frequently  seen,  and  hemorrhages,  cutaneous  and 
retinal,  occur. 

Digestive  derangements  form  an  important  part  of  the  symptomatology 
of  pernicious  anemia.  Indisposition  to  take  food,  or,  rather,  a  disgust  for 
food,  nausea,  vomiting,  and  diarrhea  are  often  troublesome  symptoms. 
Hydrochloric  acid  is  constantly  deficient  in  gastric  digestion.  Moderate 
elevation  of  temperature,  irregular  and  intermittent,  is  also  noticed,  while 
nervous  syjuptoms,  including  numbness,  languor,  and  even  paralysis,  are 
sometimes  present. 

The  urine  exhibits  no  constant  changes,  being  sometimes  pale  and 
sometimes  dark-hued.  The  dark  color  is  ascribed  by  Mott  and  Hunter  t© 
an  excess  of  urobilin. 

Blood  Changes. — The  changes  in  the  blood  are  more  distinctive  than  in 
chlorosis,  although  it  is  true  also  that  there  is  no  single  constant  character- 


PROGRESSIVE  PERNICIOUS  ANEMIA. 


655 


istic  feature.  It  may  be  pale  and  watery.  The  most  constant  feature 
is  a  very  decided  oligocythemia,  without  a  corresponding  reduction  in  the 
hemoglobin,  although  the  hemoglobin,  m  toto,  is  much  reduced.  Rarely 
it  has  been  found  increased.  Quincke  found  as  few  as  143,000  corpuscles 
in  a  cubic  millimeter  of  blood,  while  it  is  not  uncommon  to  find  less  than 
half  a  million.  Frederick  P.  Henry  found  315,000  a  few  hours  before 
death,  and  Laache  360,000.  In  a  case  under  my  own  care  at  the  Phila- 
delphia Hospital,  in  1898,  the  red  discs  fell  to  437,000,  and  the  hemoglobin 
to  9  per  cent.,  death  taking  place  two  days  after  the  count  was  made.  The 
inevitable  conclusion  from  the  average  of  cases  observed  is  that  either  the 
hemoglobin  value  of  each  corpuscle  must  be  increased,  or  there  is  a  hemo- 
globinemia,  which  has  its  seat  in  the  plasma.     This  latter  view  Silbermann. 


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Red  Corpuscles — Black. 

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Hemoglobin  Red. 
ernicious  Anemia. 


has  adopted,  because  he  has  been  able  to  produce,  by  the  administration  of 
blood-corpuscle-dissolving  substances,  as  pyrogallol,  to  animals,  a  complex 
of  symptoms  like  those  of  pernicious  anemia.  If  pernicious  anemia  be  a 
hemolysis,  as  seems  likely,  rather  than  a  defective  hematogenesis,  we  would 
expect  such  a  hemoglobinemia  to  result. 

A  further  striking  peculiarity  in  the  blood  of  pernicious  anemia  is 
an  increase  in  the  size  of  the  red  corpuscles.  They  become  megalocytes,  from 
ten  to  fifteen  micromillimeters  in  diameter,  as  compared  with  a  normal  of 
from  6.5  to  9.4.  The  majority  may  be  so  enlarged.  They  are  often  also 
ovoid  in  form.  On  the  other  hand,  there  are  also  microcytes — cells  smaller 
than  normal — and  poikilocytes — corpuscles  characterized  by  great  irregu- 
larity in  shape.  While  these  irregular  shapes  were  first  demonstrated  in 
connection  with  pernicious  anemia,  and  although  they  are  more  or  less 
characteristic,  cases  of  the  disease  have  been  described  by  Grainger  Stewart, 
Lepine,  Hermann  Miiller,  and  others,  in  which  poikilocytosis  was  altogether 


656  DISEASES  OF  THE  BLOOD. 

absent.  Neither  megalocytosis,  micr'ocytosis,  nor  poikilocytosis  is  therefore 
a  pathognomonic  feature. 

Nucleated  red  corpuscles  are  a  constant  constituent  of  the  blood  of  per- 
nicious anemia,  and  have  also  been  regarded  by  their  discoverer,  Ehrlich,  as 
almost  pathognomonic.  Two  kinds  are  found — first,  the  small,  normal- 
sized  corpuscle,  with  its  deeply  stained  nucleus  (normoblasts),  and  certain 
large  forms  w4th  pale  nuclei  (megaloblasts).  They  are  not  confined  to 
this  disease.  Blood  plaques  are  either  absent  or  very  scanty.  Leukocytes 
are  usually  slightly  diminished  in  number,  while  there  is  a  tendency  to  an 
increase  of  the  mononuclear  white  cells,  as  compared  wdth  health.  F.  P. 
Henry  *  has  called  attention  to  a  fact  which  condenses  the  peculiarities  of 
the  blood  changes,  by  saying  that  in  this  disease  the  red  corpuscles  "  ap- 
proach those  of  the  lower  animals  in  many,  if  not  all,  of  their  chief  charac- 
teristics— namely,  in  their  number,  their  size,  their  shape,  and  the  amount  of 
hemoglobin  they  carry." 

There  are  also  sometimes  found  in  the  blood  numerous  minute  highly 
colored  spherical  bodies,  called  Eichhorst's  corpuscles.  Eichhorst  regarded 
them  as  pathognomonic,  but  they,  too,  are  sometimes  absent.  When  present 
they  contribute  to  the  hemoglobin  in  the  blood,  but  as  they  are  not  included 
in  the  blood-count,  they  get  no  credit  for  their  effect.  The  relative  excess 
of  the  hemoglobin  may,  in  a  measure,  be  thus  accounted  for. 

Morbid  Anatomy, — X'arious  tissues  have  been  studied  in  the  eft'ort 
to  find  a  morbid  anatomy  for  pernicious  anemia.  In  the  absence  of  lym- 
phatic involvement  or  enlargement  of  the  spleen,  except  sometimes  in  small 
degree,  the  marrow  of  hones  has  claimed  close  study.  H.  C.  Wood  de- 
scribed the  red  condition  of  the  marrow  of  long  bones  in  1871.  It  was 
further  studied  in  this  country  by  William  Pepper  f  and  myself ,t  and  abroad 
especially  by  Cohnheim.§ 

Although  the  appearances  described  by  these  observ^ers  are  not  identical, 
they  are  sufficiently  constant  to  justify  their  association  as  more  than 
accidental.  Summed  up,  they  amount  to  this:  ]\Iarrow  dark  red;  consist- 
ence less  soft ;  fat  vesicles  absent ;  specific  lymphoid  cells  increased,  including 
marrow  cells  of  various  sizes,  containing  one  or  more  nuclei ;  numerous 
nucleated  red  corpuscles  present,  especially  the  larger  forms,  the  giganto- 
b)lasts  of  Ehrlich.  These  studies  were  made  before  the  days  of  differential 
staining  and  counting.  ]\Iore  recent  studies  add  neutrophiles  and  eosino- 
philes.  These  appearances  are  now  commonly  interpreted  as  due  to  an 
eflfort  of  the  blood-making  apparatus  to  reproduce  the  disintegrated  erythro- 
cytes. They  are  not,  however,  constant,  as  the  marrow  is  sometimes  pale 
or  yellow. 

The  deposition  of  iron  in  the  liver  cells  has  already  been  alluded  to. 
It  is  found  in  the  outer  and  middle  zones  of  the  lobules,  and  may  be  so 
distributed  as  to  outline  the  bile  capillaries.  It  is  regarded  by  Hunter  as 
characteristic.  I  have  myself  examined  the  preparations  of  Griffith  and 
Burr,  and  they  are  striking  and  seem  unmistakable.  The  liver  itself  is  often 
fatty  and  is  sometimes  enlarged.  The  iron  is,  in  like  manner,  sometimes 
increased  in  the  kidney,  but  not  in  the  spleen,  and  these  organs  are  not 


*  "Anemia,"  Philadelphia.  1887. 

t  "Progressive  Pernicious  Anemia,"  "American  Journal  of  the  Medical  Sciences,"  October, 
1895. 

X  "Die  Betheiligung  des  Knochenmarkes  bei  pernicioser  Anaemie,"  "  Virchow's  Archiv,"  1877, 
Ixxi.  118-126. 

§  "Virchow's  Archiv,"  October,  1876. 


PROGRESSIVE  PERNICIOUS  ANEMIA.  6^7 

otherwise  essentially  changed.  The  spleen  also  has  its  iron  pigment  in- 
creased, and  has  been  found  reduced  in  size. 

The  heart  muscle  is  fatty,  while  the  other  muscles  are  unusually  red. 
Other  morbid  .changes  are  described,  but  they  cannot  be  regarded  as  essen- 
tial. Such  are  changes  in  the  ganglion  cells  of  the  sympathetic,  and  scle- 
rosis of  the  posterior  columns  of  the  cord,  first  studied  by  Lichtheim.* 
Softening  of  the  upper  part  of  the  lumbar  cord  has  also  been  reported  by 
Sir  Dyce  Duckworth. f  While  the  association  of  the  changes  in  the  pos- 
terior columns  are  so  constant  that  they  cannot  be  regarded  as  accidental, 
.experimental  studies  by  Burr  and  Griffith  intended  to  determine  this  relation 
to  pernicious  anemia  resulted  in  nothing  definite.  Complete  atrophy  of  the 
secreting  tubules  of  the  stomach  has  been  described  by  Fenwick,  and  by 
William  Osier  and  F.  P.  Henry  in  one  case  studied  jointly  by  them. 

Diagnosis. — The  diagnosis  of  pernicious  anemia  may  be  uncertain  at 
first,  but  the  true  nature  of  the  disease  soon  declares  itself.  The  intense 
anemia,  extreme  weakness,  digestive  derangements,  and  cardiovascular 
symptoms,  in  connection  with  a  blood-count  of  1,000,000  or  below,  with  a 
relative  increase,  or  at  least  no  proportionate  diminution,  in  the  hemoglobin, 
and  an  admixture  of  megalocytes,  microcytes,  and  poikilocytes,  point  to  a 
condition  scarcely  mistakable.  It  may  be  said,  moreover,  that  almost  never 
in  the  case  of  a  pernicious  anemia  do  the  number  of  corpuscles  fail  to  fall 
below  1,000,000.  The  large  forms  of  nucleated  red  corpuscles  have  been 
regarded  as  characteristic,  but  are  also  found  in  leukemia  (see  also  diagnosis 
of  Cancer  of  the  Stomach,  p.  371). 

Prognosis. — The  prognosis  is  to-day  regarded  as  less  unfavorable  than 
it  was  a  few  years  ago,  since  recent  experience  has  developed  the  fact  that 
temporary  improvement  is  not  uncommon,  and  it  is  said  that  recovery  some- 
times takes  place.  Still,  Addison's  original  prognosis,  of  a  termination 
sooner  or  later  fatal,  is  seldom  astray. 

Treatment. — Treatment  of  this  form  of  anemia  is,  moreover,  not 
fruitless.  The  same  measures  which  are  almost  a  specific  for  chlorosis  are 
not  without  effect  in  pernicious  anemia.  Accordingly,  arsenic,  to  a  less 
degree  iron,  good  food,  and  favorable  hygienic  surroundings,  are  to  be 
adopted.  The  arsenic  treatment  has  been  followed  by  results  which  justify 
the  words  "  temporary  cure,"  and  it  is  said  that  permanent  cure  has  fol- 
lowed. Such  temporary  cures  have  covered  a  period  of  three  years.  The 
best  preparation  appears  to  be  Fowler's  solution,  in  gradually  increasing 
doses,  until  twenty  and  even  thirty  minims  (1.3  to  2  c.  c.)  are  reached,  and 
this  three  times  a  day.  It  should  be  continued  for  a  long  time,  for  weeks 
or  months,  with  intermissions  of  a  few  days  if  unpleasant  results  appear, 
to  be  again  resumed.  Arsenic  is  not  a  specific  for  pernicious  anemia,  but 
the  results  of  its  use  are  often  surprisingly  gratifying.  Cakodylate  of 
sodium  has  been  recommended  for  other  preparations  of  arsenic.  It  is  said 
to  be  less  irritating  and  suitable  for  hypodermic  use.  The  dose  is  half  a 
grain  (0.033  g"^-)-  three  times  a  day.  Inhalation  of  oxygen  has  also  been 
recommended,  as  advised  in  leukemia.  The  relation  between  chlorosis  and 
pernicious  anemia,  already  referred  to.  is  sustained  by  therapeutic  results. 
Certain  cases  of  chlorosis  very  closely  resemble  pernicious  anemia,  especially 
when  not  arrested  by  treatment.  Tjie  arsenic,  administered  as  directed,  is 
wonderfully  well  borne,  nausea  and  vomiting  being  rare.     Rest  in  bed  is 


*  "  Congress  fiir  innere  Medicin,"  1887. 

t  "  British  Medical  Journal,"  November  10,  igoo. 


42 


658  DISEASES  OF  THE  BLOOD. 

indispensable,  but  sbould  be  supplemented  with  massage,  if  possible.  Food 
should  be  in  easily  assimilable  shape,  such  as  beef-juice,  beef-peptonoids, 
and  peptonized  milk.  Pernicious  anemia  is  one  of  the  diseases  in  which 
much  was  expected  from  the  use  of  bouc-iiiarrozv,  originally  suggested  by 
Thomas  R.  Fraser."^  Fraser  used  three  ounces  (90  gm.)  daily  of  beef- 
marrow,  in  addition  to  iron  and  arsenic,  with  apparent  cure.  At  the  pres- 
ent day  the  glycerids  are  used  in  doses  of  half  an  ounce  (15  c.  c. ),  three 
times  a  day.  I  have  had  some  experience  with  it,  but  my  results  have  not 
been  very  encouraging.  Salol  has  been  suggested  as  an  intestinal  antiseptic, 
from  the  standpoint  that  the  disease  may  be  due  to  toxins  absorbed  from 
that  canal.  Recently,  too,  Dr.  William  Hunter  has  suggested  the  use  of 
antistreptococcus  serum  to  counteract  possible  general  infection. 

Transfusion  of  blood  and  of  milk,  which  seemed  at  one  time  to  give 
promise  of  favorable  results,  has  been  discontinued.  At  the  present  day, 
hypodermoclysis  would  probably  answer  the  same  purpose,  and  is  much 
easier  done. 

III.  LEUKEMIA. 

Definition. — A  disease  characterized  by  an  enormous  increase  in  the 
colorless  corpuscles  of  the  blood,  by  hyperplastic  changes  in  the  spleen,  in 
the  lymphatic  glands,  or  bone-marrow,  any  one  or  more  of  these. 

It  has  been  called  leukocythemia  as  well  as  leukemia,  the  former  of 
these  words  meaning  white-cell  blood,  the  latter  simply  white  blood.  From 
the  etymological  and  histological  standpoint,  leukocythemia,  suggested  by 
Hughes-Bennett,  is  the  more  accurate  term,  but  Virchow's  term,  leukemia, 
has  become  the  one  in  common  use. 

Historical. — The  history  of  the  development  of  our  knowledge  of  leukemia  pos- 
sesses unusual  interest.  The  older  observers  spoke  of  a  purulent  blood,  ascribed  to 
an  inflammation  of  this  tissue,  while  Piorry  and  Rokitansky  spoke  of  a  hematitis  as 
the  cause  of  a  literal  pyemia.  Craigie  undoubtedly  saw  a  case  of  the  disease  in 
Edinburgh  in  1841.  He  did  not,  however,  publish  the  case  until  John  Hughes-Bennett 
published  his  on  October  i,  1S45,  in  the  "  Edinburgh  Monthly  Journal  of  Medicine." 
Both  Craigie  and  Bennett  noted  enlargement  of  the  spleen.  Rudolph  Virchow  pub- 
lished his  case  in  Froriep's  "A^otiseii  "  in  the  second  or  third  week  of  November,  1845. 
The  matter  of  priority  between  Bennett  and  Virchow  has  given  rise  to  much  discus- 
sion. There  can  be  no  doubt  that  Bennett's  case  was  published  first ;  also  that  he 
declared  it  unconnected  with  inflammation  of  any  of  the  tissues,  and  especiall^^  uncon- 
nected wnth  phlebitis,  and  that  he  attributed  the  condition  to  the  development  of 
white  corpuscles  in  the  blood.  Craigie,  on  the  other  hand,  ascribed  it  to  the  absorp- 
tion of  pus  from  an  inflammatory  lesion  either  in  the  mesenteric  veins  or  the  spleen. 
Virchow  confirmed  all  the  observations  made  by  Bennett  and  published  new  cases, 
especially  one  of  great  importance,  in  which  there  was  enla7-ge7}ient  of  the  lymphatic 
glands  iiiithout  enlargeineyit  of  the  spleen.  Virchow  also  said  the  blood  changes 
consisted  essentially  in  an  increase  of  the  colorless  cells  of  the  blood,  and  that  these 
cells  originated  in  the  lymphatic  glands.  He  also  suggested  the  name  leuketnia,  while 
Bennett  did  not  suggest  that  of  leiicocytJiemia  until  185 1  in  a  series  of  papers,  and  again 
in  1852  in  a  separate  work.  It  appears  to  me  that  Bennett  is  clearly  entitled  to  priority, 
and  was  the  first  to  interpret  the  condition  as  an  increase  in  the  colorless  corpuscles 
of  the  blood,  though  he  speaks  of  it  ^.s  pus.  Virchow's  added  point  w^as  ascribing  the 
formation  of  the  cells  to  the  lymphatic  glands. 

Vogel  first  recognized  a  case  during  life  in  1849.  Virchow  described  two  forms 
of  the  disease  in  his  "Cellular  Pathology,"  in  one  of  which  the  smaller  forms  of 
leukocytes  predominated  and  in  which  there  was  marked  involvement  of  the  lymph 
glands.  In  the  second  the  larger  white  blood  cells  predominated,  and  there  was 
marked  enlargement  of  the  spleen  ;  hence  he  inferred  that  the  Ij'mphatic  glands  were 
at  fault  when  the  smaller  cells  predominated,  and  the  spleen  when  larger  cells  pre- 
vailed. Varieties  thus  characterized  do  exist,  but  we  dare  not  draw  conclusions  as  to 
the  organs  involved  as  sharply  as  Virchow  did.      Large  cells  predominate  in  the 

♦  "  British  Medical  Journal,"  June  2,  1894. 


LEUKEMIA.  659 

lienomedullary  form,  while  small  cells  characterize  the  lymphatic  variety.  Interme- 
diate forms,  however,  interfere  with  sharp  distinctions.  It  was  many  years  later  that 
Neumann  described  a  case  in  which  the  dofie-Diarrow  was  markedly  altered.  Pure 
splenic  and  pure  medullar}^  forms  scarcely  exi^t,  though  a  case  or  two  of  the  latter  is 
described.  The  pure  lymphatic  form  does  occur,  but  even  this  is  rare.  Most  common 
is  the  mixed  lieiioinednllary  or  lietiomyelogenoiis. 

The  extremely  rapid  course  of  certain  cases  of  leukemia  justifies  its 
division  into  an  acute  and  chronic  form.  An  instance  of  the  former  was  a 
fatal  case  reported  by  Ebstein,  in  which  the  w^hole  duration  of  the  disease, 
including  a  prodromal  stage,  w-as  but  six  weeks.  Similar  cases  are  reported 
-by  others,  eleven  by  Fraenkel.*  M.  H.  Fussel  and  A.  E.  Taylor  collected 
fifty-six  cases.  The  duration  of  the  chronic  form  may  extend  over  years. 
Leukemic  women  have  been  repeatedly  pregnant  and  have  borne  children 
at  term. 

Etiology. — Xothing  definite  is  known  of  the  cause  of  leukemia.  It 
occurs  in  all  countries,  in  both  sexes,  and  at  all  ages,  although  it  is  more 
common  in  middle  life  and  in  males.  Cases  have  occurred  in  the  eighth 
week  and  seventieth  year.  It  is  sometimes  hereditary,  but  leukemic  women 
have  borne  non-leukemic  children.  ]\Ialaria  has  been  assigned  as  a  cause, 
and  certainly  its  association  with  this  disease  has  been  seemingly  more  than 
accidentally  frequent.  To  a  less  degree  this  is  true  of  syphilis.  Pregnancy 
is  said  to  favor  it.  It  is  said  to  have  followed  a  blow  or  injury,  and  to  have 
been  found  in  the  lower  animals. 

The  idea  of  the  infectious  origin  of  leukemia,  advanced  by  Klebs  and 
supported  by  observations  of  Osterwold,  Roux,  Byrom  Bramwell,  Pawlow- 
sky,  Kelsch,  Vaillard,  and  others,  seems  well  founded,  but  no  single  micro- 
organism has  been  found  associated.  A  case  has,  however,  been  reported 
where  an  attendant  on  a  case  of  leukemia  contracted  the  disease  and  died. 
The  frequent  association  of  leukemia  with  stomatitis  and  intestinal  ulceration 
was  pointed  out  by  Hunterberger. 

Morbid  Anatomy. — Leukemia  has  a  definite  morbid  anatomy,  con- 
sisting in  alterations  in  the  blood  and  in  the  hemogenic  apparatus,  including 
the  spleen,  the  lymphatic  glands,  and  the  marrow  of  bones,  and  it  is  called, 
accordingly,  splenic,  lymphatic,  myelogenic,  while  combined  or  mixed  forms 
are  indicated  by  suitable  compound  terms,  such  as  lieno-myelogenous.  Most 
leukemias  are  mixed. 

In  the  first  place,  the  spleen  is  almost  always  enlarged.  It  may  be 
adherent  to  the  abdominal  walls,  the  diaphragm,  stomach,  or  other  viscera. 
The  splenic  changes  exhibit  three  stages  in  their  development.  In  the  first, 
the  spleen  is  simply  hyperemic,  soft,  and  swollen,  sometimes  even  ruptured. 
The  Malpighian  bodies  share  in  the  hyperemia,  and  may  be  slightly  en- 
larged, but  are  overshadowed  by  the  swollen  pulp.  In  the  second  stage, 
hyperplastic  changes  make  their  appearance  in  the  Malpighian  bodies,  and 
as  these  grow  the  pulp  is  intruded  upon.  They  may  reach  such  size  as  to 
be  recognized  by  the  naked  eye  as  spherical  gray  nodules  one  to  three  lines 
in  diameter,  or  they  may  be  elongated  or  forked,  following  the  course  of 
the  blood-vessels.  The  third  stage  furnishes  the  granitic  spleen,  in  which 
white  dots  are  separated  by  dark  streaks  representing  the  destroyed  pulp, 
pigmented  by  the  disintegrated  blood.  The  spleen  is  now  hard,  and  is  cut 
with  resistance.  Its  size  may  be  enormous,  and  the  organ  may  weigh  from 
two  to  eighteen  pounds  ( i  to  9  kilos.). 


*  "Wiener  klin.  W'ochenschrift,"  i8 


66o  DISEASES  OF  THE  BLOOD. 

The  lymphatic  enlargement  is  a  true  hyperplasia.  Xot  only  do  the 
glands  enlarge,  but  new  foci  of  lymphatic  tissue  appear  in  various  organs, 
as  the  liver  and  kidneys.  These  arfe  regarded  by  some  as  simple  extravasa- 
tions of  leukemic  blood  from  the  capillaries.  All  the  more  prominent  groups 
may  share  in  the  enlargement — the  cervical,  axillary,  inguinal,  and  perineal 
glands.  The  individual  glands  remain,  however,  soft.  The  lymphatic  folli- 
cles in  the  tonsils  and  in  the  tongue,  pharynx,  and  mouth  may'  enlarge. 
This  is  also  occasionally  the  case  with  the  solitary  glands  of  the  intestine 
and  the  agminated  glands  of  Peyer. 

The  uiarrozv  changes  may  be  described,  in  a  word,  as  reversion  to  the 
embryonal  type  of  medullary  tissue.  The  fat  of  the  adult  marrow  has  dis- 
appeared, and  a  mass  of  lymph  cells  mingled  with  nucleated  red  corpuscles 
in  all  stages  of  development  takes  its  place.  The  marrow  is  often  pyoid. 
The  lymph  cells  include  numerous  large  mononuclear  cells,  many  in  the  act 
of  division,  also  miultinuclear  leukocytes.  There  are  also  numerous  marrow- 
cells  or  myelocytes  and  eosinophiles,  like  those  found  in  the  blood. 

The  liver  is  often  enlarged,  and,  according  to  von  Jaksch,*  pari  passu 
with  the  spleen,  and  it  has  this  further  peculiarity,  that  its  edges  are  rounded, 
while  in  what  he  describes  as  pseudoleukemia  infantum  the  edges  are  sharp, 
and  the  enlargement  does  not  go  hand  in  hand  with  that  of  the  spleen.  The 
liver  is  also  at  times  infiltrated  with  leukemic  patches  and  nodules,  not  unlike 
miliary  tubercles.     The  same  is  occasionally  true  of  the  kidney. 

The  thymus  gland  has  been  found  enlarged  in  some  cases  of  acute 
lymphatic  leukemia,  and  even  the  skin,  stomach,  and  gastrosplenic  omentum 
have  been  the  seat  of  growths,  presumably  lymphatic.  In  fact,  there  is  no 
situation  in  which  such  growths  may  not  make  their  appearance.  The  pos- 
sibility of  their  being  blood  extravasations,  white  in  consequence  of  the 
large  proportion  of  white  cells,  is  always  to  be  remembered. 

The  lungs  and  heart  alone  seem  free  from  encroachment  by  the 
lymphatic  tissue.     The  heart  may,  however,  be  dislocated  by  a  large  spleen. 

The  alterations  in  the  hlood  constitute  really  a  part  of  the  morbid 
anatomy  of  leukemia,  but  are  commonly  treated  under  the  head  of  symp- 
tomatology, where  I,  too,  will  consider  them.  An  increase  in  the  mass  of 
the  blood  may,  however,  here  be  mentioned.  The  heart  and  vessels  are 
commonly  found  gorged  with  blood,  usually  coagulated,  sometimes  whitish 
or  yellow  in  color. 

Symptoms. — The  early  symptoms  of  leukemia  are  precisely  those  of 
the  other  anemias,  viz. :  Insidious  onset,  pallor,  rapid  breathing  amounting 
to  dyspnea  on  exertion,  iveakness  and  faintness,  headache,  indigestion,  and 
loss  of  appetite.  The  last  two  symptoms  may  precede  all  others.  Emacia- 
tion is  ultimately  added.  Moderate  fever,  with  rapid  pulse,  is  also  present  in 
the  majority  of  cases,  the  temperature  sometimes  reaching  103°  F.  (39.4°  C). 
Headache,  more  or  less  continuous,  is  a  symptom  noticed.  Lymphatic  gland 
enlargements  are  evident.  In  a  case  recently  under  my  care  the  first 
intimation  of  the  presence  of  a  large  spleen  was  an  attack  of  circumscribed 
peritonitis,  favored,  doubtless,  by  the  presence  of  the  splenic  tumor  and 
ascribed  to  exposure  to  cool  air  while  perspiring.  Hemorrhages  from  the 
nose  and  stomach  are  common,  and  dropsical  swelling  appears  toward 
the  close.  Nasal  hemorrhages  are  sometimes  fatal.  Thomas  Oliver 
reported  a  case  terminating  fatally  by  sudden  post-peritoneal  hemorrhage. f 

*  See  cases  reported  by  J.  Chalmers  Cameron  and  Saenger,  Sajous'  "Annual  "  for  1S151,  E. 
t  Sajous'  "  Annual  "  for  1890,  vol.  i.,  E,  p.  12. 


LEUKEMIA. 


66 1 


Hematemesis  may  be  an  early  and  almost  initiatory  fatal  symptom.  Purpura 
hcsmorrhagica  sometimes  presents  itself  as  a  manifestation  of  the  same  tend- 
ency, as  may  also  cerebral  hemorrhage,  producing  coma.  Priapism  is  an 
occasional  symptom ;  it  is  sometimes  persistent,  and  in  a  case  of  Edes  was 
the  first  symptom  noticed. 


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Black— Red  Corpuscles.  Red— Hemoglobin.  Blue— Colorless  Corpuscles. 

Fig.  67 — The  Blood  in  Leukemia. 

The  urine  often  contains  a  small  quantity  of  albumin,  is  highly  colored 
and  scanty,  and  deposits  a  copious  sediment  of  uric  acid. 

Blood  Changes. — The  blood  exhibits  a  most  marked  and  diagnostic 
change  consisting  in  an  enormous  leukocytosis.  The  mean  number  in  normal 
blood  is  about  8000  colorless  corpuscles  to  the  cubic  millimeter,  which,  with 
the  red  discs  at  4,500,000,  miakes  the  proportion  i  to  580 ;  or  with  these  at 
5,000,000,  to  I  to  625.  There  is  a  physiological  leukocytosis  which,  after  a 
ful!  meal,  may  reach  i  to  150,  and  even  i  to  100,  while  there  are  pathological 


662  DISEASES  OF  THE  BLOOD. 

leukocytoses  which  quite  equal  those  of  many  true  leukemias.  In  leukemia, 
however,  there  may  be  i  to  50,  to  25,  to  10,  to  3,  to  2,  or  the  leukocytes  may 
equal,  and  in  rare  cases  even  exceed,  the  red  discs.  The  maximum  propor- 
tion of  colorless  corpuscles  impresses  decidedly  the  color  of  the  blood  en 
masse,  making  it  pink,  or  even  the  color  of  chocolate  and  milk^  while  aggre- 
gations of  leukocytes  may  produce  white  streaks,  and  w-ell  justify  the  belief 
of  the  older  pathologists  that  there  was  pus  in  the  blood — a  suppuration  of 
the  blood,  as  they  called  it. 

There  is  also  a  reduction  in  the  total  number  of  blood-cells,  including 
white  and  colored,  the  quantity  in  a  cubic  millimeter  being  sometimes  reduced 
to  between  2,000,000  and  3,000,000.  This  reduction  may  be  even  more  posi- 
tive, as  in  a  case  reported  by  Suchannek,*  in  which  there  were  301,600  red 
discs  and  306,100  colorless  corpuscles. 

Numerous  nucleated  red  discs  are  present,  and  occasionally  also  poikilo- 
cytes.  The  hemoglobin  falls  below  the  normal  proportion,  so  that  the  value 
of  each  disc  is  lowered.  The  blood  plaques  may  be  slightly  increased.  The 
beautiful  plate  opposite  page  662  was  made  from  the  blood  of  a  patient  in  the 
Hospital  of  the  University  of  Pennsylvania.      (See  also  Diagnosis.) 

An  early  discovery  in  the  study  of  leukemia  was  that  of  certain  trans- 
parent octahedral  crystals,  known  as  Charcot's  crystals,  wdiich  form  in  blood 
which  has  been  kept  for  some  time  on  slides.  Neumann  referred  these 
crystals  to  the  bone-marr'ow,  but  they  are  commonly  conceded  to  be  the  same 
as  those  sometimes  found  in  the  expectoration  and  in  feces  and  in  seminal 
fluid.  There  is  reason  to  believe  they  are  decomposition  products,  and  that 
they  hold  no  essential  relation  to  leukemia. 

That  the  alkalinity  of  the  blood  is  sometimes  diminished  is  true ;  that  it 
is  ever  replaced  by  acidity  is  not  true,  as  was  at  one  time  held.  Its  specific 
gravity  is  lowered  to  1030  to  1050.  Leukemic  blood  coagulates  slowly,  a 
feature  which  has  been  ascribed  to  the  presence  of  albumoses. 

Diagnosis. — The  diagnosis  of  leukemia  requires  the  aid  of  the  micro- 
scope, but  with  it  it  becomes  easy.  (See  Blood  Changes.)  A  refinement  of 
diagnosis,  thus  aided,  attempts  with  partial  success  to  separate  the  differen^ 
varieties,  which  are  known  as  simple  or  complex,  according  as  one  or  more 
of  the  cytogenous  organs  are  implicated.  Most  leukemias  are,  however, 
mixed.  In  his  monograph  Hermann  Rieder  says  that,  so  far  as  he 
knows,  pure  splenic  and  pure  myelogenous  forms  have  never  been  observed, 
while  the  pure  lymphatic  form  does  occur. f  Even  the  latter  is  rare.  A  case 
of  the  pure  myelogenous  variety  reported  by  Frankel,  in  a  girl  of  fourteen,^ 
is  not  now  admitted  to  be  a  4;rue  instance.  Another  was  reported  by  von 
Leube  and  Fleischer. §  On  the  other  hand,  Ehrlich  prefers  to  call  the  most 
common  form  the  splenomedullary,  "  myelogenous,"  because  he  thinks  the 
spleen  is  purely  passive. 

I.  For  the  present  I  shall  retain  the  term  splenomedullary  or  lieno- 
myelogenous  for  the  most  usual  form.  The  spleen  is  very  large,  and  the 
leukocytosis  is  intense,  the  ratio  of  w^hite  to  red  corpuscles  being  i  to  3,  i  to  2, 
or  I  to  I.  The  lymphocytes,  while  actually  increased,  are  relatively  dimin- 
ished— that  is,  instead  of  representing  20  to  30  per  cent,  of  all  the  leukocytes, 
they  represent  a  smaller  proportion,  an  average  of  10.6  per  cent.     The  poly- 

*  Sajoiis'  "  Annual  "  for  i8gr,  vol.  ii.,  E,  p.  i8. 

t  "  Beitrage  zur  Kenntniss  der  Leukocytosis,"  von  Dr.  Hermann  Rieder,  i8q2,  S.  36. 
+  "Deutsche  medizinische  Zeitung."  Berlin,  1800.     Sajous'  "Annual,"  vol.  ii.,  E,  p.  iq. 
§  Recall   Virchow's  announcement  in  "Cellular  Pathology"  in  1849,   alluded  to   or  p.  644,  last 
paragraph. 


A.— MYELOCYTES 
OF   EHRLICH. 


■^ 


^ 


B.— NORMAL      MONON- 
UCLEAR   LEUCOCYTES. 


FIG.    1.— STAINED    WITH    M  ETH  YL- GREEN— ORANGE    G— ACID  -  FUCHSI  N  . 
NUCLEI      GREEN,      NEUTROPHILIC      GRANULATIONS      PURPLE. 


FIG.     2.— STAINED     WITH      EOSIN-HAEMOTOXYLON.  A.— MYELOCYTES      OF      EHRLICH. 

n.— POLYNUCLEAR     LEUCOCYTES'.  C  — LYM  PHOCYTE.  1).— NUCLEATED     RED 

CORPUSCLE.  E.— DEGENERATED     NUCLEUS.  F.— RED     CORPUSCLES. 


PLATE    EXHIBITING    STAINED    CORPUSCLES    FROM    THE    BLOOD 
OF    A    CASE    OF    LEUKHAEMIA. 


LEUKEMIA.  663 

morphomiclear  cells  are  increased  as  to  absolute  number,  but  the  percentage 
is  reduced,  particularly  toward  the  close,  to  an  average  of  46  per  cent.,  a  range 
17  to  72  per  cent.  Eosinopliiles  are  increased,  but  not  their  percentage,  and 
they  are  not  now  assigned  any  distinctive  value,  because  so  numerous  in  other 
conditions.  But  the  most  characteristic  feature  of  this  variety  is  the  presence 
of  the  large  neutrophilic  myelocytes,  and  the  more  of  these,  the  more  likely 
is  it  that  the  leukemia  is  myelogenous.  The  percentage  rises,  sometimes  as 
high  as  60  per  cent,  and  often  above  20,  with  an  average  of  35  per  cent. 
Basophilic  leukocytes,  including  "  mast  "  cells,  are  much  more  numerous  than 
in  normal  blood. 

The  red  corpuscles  are  those  characteristic  of  anemic  blood,  and  nucle- 
ated cells  are  numerous. 

II.  Pure  lymphatic  leukemia  is  less  frequently  met,  probably  less  than 
15  per  cent,  of  all  the  cases.  The  external  lymphatic  glands  are  most 
involved.  The  leukocytosis  is  not  nearly  so  marked,  the  colorless  cells 
scarcely  ever  exceeding  one  in  ten.  often  only  one  in  forty.  The  lymphocytes 
predominate,  equaling  90  per  cent.,  including  all  forms,  large  and  small  and 
mixed.  Alyelocytes  are  infrequent.  In  a  case  reported  by  Uthemann,  93  per 
cent,  of  all  the  leukocytes  were  lymphocytes,  as  compared  with  15  to  30  per 
cent,  in  normal  blood ;  in  one  of  Osier's,  98  per  cent.  Even  in  the  combined 
form  lymphatic  involvement  is  found.  The  superficial  groups  of  glands  are 
usually  involved,  but  never  to  the  same  degree  as  in  Hodgkin's  disease. 

Caution  should  be  observed,  too,  in  basing  the  presence  of  leukemia 
solely  on  a  leukocytosis,  as  some  remarkable  instances  of  this  condition  have 
been  reported  wherein  leukemia  did  not  supervene.  Thus,  von  Jaksch,  in  his 
studies  of  the  anemia  of  children,  found  such  proportions  as  i  white  to  12  red 
corpuscles,  i  to  17,  and  i  to  20 ;  and  in  the  case  of  an  adult,  i  to  8,  and  still 
no  leukemia  followed.*  Eighty  thousand  white  corpuscles  in  a  cubic  milli- 
meter are  not  unusual  in  leukocytosis,  while  170,000  have  been  produced 
experimentally  in  the  dog.  The  association  of  lymphatic  or  splenic  or 
myelogenous  change  with  the  leukocytosis  is  therefore  essential  to  a  diag- 
nosis. Nay,  more,  we  must  look  to  the  proportions  of  the  varieties  of  leuko- 
cytes. It  will  be  remembered  that  in  the  most  frequent  form  of  leukamia  at 
least,  myelocytes  predominate  over  lymphocytes  and  polymorphonuclear 
cells.  But  in  most  cases  of  non-leukemic  leukocytosis  the  adult  polymorpho- 
nuclear cells  are  in  relative  as  well  as  actual  excess — 90  per  cent,  being  made 
up  of  this  form  in  leukocytosis.  Rieder  is  also  inclined  to  regard  the  cases 
of  so-called  acute  leukemia  as  really  acute  inflammatory  leukocytosis  rather 
than  leukemia. 

Allusion  has  already  been  made  to  an  anemia  described  by  von  Jaksch 
as  ancBmia  infantum  pseudoleukcemia,  further  studied  by  Loos  and  Luzet, 
which  is  not  to  be  confounded  with  leukemia.  Its  essential  feature  is  an 
enormous  falling  off  in  the  red  cells  of  the  blood,  often  as  low  as  820,000. 
The  proportion  of  leukocytes  is  always  increased,  but  never  to  the  same 
degree  as  in  leukemia,  nor  is  it  so  rapidly  brought  about.  They  have  been 
found  to  the  number  of  54,666.  On  the  other  hand,  the  leukocytes  are  char- 
acterized by  their  varied  shape  and  unusual  size.  The  red  cells  display  a 
high  degree  of  poikilocytosis,  while  white  cells  inclosing  red  cells  and  frag- 
ments of  red  cells  are  also  found,'  together  with  occasional  eosinophilic 
leukocytes  and  large  multinuclear  neutrophilic  leukocytes  and  nucleated  red 

*  C/.  ci'f.,  p.  29. 


664  DISEASES  OF  THE  BLOOD. 

cells.  All  of  these  modifications  of  the  blood-corpuscles  may  occur  in  leu- 
kemia, but  in  the  latter  disease  there  is  not  so  marked  a  reduction  either  in 
the  hemoglobin  or  in  the  number  of  erythrocytes.  The  difference  in  the  form 
of  the  liver  and  splenic  enlargement  in  the  two  conditions  has  been  referred 
to  on  page  659.  It  has  been  suggested  that  this  is  a  form  of  disease 
intermediate  between  pseudo-leunemia,  or  Hodgkin's  disease,  and  true 
leukemia. 

Prognosis. — The  prognosis  of  leukemia  is  unfavorable,  the  best  that  can 
be  expected  from  treatment  being  the  deferring  of  the  fatal  end.  Some 
rather  remarkable  fluctuations  are  noted,  and  cases  of  cure  are  even  reported, 
especially  of  late,  by  inhalations  of  oxygen.  Osier  saw  a  case  ten  years  after 
the  original  diagnosis  was  made  by  Wm.  H.  Draper.  The  lymphatic  leuke- 
mias  are  the  more  acute  and  more  intractable. 

Treatment, — The  treatment  has  heretofore  been  mainly  with  iron, 
quinin,  and  arsenic,  fresh  air,  and  good  food.  Large  doses  of  arsenic — as. 
much  as  thirty  drops  (0.92  c.  c. )  of  Fowler's  solution,  reached  by  gradual 
increment  have  been  especially  recommended  and  certainly  should  be 
tried. 

Inhalations  of  oxygen,  suggested  in  1887,  were  used  by  Sticker  and 
Pletzer  with  temporary  benefit,  and  Da  Costa  and  Hershey  report  the  appar- 
ent cure  of  one  case,  a  boy  of  thirteen,  and  such  marked  improvement  in  a 
man  of  thirty-five  that  he  was  thought  for  a  time  to  be  cured.  This  treat- 
ment deserves,  therefore,  to  be  tried  along  with  that  first  named.  Thirty 
to  100  liters  (about  4  to  12  gallons)  of  oxygen  are  to  be  inhaled  daily.  Bone- 
marrow  has  been  extensively  used,  but  the  results  have  been  disappointing. 
It  should,  however,  be  tried  in  one  fluidram  (4  c.  c.)  doses  of  the  glycerin 
solution,  increased  to  half  an  ounce  (16  c.  c),  three  or  four  times  a  day. 


IV.  LYMPHATIC  ANEMIA— HODGKIN'S  DISEASE. 

Synonyms. — Hodgkin's  Disease;  Pseudo-leukemia ;  Lymphadenosis;  Lym- 
phadenoma;  Malignant  Lymphoma  (Billroth);  Adenie  and  Lym- 
phadenie. 

Definition. — The  disease  consists  essentially  in  an  anemia  accompanied 
by  a  fibro-adenic  enlargement  of  the  lymphatic  glands  and  the  formation  of 
lymphatic  foci  in  the  spleen  and  occasionally  in  other  glandular  organs,  but 
unassociated  with  an  increase  in  the  colorless  corpuscles  of  the  blood. 

Historical. — Hodgkin's  paper,  to  which  we  are  indebted  for  our  first  definite 
knowledge  of  the  disease,  appeared  in  1832. 

Etiology. — Its  etiology  is  as  undetermined  as  that  of  leukemia.  De- 
pressing influences  of  all  kinds  are  believed  to  favor  it.  Scrofulosis  has 
sometimes  preceded  it.  The  presence  of  an  irritating  substance  in  the  blood 
has  been  suggested,  and  the  necessity  of  local  irritation,  associated  with  a 
lymphatic  diathesis,  has  been  insisted  upon  by  Trousseau.  It  may  occur  at 
any  age,  but  more  common  in  adult  life,  and  in  males. 

Morbid  Anatomy. —  Its  morbid  anatomy  is,  however,  definite.  There- 
is  both  lymphatic  and  splenic  involvement,  the  latter  secondary  to  the  former. 
The  tonsils,  intestinal  lymphatic  structures,  and  even  the  liver  and  kidneys 
may  be  invaded.  There  is,  moreover,  a  deposition  of  new  foci  of  lymphatic 
tissues  decidedly  more  marked  than  in  leukemia.     The  lymphatic  enlarge- 


LYMPHATIC  ANEMIA— HODGKIN'S  DISEASE.  665 

ment  usually  begins  first  in  the  more  superficial  groups,  as  those  of  the 
anterior  and  posterior  cervical  triangles,  the  glands  of  the  axilla,  and  the 
groin,  but  the  entire  lymphatic  system  may  be  involved,  including  the  retro- 
peritoneal glands,  resulting  sometimes  in  marked  abdominal  enlargements 
Occasionally  the  overgrowth  is  limited  to  the  deep-seated  glands.  Of  the 
abdominal,  the  retroperitoneal  are  most  frequently  involved,  producmg 
tumors  which  have  been  mistaken  for  myomata  of  the  uterus.  The  bronchial 
glands  may  also  be  involved,  and  by  their  pressure  produce  dyspnea. 

The  lymphatic  enlargement  is  a  hyperplastic  one,  shared  by  the  cellular 
and  trabecular  tissue  in  varying  degrees.  When  the  former  predominates,, 
the  product  is  soft  and  exudes  a  milky  juice  on  section;  when  the  latter,  it 
is  firm  and  resisting.  The  individual  glands  are  not  disposed  to  fuse  nor  to 
become  adherent  to  adjacent  tissue,  differing  in  this  respect  greatly  from 
glands  enlarged  by  the  tubercular  process.  The  enlargement  also  exceeds 
that  in  leukemia. 

The  alteration  in  the  spleen  is  hyperplastic,  involving  the  pulp  and  '\I2.\- 
pighian  bodies  jointly  or  either  alone.  The  enlarged  Alalpighian  bodies 
furnish  the  most  characteristic  feature.  They  form  grayish-white  masses, 
varying  in  size  from  that  of  a  lentil  to  that  of  a  walnut,  from  two  millimeters 
to  as  many  centimeters  in  diameter,  and  contrast  strongly  with  the  dark-red 
parenchyma.  The  process  in  the  Malpighian  bodies  is  a  true  hypertrophy  of 
the  adenoid  tissue,  ^while  in  the  pulp  it  is  rather  the  trabecular  tissue 
which  is  overgrown.  The  splenic  enlargement  is  more  limited  than  in  leu- 
kemia, the  organ  rarely  exceeding  ten  inches  (25  cm.)  in  length,  as  con- 
trasted with  the  collossal  size  of  the  leukemic  spleen.  The  spleen  is  not 
always  involved,  though  Gowers  found  splenic  enlargement  in  75  per  cent. 
of  the  cases  collected  and  the  organ  contained  lymphoid  growths  in  fifty-six 
of  these. 

There  are,  likewise,  at  times  changes  in  the  marrow  of  bones,  which  is 
converted  into  lymphoid  tissue,  sometimes  pyoid  in  consistence. 

The  liver  and  kidney,  and  even  the  thymus  gland  and  lungs,  are  some- 
times the  seat  of  lymphoid  deposits ;  in  fact,  all  organs  and  tissues  may  be 
invaded,  including  the  nervous.  Paraplegia  has  resulted  from  pressure  on 
the  cord  by  growths  in  the  spinal  canal.  The  posterior  nares  may  be  occluded 
by  invasion  of  the  tonsils  and  the  numerous  lymphoid  follicles  in  the  pharynx. 
In  like  manner  the  intestinal  walls  may  be  invaded,  producing  thickening,, 
while  even  serous  surfaces  do  not  escape. 

Symptoms. — The  symptoms  of  Hodgkin's  disease  are,  again,  the  pallor, 
zveakness,  dyspnea,  palpitation,  diaciness.  and  other  signs  of  anemia,  concur- 
rent with  or  even  sometimes  in  advance  of  the  glandular  enlargement.  There 
is  quite  often  fever,  very  irregular  and  variable  in  degree,  and  cases  have 
been  observed  by  Murchison  and  De  Renzi  in  which  there  was  paroxysmal 
glandular  enlargement  coinciding  with  fever,  the  enlargement  subsiding  with 
the  decline  of  fever,  but  not  reaching  the  degree  present  prior  to  the  enlarge- 
ment. In  a  case  of  Laache's  the  glands  diminished  in  size  during  the  fever. 
In  a  case  under  my  care  in  the  wards  of  the  Hospital  of  the  University  of 
Pennsylvania  in  which  the  glandular  enlargement  was  not  conspicuous,  there 
occurred  an  intermittent  rise  of  temperature  ascribed  to  a  concurrent  peri- 
tonitis, but  the  autopsy  discovered  this-  to  be  so  limited  that  it  is  perhaps  more 
reasonable  to  ascribe  it  to  the  feverish  tendency  characteristic  of  the  disease. 

The  external  glandular  growths  are  variously  conspicuous ;  occasionally, 
however,  thev  are  wholly  absent.     There  is  no  fixed  order  of  involvement,. 


666  DISEASES  OF  THE  BEOOD. 

although  the  glands  of  the  anterior  and  posterior  cervical  triangles  com- 
monly enlarge  first,  and  with  the  acme  of  their  growth  produce  a  striking 
picture.  The  enlargement  is  not  uniform,  but  at  times  remits  and  even  ceases. 
It  is  said  it  may  disappear  altogether  for  a  time.  The  glands  are  usuall}'' 
soft,  sometimes  there  is  even  a  sense  of  fluctuation. 

The  glandular  enlargements  themselves  contribute  further  to  the  symp- 
toms by  their  eftects.  Thus,  in  the  case  of  the  bronchial  glands,  dyspnea  from 
pressure  on  bronchi  or  trachea  may  occur,  and  is  apt  also  to  be  intermittent. 
Pressure  elsewhere  may  lead  to  pleuritic  or  abdominal  effusions,  while  the 
entanglement  of  nerves  in  the  growth  may  cause  pain.  Erosion  of  bone  may 
result.  Bro)izing  of  the  ski)i  has  been  found  associated  with  enlargement  of 
the  abdominal  glands.  A  purpuric  rash  is  sometimes  present  in  Hodgkin's 
disease,  due  perhaps  to  the  hydremic  state  of  the  blood. 

]Macroscopically,  the  blood  appears  thin  and  pale.  ^Minutely  examined 
the  red  corpuscles  are  diminished  in  number,  although  not  always.  ]\Iini- 
mum  counts  make  960.000  *  to  the  cubic  millimeter,  while  in  a  case  reported 
by  Henr\-.-r  that  of  a  boy  of  five,  with  enormous  enlargement  of  the  right 
cervical  glands,  there  were  5.462.000  to  the  cubic  millimeter.  Thus,  the 
diminution  is  less  than  in  pernicious  anemia.  The  hemoglobin  is,  however, 
reduced  to  at  least  60  per  cent.,  furnishing  thus  one  of  the  conditions  essen- 
tial to  anemia.  There  are  few  nucleated  red  corpuscles  and  poikilocytes.  and 
especially  microcytes.  The  leukocytes  may  be  slightly  increased,  occasionally 
decidedly  so,  but  this  is  rare,  and  there  is  no  approximation  to  the  leukemic 
state  of  the  blood,  and  the  two  states  are  distinct  and  separate.  A  combina- 
tion of  the  two  may  be  possible. 

Diagnosis. — The  diagnosis  requires  some  care,  as  more  than  one  con- 
dition is  attended  by  similar  glandular  outgrowths.  Chronic  and  even  acute 
adenitis  has  been  mistaken  for  the  early  manifestation  of  Hodgkin's  disease, 
while  the  converse  has  obtained  perhaps  more  frequently.  Time  is  the  arbiter 
of  such  uncertainty. 

A  group  of  tubercular  glands  resembles  more  closely  the  disease  under 
consideration,  but  it  is  not  usually  difficult  to  distinguish  between  the  two. 
Tubercular  glands  are  adherent  to  each  other  and  to  adjacent  tissues,  w^hile 
the  lymphadenoid  growths  are  loose  and  easily  movable.  Tuberculosis  rarely 
involves  more  than  one  group  of  glands,  is  characterized  by  caseation  and 
suppuration,  while  the  lymphadenoid  growths  almost  never  suppurate.  Yet 
the  tubercular  process  is  the  slower.  Tuberculosis  is  commonly  found  in 
young  persons  under  twenty.  Hodgkin's  disease  may  occur  at  any  age,  but 
the  average  age  is  greater.  It  is  more  common  in  males.  In  Gowers'  100 
cases,  75  were  males  and  25  females ;  30  were  under  twenty,  34  between 
twenty  and  forty,  and  36  above  forty. 

Sarcoma  also  involves  groups  of  glands,  and  in  the  beginning  the  con- 
sistence of  the  glands  is  similar  to  that  in  Hodgkin's  disease.  But  this  dis- 
ease rapidly  invades  surrounding  tissues,  fusing  with  them,  and  destructive 
ulceration  soon  makes  its  appearance. 

Carcinoma  of  lymphatic  glands  should  also  be  mentioned  as  producing 
a  somewhat  similar  growth,  associated  also  with  cachexia,  but  it  is  for  the 
most  part  secondary  to  cancer  elsewhere  than  in  lymphatic  glands. 

Finallv,  all  the  conditions  named  as  possible  to  be  mistaken  for  Hodg- 


*  Case  reported  bv  Richard  Geig^el.  quoted  by  F.  P.  Henry  ("Anemia,"  Philadelphia,  1887),  from 
"Deutsches  Archiv  fiir  klinische  Med.,"  1885,  Bd.  xxxvii.  p.  59. 
t  Op.  cit.,  p.  67. 


LYMPHATIC  ANEMIA-^ODGKIN'S  DISEASE.  667 

kin's  disease  are  limited  to  single  groups,  while  the  latter  always  extends, 
and  the  fact  of  such  limitation  is  of  itself  sufficient  to  preclude  the  disease. 

From  leukocythemia  the  disease  is  easily  distinguished  by  the  leuko- 
cytosis characteristic  of  the  former. 

Prognosis. — While  the  prognosis  is  ultimately  fatal,  the  course  of  the 
disease  varies  greatly,  and  death  seldom  results  in  less  than  a  year.  F.  P. 
Henry  places  the  average  duration  of  life  at  two  years,  but  admits  it  is  greatly 
modified  by  such  circumstances  as  age  and  previous  health  of  the  patient. 

Treatment. — Treatment,  too,  may  avert  the  fatal  termination  for  a  long 
time.  Extraordinary  results  in  this  respect  have  followed  the  administration 
of  arsenic,  and  even  recoveries  have  been  reported.  Large  doses,  arrived  at 
by  gradual  increment,  should  be  attained  and  kept  up  until  some  physiological 
effects  are  observed.  Such  doses  are  from  fifteen  to  twenty  minims  ( i  to 
1.3  c.  c.)  of  Fowler's  solution.  Particularly  happy  results  are  claimed  for 
the  injection  of  arsenic  into  the  lymphoid  masses.  Especially  is  this  recom- 
mended when  arsenic  is  not  well  borne  by  the  stomach.  From  eight  to  thirty 
minims  (0.5  to  2  c.  c.)  of  Fowler's  solution  have  been  injected  daily  in  divided 
doses.  Inunctions  of  iodin  and  iodid  of  potassium  are  also  recommended. 
Supporting  treatment  of  all  kinds,  including  quinin,  cod-liver  oil,  and  the 
best  of  food,  is  necessary.  Bone-marrow^  is  indicated  here  as  in  other  forms 
of  anemia,  if  it  possesses  the  qualities  claimed  for  it. 

Operative  interference  is  sometimes  necessary  to  avert  danger  to  life, 
threatened  by  the  encroachment  of  enlarged  glands  on  vital  organs  and  func- 
tions, such  as  respiration.  It  has  even  been  claimed  that  the  removal  of  a 
group  of  primarily  enlarged  glands  has  cut  short  the  spread  of  the  disease, 
but  such  an  apparent  result  is  rather  an  evidence  of  error  in  diagnosis.  In 
view  of  the  fact  that  at  an  early  stage  a  diagnosis  is  impossible,  the  removal 
of  a  local  group  of  glands  should  be  recommended. 

Status   Lymphaticus. 
Synonym. — Lymphaiism. 

Definition. — A  hyperplastic  state  of  the  lymphoid  tissues  throughout 
the  body,  including  the  lymphatic  glands,  the  spleen,  the  thymus,  and  the 
lymphoid  marrow  of  bones,  occurring  chiefly  in  children  and  young  persons. 

This  condition  is  rare  in  this  country,  and  has  never  come  under  my 
observation.  It  has  been  described  by  Poltau  and  other  Vienna  physicians, 
and  by  James  Ewing,  of  New  York.* 

Morbid  Anatomy. — The  lymphatic  glands  most  frequently  affected  are 
the  pharyngeal,  thoracic,  and  abdominal ;  those  of  the  cervical,  axillary, 
and  inguinal  regions  less  frequently  and  in  less  degree,  while  the  lymphatic 
elements  of  the  tonsils  and  the  upper  pharynx,  and  the  solitary  and  agminated 
follicles  of  the  small  and  large  intestines,  are  often  much  involved.  The 
spleen  is  moderately  enlarged,  while  the  Malpighian  bodies  stand  out  dis- 
tinctly. The  thymus  gland  is  enlarged  and  soft,  and  on  section  may  exude  a 
milky  fluid.  The  bone-marrow  may  be  hyperplastic,  and  the  yellow  marrow 
replaced  by  red  marrow.  Along  with  these  anatomical  changes  have  some- 
times been  found  rickets,  and,  again,  hyperplasia  of  the  heart  and  aorta. 

Symptoms. — The  symptoms  in  addiiton  to  the  anatomical  changes  noted 
are  a  lowered  power  of  resistance,  sometimes  evidenced  by  sudden  death  or 

*  "  New  York  Medical  Journal,"  July  lo,  1897. 


668  DISEASES  OF  THE  BLOOD. 

death  from  insufficient  cause.  The  subjects  are  said  to  be  poorly  developed 
and  infantile  in  appearance.  As  might  be  expected,  the  recognition  of  the 
actual  condition  is  not  always  easy,  if  it  dare  be  assigned  a  separate  place  in 
the  nosology. 

So  far  as  I  may  judge  from  my  limited  knowledge,  a  separation  of  it 
from  Hodgkin's  disease  seems  scarcely  justified. 


V.  SPLENIC  ANEMIA,  OR  SPLENIC  PSEUDO-LEUKEMIA. 

Definition, — This  term  is  applied  to  a  condition  in  many  respects  analo- 
gous to  Hodgkin's  disease,  but  differs  especially  in  the  absence  of  involve- 
ment of  the  lymphatic  glands,  the  spleen  being  alone  enlarged.  Attention 
was  first  called  to  it  as  a  separate  variety  of  pseudo-leukemia  by  Horatio  C. 
Wood  *  in  1 87 1,  although  reports  of  cases  corresponding  to  it  had  been  pre- 
viously made  by  others.  It  has  been  studied  by  Striimpell  and  Banti. 
More  recently  quite  a  number  of  cases  have  been  reported,  notably  by  Jarvin,t 
Alfred  Stengel,  and  others.  I  retain  the  term  not  because  I  insist  upon  the 
etiological  relation  between  the  spleen  and  blood  changes,  but  because  the 
study  of  the  subject  is  facilitated. 

Etiology. — This  is  undetermined,  except  that  there  is  reason  to  believe 
that  the  condition  sometimes  succeeds  the  infectious  diseases.  It  is  to  be 
separated  from  the  enlarged  spleen  sometimes  associated  with  a  moderate 
anemia,  so  often  the  result  of  chronic  malaria.  It  occurs  alike  in  old  and 
young. 

Morbid  Anatomy. — Its  morbid  anatomy  consists  in  the  splenic  changes. 
The  organ  is  greatly  enlarged,  approaching  that  of  the  leukemic  spleen  rather 
than  the  spleen  of  Hodgkin's  disease.  It  is  three  or  four  times  its  normal 
size,  but  retains  its  normal  shape.  It  is  indurated,  and  its  incisures  are 
deep.  Its  capsule  is  thickened  and  opaque  in  spots  and  sometimes  adherent 
to  adjacent  tissues,  as  is  often  true  of  any  large  spleen.  The  histology  of 
the  organ  differs  from  that  of  the  leukemic  enlargement  and  that  of  the 
enlarged  spleen  of  Hodgkin's  disease.  There  is  no  true  overgrowth  of  the 
lymphatic  tissue  in  the  Malpighian  body,  but  rather  a  destruction,  it  being 
replaced  by  an  overgrowth  of  the  reticulum,  producing  a  white  body  as  large 
as  a  pea.  In  addition  to  this  the  organ  is  often  traversed  by  bands  of  thick- 
ened reticulum,  visible  to  the  naked  eye.  The  change  corresponds  rather 
with  that  in  the  harder  lymphatic  glands  of  Hodgkin's  disease  than  that  in 
the  spleen.  In  a  word,  as  well-  stated  by  Banti,  the  histological  alterations  of 
the  spleen  consist  of  an  atrophy  and  sclerosis  of  the  Malpighian  corpuscles. 
Marrow  changes,  like  those  described  under  pernicious  anemia,  are  also 
sometimes  present. 

Symptoms. — The  symptoms  are  analogous  to  those  of  pernicious  anemia, 
and  include  pallor,  weakness,  dyspnea,  palpitation,  associated  with  the  signs 
of  enlarged  spleen,  evidence  of  which  is  sometimes  shown  by  its  weight  and 
the  pressure  it  exerts  before  other  symptoms  show  themselves.  Finally, 
there  results  the  cachectic  state  characterized  by  emaciation,  a  deeper  yellow 
color  of  the  skin  and  mucous  membranes,  a.  tendency  to  hemorrhage  and 
pyrexia,  edema,  serous  effusions,  extreme  muscular  prostration,  and  mental 


♦"Relations  of  Leukocythemia  and  Pseudoleukemia,"  "Araer.  Jour,  of  the  Med.  Sci.,"  Octo- 
ber, 1871. 

t  "Anemia  Splenica,"  "Berliner  klin.  Wochenschrift,"  August  16,  1897. 


SPLENIC  ANEMIA.  669 

hebetude.  There  is  also  said  to  be  at  times,  as  in  lymphatic  pseudo-leukemia, 
an  intermittent  or  per  saltitiii  course  in  the  symptoms  to  the  extent  of  apparent 
complete  restoration  to  health  in  the  intervals. 

The  blood  exhibits  the  changes  one  would  expect  in  cases  in  which  there 
is  destruction  of  the  tissue  devoted  to  its  reproduction.  It  is  anemic.  The 
red  discs  are  notably  diminished,  from  5,000,000  to  as  low  as  even  1,000,000. 
The  hemoglobin  is  diminished,  in  Jarvin's  case  especially,  relatively  less  than 
the  corpuscles.  There  are  found  also  the  other  changes  of  the  erythrocytes 
characteristic  of  pernicious  anemia.  There  are  poikilocytosis,  megalocytosis, 
and  microcytosis.  Nucleated  red  blood-cells  are  numerous.  The  leukocytes 
are  sometimes  slightly  more  numerous ;  at  other  times  they  are  in  normal 
proportion,  and  are  said  to  be  generally  mononuclear. 

An  increase  in  the  urea  of  the  urine  has  been  noted  by  Striimpell,  and 
is  regarded  as  evidence  of  increased  albuminoid  metamorphosis. 

All  clinical  facts  go  to  show  that  the  spleen  is  responsible  in  some  way  for 
a  destruction  of  erythrocytes  and  of  their  capacity  for  carrying  oxygen. 

The  duration  of  the  disease  is  from  five  to  six  months  to  three  years. 

Diagnosis. — The  diagnosis  of  splenic  anemia  depends  upon  the  presence 
of  splenic  enlargement  associated  with  the  phenomena  of  anemia  previously 
■described,  and  the  absence  of  glandular  enlargement,  so  conspicuous  in 
Hodgkin's  disease.  Anemic  symptoms  attend  the  chronic  malaria  so  often 
associated  with  enlarged  spleen,  but  the  history  of  malaria  in  such  cases  is 
invariably  present,  while  the  degree  of  anemia  in  malaria  is  not  so  high. 

Prognosis. — The  prognosis  has  been  regarded  as  unfavorable,  but  may 
be  modified  by  the  results  of  splenectomy,  which  in  the  cases  collected  by 
Banti  appears  to  have  been  successful  in  three  out  of  four. 

Treatment. — The  treatment  is  that  for  the  other  anemias,  by  iron  and 
arsenic  and  nutritious  food.  Bone-marrow  may  be  tried.  The  propriety  of 
splenectomy  must  be  determined  on  the  merits  of  each  case. 


SECTION   VI. 

DISEASES  OF  THE  DUCTLESS  GLANDS. 

DISEASES     OF    THE    THYROID     GLAND. 

GOITRE. 

Simple   Goitre   or   Struma. 

Synonyms. — Bronchocele;  Thyrocclc ;  Thick  Neck ;  Derbyshire  Neck. 

Definition. — The  name  is  derived  from  Latin,  guttur,  throat.  Under 
this  name  are  included  all  enlargements  of  the  thyroid  gland  other  than 
those  due  to  inflammation,  malignant  disease,  exophthalmic  goitre,  or 
parasites. 

Distribution. — Simple  goitre  may  occur  endemically  or  sporadically,  but 
in  this  country  it  is  only  sporadic.  It  is,  however,  quite  prevalent  about 
the  eastern  end  of  Lake  Ontario  and  in  the  State  of  Michigan.  It. is  still 
endemic  in  certain  parts  of  Switzerland  (cantons  of  Freiburg  and  Berne),  in 
Italy  (in  the  Southern  Alps  and  in  Savoy),  in  England,  the  Himalayas,  in 
Asia,  and  in  Siberia.  In  the  cantons  named  as  many  as  80  and  90  per 
cent,  of  recruits  are  found  goitrous.  It  has  even  occurred  in  epidemic  form 
in  Finland. 

Etiology. — The  exciting  cause  of  goitre  still  remains  unknown,  although 
a  belief  has  long  prevailed  as  to  the  endemic  form  that  some  constituent  of 
drinking-water  is  responsible  for  it.  That  locality  is  in  some  way  responsi- 
ble is  shown  by  the  fact  that  removal  from  a  territory  subject  to  it  arrests 
its  development,  while,  if  a  healthy  family  moves  into  a  goitrous  district,  the 
disease  develops  in  some  one  or  more  members.  A  change  in  the  water- 
supply  of  a  district  where  goitre  has  been  prevalent  has  led  to  its  disappear- 
ance, while  the  water  in  certain  wells  on  the  continent  of  Europe  is  known 
to  produce  it.  In  fact,  certain  water  is  said  to  be  drunk  by  men  who  desire 
to  develop  in  themselves  a  goitre  in  order  that  they  may  be  exempt  from 
military  service.  What  the  responsible  constituent  of  the  water  is,  is,  how- 
ever, unknown. 

It  is  much  more  common  in  women  than  in  men,  according  to  dififerent 
authorities  seven  to  forty-one  times  as  frequent.  It  has  been  suggested  that 
this  is  because  women  drink "^more  water.  The  disease  generally  develops 
after  puberty,  sometimes  after  fifty.  Congenital  cases  are  known.  It  is 
sometimes  hereditary,  but  heredity  must  be  separated  from  the  operation  of 
one  cause  on  different  members  of  the  same  family. 

Morbid  Anatomy. — All  simple  goitres  start  in  a  true  hypertrophy  of 
the  gland  follicles,  but  ultimately  assume  special  peculiarities,  on  which 
are  based  anatomical  varieties.  According  to  anatomical  peculiarities  as- 
sumed after  the  goitre  sets  in,  there  occur:  (i)  Struma  mollis,  or  paren- 
chymatous or  hypertrophic  goitre,  in  which  there  is  a  true  hypertrophic 
enlargement;  (2)  struma  aneiirysmatica,  in  which  the  vessels  are  enlarged 
and  dilated;  (3)  struma  fibrosa,  in  which  there  is  an  excessive  development 
of  fibroid  tissue;  (4)  struma  colloides,  in  which  the  follicles  are  enlarged  and 

670 


GOITRE.  671 

filled  with  colloid  matter ;  ( 5 )  struma  cystica,  when  the  follicles  have  en- 
larged to  cysts  with  liquid  contents;  (6)  struma  ossea,  characterized  by  cal- 
careous infiltration;  (7)  struma  amyloidea,  in  which  there  is  a  wax-like  prod- 
uct caused  by  amyloid  change.  There  are  various  combinations  or  inter- 
mediate types. 

Symptoms. — It  may  be  said  of  the  majority  of  goitres  that  they  cause 
no  inconvenience,  and  are  mainly  objectionable  through  the  deformity  they 
cause.  The  size  attained  varies :  the  enlargement  may  but  slightly  exceed 
that  of  the  normal  gland,  or  the  organ  may  be  very  large  and  pendulous. 
It  may  be  one-sided  or  bilateral,  or  only  affect  the  isthmus.  It  is  charac- 
teristic of  all  goitres  and  enlargements  of  the  thyroid  of  any  kind  that  they 
rise  up  when  the  patient  swallows,  and  tumors  of  doubtful  locality  may  thus 
be  located.  The  goitre  is  sometimes  low  down,  behind  the  sternum,  and 
can  only  be  felt  during  deglutition. 

A  goitre  may  press  on  the  trachea,  causing  dyspnea,  or  upon  the 
esophagus,  causing  difficulty  in  swallowing.  When  behind  the  sternum, 
it  may  press  upon  the  veins  in  the  neck,  causing  swelling  of  the  face  and 
head,  and  sometimes  headache  and  drowsiness.  There  may  be  pressure 
on  nerves,  especially  the  pneumogastric,  causing  spasm  of  the  glottis,, 
paralysis  of  the  abductor,  and  even  complete  paralysis  of  one  or  both 
vocal  cords. 

Treatment. — The  medical  treatment  of  goitre  consists  principally  in 
the  topical  application  of  tincture  of  iodin.  It  is  undoubtedly  efficient  at 
times.  The  simple  iodin  ointment  or  ointment  of  the  red  iodid  of  mercury 
may  be  daily  rubbed  into  the  goitre.  It  is  recommended  that  after  appli- 
cations of  the  latter  the  neck  should  be  exposed  to  the  rays  of  the  sun. 
This  treatment  has  been  especially  efficient  in  India.  Injections  of  iodin 
into  the  cyst  are  also  used — twenty  to  thirty  minims  (1.3  to  2  c.  c.)  of  a 
solution  of  one  part  in  twelve  parts  of  alcohol  twice  a  week,  a  new  point 
being  selected  each  time,  care  being  taken  not  to  wound  any  vessels  or 
nerves. 

Internal  treatment  is  also  recommended.  Naturally,  the  iodid  of 
potassium  is  conspicuous  among  remedies,  in  the  usual  doses — five  to 
twenty  grains  (0.3  to  1.3  gm.)  three  times  a  day.  Thyroid  extract  is  also 
being  used  with  disputed  success.  Bruns  treated  twelve  cases  with  raw 
thyroid  glands  in  doses  of  five  to  ten  gm.  (75  to  150  grains)  twice  a  week 
at  first  and  once  a  week  afterward.  Nine  were  benefited.  Kocher,  however, 
thinks  that  the  results  with  thyroid  extract  are  no  better  than  with  iodin. 

When  large  and  causing  dangerous  symptoms,  goitre  falls  properly 
into  the  hands  of  the  surgeon,  who  treats  it  as  exigencies  demand,  some- 
times extirpating  it,  though  the  operation  is  rather  formidable  at  times  and 
there  is  some  risk  of  its  being  followed  by  myxedema.  Cysts  may  be 
incised  and  drained  or  injected  with  iodin  or  perchlorid  of  iron  solution. 
Sir  Morell  Mackenzie  injected  the  latter  after  tapping,  using  two  drams 
(7.4  c.  c.)  of  a  25  per  cent,  solution. 

If  the  goitre  is  produced  by  local  causes,  a  change  of  residence  is,  of 
course,  desirable. 


6/2  DISEASES  OF  THE   THYROID  GLAKD. 


Exophthalmic  Goitre. 

Synonyms. — Struma  cxophthahnica;  Graves'  Disease;  Basedow's  Disease; 
Cardiothyroid  Exophthalmos;  Tachycardia  strumosa. 

Definition. —  A  disease  characterized  especially  by  enlargement  of  the 
thyroid  gland,  protruding  eyeballs,  and  frequent  pulse,  probably  due  to  some 
perversion  of  function  of  the  thyroid  gland. 

Historical. — In  the  early  part  of  the  nineteenth  centmy  cases  in  which  exoph- 
thalmos was  a  symptom  were  published  by  diii'erent  authors.  Some  of  these  were 
probably  e.xamples  of  exophthalmic  goitre.  In  1825  C.  Parry  published  several 
instances  of  a  disease  not  previously  described  which  were  evidently  cases  of  exoph- 
thalmic goitre.  In  1828  Adelmann  published  a  case  declared  on  Virch'ow's  authority  to 
be  one  of  exophthalmic  goitre,  and  therefore  the  first  described  in  Europe.  In  1833 
Trousseau  reported  the  history  of  a  woman  affected  with  goitre,  exophthalmos,  and 
cardiac  palpitation  at  the  same  time,  of  which  he  said  afterward  that  he  was  far  from 
supposing  that  this  symptomatic  triad  constituted  a  special  morbid  entity.  In  1835 
Graves  published  the  clinical  lecture  whence  arose  his  association  with  the  name  of 
the  disease,  which  will  perhaps  continue  through  all  time.  He  also  described  it  in 
his  "  System  of  Clinical  Medicine,"  published  in  1S43.  He  was  the  first  to  emphasize 
the  absence  of  orgaiiic  cardiac  disease.  In  1840  von  Basedow  published  the  results 
of  his  study  of  four  cases  of  exophthalmic  goitre,  and  with  it  the  most  exact 
description  of  the  disease  which  had  yet  been  given.  He  gave  to  the  disease  the 
noxne  exophthabnic  cachexia.  Although  his  name  has. also  become  associated  with 
it,  and  the  Germans  insist  on  the  priority  of  his  studies,  he  seems  to  have  been 
clearly  anticipated  by  Graves.  Others  who  described  the  disease  were  :  Romberg  in 
1851  ;  Shoch  in  1854  ;  and  in  1S55  Koeben,  who  first  ascribed  it  to  derangement  of  the 
sympathetic  nervous  system.  In  1S55,  too,  Stokes  included  the  disease  In  his  book  on 
"  Diseases  of  the  Heart,"  and  drew  special  attention  also  to  the  nervous  phenomena. 
Charcot  thoroughly  described  it  in  1856  and  1857,  and  in  1857  von  Graefe  described 
the  symptom  known  as  Graefe's.  In  1859  Fischer  referred  the  symptoms  to  the  remote 
effects  of  anemia.  In  i860  Trousseau  asserted  the  nervous  origin  of  the  disease,  and 
that  it  should  be  classed  as  a  neurosis.  In  the  same  year  Aran  ascribed  the  exoph- 
thalmos to  a  contraction  of  the  muscular  fibers  of  Miiller  supplied  by  the  sympathetic. 
In  1862  a  notable  discussion  in  the  Academy  of  Medicine  of  Paris  took  place,  when 
Trousseau  maintained  that  in  all  cases  of  exophthalmic  goitre  there  was  either  an 
antecedent  or  a  coincident  derangement  of  the  heart,  and  reasserted  its  nervous 
origin.  Piorry  denied  the  unity  of  the  disease,  and  claimed  that  the  prominence  of 
the  eyeballs  was  the  result  of  retarded  intracranial  circulation  due  to  pressure  of  the 
enlarged  th\-roid  upon  the  external  and  internal  jugular  veins. 

The  neurotic  nature  of  the  disease  has  much  in  its  favor,  and  most  recentlj-  the 
medulla  oblongata  has  been  selected  as  the  site  for  the  lesion.  This  view  has  the 
support  of  some  experimental  evidence,  and  in  a  few  autopsies  changes  have  been 
found  in  the  medulla.  The  view  that  it  is  a  sympathetic  neurosis  has  alwaj-s  com- 
mended itself,  appearing  as  it  does  to  explain  the  symptoms  more  satisfactorilj-  than 
any  other-^the  frequent  pulse,  the  exophthalmos,  the  thyroid  pulsation,  the  sweating, 
and  the  general  nervousness  being  all  thus  accounted  for. 

Most  recently  the  startling  facts  developed  in  connection  with  myxedema  and 
the  results  of  its  treatment  have  drawn  attention  to  a  possible  antithetic  relationship 
between  the  two  conditions.  Thus  we  have,  on  the  one  hand,  associated  with 
exophthalmic  goitre,  excitability  of  the  nervous  s^-stem.  manifested  in  restlessness  of 
mind  and  body,  a  rapid  action' of  the  heart,  and  a  moist,  flushed  skin  ;  with  myxe- 
dema the  opposite  conditions  of  dullness  of  intellect,  torpor  of  bod}-,  slowness  of 
pulse,  dryness  of  skin.  From  this  standpoint  Moebius  and  Greenfield  have  taken  the 
position  that  exophthalmic  goitre  is  such  an  antithetic  disease.  Greenfield  further 
adduces  the  fact  that  the  changes  in  the  gland  are  those  of  an  organ  in  active 
evolution—/,  e.,  proliferation  with  production  of  new  tubular  spaces  and  absorption 
of  the  colloid  matrix,  to  be  replaced  by  a  more  mucous  fluid.  Further  are  the  facts 
that  thyroid  extract  in  excess  produces  tachycardia,  tremor,  headachP;  sweating, 
and  prostration,  symptoms  of  Graves'  disease  ;  that  when  administered  during  the 
disease,  it  aggravates  the  symptoms — has.  indeed,  in  an  overdose  caused  it,  as  in  a 
case  of  Beclere's  ;  and  that  the  most  successful  treatment  has  been  such  as  reduces 
the  bulk  of  the  gland. 

Etiology. —  Exophthalmic  goitre  is  more  common  in  women  than  in 
men — according  to  Trousseau,  as  fifty  to  eight.  Others  make  it  twice  as 
frequent,  others  ten  tim.es.     It  is  also  more  common  in  the  young  adult  and 


GOITRE.  67  z 

in  the  middle-aged.  The  average  age  may  be  put  down  at  from  thirty  to 
thirty-one  years ;  Byrom  Bramwell  says  fifteen  to  thirty  for  women  and 
thirty  to  forty-five  for  men.  The  oldest  patient  I  have  ever  seen  was  forty- 
four.  It  has  been  observed  as  early  as  two  and  a  half  years,  and  as  late  as 
sixty-eight.  Heredity  is  a  rare  factor,  but  its  influence  cannot  be  denied. 
It  sometimes  happens  that  several  m.embers  of  a  family  are  affected.  Some- 
times myxedema  affects  one  member  of  a  family,  and  exophthalmic  goitre 
another.  It  occurs  with  especial  frequency  in  neurotic  families.  Sudden 
mental  shock,  worry  and  grief,  and  physical  fatigue  are  assigned  as  exciting 
causes.  So  are  many  acute  diseases,  of  which  rheumatism  is  especially  cited, 
also  typhoid  fever.  Some  of  these  are  more  likely  to  be  coincidences. 
W.  H.  Thomson  ascribes  Graves'  disease  to  gastro-intestinal  ptomain  poison- 
ing from  excessive  meat  ingestion.  Some  perversion  of  function  of  the 
thyroid  gland  lies  at  the  foundation  of  exophthalmic  goitre. 

Symptoms. — Of  the  cardinal  symptoms  mentioned  in  the  definition, 
the  cardiac  and  vascular  usually  appear  first.  The  palpitation  is  extreme, 
delirious,  as  it  were,  the  pulse-rate  being  commonly  in  the  neighborhood 
of  120  to  140,  and  is  said  sometimes  to  reach  200.  The  slightest  excite- 
ment augments  the  pulse-rate  instantly.  The  cardiac  impulse  is  strong,  but 
the  volume  of  the  pulse  small.  The  normal  heart-sounds  are  loud,  audible 
to  the  patient  and  even  at  a  distance  from  the  body,  in  one  case  described  by 
Graves  himself  as  far  as  four  feet.  A  systolic  nnirmur  is  often  heard 
at  the  base,  usually  soft,  but  sometimes  loud ;  more  rarely  at  the  apex,  when 
it  may  be  due  to  relative  insufficiency  of  the  mitral  or  tricuspid  valve. 

Exophthalmos  is  commonly  described  as  the  second  of  the  cardinal 
symptoms  to  appear,  but  it  is  not  far  behind  the  palpitation.  The  degree 
of  this  protrusion  varies  very  decidedly.  It  may  be  so  slight  as  to  be 
scarcely  noticeable,  while  again  the  peculiar  staring  effect  arising  from  it  is 
conspicuous,  and  attracts  attention  instantly.  The  eyes  show  a  large  amount 
of  white,  and  the  eyelids  when  closed  often  cannot  cover  the  eyes.  It  is  in 
these  extreme  cases  that  z'on  Graefe's  symptom  presents  itself — a  condition 
in  which,  when  the  eye  is  cast  down  or  raised,  the  lid  fails  to  follow  it  as  it 
does  in  health.  This  symptom,  of  which  so  much  has  been  said,  is  not  a 
very  frequent  one.  Stelkvag's  sign,  which  is  less  known,  seems  more  fre- 
quently met.  In  it,  the  palpebral  fissure  is  increased  in  width,  owing  to 
the  persistent  retraction  of  the  upper  lid.  It  may  occur  with  or  without 
von  Graefe's.  Retraction  of  the  lower  lid  is  occasionally  seen.  Moebius 
considers  Graefe's  symptom  the  result  of  Stellzvag's.  The  patient  "minks 
less  frequently  than  in  health.  Pulsation  of  the  retinal  arteries  can  be  seen 
v^ith  the  ophthalmoscope,  but  other  changes  in  the  retinae  are  rare.  The 
same  is  true  of  the  pupils.  A  la€k  in  convergence  of  the  two  eyes  was 
pointed  out  by  Moebius. 

The  thyroid  enlargement  commonly  presents  itself  at  about  the  same 
time  as  exophthalmos.  A  patient  of  mine  said,  almost  as  early  as  she 
noticed  swelling  she  observed  her  eyes  began  to  protrude,  showing  that  the 
events  are  not  far  apart,  and  that  the  three  distinctive  symptoms  appear 
almost  simultaneously.  The  goitre  itself  is  in  no  way  peculiar.  It  is 
usually  of  moderate  size,  almost  never  reaching  the  dimensions  sometimes 
attained  by  a  simple  goitre.  The  tumor  is  largely  contributed  to  by  its  vas- 
cularity, though  there  is  also  an  overgrowth  of  the  proper  glandular  tissue 
of  the  thyroid.  Pulse  and  thrill  are  both  palpable,  while  a  loud  systolic 
murmur  may  be  heard  on  auscultation. 

43 


674  DISEASES  OF  THE  THYROID  GLAND. 

Another  symptom,  already  alluded  to,  included  by  some  as  cardinal,  is 
what  is  commonly  known  as  "  iicn'ousiicss:"'  It  includes  irritability,  rest- 
lessness, a  disposition  to  start  at  the  slightest  sound,  and  wakefulness  at 
night.  At  a  part  of  this,  or  as  due  to  the  same  cause,  at  least,  is  "  tremor," 
a  highly  important  symptom,  of  such  frequency  as  to  be  included  by  George 
R.  Murray  in  his  definition.*  It  does  not,  however,  appear,  as  a  rule, 
until  the  other  symptoms  have  been  present  for  some  time.  It  may  be 
best  studied  by  holding  out  the  hand  with  the  palm  downward ;  even 
better  by  laying  the  examiner's  palm  lightly  upon  the  patient's  fingers  when 
the  hand  of  the  latter  is  held  out.  The  tremor  affects  the  flexor  and  ex- 
tensor muscles  of  the  wrist,  and  not  the  intrinsic  muscles  of  the  hand,  sa 
that  the  fingers  do  not  vibrate  independently,  but  the  whole  hand  moves. 
It  is  rapid,  regular,  and  uniform  while  it  lasts.  It  occurs  eight  or  nine  times- 
in  a  second.  Its  extent  is  small,  but  not  always  the  same.  It  may  be 
seen,  too,  in  the  foot,  and  in  some  instances  the  whole  body  appears  to 
tremble.  It  is  generally  equal  on  the  two  sides  of  the  body,  but  has  been 
unilateral  when  goitre  and  exophthalmos  have  been  on  one  side.  It  is 
variously  modified  by  position — lying,  sitting,  or  standing.  It  does  not,  as- 
a  rule,  interfere  with  the  movements  of  the  hand,  but  when  excessive  may 
hinder  sewing  or  writing.  The  tremor  of  general  paralysis  and  alcoholism 
is  less  regular  in  extent,  while  the  individual  fingers  tremble,  the  rate  being 
practically  the  same.  In  the  tremor  of  old  age,  the  rate  is  only  one-half  as- 
rapid  ;  in  disseminated  sclerosis,  it  occurs  from  three  to  six  times  a  second, 
and  in  paralysis  agitans  it  is  less  regular.  It  resembles  more  the  tremor 
of  fatigue  or  that  seen  in  recovery  from  long  illness.  Another  symptom 
included  in  the  same  category  is  a  sudden  giving  ivay  of  the  legs,  so  that 
the  patient  falls  to  the  ground  without  previous  feeling  of  faintness  or  giddi- 
ness, and  Charcot  mentions  also  a  weakness  of  the  legs.  Painful  cramps 
sometimes  occur.  Localised  muscular  atrophy  and  that  peculiar  nervous 
symptom  known  as  astasia  abasia,  in  which  there  are  inability  to  stand  and 
inability  to  walk,  are  occasionally  met. 

Excessive  szveating  is  a  frequent  symptom.  It  may  be  intermittent  or 
irregular,  or  there  may  be  a  simple  feeling  of  flushing  without  sweating. 
Diminished  electrical  resistance  was  pointed  out  by  Vigouroux.  This  is  a 
natural  result  of  the  constant  moisture  of  the  skin.  Polyuria  often  occurs, 
caused,  perhaps,  as  is  the  sweating.  A  dark  coloration  of  the  skin  some- 
times takes  place,  more  decided  in  those  situations  in  which  the  pigment 
is  naturally  more  abundant,  such  as  the  face  and  arms.  Yet  the  flexures 
of  the  joints,  the  axillae,  the  genitals,  and  the  inside  of  the  thighs  are  alsa 
affected.  The  skin  may  be  uniformly  bronzed,  or  it  may  be  darker  in 
patches.  Parts  of  the  body  which  are  subject  to  constant  pressure  are  also 
disposed  to  take  on  pigmentation  more  deeply.  Edematous  szvelUngs  of  the 
skin  in  various  parts  of  the  body  may  occur,  and  are  to  be  carefully  sepa- 
rated from  edema  the  result  of  associated  conditions,  such  as  anemia,  organic 
heart  disease,  etc.  It  manifests  itself  as  swelling  in  the  feet  and  ankles,  and 
has  been  ascribed  to  vasomotor  paralysis.  The  nails  sometimes  become 
thin,  and  occasionally  have  a  corrugated  appearance. 

Gastro-intestinal  symptoms  are  frequent,  manifesting  themselves  by 
attacks  of  diarrhea,  apparently  of  nervous  origin,  coming  on  suddenly  with- 
out pain,  with  copious  loose  motions,  of  which  there  are  two  or  three  or 

*  "Twentieth  Century  Practice  of  Medicine,"  vol.  iv.,  1895. 


GOITRE.  675 

more  in  a  day.  With  this  uncontrollable  vomiting  may  be  associated. 
Acute  forms  are  sometimes  thus  ushered  in.  The  tongue,  however,  remains 
clean,  and  there  is,  as  a  rule  no  rise  of  temperature.  Sometimes  there  may 
be  very  slight  fever.  The  skin  discoloration  and  gastro-intestinal  symptoms 
suggest  those  of  Addison's  disease,  and  it  is  not  impossible  it  may  have 
been  associated.  Rapid  breathing  is  a  frequent  accompaniment,  equaling 
thirty  to  forty  respirations  a  minute.  It  may  be  associated  with  cyanosis 
of  the  face  and  swelling  of  the  vessels  of  the  neck.  Intermittent  albumi- 
nuria is  frequent,  as  pointed  out  by  Dr.  Begbie.  Derangements  of  men- 
struation are  less  frequent  than  might  be  expected,  this  function  being 
normally  maintained  in  the  majority  of  instances.     Pregnancy  is  infrequent. 

The  mental  condition  has  been  alluded  to.  It  may  be  added  that  fits 
of  depression  alternate  with  buoyancy,  while  the  moral  nature  may  also  be 
changed  to  a  degree  amounting  to  melancholia  and  mania.  Active  cerebral 
symptoms  are  sometimes  present.  This  mania  is  of  bad  augury.  Dullness 
or  stupor  seems  to  be  entirely  absent. 

Among  complications,  hysteria  and  chorea,  and  even  epilepsy  are  in- 
cluded. 

Diagnosis. — This  needs  no  description.  The  combination  of  the  three 
cardinal  symptoms  named  can  receive  no  other  interpretation.  There  may 
be  some  doubt  at  the  beginning,  which  time  will  shortly  remove. 

Prognosis. — Exophthalmic  goitre  is  rarely  fatal  in  itself,  the  patient 
usually  dying  of  some  other  disease.  At  times  the  condition  remains  per- 
manent, with  little  change,  but  in  the  course  of  time  the  majority  of  cases 
improve  greatly,  and  some  get  well.  I  have  been  watching  for  years  a  young 
woman  who,  nineteen  years  ago,  had  striking  exopththalmic  goitre,  with  its 
usual  train  of  symptoms,  who  is  now  well,  except  that  her  eyes  are  slightly 
more  prominent  than  is  strictly  natural.  A  physician  of  my  acquaintance 
is  in  the  same  condition,  attending  actively  to  practice. 

In  some  rare  instances  a  rapidly  fatal  course  ensues,  death  taking  place 
in  a  few  days  after  the  onset.  The  majority  of  cases  run  a  chronic  course, 
the  symptoms  persisting  more  or  less  for  years.  When  death  occurs,  it  is 
from  failure  of  the  heart.  It  is  generally  preceded  by  an  aggravation  of  all 
the  symptoms.  It  may  be  sudden,  as  by  syncope.  Acute  cases  are  reported, 
with  characteristic  symptoms,  following  one  of  the  cited  causes,  in  which 
the  symptoms  lasted  a  few  days,  and  then  disappeared  completely. 

Treatment. — Rest  and  protection  from  excitement  are  essential  con- 
ditions to  successful  treatment.  After  this,  the  treatment  is  mainly  directed 
to  the  symptoms.  The  remedies  most  used  are  the  bromids  and  digitaHs : 
digitalis  to  slow  and  steady  the  pulse;  the  bromids  for  two  reasons — (i) 
as  nervous  sedatives,  and  (2)  for  their  reputed  action  in  producing  anemia 
of  the  nerve  centers. 

In  some  cases,  where  there  is  no  cardiac  lesion  and  the  pulse  is  good 
and  strong,  aconite  with  the  bromids  is  of  service.  Ergot,  for  its  power 
of  contracting  the  caliber  of  blood-vessels,  is  also  a  rational  remedy.  There 
is  a  difference  of  opinion  as  to  the  propriety  of  administering  iron.  I 
believe  the  decision  should  be  based  on  the  condition  of  the  patient  and  the 
presence  or  absence  of  anemia.  By  German  writers,  galvanism  of  the 
sympathetic  is  claimed  to  be  of  ser\^ice.  Theoretically,  it  should  be.  A 
constant  current  of  from  five  to  eight  cells  is  used ;  the  negative  pole  is 
placed  on  the  fifth  cervical  vertebra,  the  positive  pole  along  the  sternum. 
Special  efficiency  has  been  claimed  for  the  tincture  of  nux  vomica  by  J.  New- 


6-/^  DISEASES  OF  THE  THYROID  GLAXD. 

ton  Hunsberger,  of  Skippack,  Pa.,  who  called  my  attention  to  it.  Dr.  Huns- 
berger  gave  it  to  a  well-marked  case,  beginning  with  doses  of  twenty-five 
drops,  increased  to  fifty  (0.77  to  1.54  c.  c).  In  three  months  after  the  treat- 
ment commenced  the  patient  was  able  to  do  all  her  work,  and  has  continued 
well  ever  since. 

Consistent  with  his  view  as  to  its  etiology,  Prof.  Thomson  insists  upon 
the  absolute  necessity  of  a  milk  diet,  which  he  says  should  be  kept  up  for 
two  years.  He  suggests  the  fermented  milks  where  the  ordinary  milk  is  not 
well  borne. 

Thyroid  extract  has  not  proved  useful  so  far  as  tried — in  fact,  has  ap- 
peared to  be  harmful.  My  friend,  Dr.  James  C.  \Mlson,  has  used  extract  of 
suprarenal  capsule  with  apparent  advantage — five  grains  (0.33  gm.)  in  tablet 
form  at  a  dose.  The  results  of  operative  treatment  have  been  somewhat 
satisfactor}-.  Oppenheimer  has  collected  68  cases,  of  which  18  recovered 
completely,  in  26  there  was  more  or  less  improvement,  in  9  there  was  no 
change.  5  died  almost  immediately,  and  4  within  twenty-four  hours. 


MYXEDEMA* 

Synonyms. — Cachexie  pachydermique  (Charcot)  ;  Cachexia  thyroidea  vel 
strumipriva  vel  thyreopriva  (Kochler)  ;  Athyrea;  A  Cretinoid  State 
Superi'ening  in  Adult  Life  in  Women  (Gull). 

Definition. — A  myxomatous  infiltration  of  the  subcutaneous  connective 
tissue  of  the  body,  characterized  also  by  dryness  of  the  skin,  subnormal 
temperature,  mental  failure,  and  atrophy  of  the  thyroid  gland. 

Historical. — Nearly  one  hundred  years  ago  King,  of  Guy's  Hospital,  London, 
showed  experimental^  that  the  colloid  matter  of  the  acini  of  the  th5'roid  gland 
passed  into  the  lymphatics  and  thus  suggested  the  idea  of  what  is  called  in  modern 
times  an  internal  secretion.  Schiif  showed  in  1859,  by  experiment  on  carnivora,  that 
the  gland  is  important  to  life,  and  confirmed  this  in  1884  by  showing  that  the  removal 
of  the  organ  alone  in  these  animals  is  followed  b}-  striking  symptoms  preceding 
death.  In  18S4-85-S6  Victor  Horsley,  experimenting  on  monkeys  and  later  herbivo- 
rous animals,  showed  that  myxedema  could  be  produced  in  the  monkey  by  removing 
the  thyroid  gland.  The  disease  itself,  as  occurring  in  man,  was  first  described  by  Sir 
AVilliam  Gull  in  England  in  1873  as  a  cretinoid  change  ;  further  described  bv 
William  M.  Ord  in  1877,  and  named  by  him  myxedema.  It  was  also  studied  by 
Charcot,  who  called  it  cachexie  pachydej-viiqite.  In  1882  Jacques  L.  Reverdin  called 
the  attention  of  the  ^ledical  Societj'  of  Geneva  to  the  occurrence  of  the  S3-mptoms  of 
myxedema  after  total  extirpation  of  tl''e  thyroid  in  the  human  subject.  Theodor 
Kocher  states  that  in  the  autumn  of  1S82,  previous  to  this  event,  he  spoke  to  Pro- 
fessor Reverdin  of  the  remarkable  consequences  of  the  operation,  and  that  six  days 
later  Reverdin  read  a  paper  on  t]ie  subject.  In  1883  Kocher  reported  to  the  Twelfth 
Surgical  Congress  at  Berlin  similar  results  in  patients  from*  whom  he  had  entirely 
removed  the  thyroid  gland,  calling  the  condition  cachexm  strti7)n'prtva.  having 
previously  known  nothing  of  myxedema  as  a  disease.  He  did  not.  therefore,  attribute 
the  condition  to  the  loss  of  the  thyroid,  but  to  injuries  received  in  the  structures  of 
the  neck  in  the  operation.  In  a  succeeding  paper  the  brothers  Reverdin  recognized 
the  condition  as  identical  with  myxedema,  and  called  it  myxedema  operatoire. 
Shortly  afterward  Felix  Semon  suggested  that  the  loss  of  function  in  the  thyroid 
gland  was  probably  the  common  factor  in  the  production  of  both.  Victor  Horsley's 
results  were  not  published  until  i8go,  the  same  year  in  which  von  Eiselberg+  announced 
that  the  removal  of  the  th\'roid  caused  tetany.  Horsle}-  ascribes  the  tetanic  symp- 
toms to  the  fact  that  the  animals  were  kept  at  a  temperature  of  90"  F.  (32.2"  C.)  after 

*The  student  is  referred  to  five  noteworthy  papers  on  the  subject  of  "  Myxedema  and  Cretin- 
ism "  in  vol.  viii.,  1893,  "Transactions  of  the  Association  of  .American  Physicians,"  by  Francis  P. 
Kinnicutt,  James  J.  Putnam.  M.  Allen  Starr,  W.  Gilrnan  Thompson,  and'  William  Osier;  to  the 
"  Atlas  of  Clinical  ^Iedicine,"  by  Byrom  Bramwe!'..  for  admirable  illustrations;  and  to  the  exhaustive 
article  on  "  Mvxedema"  bv  George  R.  Murray,  of  Newcastle,  England,  in  the  "  Twentieth  Century 
Practice  of  Medicine,"  vol.  iv.,  1895.  Also  to  an  Address  by  Victor  Horsley  on  the  "  Physiolog-y  and 
Pathology  of  the  ThjToid  Gland,"  published  in  the  "  British  Medical  Journal,"  December  5,  iSgc. 

+  Von.  Eiseiberg's  experiments  were  made  chiefly  on  cats. 


MYXEDEMA.  677 

the  operation.  N.  Weiss  also  pointed  out  that  tetany  is  apt  to  follow  operative 
extirpation  of  goitre.  In  i8go  Horsley  published  a  note  on  the  possibility  of  the 
successful  treatment  of  myxedema,  sporadic  cretinism,  and  cachexia  strumipriva  by 
grafting  with  thyroid  tissue  from  the  necks  of  animals,  though  in  this  he  was 
anticipated  by  Kocher  in  1883  and  Bircher  in  1889.  Kocher's  graft  was  absorbed,  but 
Bircher's  patient  was  enabled  to  return  to  work.  Victor  Horsley's  results  were  a  part 
of  a  report  by  a  committee  of  the  Clinical  Society  of  London,  appointed  in  1883,  whose 
conclusions  were  as  follows  : 

1.  Myxedema  is  identical  with  cachexia  strumipriva. 

2.  Sporadic  cretinism  is  myxedema  occurring  in  childhood. 

3.  Endemic  cretinism  is  also  closely  allied  to  myxedema. 

4.  Further,  that  while  these  conditions  are  dependent  on  loss  of  function  due  to 
removal  or  disease  of  the  thyroid  gland,  the  ultimate  cause  of  this  loss  of  function  in 
ordinary  myxedema  is  not  as  yet  explained.  George  R.  Murray  suggested  the  hypo- 
dermic injection  of  the  gland  extract  in  1891  and  Horwitz  of  Copenhagen,  E.  L.  Fox, 
and  H.  Mackenzie  its  internal  administration. 

Etiology. — All  forms  of  myxedema  are  the  result  of  disease  or  removal 
of  the  thyroid  gland,  but  what  excites  this  disease  is  not  known.  It  is  much 
more  common  in  girls.  In  the  simple  form,  a  minor  role  may  be  assigned 
to  heredity,  but  in  cretinism  heredity  plays  no  part,  as  cretins  are  not 
sexually  developed.  Yet  it  occurs  in  members  of  the  same  family,  which  only 
goes  to  show  that  one  cause  operates  to  produce  it.  Many  are  the  children 
of  neurotic  persons,  while  Langdon  Down  considers  that  alchohol  is  respon- 
sible, especially  if  the  alcohol  habit  is  present  at  the  time  of  procreation. 

Morbid  Anatomy. — The  morbid  changes  in  the  myxedema  after  death 
are  those  described  as  characteristic  in  life,  but  autopsy  has  disclosed  the 
thyroid  absent  in  nine  out  of  ten  cases  of  cretinism  examined,  confirming 
the  theory  of  its  ofigin.  Enlargement  of  the  hypophysis  cerebri  was  found 
in  six  cases  of  cretinism  by  different  observers,  and  Horsley  says  th'at  the 
convolutions  of  the  brain  are  ill-defined,  and  the  blood-vessels  small,  even 
in  proportion  to  the  rudimentary  condition  of  the  nervous  system. 

Symptoms. — Three  groups  of  cases  are  recognizable : 

1.  Pure  myxedema. 

2.  Myxedema  associated  with  congential  or  sporadic  cretinism. 

3.  Operative  myxedema  or  cachexia  strumipriva. 

I.  Pure  Myxedema. — This  is  much  more  frequent  in  women  than  in 
men, — at  least  as  six  to  one, — and  occurs  usually  between  the  ages  of 
thirty  and  fifty,  but  is  not  confined  to  these  ages,  being  found  in  those 
who  are  younger  and  older.  Heredity  is  a  recognized  factor,  acting  usually 
through  the  mother.  Several  members  of  a  family  may  be  affected.  The 
•poor  suffer  most.  It  is  said  to  have  no  relation  to  the  catamenia,  but  has 
followed  frequent  pregnancies,  injuries,  severe  hemorrhage,  and  mental 
disturbance.  Most  essential  is  some  change  in  the  thyroid  gland.  Formerly 
thought  to  be  rare  in  this  country,  cases  have  multiplied  since  attention  has 
been  called  to  it. 

The  face  is  the  chief  seat,  but  the  extremities,  the  trunk,  the  tongue, 
and  even  the  internal  organs  may  be  involved.  The  face  is  uniformly 
swollen,  broadened,  and  flattened,  the  nose  is  broad,  the  mouth  large,  all  lines 
are  obliterated,  and  expression  is  gone.  The  skin  of  the  neck  above  and 
below  the  clavicle  is  thrown  into  folds  of  fatty  and  myxomatous  tissue.  It 
is  yellow,  translucent  or  waxy,  dry  and  scaly.  The  cheeks  and  sometimes 
the  nose  are  flushed.  True  edema  may  be  associated,  and  there  are  rarely 
albuminuria  and  glycosuria.  The  hands  lose  their  natural  shape,  and  were 
described  by  Gull  as  "  spade-like  " ;  the  feet  are  also  misshapen ;  the  gait 
is  slow  and  labored.  The  mind  is  feeble,  slow  in  its  action,  memory  is  poor, 
while  irritability  and  suspicion  are  added  qualities,  and  sometimes  there  are 


678  DISEASES  OF  THE  THYROID  GLAXD. 

delusions  and  hallucinations,  ultimately  often  dementia.  The  organic  func- 
tions are  fairly  well  performed.  Atrophy  of  the  optic  nerve  is  a  rare  but 
possible  symptom,  also  synovitis  from  trifling  causes.  Subnormal  temper- 
ature is  characteristic,  though  in  early  stages  the  temperature  may  be  normal 
or  slightly  above.  In  winter  the  patient  always  feels  cold  and  hugs  the 
stove.  The  course  of  the  disease  is  slow,  and  the  patient  usually  dies  of 
some  intercurrent  affection. 

2.  Myxedema  Associated  zcitJi  Cretinism,  Congenital  or  Acquired. — 
(Cretinoid  idiocy:  Idiotic  avec  cachexie  pachydermique.)  Cretinism  is  a 
form  of  idiocy  associated  with  absence  of  the  thyroid  or  with  a  functionless 
thyroid.  It  is  myxedema  in  childhood.  There  is  almost  complete  arrest  of 
mental  and  bodily  development.  The  cretin  is  a  dwarf.  In  the  congenital 
form,  there  is  congenital  absence  of  the  thyroid,  and  the  child  is  further 
characterized  by  its  thick  neck,  short  arms  and  legs,  and  prominent  belly. 
The  face  is  large,  the  lips  are  thick,  and  the  tongue  is  large  and  often 
protruding.  All  the  bones  of  the  skeleton  are  short  and  broad,  the  epiphyses 
swollen,  but  not  ossified.  The  skull  is  short  and  broad,  and  the  basosphenoid 
junction  early  ossified.  The  cretin  resembles  the  rickety  child,  and  may 
be  confounded  with  it. 

Acquired  cretinism  may  start  before  birth  and  be  barely  appreciable  at 
birth.  ]\Iore  frequently  the  infant  appears  normal  at  birth,  and  the  changes 
make  their  appearance  between  the  second  and  fifth  years.  The  arrest  of 
development  continues,  or,  rather,  there  is  very  slow  development,  so  that  at 
adult  age  the  man  or  woman  does  not  exceed  in  stature  a  child  of  from  five 
to  seven  years.  The  myxedemic  symptoms  are  similar  to  those  described 
in  pure  myxedema. 

From  the  fact,  however,  that  the  disease  may  start  to  develop  later 
than  infancy,  there  results  a  series  of  types  intermediate  between  those 
represented  by  congenital  and  adult  cretinism.  This  arrest  of  mental  and 
physical  development  is,  of  course,  greater  the  earlier  the  disease  begins 
to  develop ;  whence  two  cretins  of  the  same  age  will  dift'er  materially  if 
one  has  commenced  to  develop  at  or  before  birth,  and  the  other  not  until 
seven  or  eight  years  of  age. 

True  congenital  cretinism — that  is,  cretinism  which  is  evident  at  birth — 
is  very  rare.  Some  cases  of  supposed  intra-uterine  rickets  may  have  been 
cretinism.  In  most  cases,  the  child  does  not  long  survive  its  birth.  In 
another  form  described  by  Horsley  the  disease  is  supposed  to  begin  shortly 
before  birth,  but  develops  slowly,  so  that  at  birth  it  has  not  attained  the  de- 
gree incompatible  with  life,  and  the  child  can  live.  In  this  there  is  usually 
a  goitre  at  birth. 

Cretinism  may  be  endemic,  as  in  some  parts  of  the  continent  of  Europe ; 
or  sporadic,  as  in  England,  and  America  as  well.  The  sporadic  cases  are,  as 
a  rule,  without  goitre,  the  thyroid  glands  being  either  undeveloped  or 
atrophied,  while  one-third  also  of  the  endemic  cretins  are  without  goitre. 
In  either  event,  the  gland  is  functionally  dead,  even  though  it  may  appear 
natural  in  size,  the  original  true  gland  tissue  having  been  replaced  by  an  in- 
different element.  Endemic  cretinism  -occurs  in  localities  where  goitre  is 
also  endemic — in  the  shut-up  valleys  of  mountainous  districts  of  Europe 
and  Asia,  to  which  it  is  confined.  At  one  time — in  1847 — a  number  of 
cases — some  24  out  of  a  population  of  350 — prevailed  in  Cheselborough, 
Somerset,  England,  but  the  disease  has  died  out.  The  endemic  form  is 
commonly  ascribed  to  the  use  of  certain  drinking  waters,  but  no  responsible 


MYXEDEMA.  67^ 

constituents  have  been  isolated.  The  child,  being  normal  at  birth,  remains 
so  until  the  change  begins  in  the  thyroid,  when  it  becomes  less  lively,  de- 
velopment is  arrested,  and  the  conditions  described  on  page  678  slowly 
develop.  The  cretin  may  reach  the  age  of  thirty  or  forty  years,  but  ceases 
to  change  after  the  twentieth  year,  whether  the  case  be  sporadic  or  endemic. 

3.  Operative  Myxedema  or  Cachexia  Strumipriva. — By  this  is  meant  a 
condition  of  myxedema  the  result  of  removal  of  the  thyroid  (see  History, 
p.  676).  It  is  more  likely  to  follow  total  than  partial  removal  of  the  thyroid, 
■but  does  not  follow  every  case,  having  been  observed  in  69  out  of  408  cases. 
Cases  of  operative  myxedema  are  very  rare  in  this  country. 

Diagnosis, — This  is  easy.  The  edema  of  Bright's  disease  or  heart  dis- 
ease may  be  confounded,  especially  as  albuminuria  and  casts  are  sometimes 
present  in  myxedema ;  but  the  peculiar  flat  face,  the  absence  of  pitting  on 
pressure,  and  of  the  signs  of  heart  disease  are  distinctive  features  of  myx- 
edema. 

Prognosis. — This  was  regarded  as  unfavorable  until  the  hypodermic 
tise  of  thyroid  extract  was  suggested  by  George  R.  Murray,  of  Newcastle, 
England,  in  1891,  based  upon  the  satisfactory  efifect  obtained  by  Betten- 
court  and  Serrano,  in  1890,  in  ingrafting  sheep's  thyroid  in  human  subjects 
having  myxedema,  the  idea  being  in  this  manner  to  substitute  the  juice  or 
secretion  of  the  gland.  Every  expectation  was  realized.  In  1892,  Howitz, 
of  Copenhagen,  and  soon  after,  E.  L.  Fox  and  H.  Mackenzie,  in  England, 
substituted  for  the  hypodermic  use  the  administration  of  the  gland  itself  or 
some  preparation  of  it  by  the  mouth.  At  the  present  day,  the  effects  of  the 
administration  of  thyroid  preparations  in  myxedema  are  among  the  mar- 
"velous  results  of  medicine. 

Treatment. — The  treatment  at  the  present  day  is,  therefore,  solely  b}^ 
the  sheep's  thyroid.  The  gland  is  best  administered  in  the  shape  of  glycerin 
extract  or  tablet.  From  fifteen  minims  (i  gm.)  to  thirty  minims  (2  gm.) 
of  the  former  and  five  grains  f  .33  gm.)  of  the  latter  are  to  be  given  daily,  its 
efifect  being  carefully  watched.  If  no  efifect  follows,  the  dose  should  be 
doubled,  and  further  increased  if  necessary.  As  improvement  takes  place, 
smaller  doses  should  be  given  at  longer  intervals,  until  finally  from  ten  to 
fifteen  minims  (0.66  to  i  gm.)  or  ten  to  fifteen  grains  (.66  to  i  gm.)  of  the 
solid  extract  are  given  once  a  week  or  less  often.  During  the  first  week  the 
patient  should  be  watched,  with  a  view  to  guarding  against  heart  failure, 
prohibiting  all  physical  exertion  on  his  part,  this  being  an  apparent  efifect 
of  the  medicine  in  excessive  doses. 

The  myxedema  being  removed,  it  is  necessary,  of  course,  to  continue 
the  treatment  in  this  second  stage  by  such  doses  as  will  maintain  the  cure, 
ior  it  is  to  be  understood  that,  as  the  thyroid  is  still  functionless,  the 
omission  of  the  treatment  is  followed,  sooner  or  later,  by  its  return.  The 
quantity  required  varies  in  different  cases,  but  it  is  found  to  range  between 
five  and  fifteen  minims  (0.33  to  i  c.  c),  the  more  precise  dose  being  de- 
termined by  trial.  A  single  daily  dose  is  preferred  by  ^Murray  to  a  smaller 
dose  more  frequently  repeated.  A  fall  of  temperature  below  normal,  a 
slight  return  of  swelling  or  of  other  symptoms,  indicate  that  too  small  a 
dose  is  being  given,  while  acceleration  of  the  pulse  indicates  that  the  dose 
should  be  reduced.  In  a  climate  not  subject  to  great  variations  the  same 
dose  may  be  given  the  year  round.  In  hot  weather  a  smaller  dose  suffices 
than  in  cold,  and  a  dose  that  has  been  found  sufficient  during  the  summer 
mav  not  be  enough  in  the  winter. 


68o  DISEASES  OF  THE   THYROID  GLAND. 

The  treatment  of  cretinism  is  also  by  the  thyroid  extract.  Relatively 
larger  doses  of  thyroid  extract  can  be  given  to  children  than  to  adults.  The 
liability  to  syncope  during  treatment  is  less  marked  than  in  myxedematous 
adults,  but  it  is  advisable  not  to  allow  any  unusual  exercise  during  the  first 
part  of  the  treatment.  In  the  absence  of  the  extract,  the  sheep's  raw  thyroid 
may  be  administered,  giving  one-eighth  to  one-quarter  of  a  lobe  twice  a 
week. 

Thyroid  grafting  is  also  employed  for  the  treatment  of  cretinism,  with 
the  same  results  and  same  shortcomings,  and  is  carried  out  in  the  same  way. 
It  is  especially  with  a  view  to  more  permanent  results  that  the  successful 
application  of  this  method  is  desirable,  and  symptoms  have  been  kept  in 
abeyance  for  some  time  by  it.  Sooner  or  later,  however,  they  return,  and 
the  operation  must  be  repeated  or  the  extract  administered.  If  grafting,, 
which  is  usually  done  into  the  peritoneal  cavity,  is  practiced,  it  should  be 
preceded  by  a  course  of  thyroid  extract,  and  the  symptoms  of  myxedema 
removed  as  far  as  possible  before  the  operation  is  done,  usually  for  two  or 
three  months.     The  details  of  operative  treatment  are  left  to  the  surgeon. 

The  results  of  treatment  in  cretinism  are  as  marvelous  as  in  myxedema. 
They  include  not  only  the  removal  of  the  hideous  deformity  and  the  restora- 
tion of  intellect,  but  also  an  increase  in  height,  which,  though  not  amounting" 
to  a  restoration  of  the  normal  height,  is  still  appreciable.  The  earlier  treat- 
ment is  commenced,  the  more  prompt  and  marked  is  its  efifect. 

Of  the  treatment  previous  to  the  introduction  of  that  by  thyroid  extract, 
that  by  jaborandi  and  pilocarpin  should  be  mentioned,  because  the  partial 
benefit  derived  from  them  is  explainable  by  supposing  that  they  produced 
increased  activity  in  small  portions  of  residual  glandular  tissue.  Shoulct 
thyroid  extract  be  unattainable,  these  drugs  may  still  be  used. 


NEOPLASMS  OF  THE  THYROID. 

The  thyroid  is  subject  to  a  variety  of  morbid  growths,  among  which  ma}^ 
be  mentioned : 

1.  Adenoma,  which  occurs  as  an  encapsulated  growth,  varying  con- 
siderably in  size.  There  may  be  nodules  in  both  lobes.  Metastases  of 
growths  resembling  thyroid  tissue  are  reported  to  have  been  found  in  the 
lungs  and  bones  of  the  body. 

2.  Primary  medullary  cancer,  as  a  rare  growth  with  a  tendency  to  invade 
the  trachea  and  esophagus,  developed  from  the  epithelial  cells  of  the  follicles. 
Secondary  cancer  has  also  been  reported. 

3.  Tuberculosis,  always  supposed  to  be  a  possible  but  rare  disease,  has 
been  found  by  Chiari  in  seven  out  of  100  postmortems  on  persons  who  had 
had  tuberculosis.     Bruns  refers  to  six  cases  of  tuberculous  goitre. 

4.  Syphilis,  including  gummy  growths. 

5.  Hydatid  disease. 

6.  Actinomycosis. 

Abscess  of  the  thyroid  is  an  occasional  event. 

The  treatment  of  these  abnormalities  is  surgical,  except  in  the  case  of 
tuberculosis  and  syphilis,  which  demand  the  usual  antitubercular  and  anti- 
syphilitic  remedies. 


ADDISON'S  DISEASE.  681 

DISEASES  OF  THE  SUPRARENAL  CAPSULES. 

ADDISON'S  DISEASE. 

Definition. — A  term  applied  to  any  disease  of  the  suprarenal  capsule. 

Morbid  Anatomy. — This  includes  (i)  tuberculosis  with  fibrocaseous 
and  calcareous  degeneration;  (2)  cystic  degeneration;  (3)  fatty  degener- 
ation; (4)  simple  atrophy;  (5)  chronic  interstitial  inflammation  which  may 
lead  to  atrophy;  (6)  malignant  disease,  including  carcinoma  and  sarcoma; 
(7)  hemorrhagic  extravasations  ;  (8)  embolism. 

Symptoms. — Some  of  these  morbid  states  appear  to  be  totally  without 
symptoms,  the  conditions  having  first  come  to  light  at  autopsy.  Other 
symptoms  may  be  produced  by  any  of  them,  and  there  is  none  distinctive 
for  any  one  state.     They  include : 

Pigmentation  or  bron::ing  of  the  skin.  This  was  first  described  by 
Addison  as  associated  with  disease  of  the  suprarenal  capsules,  an  association 
which,  since  the  publication  of  his  paper  in  1855,  has  been  called  Addison's 
disease.  The  clinical  concept  thus  named  is  especially  a  disease  of  the  lower 
classes,  Dr.  Greenhow  having  found  nine-tenths  of  cases  among  laboring" 
people.  It  is  also  a  disease  of  adults,  being  rare  under  thirty-five  years. 
The  lesion  most  frequenth'  thus  associated  is  the  fibrocaseous  tubercular 
one.  But,  as  stated,  the  pigmentation  may  accompany  any  one  of  the 
above-named  lesions,  if  prolonged,  or  may  be  absent  in  the  presence  of  any 
one.  As  to  the  coloration  itself,  which  is  usually  the  first  symptom  to  at- 
tract attention,  it  varies  from  a  light  yellow  to  a  deep  brown,  and  even  almost 
black.  It  is  deeper  on  the  more  exposed  parts  of  the  body,  where  the  normal 
pigmentation  is  greater,  and  therefore  is  commonly  first  seen  on  the  face 
and  hands.  In  rare  instances  only  is  it  general.  It  is  associated  at  times 
with  patches  of  absent  pigmentation — leukoderma.  It  is  noticeable  also 
at  times  on  the  mucous  membrane  of  the  mouth,  conjunctiva,  and  vagina, 
and  very  rarely  even  upon  serous  membranes  in  patches. 

Great  pains  have  been  taken  to  explain  this  peculiar  "  bronzing," 
ascribed  by  Addison  himself  to  the  loss  of  function  of  the  adrenals.  Two 
chief  theories  have  been  suggested  : 

1.  By  experimental  evidence  it  has  been  sought  to  show  with  some 
reason  that  these  glands  furnish  some  sort  of  internal  secretion  essential  to 
normal  metabolism.  To  explain  those  cases  in  which  the  adrenals  are 
diseased  and  yet  there  is  no  pigmentation,  it  is  suggested  that  accessory 
adrenals  may  be  present,  though  none  has  been  demonstrated,  so  far  as  I 
know  ;  while  the  presence  of  pigmentation  in  association  with  healthy  adrenals 
is  ascribed  to  disease  of  the  adjacent  semilunar  ganglia  interfering  in  some 
way  with  the  blood-vessels  or  lymphatics  of  the  glands.  Such  a  theory,  that 
a  secretion  furnished  in  health  by  the  suprarenal  capsule  is  necessary  to 
normal  metabolism,  is  analagous  to  that  which  ascribes  myxedema  to  the  loss 
of  function  of  the  thyroid  gland,  and  has  acquired  some  additional  support 
from  the  knowledge  recently  added  upon  this  subject. 

2.  According  to  the  second  theory,  the  pigmentation  is  ascribed  to 
disease  of  the  abdominal  sympathetic  system  itself,  commonly  associated 
with  disease  of  the  adrenals,  but  also  at  times  caused  by  other  chronic  dis- 
orders which  invade  the  solar  plexus  and  ganglia.  In  one  of  my  own  cases 
in  which  all  the  S3'mptoms,  including  pigmentation,  were  conspicuous,  and 


6^2  DISEASES  OF  THE  THYROID  GLAND. 

which  came  to  autopsy,  there  was  found,  in  addition  to  the  advanced 
tuberculosis  of  the  suprarenal  capsules,  also  an  enlarged  semilunar  ganglion. 
The  latter  view  would  make  it  a  disease  of  the  nervous  system,  and  the  pig- 
mentation a  trophic  phenomenon. 

As  stated,  there  are  no  other  symptoms  which  are  distinctive  of  any 
one  of  the  lesions  of  the  suprarenal  capsule  described,  but  among  those 
which  are  more  or  less  constantly  associated  are  anemia,  extreme  debility 
and  general  languor,  irritability  of  the  stomach,  and  quite  often  diarrhea. 
The  irritability  of  the  stomach  is  manifested  by  anorexia,  nausea,  and  vomit- 
ing, and  may  be  a  very  early  symptom.  The  heart's  action  is  feeble,  the 
pulse  correspondingly  small  and  rapid,  and  there  is  also  often  a  tendency  to 
fainting.  There  is  dyspnea.  At  other  times  there  is  headache.  Mental 
hebetude  goes  pari  passu  with  bodily  weakness,  while  the  other  symptoms 
commonly  associated  with  the  latter  condition  are  also  present — namely, 
dizziness  and  ringing  in  the  ears.  Ultimately,  the  asthenia  becomes  so  pro- 
found that  the  patient  cannot  rise,  but  keeps  his  bed,  growing  weaker  and 
weaker,  until  he  dies  of  sheer  exhaustion.  Sometimes  there  are  convulsions, 
possibly  due  to  brain  anemiia. 

The  urine  is  usually  normal,  although  occasionally  there  is  polyuria, 
and  sometimes  the  urinary  pigments  have  been  found  increased. 

Diagnosis. — It  is  probable  that  pigmentation  alone,  at  least  unless  it 
be  very  decided  and  general,  is  never  sufficient  to  justify  a  diagnosis  of 
suprarenal  disease,  since  other  abdominal  affections  are  known  to  produce  a 
similar  condition.  Among  these  are  tuberculosis  of  the  peritoneum,  cancer, 
and  lymphoma ;  pregnancy,  uterine  and  even  hepatic  disease.  The  popular 
notion  that  every  discoloration  of  the  skin  is  due  to  some  derangement  of  the 
liver  (liver-spot)  has  scanty  foundation.  In  the  hardening  of  the  liver 
sometimes  associated  with  diabetes,  pigmentation  has  been  noticed.  All  these 
facts  go  to  show  that  the  nervous  system  must  have  some  powerful  influence, 
supporting  the  second  theory.  The  same  testimony  is  afforded  by  the 
pigmentation  which  attends  exophthahuhc  goitre.  Protracted  Ulthiness  and 
vagabondism  also  produce  discoloration  of  the  body  which  is  not  distinguish- 
able per  se  from  that  of  Addison's  disease.  Deep  general  pigmentation  has 
been  found  associated  with  melanotic  cancer.  Finally,  pigmentation  is 
sometimes  the  result  of  the  prolonged  administration  of  arsenic.  It  is  well, 
therefore,  to  seek  carefully  for  signs  and  symptoms  other  than  pigmentation 
before  a  diagnosis  is  made.  In  the  case  of  my  own  referred  to,  there  were 
pulmonary  tuberculosis  and  tuberculous  disease  of  the  spine,  with  pigmenta- 
tion and  asthenia,  on  which  w^as  based  the  diagnosis  of  Addison's  disease, 
confirmed  by  autopsy. 

Prognosis. — In  a  well-determined  case  of  Addison's  disease,  as  might 
be  inferred  from  the  nature  of  the  causes,  recovery  is  impossible,  though 
the  course  of  the  disease  is  commonly  prolonged  and  improvement  may 
take  place.  In  a  few  cases  only  is  the  course  rapid.  From  eighteen  months 
to  several  years  usually  cover  the  duration. 

Treatment. — This  is  principally  symptomatic.  We  aim  to  restore  the 
condition  of  the  blood,  and,  of  course,  above  all,  iron  is  indicated.  It  may 
be  associated  with  that  other  tonic  so  constantly  used  with  iron  especially — 
arsenic.  An  excellent  preparation  of  arsenic  in  the  solution  of  the  chlorid, 
which  is  as  good  as  Fowler's  solution  and  mixes  well  with  the  chlorid  of 
iron.  The  doses  are  the  same  as  those  of  Fowler's  solution — from  three  to 
five  minims  (0.18  to  3  c.  c.)  ;  or  the  iron  and  arsenic  may  be  given  in  pill 


ADDISON'S  DISEASE.  683 

form  as  the  carbonate  of  iron  and  arsenious  acid,  and  to  this  strychnin 
may  be  conveniently  added.  If  very  asthenic,  the  patient  should  be  kept 
in  bed  and  fed  on  alcohol,  with  nutritious,  easily-assimilable  food,  of  which 
peptonized  milk  and  broths,  beef-juice,  cod-liver  oil,  and  glycerin  are  the 
type.  The  diarrhea  should  be  treated  as  other  diarrheas,  with  bismuth 
and  other  remedies.  For  the  nausea  the  usual  gastric  sedatives,  including 
ice,  carbonic  acid  water,  champagne,  milk  and  lime-water  in  small  doses, 
koumiss,  whey,  and  the  like  are  suitable. 

With  the  knowledge  which  has  grown  out  of  the  treatment  of  myx- 
edema with  thyroid  extract,  no  treatment  of  the  combination  of  symptoms 
known  as  Addison's  disease  would  be  complete  without  the  administration 
of  some  similar  preparation  of  the  adrenal.  George  Oliver  has  had  pre- 
pared an  extract  in  the  shape  of  the  tincture ;  a  powder  and  a  glycerin  ex- 
tract are  made ;  and  the  glands  are  eaten  fresh  or  dried.  The  equivalent 
of  two  a  day  is  recommended.  Of  the  powder,  three  to  five  grains  (0.2  to 
0.3  gm.)  are  given  three  or  four  times  a  day.  While  no  conclusive  evidence 
of  its  efficiency  has  been  obtained,  the  results  of  experience  favor  further 
trial  of  the  preparation. 


SECTION    VII. 

DISEASES  OF  THE  URINARY  ORGANS. 

GENERAL  SYMPTOMATOLOGY. 

Three  important  symptoms  more  or  less  characteristic  of  diseases  of  the 
urinary  organs,  and  especially  of  disease  of  the  kidneys,  may,  for  the  sake 
of  brevity,  be  considered  at  the  outset  of  our  studies  of  these  affections. 
They  include  albimiiniiria,  renal  dropsy,  and  uremia. 

ALBUMINURIA. 

Definition. — By  albuminuria  is  meant  a  condition  of  the  urine  in  which 
it  contains  some  one  of  the  forms  of  albumin  of  which  at  present  we  need 
consider  only  serum  albumin  and  globulin.  The  sources  of  the  albumins  in 
urine  are  various,  and  may  be  conveniently  divided  into  extrarenal  and  renal. 

Extrarenal  Albuminuria. — The  pelvis  of  the  kidney,  the  ureters,  the 
bladder,  the  urethra,  and  in  the  female  the  vagina  and  uterus  in  addition,  are 
the  most  important  sources  of  extrarenal  albuminuria.  In  all  of  them  it  is 
almost  invariably  the  serum  of  pus  formed  during  catarrhal  inflammation 
which  furnishes  the  albumin.  The  presence  of  pus-corpuscles,  therefore,  in 
sufficient  number  in  the  urine  commonly  explains  the  source  of  such  albumin,, 
which  is,  moreover,  usually  small  in  quantity — never  more  than  about  one- 
tenth  the  volume  of  urine  tested,  even  with  the  most  copious  sediment  of  pus. 
It  must  not  be  overlooked,  however,  that  the  two  sources,  kidney  disease  itself 
and  the  mucous  surfaces  referred  to,  may  coexist,  in  which  event  careful 
microscopic  examination  will  sooner  or  later  discover  tube-casts,  while  the 
quantity  of  albumin  will  be  larger  than  can  be  accounted  for  by  the  presence 
of  pus  alone. 

Menstrual  or  lochial  blood  need  only  be  referred  to  as  sources  of  albumin 
in  the  urine  hardly  likely  to  be  overlooked  by  any  physician ;  while  hemor- 
rhage from  any  one  of  the  mucous  surfaces  referred  to,  as  well  as  from  the 
kidney  itself,  would  be  a  source  of  albuminuria.  It  is  usually  comparatively 
easy  to  determine  whether  a  hertiorrhage  has  its  source  in  the  kidney  or  in  the 
mucous  membranes  previously  mentioned.  In  the  former  coagula  are  rarely 
present,  for  the  blood,  entering  the  ureter  slowly,  becomes  intimately  mixed 
with  the  urine.  It  imparts  to  it,  too,  when  acid  in  reaction,  a  smoky  hue 
which  is  very  characteristic.  The  coloring-matter  of  the  corpuscles  is  com- 
monly dissolved  out  by  the  urine  which  is  thus  tinged,  and  on  standing,  the 
stroma  of  the  corpuscles  sinks  to  the  bottom  as  a  brownish  sediment.  The 
microscope  reveals  these  corpuscles  shrunken,  almost  colorless,  and  often 
crenated.  I  have  said  that  the  smoky  hue  is  present  only  in  acid  urine.  When 
the  latter  becomes  alkaline,  either  by  spontaneous  or  artificial  change  in  reac- 
tion, it  assumes  a  brighter  red  hue,  the  degree  of  which  depends  upon  the 
quantity  of  blood.    The  same  cause,  acidity,  produces  the  smoky  hue  of  blood 

684 


ALBUMINURIA.  685 

which  is  vomited,  and  therefore  mixed  with  gastric  juice.  When  blood  comes 
from  the  pelvis  of  the  kidney  or  the  ureter  in  any  quantity,  coagula  which  are 
molds  of  the  ureter  are  sometimes  found,  the  descent  of  which  is  often 
attended  with  severe  pain. 

Another  source  of  albuminous  urine,  though  not  likely  to  cause  error, 
should  be  mentioned — viz.,  the  so-called  chylous  urine,  or  chyluria,  in  which 
in  consequence  of  some  as  yet  imperfectly  understood  communication  between 
the  lymphatic  system  and  the  urinary  tracts,  chyle  enters  the  urine  and 
imparts  its  physical  and  chemical  characters  thereto.  These  are  the  presence 
of  albumin,  a  milk-white  appearance  due  to  the  presence  of  fat  in  a  molecular 
state. 

The  kidney  itself  may  be  the  seat  of  suppuration,  and  contribute  through 
the  pus  thus  added  to  an  albuminuria. 

Renal  Albuminuria. 

The  Immediate  Cause  of  Renal  Albuminuria. — Delayed  circulation  of 
the  blood  through  the  glomeruli  is  doubtless  of  itself  sufficient  to  cause 
albumin,  an  otherwise  non-osmotic  substance,  to  pass  through  the  walls  of  the 
capillary  blood-vessels  into  the  urine,  though  it  is  more  than  probable  that  an 
altered  state  of  the  renal  epithelium  also  contributes  to  a  facility  of  transit. 
The  necessary  obstruction  is  produced  by  any  cause  which  sufficiently  resists 
the  movement  of  the  blood  through  the  kidneys,  whether  it  resides  in  the 
organ  itself  or  in  the  venous  system  beyond  it,  whence  the  albuminuria  which 
so  often  attends  extreme  valvular  disease  of  the  heart.  The  comparative 
smallness  of  such  albuminuria  as  contrasted  with  that  in  parenchymatous 
nephritis,  in  which  the  renal  cells  are  an  early  seat  of  change,  is  strong  evi- 
dence in  favor  of  some  active  participation  of  epithelial  change  in  causing 
albuminuria.  In  chronic  albuminuria  another  important  influence  operating 
to  facilitate  the  transudation  of  albumin  is  a  hydremic  state  of  the  blood, 
which  is  in  turn  a  consequence  of  albuminuria. 

Renal  albuminuria  also  occurs  as  a  secondary  symptom  in  diseases  other 
than  renal.  First  may  be  mentioned  the  albuminuria  of  fever,  such  as  that  of 
typhoid  fever,  smallpox,  etc.  The  albuminuria  of  diphtheria  and  scarlatina, 
due  to  an  intercurrent  parenchymatous  nephritis,  is,  of  course,  not  intended. 
The  febrile  albuminuria  alluded  to  is  not  usually  large,  and  disappears  with 
the  decline  of  the  disease.  It  is  in  great  measure  the  result  of  irritation  of 
the  kidney  by  the  infectious  agent ;  possibly  also,  in  part,  the  result  of  dimin- 
ished cardiac  force  with  which  the  blood  is  driven  through  the  kidneys  and 
of  the  resulting  turgor. 

Other  conditions  in  which  albuminuria  thus  occurs  are  anemia,  leukemia, 
diarrhea,  cholera,  lead  colic,  also  certain  conditions  of  the  brain  and  spinal 
cord,  including  hemorrhages  into  the  brain,  meningitis,  epilepsy,  tetanus,  and 
others.  In  all  of  these  there  is  probably  diminished  arterial  pressure  directly 
or  indirectly  through  the  nervous  system. 

The  significance  of  renal  albuminuria  has  altered  greatly  as  our  knowl- 
edge of  this  subject  has  increased.  While  large  albuminurias  of 
renal  origin  can  scarcely  be  due  to  anything  else  but  renal  dis- 
ease, and  the  degree  of  albuminuria  is  within  limits  a  measure 
of  the  seriousness  of  the  disease,  yet  the  important  fact  remains  that 
there  may  be  true  albuminuria,  usually  moderate,  in  which  there 
is  no  disease  of  the  kidney  whatever ;  there  may  also  rarely  be  Bright's  dis- 


686  DISEASES  OF  THE  URINARY  ORGANS. 

ease  in  which  there  is  no  albuminuria.  The  significance  of  albuminuria 
is  always  incerased  by  its  association  with  tube-casts,  yet  there  may  be 
both  albumin  and  casts  in  urine  where  there  is  no  Bright's  disease,  while 
again,  there  may  be  Bright's  disease  without  albumin  or  casts.  I  myself 
incline  to  the  belief  that  such  cases  are  infrequent,  and  yet  this  possibility 
must  be  acknowledged.     In  illustration  of  what  has  been  said  I  may  refer  to : 

Physiological  or  Functional  Albuminuria. — The  presence  of  a 
physiological  or  functional  albuminuria  at  the  present  day  is  generally  con- 
ceded. By  it  is  meant  an  albuminuria  unassociated  with  other  symptoms. 
There  are  no  tube-casts  or  feeling  of  ill-health.  Such  albuminurias  are  often 
discovered  accidentally,  especially  by  examiners  for  life-insurance.  Much 
care  should  be  exercised  in  concluding  upon  the  nature  of  an  albuminuria  sus- 
pected to  be  functional.  In  the  first  place,  it  should  be  small,  not  exceeding" 
one-tenth  the  bulk  of  urine  tested,  and  through  it  is  not  necessary  that  it  should 
be  absent  on  rising,  yet  it  is  a  strong  point  in  favor  of  the  functional  nature  if 
it  is  absent  at  this  time  and  present  only  after  some  exertion  has  been  made 
or  on  taking  food.  No  tube-casts  should  be  in  the  urine,  the  urea  should  be 
in  sufficient  quantity,  there  should  be  no  retinal  change,  no  hypertrophy  of  the 
left  ventricle,  no  high  tension  to  the  pulse,  nor  even  a  suggestion  of  dropsy. 
Further,  this  condition  should  be  watched  over  a  considerable  length  of  time 
before  the  conclusion  is  arrived  at  that  we  have  to  do  with  a  harmless  func- 
tional albuminuria. 

Other  proteid  matters  are  sometimes  found  in  the  urine,  such  as  globulin, 
mucin,  peptone,  and  hemialbumose,  but  except  in  the  case  of  globulin,  their 
clinical  significance  is  not  sufficiently  determined  to  justify  their  further  con- 
sideration in  a  text-book.  A  certain  amount  of  globulin  is  always  associated 
with  albumin.  In  an  ordinary  serum  albuminuria  the  ratio  commonly  main- 
tained is  ID  to  1 8  of  serum  albumin  to  i  of  globulin,  the  ratio  in  the  blood 
being  i  of  serum  albumin  to  i  1-2  to  3  of  globulin.  A  like  ratio  holds  for 
these  constituents  in  pus. 

This  ratio'  in  albuminuria  is  at  times  exceeded  especially  in  the  case  of 
the  amyloid  kidney,  where  I  regard  the  presence  of  globulin  in  large  amount 
as  of  diagnostic  value. 

Tests  for  Albumin  and  Globulin. 

To  Test  for  Albumin. — The  test  which  is  at  the  same  time  the  most 
delicate  and  reliable  is  the  heat-and-acid  test.  It  is  best  applied  in  the  fol- 
lowing manner: 

The  Heat-and-Acid  Test. — A.  suitable  quantity  of  urine,  filtered  if  not 
clear,  is  poured  into  a  test-tube,  say  to  a  depth  of  five  cm.  (2  inches),  and 
boiled  over  a  Bunsen  flame  or  spirit-lamp.  Then  nitric  acid  is  added,  drop 
by  drop,  until  from  ten  to  fifteen  drops  are  added  to  this  quantity  of  urine. 
Any  precipitate  produced  in  the  act  of  boiling  which  is  dissolved  by  the  acid  is 
phosphates.  After  the  total  quantity  of  acid  has  been  added  the  tube  is  placed 
aside  for  half  an  hour,  and  if  at  the  end  of  this  time  no  further  precipitate 
appears,  the  specimen  may,  for  clinical  purposes,  be  declared  free  from 
albumin.  It  is  very  important  that  the  acid  should  not  be  added  first,  as  is 
sometimes  directed,  for  it  often  happens  that  when  a  considerable  amount  of 
albumin  is  present,  acid  albumin  is  formed  which  is  not  precipitable  by  heat, 
and  thus  such  quantities  of  albumin  may  elude  detection.  The  test  of  heat 
and  acid  applied  in  the  manner  described  is  really  more  delicate  than  the  con- 


RENAL  DROPSY.  687 

tact  method  with  nitric  acid,  recognizing,  as  it  does,  smaller  quantities  of 
albumin. 

The  Contact  Method  n'itJi  Nitric  Acid,  or  Heller's  Test. — On  the  other 
hand,  the  contact  method  with  nitric  acid  is  free  from  the  error  possibly  occa- 
sioned by  acid  albumin  to  which  the  heat-and-acid  test  is  subject.  The  con- 
tact method,  also  known  as  Heller's  test,  is  best  done  by  placing  a  sufficient 
quantit}'  of  nitric  acid  in  the  bottom  of  a  test-tube  and  overlaying  it  gently 
with  urine.  If  albumin  is  present,  a  sharp  white  line  will  promptly  form 
above  the  acid.  A  dark,  reddish-brown  color-line  which  forms  in  concen- 
trated urines  at  this  point  will  not,  of  course,  be  confounded  with  albumin. 
Furthermore,  in  concentrated  urines  a  layer  of  acid  urates,  dirty  white,  is 
sometimes  found  at  the  junction  between  the  two  fluids.  It  behaves  very  dif- 
ferently, however,  from  the  sharp  white  line  of  albumin,  since  it  soon  begins 
to  rise  above  the  surface,  while  the  albumin  remains  at  its  primary  position. 
Further,  this  less  definite  layer  is  promptly  dissipated  on  the  application  of  a 
moderate  heat.  When  the  heat-and-acid  method  and  the  contact  method  are 
jointly  used  in  the  way  described,  it  is  impossible  for  such  an  amount  of 
albumin  as  is  of  clinical  significance  to  elude  detection.  It  is  true  that  picric 
acid  solution,  Tanret's  iodo-mercuric  solution,  and  one  or  two  others  are 
slightly  more  delicate  than  the  heat  and  acid,  but  they  are  subject  to  a  now 
generally  acknowledged  source  of  error,  the  precipitation  of  mucin  and  of  the 
vegetable  alkaloids  of  which  quinin  is  the  type,  which  always  appear  in  the 
urine  when  administered  in  full  doses. 

'I  he  Picric  Acid  Test. — As  confirmatory  test,  however,  the  picric  acid 
solution  is  very  useful,  and  if  its  application  is  negative,  we  may  feel  assured 
that  there  is  no  albumin  present,  while  a  delicate  response  is  doubtful,  for  the 
reason  named.  The  picric  acid  test  is  also  best  applied  in  the  contact  method, 
the  urine  being  placed  in  the  tube  first  and  overlaid  with  the  saturated  picric 
solution,  because  the  picric  acid  is  commonly  lighter  than  the  urine  to  be 
tested.  When  they  are  of  the  same  specific  gravity,  it  is  not  easy  to  maintain 
a  separation  at  the  line  of  contact,  but  a  careful  examination  of  the  fused  por- 
tions will  recognize  a  diminished  transparency  due  to  either  mucin  or  albumin. 
A  saturated  solution  of  picric  acid  should  always  be  kept  on  hand  for  the 
control  purposes  named. 

To  Test  for  Globulin. — Globulin  may  be  separated  by  Poehl's  method 
as  follows : 

Render  the  urine  slightly  alkaline  by  ammonium  hydrate,  and  after  sev- 
eral hours  filter,  to  separate  the  phosphates.  Then  add  saturated  neutral  solu- 
tion of  ammonium  sulphate  in  the  proportion  of  one  volume  to  one  volume  of 
the  filtrate.     If  a  precipitate  forms,  it  is  globulin. 


RENAL   DROPSY. 

Renal  dropsy  does  not  differ  essentially  from  cardiac  dropsy,  though  it 
is  less  directly  traceable  to  venous  obstruction  and  consequent  transudation. 
It  very  frequently  appears  first  in  the  face  and  upper  extremities,  and  this  fact 
alone  goes  to  show  that  something  ,else  than  obstruction  to  the  circulation 
enters  into  its  causation.  In  addition,  it  is  well  known  that  there  may  be  ad- 
vanced renal  disease  without  dropsy  when  one  would  naturally  expect  obstruc- 
tion.    Venous  obstruction  must,  however,  be  considered  as  one  of  the  con- 


688  DISEASES  OF  THE   URIXARY  ORGAXS. 

tributing  factors,  especially  when  in  the  lower  extremities.  Aside  from  this 
we  must  have  recourse  to  theory  to  explain  it.  A  hydremic  state  of  the  blood 
very  probably  favors  the  transudation  in  certain  cases,  this  being  occasioned 
bv  the  deficient  water  secretion  so  often  present.  At  first  thought  this  would 
seem  an  explanation  scarcely  sufficient  to  explain  the  edema  which  appears  so 
early  in  many  cases  of  acute  Bright's  disease,  but  this  objection  is  more 
apparent  than  real,  for  one  need  pause  but  for  a  moment  to  realize  how 
quickly  blood  may  become  hydremic  with  an  almost  total  anuria,  while  the 
habitual  quantity  of  water  continues  to  be  ingested  daily.  ^Moreover,  dimin- 
ished urinary  secretion  often  exists  for  some  time  before  attention  is  called  to 
it.    I  believe  that  sufficient  stress  has  not  been  heretofore  laid  on  this  factor. 

As  the  disease  advances,  the  conditions  favoring  the  hydremic  state  con- 
tinue and  grow  so  that  in  advanced  stages  this  element  doubtless  contributes 
largely.  It  is  more  than  likely  also  that  in  such  stages  alterations  of  some 
kind  in  the  vascular  and  lymphatic  walls  contribute  to  facilitate  the  transuda- 
tion, while  the  diminished  elasticity  of  surrounding  tissues  may  also  constitute 
a  factor.  Where  edema  does  not  occur,  its  absence  can  only  be  explained  by 
the  presence  of  continued  secretion  of  water  by  the  kidneys  or  by  supple- 
mental secretion  by  some  other  organs,  as  the  skin  and  bowels. 

The  degree  of  dropsy  varies  greatly  in  different  cases  and  different  forms 
of  Bright's  disease,  being  in  some  cases  trifling  and  in  others  enormous, 
including,  ultimately,  invasion  of  serous  cavities  like  those  of  the  pleura,  peri- 
toneum, and  even  pericardium. 

UREMIA. 

The  third  symptom  common  "to  renal  disease,  and,  indeed,  peculiar  to  it, 
is  uremia.  It  may  be  defined  in  general  terms  as  a  condition  due  to  retention 
within  the  blood  of  excrementitious  substances  which  it  is  the  function  of  the 
kidney  to  excrete  and  which  it  does  excrete  in  health.  A\"hen  we  come  to 
separate  these  substances,  we  are,  however,  completely  at  a  loss,  for  no  clinical 
or  experimental  studies  have  as  yet  given  us  the  required  information.  Pre- 
eminently the  experimental  introduction  of  urea  into  the  blood  has  repeatedly 
failed  to  excite  symptoms  of  uremia,  though  the  animals  on  w-hich  these  ex- 
periments were  made  were  presumably  sound.  Ligation  of  the  renal  veins  has 
been  equally  futile  in  producing  them.  C.  A.  Herter  has  shown  that  the 
toxicity  of  the  blood-serum  is  increased  in  uremic  states,  while  extirpation  of 
the  kidney  or  a  part  of  it  increases  the  accumulation  in  the  blood  of  urea  and 
nitrogenous  substances  of  the  creatin  class.  It  is  probable  also  that  the  allox- 
uric  bases,  xanthin,  hypoxanthm,  which  are  virulently  toxic,  contribute  to  the 
sum  of  toxins  responsible  for  uremia. 

In  consequence  of  such  failure,  clinicians — and  pre-eminently  Traube — 
have  sought  to  explain  certain  of  the  more  active  nervous  symptoms,  such  as 
the  coma  and  convulsions,  by  supposing  a  localized  edema  of  the  brain  or  its 
membranes. 

Symptoms. — It  is  not  unlikely  that  gastvo-intestinal  symptoms  includ- 
ing the  loss  of  appetite,  nausea,  vomiting,  and  headache  which  sometimes 
usher  in  an  attack  of  nephritis  may  be  the  result  of  retained  excrementitious 
matter.  At  all  events,  these  same  symptoms  may  be  the  initial  ones  of  a 
uremia,  coming  on  si:ddenly  when  the  cause  is  unsuspected.  \'omiting  thus 
caused  may  persist,  and  the  patient  perish  in  consequence.  Headache  is 
often  occipital,  extending  down  the  neck.     To  it  is  superadded  dissiness. 


UREMIA.  689 

x\n  early  symptom  is  drozvsiness,  which  may  be  sudden  or  gradual  in  its 
onset  and  may  be  slight  or  decided.  From  the  latter  degree  the  transition  is 
easy  to  the  next  symptom,  that  of  coma,  from  which  the  patient  may  or  may 
not  be  temporarily  aroused.  Alternating  w  ith  the  latter  may  be  epileptoid 
convulsions^  which  are  the  most  alarming  and  dangerous  symptom  of 
Bright's  disease.  This  is  not  always  the  succession  of  these  symptoms.  Con- 
vulsions may  succeed  drowsiness,  but  as  often  precede  and  they  may  occur 
without  warning.  Indeed,  there  may  be  no  suspicion  of  Bright's  disease 
whatever  until  a  convulsion  suddenly  occurs.  Drowsiness,  in  like  manner, 
may  be  the  first  symptom  of  the  renal  disease  to  attract  attention,  others  being 
overlooked  or  possibly  even  absent.  The  convulsions  exhibit  every  grade  of 
movement,  from  the  slightest  twitching  to  the  most  violent  epileptiform 
:spasm. 

Suppression  of  iirine,  an  almost  constant  symptom,  is  frequently  the 
initial  one  which  should  at  once  excite  suspicion.  Accompanying  it  is  often 
a  breath  of  urinous  odor,  and  when  vomiting  accompanies  scanty  or  sup- 
pressed urine,  the  vomited  matters  sometimes  have  the  same  odor,  the  ele- 
ments of  urine  being  thus  supplementarily  eliminated. 

Impairment  of  ■z'ision  or  actual  blindness — amaurosis — suddenly  occur- 
ring is  another  symptom  of  acute  uremia  which  sometimes  supervenes  upon 
■others,  or  it  may  itself  usher  in  the  complication.  This  blindness,  it  must  be 
remembered,  is  altogether  different  from  that  which  is  the  result  of  organic 
retinal  changes,  which  are  rare  in  acute  nephritis,  but  common  in  some  of  the 
chronic  forms.  It  may  be  due  to  retinal  hemorrhage,  but  is  often  unasso- 
ciated  with  demonstrable  retinal  change.  Uremic  amaurosis  often  disappears 
as  suddenly  as  it  sets  in.     Uremic  deafness  is  also  possible,  but  is  a  rare  event. 

Itching  of  the  skin  is  another  symptom  sometimes  present  in  uremia. 
It  is  probably  due  to  the  irritant  action  of  urea  upon  the  nerves  of  the  skin 
as  it  is  being  supplementarily  eliminated  by  that  organ.  That  such  increased 
elimination  takes  place  is  attested  by  that  rare  but  still  tmquestioned  occur- 
rence, in  which  the  entire  integument  is  covered  with  a  frost-like  coating, 
which  has  been  found  upon  analysis  to  be  made  up  of  crystals  of  pure  urea. 

Another  symptom  of  uremia  which  belongs  rather  to  the  uremia  of 
chronic  renal  disease  is  shortness  of  breath — uremic  asthma,  it  is  called. 
This  is  an  asthma  which  differs  from  bronchial  asthma  in  the  absence  of  spas- 
modic contraction  of  the  bronchi,  and  its  uremic  origin,  I  think,  is  extremely 
doubtful.  I  believe  it  is  more  frequently  what  I  have  described  as  cardiac 
asthma,  du-e  to  heart  failure,  the  result  of  dilatation  succeeding  some  cases  of 
hypertrophy.  It  may  happen  that  true  spasmodic  asthma  is  produced  by 
uremia,  but  it  must  be  exceedingly  rare.  The  attacks  are  likely  to  occur 
suddenly  at  night.  To  it  alone  should  the  name  uremic  asthma  be  given. 
Paroxysms  of  dyspena  are  also  caused  by  edema  of  the  lung,  which  is  not 
infrequent  in  acute  nephritis.  It  is  recognized  by  the  presence  of  fine,  moist 
rales.  Of  course,  it  is  not  impossible  for  nephritis  to  occur  in  an  asthmatic, 
whose  attacks  would  then  occur  as  before,  independent  of  the  uremic  cause, 
or  they  might  be  increased  in  frequency  or  rendered  more  unmanageable  by 
the  latter. 

Cheyne-Stokes  breathing  is  also  a  symptom  of  uremia  and  may  last  for 
a  long  time.  It  may  occur  quite  independent  of  coma.  It  is  more  than 
likely  that  other  disturbances  of  breathing,  even  some  which  closely  resemble 
dyspnea,  may  be  due  to  disturbances  of  the  respiratory  center. 

The  question  of  temperature  in  uremia  has  not  been  satisfactorily  deter- 

44 


690  DISEASES  OF  THE  URINARY  ORGANS. 

mined.  My  own  experience  points  to  the  absence  of  any  elevation,  with  at 
times  a  tendency  to  subnormal  temperature.  I  am  aware  that  studies  have 
been  published  which  go  to  show  that  an  abnormally  high  temperature  is  char- 
acteristic, and  this  may  exceptionally  be  the  case.  But  in  true,  uncomplicated 
uremia  I  believe  in  the  majority  of  cases  the  temperature  will  not  much  exceed 
the  normal.  It  is  true  that  toward  the  very  end  there  is  commonly  a  rise,  but 
this  attends  dissolution  in  so  many  diseases  that  it  cannot  be  considered 
characteristic. 

The  pulse  is  often  slow  in  uremia  before  the  appearance  of  severe  symp- 
toms :  sometimes  as  infrequent  as  from  forty  to  fifty,  but  with  severe  symp- 
toms it  becomes  frequent. 

Acute  mania  and  delusional  insanity  (Folie  Britique)  may  also  be  symp- 
toms ;  rarely  melancholia  and  paralysis,  including  hemiplegia  and  even  mono- 
plegia. These  may  occur  independently  of  a  convulsion  or  succeed  it,  in 
which  event  there  may  or  may  not  be  any  coarse  lesion  found  at  necropsy. 
True  uremic  palsies  are  of  undoubted  occurrence.  I  have  met  hemiplegias- 
which  could  not  be  distinguished  from  those  of  apoplectic  origin  until  their 
total  disappearance  cleared  up  the  matter. 


TUBE-CASTS. 

Tube-casts  or  "  cylinders,"  as  they  are  sometimes  called,  are  molds  of 
the  uriniferous  tubules.  Their  origin  is  not  always  the  same.  They  may  be 
produced  by  admission  into  the  latter,  by  reason  of  capillary  rupture  or  other- 
wise, of  a  coagulable  constituent  of  the  blood  which  there  solidifies,  and  in 
this  act  entangles  whatever  it  may  have  surrounded  in  its  liquid  state ;  sub- 
sequently it  may  contract  and  slip  out  of  the  tubule  into  the  pelvis  of  the 
kidney,  whence  it  is  carried  to  the  bladder  and  voided  with  the  urine.  Casts 
rarely  exceed  1-25  inch  (i  mm.)  in  length. 

Two  other  possible  modes  of  formation  of  casts  must  be  mentioned^ 
according  to  one  of  which  the  cast  represents  disintegrated  and  fused  cells 
which  may  be  the  epithelial  lining  of  the  tubules,  red  corpuscles,  or  leuko- 
cytes ;  and  according  to  another,  of  a  secretion  from  these  same  cells  as  origi- 
nally suggested  by  Rovido.  That  casts  are  sometimes  formed  according  to^ 
the  first,  at  least,  of  these  two  methods  is  not  unlikely,  while  there  is  reason 
also  to  believe  that  the  so-called  "  cylindroids  "  or  mucus-casts  originate  in 
the  second  way. 

That  casts  are  sometimes  found  in  urine  free  from  albumin  is  undoubt- 
edly true.  That  persons  in  wh'cDm  such  casts  occur  are  entirely  healthy  can- 
not be  as  unqualifiedly  asserted. 

The  mechanism  of  the  formation  of  the  different  varieties  of  casts,  on 
the  supposition  of  an  albuminoid  exudation  from  the  blood,  is  very  simple. 
Thus,  suppose  a  tubule  to  be  filled  with  detached  and  loosely  attached  epi- 
thelium at  the  time  the  coagulable  material  is  poured  into  it.  These  ele- 
ments are  entangled,  and,  as  the  casts  contract,  are  carried  out  in  the  shape 
of  an  "  epithelial "  cast  (Fig.  68).  If  the  tubule  should  happen  to  have  con- 
tained blood,  the  cast  entangling  it  is  called  a  "  hlood  cast "  ( Fig.  70)  ;  if 
white  corpuscles  or  leukocytes,  a  "pus  cast"  (Fig.  69).  Casts  containing 
even  a  few  blood-corpuscles  are  also  called  blood  casts.  The  basic  substance 
of  blood  casts  is  most  probably  the  fibrin  of  the  blood.  If  the  epithelium  be 
firmly  attached  to  the  basement  membrane  of  the  tube  and  remain  behind 


TUBE-CASTS. 


691 


when  the  cast  passes  out,  or  if  the  tube  be  entirely  bereft  of  epithelium,  then 
is  the  cast  a  "hyaline''  (Fig.  71)  or  structureless  cast.  In  the  former 
instance  the  cast  is  of  smaller  diameter,  and  in  the  latter  of  larger,  the 
diameter  in  the  latter  being  that  of  the  former  plus  twice  the  thickness  of  an 


Fig.  68.— Epithelial 
Casts  and  Com- 
pound Granule 
Cells. 


Fig.  69. — Pus  Cast. 


Fig.    70.— Blood  Casts— {a//er 
Whittaker). 


epithelial  cell.  Figure  'J2  a,  from  Rindfleisch,  explains  this  sufficiently. 
From  causes  like  these,  as  well  as  a  subsequent  contraction  of  the  cast  itself, 
the  diameter  of  casts  may  vary  considerably,  ranging  commonly  from  1-2500 
to  1-500  inch  (o.oi  to  0.05  mm.).     A  cast  is  seldom  completely  hyaline,  gen- 


Fig.  71.— Hyaline  Casts.  X  210. 


Fig.  72. — Hyaline  and  Granular  Casts. 
Illustrating  the  Formation  of  the 
Former  at  a. — {Rindfleisch). 


erally  containing  a  few  granules  and  one  or  two  glistening  oil  drops,  but  it 
is  still  called  hyaline.  Completely  hyaline  casts  do,  however,  occur.  A 
variety  of  hyaline  cast,  more  solid  in  appearance  and  resembling  molten  wax, 
is  a  "waxy  cast"  (Fig.  74).  Some  hyaline  casts  are  so  delicate  as  to  be 
overlooked  unless  the  light  from  the  mirror  illuminating  the  field  of  view  be 


692 


DISEASES  OF  THE  URINARY  ORGANS. 


modified  by  shading  with  the  hand  or  by  manipulation  of  the  mirror  itself. 
If  a  cast  contains  granular  matter,  which  is  generally  the  granular  debris  of 
the  degenerated  epithelial  lining  of  the  tubule  or  blood-corpuscles,  it  is  called 
a  ''granular"  cast,  and  highly  granular"  (Fig.  73,  a),  moderately  or  pale 
granular  (Fig.  72,  c),  slightly  or  delicately  granular  (Fig.  72,  b),  according 
to  the  amount  of  granular  matter  present.  When  the  material  of  granular 
casts  is  derived  from  broken-down  blood  corpuscles,  the  casts  appear  yellow 
or  yellowish-red.  Finally,  if  a  cast  is  loaded  with  oil  drops,  either  free  or 
contained  in  epithelial  cells,  it  is  called  an  "  oil  cast  or  fatty  cast"  (Fig.  75). 
Casts  of  smaller  diameter  are  sometimes  found  within  those  of  larger, 
the  material  of  the  latter  having  been  poured  out  around  that  of  the  former 
after  it  has  undergone  some  contraction.  This  occurs  usually  with  waxy  or 
hyaline  casts.  In  consequence  of  the  mode  of  formation  previously  referred 
to,  hyaline  and  waxy  casts  vary  considerably  in  diameter,  some  being  as  nar- 


Fig.  73. — a,  a.    Dark  Granular  Casts,    d,  b. 
Casts   Partially    Hyaline,   Containing 
Oil-Drops  and  Granular   Matter.    X 
225. 


Fig,  74. — Waxy  Casts.     X  150. 


row  as  i-iooo  inch  (0.025  mm.)  and  even  narrower,  while  others  are  as  much 
as  1-500  inch  (0.05  mm.)  wide.  There  is  no  doubt  that  some  of  these  are 
formed  in  the  straight  or  colletsting  tubes  near  their  openings  on  the  papillae. 
To  these  a  limited  number  of  epithelial  cells  is  sometimes  attached. 

In  addition  to  the  epithelial  casts  previously  described,  there  are  found 
in  urine  under  the  same  circumstances  molds  of  the  uriniferous  tubules  made 
up  of  simple  aggregatioits  of  the  epithelial  cells  themselves — simple  exfolia- 
tions of  the  cellular  contents  of  the  tubule,  which,  having  increased  by  pro- 
liferation, form  a  compact  cellular  mass.  In  addition  to  this  are  sometimes 
found  epithelial  casts  in  which  the  cells  are  seated  on  the  outside  or  around 
the  fibrinous  mold. 

Mucus-casts,  Cylindroids. — Casts  are  occasionally  found  which  are 
apparently  pure  mncus-inolds  of  the  uriniferous  tubules  (Fig.  76).  Unless 
covered  by  accidental  elements,  as  granular  urates  or  phosphates  of  lime, 
they  are  smooth,  hyaline,  or  gently  fibrillated  molds,  especially  characterized 


DERANGEMENTS  OF  CIRCULATION. 


693 


by  their  ^reat  length,  in  the  course  of  which  they  divide  and  subdivide, 
diminishing  in  diameter  as  the  division  proceeds,  showing  positively  that  they 
come  from  the  kidney.  Yet  there  is  no  albumin,  or  merely  as  much  as  could 
be  accounted  for  by  the  presence  of  pus  which  som.etimes  attends  them.  For 
they  are  particularly  apt  to  occur  where  there  is  irritation  of  the  bladder, 
which  is  apparently  extended  through  the  ureters  of  the  kidney.  Under  these 
circumstances  they  are  frequently  met.     They  are  not  infrequently  voided  in 


Fig-  75.— Oil-Casts  and  Fatty 
Epithelium.     X  200. 


Fig,  76. — Cylindroid  or  Mucus- 
Casts.     X  200. 


cases  where  the  urine  has  a  very  high  specific  gravity,  1030  or  higher,  con- 
taining an  excess  of  urea  and  urates. 

These  casts  are  not  identical  with  the  bands  of  mucin  which  are  found 
in  urine  of  highly  acid  reaction.  The  mucin  bands  are  probably  precipitated 
by  the  acids,  are  often  beset  with  granular  urates,  and  might  on  this  account 
be  mistaken  for  casts.  At  the  same  time  the  mucus-cast  is  probably  nothing 
but  pure  mucus  or  mucin. 


DISEASES  OF  THE  KIDNEY. 

DERANGEMENTS  OF  CIRCULATION. 


Active  Congestion. 

Etiology. — Axtive  congestion  occurs  as  the  result  of  poisoning  lay  can- 
tharides  or  arsenic,  overdoses  of  turpentine,  copaiba,  cubebs,  and  carbolic  acid. 
It  is  identical  with  the  first  stage  of  acute  nephritis,  however  caused.  The 
kidney  in  acute  fever  has  usually  been  considered  as  actively  congested,  but 
recent  experiments  by  Walter  Mendelsohn  go  to  show  that  the  kidney  in  fever 
is  really  anemic,  small,  pale,  and  bloodless,  so  that  the  kidney  is  really  com- 
parable to  the  anemic  kidney  of  cholefa,  in  which,  too,  there  are  albuminuria 
and  nutritional  changes  of  a  degenerative  kind  analogous  to  the  cloudy  swell- 
ing affecting  the  renal  cells  in  acute  fever,  but  more  advanced  in  degree. 

Morbid  Anatomy.— The     kidney     of     active     congestion     is     slightly 


694  DISEASES  OF  THE  URINARY  ORGANS. 

enlarged,  swollen,  and,  after  removal  of  the  capsule,  brown  or  mottled.  On 
section,  the  cortex  is  wider  and  darker  than  in  health,  the  blood-vessels  are 
overfull,  the  Malpighian  bodies  are  distended,  and  the  cells  are  the  seat  of 
cloudy  swelling.  The  medulla  is  less  markedly  red  and  sharply  defined  from 
the  cortex. 

Symptoms. — There  are  none  except  a  scanty  urine  of  high  specific 
gravity  and  high  color,  sometimes  small  albuminuria,  with  a  few  hyaline  and 
pale  granular  casts. 

Passive  Congestion  or  Cyanotic  Induration. 

Etiology  and  Pathogeny. — While  any  agency  which  obstructs  the 
movement  of  the  blood  through  the  kidney  may  cause  passive  congestion,  the 
causes  encountered  in  actual  practice  are  mostly  limited  to  valvular  disease 
of  the  heart  and  chronic  pulmonary  disease  involving  extensive  areas  of  the 
lung,  such  as  emphysema,  interstitial  pneumonia,  and  pleurisy,  with  exten- 
sive effusion  or  marked  adhesions.  Tubercular  phthisis  is  a  less  common 
cause,  because  of  the  impaired  nutrition  and  small  quantity  of  blood. 
Pressure  on  the  renal  veins  by  tumors,  the  pregnant  uterus,  or  ascitic  fluid 
acts  similarly. 

In  any  event  the  mechanism  of  its  production  is  the  same.  The  blood 
is  crowded  into  the  venous  side  of  the  vascular  system.  In  mitral  insuffi- 
ciency the  blood  is  regurgitated  from  the  left  ventricle  into  the  correspond- 
ing auricle,  and  thence  into  the  lungs ;  the  latter  organs  become  engorged,  and 
again  resist  the  entrance  of  blood  from  the  right  side  of  the  heart,  whence 
it  is  backed  into  the  right  auricle  and  valveless  vena  cava.  The  smaller  veins 
of  the  extremities  at  first  resist  the  encroachment  by  means  of  their  valves, 
but  the  veins  of  the  abdominal  viscera,  including  the  liver  and  the  kidneys, 
are  without  valves,  and  are  first,  therefore,  to  receive  the  brunt  of  the  stagna- 
tion, and  they  become  engorged  with  blood.  In  pulmonary  or  pleural  disease 
the  obstruction  begins  in  the  lungs  instead  of  in  the  heart,  but  the  mechanism 
is  the  same.     Pressure  by  tumor  on  the  renal  vein  is  even  more  direct. 

Morbid  Anatomy. — The  kidney  of  cyanotic  induration  or  passive  con- 
gestion is  hard,  firm,  and  bluish-red  as  to  its  external  surface.  In  the  earlier 
stages  it  is  enlarged  simply  from  the  presence  of  the  large  amount  of  blood 
detained  in  its  vessels.  The  stellate  veins  are  unusually  distinct.  The  cap- 
sule strips  off  easily,  and  on  section  the  enlargement  is  found  to  involve  the 
cortex,  but  the  veins  of  both  cortex  and  medulla  are  engorged,  that  of  the 
straight  veins  causing  the  me^dulla  to  appear  darker  in  hue  than  the  cortex. 
The  Malpighian  bodies,  on  the  other  hand,  are  not  always  engorged.  The 
cut  surface  of  the  kidney  is  moist  and  succulent,  but  the  microscope  reveals 
no  further  changes  either  in  the  cortex  or  the  medulla,  the  epithelium  being 
unchanged. 

After  some  duration  the  kidney  is  slightly  if  at  all  larger  than  the  nor- 
mal organ,  though  rarely  smaller.  The  other  superficial  characters  of  hard- 
ness, smoothness,  and  bluish-red  color,  however,  remain.  Sometimes  there 
appears  a  slight  tendency  to  lobulation.  At  this  stage  the  capsule  does  not 
strip  off  quite  so  easily  as  usual,  but  may  drag  small  portions  of  the  paren- 
chyma with  it.  There  may  then  be  seen  some  shallow  depressions.  On 
section,  the  vessels  are  less  turgid,  and  the  relations  of  the  cortex  and  medulla 
are  not  much  altered.  There  may  be  a  slight  overgrowth  of  interstitial  tissue 
and  a  small-celled  infiltration  between  the  tubules.     Malpighian  bodies  are 


DERANGEMENTS  OF  CIRCULATION.  695 

sometimes  shriveled,  and  the  epithehum  of  the  tubules  is  granular  and  slightly 
fatty. 

Symptoms. — These  are  primarily  those  of  the  diseases  of  which  it  is  the 
consequence,  of  which  I  will  emphasize  only  anasarca,  because  of  its  impor- 
tance. To  such  is  superadded  scanty  urine  of  high  speciHc  gravity,  contain- 
ing usually  a  small  amount  of  albumin  and  a  few  small  hyaline  casts. 

The  dropsy  first  involves  the  lower  extremities,  in  the  area  drained  by 
the  inferior  vena  cava.  There  also  occur,  however,  effusions  into  the  pleural 
sac  and  peritoneum,  and  the  hands  and  arms  may  be  involved. 

The  urine  is  scanty  and  of  high  specific  gravity,  often  1030  to  1035,  and 
even  higher.  It  is  turbid  with  urates,  depositing  a  copious  sediment  of  them 
and  of  uric  acid.  The  albumin  is  usually  small  in  quantity,  but  may  become 
larger  if  the  obstruction  to  the  movement  of  the  blood  is  great.  The  casts 
are  small,  transparent,  or  faintly  granular,  and  not  numerous — indeed,  often 
absent.  Blood  is  rarely  present,  while  its  presence  may  be  considered  evi- 
dence of  a  superadded  nephritis.  The  solids  are  secreted  in  normal  amount. 
In  fact,  such  kidneys  can  apparently  be  restored  to  their  normal  function  at 
any  time  by  proper  treatment.  Uremia  is  exceedingly  rare.  Very  rarely 
does  it  happen  that  an  interstitial  nephritis  is  induced. 

Diagnosis. — Passive  congestion  exists  to  a  certain  degree  in  all  cases  of 
valvular  heart  disease  without  compensation,  but  higher  degrees  may  be  sus- 
pected when  the  urine  becomes  scanty  and  albuminous,  and  when  all  the 
symptoms  of  the  cardiac  affection  become  aggravated.  When  the  physician 
sees  the  patient  after  the  symptoms  of  passive  congestion  have  become 
marked,  it  is  often  a  nice  question  to  decide  which  of  the  two  conditions  is  pri- 
mary, the  cardiac  or  the  renal  condition;  but  this  subject  will  be  further  con- 
sidered in  treating  of  the  relations  between  kidney  disease  and  heart  disease. 

Prognosis.— With  the  addition  of  the  renal  complication,  the  incon- 
veniences and  annoyances  of  the  cardiac  disease  become  greatly  aggravated, 
while  the  difficulties  in  the  way  of  successful  treatment  are  greater.  Yet  the 
results  which  sometimes  follow  appropriate  and  energetic  treatment  and  the 
substitution  of  favorable  for  unfavorable  hygienic  surroundings,  such  as  suc- 
ceed the  admission  of  a  neglected  outcast  to  the  wards  of  a  hospital,  are  often 
astonishing.  Under  these  circumstances  it  is  not  unusual  for  the  dropsy  to 
■decline,  the  albumin  and  casts  to  disappear,  and  the  patient  to  be  restored  to 
comparative  comfort,  without,  however,  any  change  in  the  original  lesion, 
which,  upon  the  slightest  provocation,  may  re-excite  all  the  symptoms. 

Treatment. — As  intimated  under  prognosis,  the  substitution  of  favorable 
for  unfavorable  hygienic  surroundings,  if  the  former  exist,  is  the  primary 
requisite.  Shelter,  warmth,  rest,  and  good  food  are  indispensable.  After 
this  digitalis  is  the  sheet-anchor,  for  evident  reasons.  We  have  here  to  deal 
with  a  dilated,  weak,  failing  heart,  unable  to  drive  the  blood  forward.  Its 
power  must  be  increased,  and  we  have  a  remedy  capable  of  doing  this  in  digi- 
talis. Sufficient  doses  must,  however,  be  given,  whether  of  the  tincture, 
powder,  or  infusion.  A  half  ounce  (15  c.  c.)  of  the  infusion  may  be  given 
every  four  hours  to  an  adult ;  of  the  tincture,  not  less  than  ten  minims 
(0.65  c.  c),  or  twenty  drops,  to  be  reduced  when  diuresis  sets  in.  Under 
such  doses,  if  the  cardiac  disease  is  not  too  advanced,  the  quantity  of  urine 
may  increase,  become  clear,  its  albumin  and  casts  diminish,  and  with  these 
also  the  dropsy,  dyspnea,  and  restless,  sleepless  nights.  All  that  has  been 
said  under  the  treatment  of  cardiac  valvular  disease  of  substitutes  for  digi- 
talis is  applicable  here,  and  the  reader  is  referred  to  that  section. 


696  DISEASES  OF  THE  URINARY  ORGANS. 

Due  attention  must  also  be  paid  to  the  bowels,  for  the  sake  of  securing^ 
prompt  action  of  the  diuretics,  as  well  as  the  elimination  which  their  free 
action  accomplishes.  The  hydragogue  cathartics,  such  as  elaterium  and 
the  salines,  are  often  excellent  adjuvants. 


ACUTE  PARENCHYMATOUS  NEPHRITIS. 

Synonyms. — Acute  Nephitis;  Acute  Diffuse  Nephritis;  Acute  Desquamative 
Nephritis;  Acute  Tubal  Nephritis;  Acute  Bright's  Disease;  Acute  Ca^ 
tarrhal  Nephritis;  Croupous  Nephritis;  Albuminous  Nephritis; 
Hemorrhagic  Nephritis;  Acute  Albuminuria^;  Acute  Renal  Dropsy. 

Definition. —  .A.cute  parenchymatous  nephritis  is  an  acute  inflammation 
of  the  kidney,  the  tubular,  vascular,  and  interstitial  tissues  being  simultane- 
ously involved  in  different  degrees  in  different  cases.  In  the  majority  of 
cases,  perhaps,  the  parenchyma,  or  secreting  structure,  is  first  and  most  in- 
vaded, whence  the  term  parenchymatous  nephritis. 

Etiology. — Most  cases  of  acute  parenchymatous  nephritis  are  caused 
by  the  poison  of  scarlet  fever  or  diphtheria,  and  occur,  therefore,  in  children. 
A  certain  number  originate  in  exposure  to  cold,  especially  cold  and  damp- 
ness, while  the  body  is  warm  and  perspiring.  The  latter  cause  is  particu- 
larly potent  if  the  person  be  fatigued  or  exhausted.  When  acute  nephritis 
supervenes  on  scarlet  fever,  it  is  usually  not  until  the  end  of  the  second 
week,  often  when  convalescence  is  well  established.  It  may  occur  as  early 
as  the  tenth  day,  seldom,  if  ever,  later  than  the  thirty-first. 

Other  grave  infectious  diseases,  as  smallpox,  acute  endocarditis,  and 
acute  articular  rheumatism,  typhus  and  typhoid  fevers,  pneumonia,  and 
malaria  are  also  occasional  causes.  Measles,  erysipelas,  pyemia,  jaundice, 
and  diabetes  have  been  known  to  cause  it.  Skin  diseases,  as  well  as  ex- 
tensive burns  of  the  skin,  are  acknowledged  causes :  the  former  rarely, 
but  the  latter  almost  always  if  the  burns  be  sufficiently  extensive.  Simple 
follicular  tonsillitis  is  also  a  not  infrequent  cause.  I  have  known  an  abscess 
in  the  thigh,  succeeding  the  lodgment  of  a  splinter  in  the  toe,  to  be  followed 
by  typical  acute  nephritis.  Pregnancy  is  the  cause  of  a  good  many  cases  of 
acute  parenchymatous  nephritis,  to  which,  in  turn,  most  cases  of  puerperal 
convulsions  are  due. 

Most  cases  of  acute  nephritis  due  to  other  causes  than  scarlatina^ 
diphtheria,  cold,  and  pregnancy  are  mild  in  degree ;  and  even  in  cases  due 
to  pregnancy,  if  the  patient  is  once  safely  delivered,  recovery  is  usually  rapid. 
In  looking  for  the  evidence  of  nephritis  in  acute  infectious  diseases,  it 
must  not  be  forgotten  that  intense  febrile  movement  may  cause  albumi- 
nuria, independently  of  any  structural  change  in  the  kidney  due  to  the 
toxic  agent.     When  thus  caused,  the  albuminuria  is  always  small. 

Certain  specific  poisons  of  vegetable  and  mineral  origin  are  capable 
of  producing  acute  nephritis.  Among  the  best  known  of  these  substances 
are  cantharides,  turpentine,  oil  of  mustard,  wormseed  oil,  and  phosphorus ;; 
in  a  less  degree,  the  mineral  acids,  arsenic,  nitrate  of  silver,  lead,  and  mer- 
cury. Very  large  quantities  of  alcohol,  when  swallowed,  have  caused  acute 
nephritis. 

The  microbic  origin  of  nephritis  has  also  been  invoked.  Apart  from 
analogy,  which,   with  our  present  knowledge  of  bacterial  agency,  renders 


ACUTE  PARENCHYMATOUS  NEPHRITIS.  697 

such  cause  highly  probable,  pathogenic  organisms  have  been  found  in  the 
urine  of  cases,  pure  cultures  from  which,  by  Mannaberg,  produced  intense 
nephritis  when  injected  into  the  blood  of  animals.  Oertel  claimed,  fifteen 
years  ago,  that  in  renal  diseases  following  diphtheria  he  found  "  great 
numbers  of  micrococci  and  exuberant  proliferations  of  the  same,"  both 
in  the  renal  tubes  and  Malpighian  bodies ;  Heller,  that  he  had  repeatedly 
found  the  blood-vessels  and  their  branches  in  acutely  inflamed  and  swollen 
kidneys  from  cases  of  pyemia  greatly  dilated  and  plugged  with  masses 
which,  under  low  powers,  presented  a  peculiar  grayish-yellow  appearance, 
and  with  high  powers  were  found  to  consist  of  extremely  minute,  highly 
refracting  granular  particles.  These  particles  he  considered  spherical  bac- 
teria, and  the  resulting  masses  bacteria  emboli.  It  is,  therefore,  now  com- 
monly conceded  that  the  bacteria  responsible  for  the  acute  infectious- 
diseases  are  also  the  agents  which  produce  the  complimentary  nephritides  in 
all  of  them. 

As  may  be  inferred  from  the  etiology,  acute  nephritis  is  often  a  disease 
of  early  age,  although  when  due  to  cold  or  any  one  of  the  causes  named 
except  scarlatina,  it  is  as  much  more  likely  to  afifect  adults  as  these  latter  are 
more  frequently  subjected  to  such  causes.  It  is  rare  after  forty,  almost  un- 
known after  fifty.  More  males  are  attacked  than  females  in  adult  life, 
evidently  because  they  are  more  frequently  exposed  to  the  causes.  But 
even  in  childhood  there  is  a  slight  preponderance  of  cases  in  boys  affected,, 
which  can  hardly  be  thus  accounted  for. 

Morbid  Anatomy. —  This  varies  with  the  stage  of  the  disease,  as  well 
as  its  severity.  In  the  first  place,  as  ordinarily  caused,  the  disease  is  sym- 
metrical, both  organs  being  alike  involved.  In  the  fully  developed  stage 
the  kidneys  are  more  or  less  enlarged,  in  the  latter  stages  always  so,  some- 
times to  more  than  twice  their  normal  volume,  and  they  may  weigh  from 
eight  to  twelve  ounces  (240  to  360  gm.),  those  of  children  reaching  the 
former,  and  those  of  adults  the  latter. 

The  capsule  strips  off  easily,  without  dragging  any  of  the  parenchyma 
with  it.  Bereft  of  its  capsule,  the  kidney  itself  is  softer,  inelastic,  and 
doughy.  Its  surface  is  smooth  and  exhibits  a  peculiar  mottled  appearance, 
which  is  due  to  the  fact  that  the  little  circlets  of  veins  which  form  the 
boundary  of  the  lobules  are  distinctly  injected,  while  the  area  surrounded 
by  each  circlet  is  paler  than  in  health,  and  in  the  more  advanced  stages  even 
yellowish-white  in  color.  This  "  irregular  mixture  of  congestion  and 
anemia,"  as  Sir  George  Johnson  early  called  it,  is  further  contributed  to 
by  the  injection  of  other  veins  indistinct  in  health.  Spots  of  hemorrhagic 
extravasation  may  also  be  found  scattered  over  the  surface. 

On  section,  it  is  evident  that  the  enlargement  is  due  to  change  in  the 
cortex  and  the  interpyramidal  convoluted  portion.  The  cut  surface  is 
smeared  over  with  a  dark-red  or  chocolate-hued  blood,  but  on  scraping  or 
washing  it  away,  the  vessels  are  found  injected  like  those  of  the  surface, 
and  between  them  the  same  paleness  or  yellowish-white  hue  is  seen.  The 
Malpighian  bodies  are  enlarged  and  distinct,  dark  red,  sometimes  pale, 
Punctiform  hemorrhages  may  also  be  present,  as  on  the  surface  of  the  organ. 
The  pyramids  are  dark  red. 

Minute  Changes. — These  are  confined  almost  solely  to  the  labyrinthine 
structure.  They  by  no  means  always  correspond  in  degree  with  what  would 
be  expected  from  the  symptoms,  being  often  entirely  inadequate  to  explain 
them.     The  changes  are  tubal,  glomerular,  and  interstitial. 


698  DISEASES  OF  THE  URINARY  ORGANS. 

1.  Tubal  Changes. — These  vary  a  great  deal  with  the  stage  of  the  dis- 
ease. The  earhest  change  assumed  by  the  cells  is  cloudy  swelling,  a  result 
of  increased  nutritive  activity.  In  this  state  the  cells  are  swollen  and 
"  cloudy  "  from  a  deposition  of  albuminous  granules,  which  may  obscure 
the  nucleus.  Although  kidneys  removed  after  death  from  cases  of  acute 
parenchymatous  nephritis  have,  as  a  rule,  advanced  far  beyond  this  stage, 
yet  it  is  often  possible  to  find  points  at  which  cloudy  swelling  exists  along- 
side of  more  advanced  stages,  while  alongside  of  these,  again,  may  be  tubes 
in  which  the  epithelium  is  normal.  As  a  result  of  the  cloudy  swelling,  the 
cells  are  larger,  and  the  tubes  are  therefore  distended,  broader  than  in 
health,  but  a  stage  later  they  are  still  more  distended  with  granular  cells, 
granular  debris,  and  often  red-blood  discs  and  leukocytes.  Under  a  low 
power,  the  tubules  appear  as  black,  more  or  less  opaque  lines.  A  closer 
examination  of  the  cells  at  this  stage,  as  obtained  by  scraping,  shows  them 
to  be  granular  in  various  degrees.  In  some  the  nucleus  is  still  visible,  in 
others  demonstrable  by  the  aid  of  staining  fluids  only,  and  in  others  still 
entirely  obscured.  Occasionally  a  few  fat  drops  may  be  present.  In  other 
situations  the  cells  are  so  closely  packed  in  the  tubules  that  they  cannot  be 
differentiated,  being  apparently  fused  in  one  continuous,  dark,  granular 
mass.  It  is  to  these  tubules,  distended  with  granular  cells  and  their  debris, 
dark  by  transmitted  light,  but  white  by  reflected",  that  the  pale  or  white 
color  seen  between  the  injected  blood-vessels  is  due.  Casts  of  the  urinifer- 
ous  tubes  are  also  found  in  situ,  usually  blood  casts  or  small  hyaline  casts. 
Minute  extravasations  of  blood,  visible  to  the  naked  eye,  have  been  referred 
to.  They  occupy  the  tubules,  and  in  the  "  hemorrhagic  "  form  the  interstitial 
tissue. 

2.  Glomerular  Changes. — In  all  cases  in  which  the  nephritis  is  due  to 
a  toxic  substance  which  enters  the  blood  the  glomerule  suffers  first.  The 
capillaries  of  the  tuft  are  distended  with  blood,  which  bursts  through  into 
the  Malpighian  capsule,  distending  it  with  red  blood-corpuscles  and  leuko- 
cytes. In  a  more  advanced  stage,  the  glomeruli  may  be  paler,  in  consequence 
of  the  proliferation  of  the  cells  lining  the  capsule  and  covering  the  glomerule 
( glomerulo-nephritis  ) . 

These  glomerular  changes  are  present  in  almost  all  cases.  They  in- 
clude swelling  and  desquamation  of  the  capsular  epithelium,  and  an  accumu- 
lation of  cells  in  the  interior  of  the  capillaries,  probably  due  to  a  prolifer- 
ation of  their  endothelial  lining  or  an  accumulation  of  white  blood-cells,  or 
thickening  and  hyaline  degeneration  of  the  capillary  walls.  These  are 
•especially  frequent  in  nephritis  after  scarlet  fever  or  diphtheria. 

3.  Intestitial  Changes. — Pii  mild  cases  there  is  no  interstitial  change, 
no  formation  or  deposit  of  new  material  between  the  tubes.  In  others  there 
is  a  serous  transudate,  with  a  few  leukocytes  in  most  cases,  and  red  blood- 
discs.  In  severer  cases  there  is  a  large  outwandering  of  cells,  and  a  small- 
celled  infiltrate  settles  itself  between  the  convoluted  tubes  and  around  the 
capsules.  In  cases  of  extreme  severity,  a  diffuse  nephritis  involving  both 
tubes  and  intertubular  tissue  may  be  present  from  the  outset.  In  such 
event,  the  latter  is  uniformly  infiltrated  or  pervaded  more  intensely  in  cer- 
tain places  by  leukocytes. 

The  epithelial  lining  of  the  straight  tubes  of  the  pyramids  is  unchanged, 
"but  the  tubes  themselves  often  contain  cellular  and  granular  material  which 
"has  descended  from  the  convoluted  tubes. 

Serous  infiltration  and  effusion  are  present  in  various  tissues  when  the 


ACUTE  PARENCHYMATOUS  NEPHRITIS.  699 

patient  is  dropsical  at  the  time  of  death.  Among  other  tissues  sometimes  thus 
infiltrated  are  the  membranes  of  the  brain,  constituting-  what  is  known 
as  edema  of  the  brain.  The  mucous  membrane  of  the  pelvis  of  the  kidney 
may  be  injected,  but  is  otherwise  unchanged. 

Symptoms. — The  mode  of  onset  of  acute  nephritis  is  not  uniform,  but 
among  the  symptoms  earliest  noticed  is  slight  sz\.'elling  or  puifiness  in  the 
face,  below  the  eyes,  associated  with  more  or  less  falling  off  in  urinary  se- 
cretion. This  edema  rapidly  extends  to  the  upper  extremities  and  trunk, 
and  thence,  if  the  disease  does  not  abate,  into  the  lower  extremities  and 
abdominal  walls.  In  the  male,  the  scrotum  and  prepuce  are  favorite  seats  of 
swelling.  The  great  serous  sacs  are  the  last  to  fill  with  fluid  in  acute  ne- 
phritis, although  in  bad  cases  ascites  not  infrequently  occurs,  while  there 
may  also  be  transudation  into  the  pleural  and  pericardial  cavities.  The 
degree  assumed  by  the  general  anasarca  is  sometimes  enormous,  resulting 
in  the  extremest  distortion.  The  eyes  may  be  actually  closed  by  the  swelling, 
and  movement  of  the  lower  limbs  rendered  almost  impossible.  Dropsy  does 
not  always  follow  the  order  here  named.  Much  depends  upon  the  position 
of  the  patient.  Thus,  if  he  be  upon  his  feet,  the  latter  may  be  the  first  to 
swell,  or  if  he  be  lying  in  the  recumbent  position,  the  back  may  be  the  seat 
of  the  first  swelling.  While  dropsy  is  a  very  frequent  symptom  in  acute 
nephritis,  it  is  not,  however,  always  present.  It  is  more  particularly  in 
the  nephritis  after  scarlet  fever  and  exposure  to  cold  that  it  is  a  decided  and 
almost  invariable  symptom.  After  the  other  infectious  diseases  it  is  fre- 
quently absent. 

Not  infrequently  the  disease  is  ushered  in  by  nausea  and  vomiting  and 
very  rarely  by  uremic  symptoms  (see  p.  685). 

Changes  in  the  Urine. — Simultaneously  with,  and  sometimes  earlier 
than,  the  dropsical  symptoms  are  diminution  in  the  quantity  and  alteration 
in  the  quality  of  the  urine.  The  former  may  amount  to  actual  suppression. 
The  urine  is  darker  than  natural,  and  often  smoke-hued  from  the  effect  of 
the  natural  acid  reaction  on  a  small  quantity  of  blood.  Should  the  urin'^ 
become  alkaline,  the  color  becomes  a  brighter  red.  The  hue  is  more  posi- 
tively red  if  the  quantity  of  blood  is  large,  which  is  not  often  the  case ;  but 
here  again  the  peculiar  tint  returns  if  the  blood  is  allowed  to  subside.  The 
blood  may  disappear,  to  return  again. 

The  specific  gravity  of  the  urine  at  first  is  high — 1025  to  1030 — mainly 
due  to  the  diminished  quantity,  while  the  solids  remain  nearly  normal.  Later, 
if  the  symptoms  abate,  the  specific  gravity  diminishes  with  the  increase  in 
the  quantity ;  or,  if  the  disease  lasts  for  any  length  of  time  or  passes  over 
into  the  chronic  form,  a  similar  reduction  in  weight  occurs ;  this  may  result 
in  a  specific  gravity  as  low  as  loio. 

The  chief  alteration  is  the  presence  of  albumin.  This  is  generally 
copious,  the  urine  often  solidifying  on  the  application  of  heat  and  acid, 
while  it  constantly  contains  more  than  half  its  bulk.  This  albumin  is  de- 
rived in  part  from  the  extravasated  blood,  and  in  part  is  a  result  of  the 
inflammatory  action.  If  estimated  by  weight,  it  will  equal  0.5  to  i  per 
cent.,  and,  in  rare  instances  only,  1.5  per  cent. 

Next  in  importance  is  a  reduction  in  the  twenty-four  hours'  secretion 
of  urea,  which  is  invariable  until  f  convalescence  sets  in.  The  percentage 
remains  as  high  or  higher  than  in  health,  but  the  twenty-four  hours'  quantity 
is  diminished.  There  is  a  good  deal  of  range  within  the  limits  of  health 
in  the  quantity  of  urea  eliminated  in  twenty-four  hours — from  twenty  to 


700  DISEASES  OF  THE  URIXARV  ORGAXS. 

forty  gm.  (300  to  600  grains)  in  adults,  and  it  varies  with  the  amount  of 
proteid  food  ingested.  Alore  frequently  the  amount  is  reduced  to  one- 
fourth  or  one-half  the  normal.  The  phosphates  and  chlorids  are  also  re- 
duced. 

As  to  sediment,  the  urine  of  all  cases  of  acute  parenchymatous  nephritis 
deposits  a  sediment  which,  in  the  early  stages  at  least,  is  copious  and 
brownish  or  reddish-brown  in  hue ;  later,  it  may  diminish  in  amount  and 
assume  a  lighter  color.  Microscopical  examination  reveals  this  deposit  to 
be  made  up  mainly  of  casts  of  the  uriniferous  tubules,  free  cells  from  these 
same  tubules,  blood-corpuscles,  red  and  colorless,  and  very  constantly  cr}-s- 
tals  of  uric  acid,  together  with  granular  urates.  The  casts  include  the 
varieties  known  as  epithelial  casts,  blood  casts,  hyaline  casts,  w^axy,  and  dark 
granular  casts.  Pus  casts  and  numerous  leukocytes  are  also  sometimes 
present.  The  hyaline  casts  are  probably  pure  fibrin.  The  epithelial  casts 
consist  of  the  same  material,  to  which  epithelial  cells  of  the  tubules  are 
attached,  and  blood  casts  have  blood-corpuscles  caught  in  the  coagulated 
exudate.  The  epithelium  thus  attached,  as  well  as  that  which  is  found  free 
in  the  urine,  is  variously  altered.  Some  of  the  cells  are  merely  the  seat 
of  cloudy  swelling,  others  are  decidedly  granular,  while  others  again  are 
converted  into  compound  granule  cells  or  granular  fatty  cells  by  complete 
fatty  degeneration.  These  arise  as  the  disease  advances.  Casts  containing 
a  few  oil  drops  may  also  be  present,  but  much  oil  is  not  found  until  the  case 
has  continued  for  some  time — in  fact,  become  chronic. 

Along  with  the  diminished  quantity  of  urine  is  often  met  a  disposition 
to  frequent  micturition,  the  efforts  at  which  are  only  partially  successful, 
resulting  in  the  emission  of  from  a  few  drops  to  a  tablespoonful.  This 
frequent  desire  to  pass  water  is  a  purely  reflex  symptom,  the  bladder  being 
free  from  disease.  It  sometimes  precedes,  in  point  of  time,  all  other  symp- 
toms.    It  is  by  no  means  constant. 

Fever  is  not  a  marked  symptom  in  acute  nephritis ;  indeed,  it  is  gen- 
erally absent,  unless  as  a  part  of  the  disease  causing  it.  To  a  less  degree 
the  same  is  true  of  pain.  It  is  mostly  absent,  and  when  present  amounts 
only  to  a  dull  ache,  as  a  rule.  CJiillincss  and  rigors  sometimes  introduce 
the  disease.  Nausea  and  vomiting  are  not  infrequent  in  the  beginning. 
Sometimes  these  symptoms  usher  in  the  disease.  The  pulse  is  quite  charac- 
teristically altered.  While  not  materially  changed  in  rate,  it  exhibits,  espe- 
cially in  sphygmogram,  a  decided  increase  in  tension,  as  shown  b}^  the 
broader  apex  and  diminished  dicrotic  element. 

U rendu. — At  almost  any  time  in  the  course  of  an  acute  nephritis  the 
patient  is  liable  to  uremia,  while  the  train  of  nervous  symptoms  usually 
known  as  uremic,  and  ascribed  to  the  accumulation  of  excrementitious  sub- 
stances in  the  blood,  is  not  confined  to  this  form  of  Bright's  disease,  and 
is  by  no  means  invariably  present.  Its  causes  and  phenomena,  so  far  as 
known,  were  considered  under  general  symptomatology,  page  688.  When 
present,  however,  it  adds  a  phase  of  extreme  gravity. 

The  duration  of  acute  nephritis  is  variable — from  a  few  days  to  several 
months,  while  the  acute  form  may  become  chronic.  The  former  class 
of  cases  are  fatal,  for  none  which  recover  do  so  in  a  few  days.  The  most 
rapid  usually  require  a  month.  As  to  the  cases  of  longer  duration,  the 
possibility  of  recovery  at  any  time  cannot  be  denied,  but  nothing  is  better 
determined  than  that  the  longer  the  duration  the  more  difficult  the  cure. 
Of  course,  such  cases  are  no  longer  acute. 


ACUTE  PARENCHYMATOUS  NEPHRITIS.  701 

Complications. — These  are  not  numerous  in  acute,  as  contrasted  with 
chronic  Bright's  disease,  and  some  which  are  described  as  compHcations  are 
not  really  such,  but  local  symptoms.  Thus,  edema  of  the  lungs  occurs  as 
a  part  of  the  general  tendency  to  dropsy,  and  may  be  a  grave  symptom, 
resulting  in  death  by  suffocation.  It  is  not  the  result  of  an  intercurrent 
bronchitis.  Pneimionia,  on  the  other  hand,  is  an  occasional  true  complica- 
tion. InHammation  of  the  serous  meinbrancs  is  more  truly  a  complication, 
but  not  every  case  in  which  there  is  effusion  into  a  serous  cavity  is  of  such 
a  nature.  Such  effusions  are  local  dropsies.  Inflammation  of  serous  mem- 
branes is  rather  more  prone  to  occur,  while  the  exudate  may  assume  a  puru- 
lent character,  thus  also  increasing  the  gravity  of  the  case.  Pleurisy  is  the 
most  frequent  form  of  this  inflammation,  pericarditis  next,  and  peritonitis 
next.  The  tubercular  origin  of  the  graver  forms  of  pleurisy  occurring  in 
Bright's  disease  has  been  suggested. 

Hypertrophy  of  the  left  z'entricle  is  not  a  frequent  complication  of  acute 
nephritis.  It  is  a  well-recognized  one  of  chronic  Bright's  disease.  Time  is 
an  essential  condition  to  its  production.  It  is  not,  therefore,  until  the  kidney 
disease  has  existed  for  some  time  that  it  can  ordinarily  occur.  It  occasion- 
ally happens,  however,  that  the  hypertrophy  occurs  earlier.  Thus,  Dickin- 
son reports  a  case  recognized  at  eight  weeks,  and  von  Leube  one  at  ten  days 
succeeding  the  first  symptom.  The  infallible  sign  of  hypertrophy  is  sharp 
accentuation  of  the  aortic  second  sound,  with  or  without  demonstrable  en- 
largement of  the  normal  area  of  dullness. 

Allusion  has  been  made  to  the  gastric  syuiptouis  which  very  commonly 
attend  acute  nephritis,  especially  after  scarlet  fever.  Samuel  Fenwick  *  and 
Wilson  Fox  f  have  shown  that  these  may  be  associated  with  organic  changes 
in  the  structure  of  the  stomach.  Dr.  Fenwick  characterizes  these  as  gas- 
tritis, as  evidenced  by  increased  vascularity  of  the  mucous  membrane,  disten- 
tion of  the  tubes  by  a  confused  mass  of  cells  and  granular  matter,  and 
occasional  thickening  of  the  basement  membrane.  To  these.  Dr.  Fox  has 
added  thickening  of  the  intertubular  tissue. 

Notwithstanding  the  frequency  of  convulsions  in  acute  nephritis,  struc- 
tural alterations  in  the  brain  are  almost  unknown.  Apoplectic  effusions  are 
rare,  probably  because  of  the  comparative  structural  integrity  of  the  blood- 
vessels of  the  brain  in  the  young,  in  whom  the  disease  mainly  occurs.  In 
like  manner,  the  blindness  which  not  infrequently  occurs  as  a  symptom  of 
uremia  is  unattended  by  retinal  changes,  nor  does  that  condition  known  as 
albuminuric  retinitis  occur  in  acute  parenchymatous  nephritis,  except  with 
the  extremest  rarity. 

Diagnosis. — The  diagnosis  of  acute  parenchymatous  nephritis  is  ordi- 
narily quite  easy.  The  previous  history,  the  usually  easily  recognizable  cause, 
the  suddenness  of  the  attack,  the  scanty  and  bloody  urine  with  its  high  specific 
gravity,  the  copious  albuminuria,  the  blood  and  epithelial  and  dark  granular 
casts,  the  blood-corpuscles,  free  epithelium,  and  granular  cells  in  the  urine — 
these  are  a  combination  of  symptoms  which  admit  of  only  one  interpretation. 
At  a  later  stage,  the  absence  of  one  or  more  of  these  symptoms  may  some- 
what increase  the  difficulty,  but  it  is  scarcely  possible  to  err  if  those  which 
remain  are  duly  considered.  It  must  be  remembered,  also,  that  an  acute 
condition,  such  as  this  described,  may  supervene  upon  any  one  of  the 
chronic  forms  of  Bright's  disease  to  be  described,  and  this  may  give  rise  to 

*  Samuel  Fetiwick,  "  The  Morbid  States  of  the  Stomach  and  Duodenum,"  1868,  p.  i77' 
t  Wilson  Fox.  "  Medico-Chirurg  Transac,"  vol.  xli.  p.  361. 


702 


DISEASES  OF  THE  URINARY  ORGANS. 


some  difficulty  of  diagnosis,  but  if  there  be  hypertrophy  of  the  left  ventricle, 
it  is  likely  that  there  was  chronic  disease  before ;  in  the  latter  case,  too,  there 
is  apt  to  have  been  anemia  existing  for  some  time,  previous  edema,  head- 
ache, and  other  symptoms  of  chronic  Bright's  disease. 

Febrile  albuminuria  is  quite  often  mistaken  for  acute  nephritis  by  those 
who  have  had  little  experience,  though  the  distinction  is  easy.  In  pure 
febrile  albuminuria,  the  quantity  of  albumin  is  very  small,  and  while  there 
may  rarely  be  a  few  hyaline  casts,  there  are  no  blood  discs  and  no  epithelial 
casts.  The  absence  of  dropsy  is  of  no  significance,  for  in  the  acute  nephritis 
of  the  infectious  diseases,  except  scarlet  fever  and  diphtheria,  there  is  seldom 
dropsy.  There  may  also  be  febrile  albuminuria  li^  scarlet  fever  which  is  quite 
different  from  the  nephritis  occasioned  by  this  disease.  It  occurs  early, 
and  in  this  stage  the  other  features  of  febrile  albuminuria  obtain,  while  the 
scarlatinal  nephritis  does  not  come  on,  as  already  stated,  until  after  the  end 
of  the  second  week. 

While  the  glomerular  changes  referred  to  are  more  usual  in  scarlatinal 
nephritis,  there  is  no  certain  way  of  recognizing  such  condition,  and  the 
term  glomerulo-nephritis,  which  is  applied  to  the  nephritis  associated  with 
these  changes,  is  scarcely  justified  from  the  clinical  standpoint,  because 
there  are  no  symptoms  by  which  it  can  be  recognized. 

The  diagnosis  of  uremia,  commonly  easy,  is  sometimes  difficult.  This 
is  especially  the  case  when,  instead  of  the  usual  complex  list  of  symptoms 
detailed  on  page  689,  there  are  but  one  or  two.  By  no  means  every  nervous 
manifestation  coincident  with  Bright's  disease  is  uremic,  and  I  am  inclined 
to  believe  that  some  are  ascribed  to  it  which  should  not  be.  On  the  other 
hand,  localized  convulsions  and  hemiplegias,  commonly  ascribed  to  some 
anatomical  lesion  in  the  brain,  are  often  uremic  in  origin.  Given,  however, 
a  case  of  sudden  convulsions  or  coma,  or  even  muscular  twitching,  if  it  is 
associated  with  scanty  urine  and  diminished  urea  excretion,  it  may  be  ascribed 
to  uremia,  provided  there  is  no  cause  which  will  explain  it  more  satisfactorily. 
Uremia  has  been  mistaken  for  opium  and  alcohol  intoxication,  and  it  must 
be  admitted  that  the  coma  in  all  three  is  very  much  alike.  But  one  need 
only  be  forewarned  to  prevent  such  error.  In  opium-poisoning  the  pupils  are 
contracted,  in  alcoholism  they  are  dilated,  in  uremia  they  vary. 

Prognosis. — Grave  as  this  disease  is  justly  considered,  recoveries  from 
it  are  numerous  and  the  prognosis  is  generally  favorable.  Even  without 
treatment,  cases  may  recover,  and  more  recoveries  follow  a  judicious  treat- 
ment. The  prognosis  should,  however,  always  be  guarded,  as  insidious 
causes  may  produce  death  when  it  is  least  expected.  Among  the  most  im- 
portant of  these  is  uremia. 

Bartels  says  that  death  from  uremia  in  acute  nephritis  has  never  oc- 
curred in  his  experience,  except  when  the  disease  has  resulted  from  scarlatina 
or  diphtheria;  but  Dickinson  narrates  a  fatal  case  resulting  from  exposure, 
in  which  death  was  preceded  by  coma  and  other  symptoms  of  evident  uremic 
origin,  and  I  am  certain  I  have  seen  similar  cases. 

Pulmonary  edema  is  a  cause  of  sudden  death,  the  patient  drowning,  as 
it  were,  in  his  own  secretions.  Its  onset  is  characterized  by  shortness  of 
breath,  frothy  expectoration,  and  abundant  small  rales.  Purulent  exuda- 
tion into  the  serous  cavities  may  also  precipitate  death,  very  rarely. 

The  symptoms  of  gravest  import  are,  therefore,  those  of  uremia,  mani- 
fested in  any  one  or  all  the  various  ways,  the  presence  of  any  of  the  com- 
plications alluded  to,  and  especially  suppression  of  urine.     Cases  should  not, 


ACUTE  PARENCHYMATOUS  NEPHRITIS.  705. 

however,  be  despaired  of,  even  when  there  is  complete  suppression  of  urine. 
Always,  however,  this  is  the  gravest  of  symptoms,  and  death  generally 
ensues  within  a  couple  of  days  after  it  sets  in.  The  possibility  of  sudden 
death  should  always  be  borne  in  mind,  and  mentioned  to  the  relatives  of  the 
patient,  although  the  number  of  cases  in  which  this  occurs  is  not  very  great. 
Of  course,  the  longer  the  duration  of  the  case  the  less  the  likelihood  of 
recovery. 

Treatment. — ^Many  cases  of  acute  nephritis  recover  under  the  con- 
ditions of  rest,  quietude,  and  warmth,  and  it  is  further  certain  that,  whatever 
other  means  of  treatment  are  used,  these  three  conditions  are  absolutely 
necessary  to  recovery.  A  patient  with  acute  Bright's  disease,  therefore, 
whatever  its  mode  of  origin,  should  be  put  to  bed,  kept  quiet,  and  covered 
warmly. 

The  diet  of  patients  with  acute  Bright's  disease  should  be  of  the 
simplest  and  easiest  of  digestion,  and  should  contain  a  minimum  of  proteids. 
The  iritability  of  the  stomach  in  this  disease  has  been  alluded  to,  and  it  is 
important  that  food  should  be  adapted  to  it.  Milk  may  be  considered  the 
typical  food,  not  merely  because  of  its  easy  assimilation  and  nutritious  charac- 
ter, but  because  there  is  abundant  testimony  to  prove  that  albuminuria 
diminishes  ilnder  its  use,  while  the  amount  of  nitrogen  contributed  to  the 
blood  is  less  than  by  animal  flesh.  The  combination  of  lime-water,  and 
still  better  of  carbonated  water  or  Vichy,  with  milk,  is  an  eminently  suitable 
one.  While  solid  animal  food  is  not  to  be  recommended,  weak  animal 
broths  may  be  permitted,  to  break  up  the  monotony  of  a  pure  milk  diet. 
Beef-teas  and  extracts  should  be  prohibited  as  harmful.  Rice  and  farinaceous, 
preparations  generally  are  suitable  adjuvants  to  the  milk  diet. 

We  should  seldom,  however,  be  satisfied  with  this  treatment  alone. 
The  selection  of  other  measures  will  depend  somewhat  upon  the  severity  of 
the  case.  If  the  urine  be  suppressed,  dry  cups,  or,  in  severe  cases,  cut  cups 
to  the  loins  may  divert  the  blood  and  relieve  the  stagnation  which  always, 
exists  in  the  acutely  inflamed  kidney.  Cups  should  be  followed  by  a  warm 
poultice  to  the  same  region,  which,  indeed,  should  be  used  under  any  circum- 
stances, whether  the  cupping  is  necessary  or  not.  Dry  cups  should  not 
be  allowed  to  remain  on  one  spot  longer  than  to  secure  a  bright  redness,, 
after  which  they  must  be  withdrawn  or  moved  to  another  spot  in  the  vicinity. 
By  allowing  them  to  remain  too  long,  the  blood  is  stagnated  in  the  capillaries, 
its  onward  movement  prevented,  and  there  is,  therefore,  no  derivation  of 
blood  from  the  involved  organ. 

The  foregoing  measures  have  for  their  object  the  direct  relief  of  the 
congestion  of  the  kidney.  This  is  further  accomplished  by  purgation,  which 
supplements  the  action  of  the  kidney.  But  a  purgative  is  early  employed  not 
more  for  this  purpose  than  to  promote  the  action  of  other  remedies.  Ab- 
sorption is  slow  when  the  blood-vessels  are  congested  and  there  is  a  sluggish 
current.  The  cathartic  relieves  this  turgor,  and  after  its  effect  prompt 
absorption  and  action  of  other  remedies  may  be  looked  for.  The  purgative 
most  suitable  is  a  saline.  A  simple  dose  of  bitartate  of  potassium,  simple 
magnesia  for  children,  citrate  of  magnesium,  or  Epsom  salts  for  adults 
will  be  sufficient.  The  indication  is  to  get  a  watery  stool  as  soon  as 
possible.  In  view  of  the  fact  that  the  stomach  is  often  sensitive,  it  is  desir- 
able to  use  an  aperient  which  is  not  nauseous  or  irritating,  and  to  this  end 
some  one  of  the  delicate  effervescing  preparations  so  common  in  modern 
pharmacy  may  be  used. 


704  DISEASES  OF  THE  URINARY  ORGANS. 

Next,  or  simultaneously,  the  action  of  the  skin  should  be  promoted. 
This  is  done  by  maintaining  warmth  and  avoiding  cold,  as  already  insisted 
upon.  But  we  are  not  confined  to  these  protecting  measures.  The  skin 
may  be  made  to  do  the  work  of  the  kidney  itself,  and  thus  one  of  the  most 
alarming  dangers  of  Bright's  disease,  uremic  intoxication,  averted,  while  at 
the  same  time  the  congestion  of  the  kidney  is  also  relieved.  The  class  of 
remedies  which  produces  this  action  are  diaphoretics  (the  warmth  described 
is  one  of  these),  and  of  the  simple  remedies,  none  is  better  than  the  ordinary 
sweet  spirit  of  niter,  especially  if  it  be  combined  with  neutral  mixture  and 
small  doses  of  ipecacuanha.  If  more  active  measures  are  required,  some 
one  of  the  preparations  of  jaborandi  may  be  used,  the  dose  varying  with  the 
effect  it  is  desired  to  obtain.  If  moderate  diaphoresis  only  is  desired,  doses 
of  from  ten  to  fifteen  minims  (0.65  to  i  gm.)  of  the  fluid  extract  may  be 
given  to  adults  every  two  hours,  and  increased,  if  necessary,  until  the  efifect 
is  brought  about.  To  children,  from  five  to  ten  minims  (0.3  to  0.6  c.  c.) 
may  be  given  in  the  same  manner,  or  pilocarpin  may  be  given  in  doses  of  from 
1-24  to  1-12  grain  (0.0027  to  0.0054  g""^-)-  The  further  use  of  this  important 
remedy  will  be  again  referred  to  in  treating  uremia. 

Another  method  of  accomplishing  the  same  end  is  by  ivann  baths,  or, 
better  still,  by  the  warm  pack,  in  which  the  patient  is  wrapped  in  a  wet 
sheet  and  then  enveloped  in  a  sufficient  number  of  blankets.  Perspiration 
is  thus  copiously  induced,  and  when  thus  caused  is  agreeable  and  never 
attended  by  the  faintness  which  sometimes  follows  the  use  of  the  hot-air 
bath.  In  an  ordinary  severe  case  of  acute  Bright's  disease,  a  single  pack  of 
this  kind  will  often  remove  all  urgent  symptoms  and  happily  inaugurate  the 
convalescence.     It  may,  however,  be  repeated  daily,  if  necessary. 

Diuretics  are,  perhaps,  the  first  means  thought  of  by  most  practitioners 
in  the  treatment  of  Bright's  disease,  and  they  are  indicated  where  there 
are  dropsy  and  scanty  urine.  They  should,  however,  be  deferred  until  the 
measures  just  described  have  been  employed.  Digitalis  is  the  diuretic  most 
to  be  relied  upon.  It  is  necessary,  however,  to  have  a  reliable  preparation, 
and  unless  one  is  sure  of  the  quality  of  the  tincture,  it  is  best  to  use  a  freshly 
prepared  infusion.  I  have  already  explained,  on  page  595,  why  I  believe 
more  efficient  results  are  obtained  from  the  infusion  than  from  the  tinc- 
ture. 

Digitalis  should,  therefore,  be  given  in  sufficient  doses — 1-2  to  one  fluid 
dram  (2  to  4  c.  c.)  of  the  infusion  to  children,  and  two  fluid  drams  to  half 
a  fluid  ounce  (8  to  16  c.  c.)  to  adults — repeated  every  three  hours,  until  an  ap- 
preciable effect  is  produced  on  the  rate  of  the  pulse,  when  it  should  be 
diminished.  Not  until  then  tan  we  look  for  a  diuretic  action.  I  prefer  at 
first  to  give  it  alone.  Later  it  may  be  combined  with  acetate,  citrate,  and 
bitartrate  of  potassium.  The  diuretic  action  of  these  salts  probably  depends 
upon  the  impetus  they  give  to  osmosis  of  fluids  holding  them  in  solution, 
thus  filling  the  blood-vessels,  which,  in  their  turn,  give  out  water  to  flush 
the  kidney.  To  adults,  twenty  grains  (1.3  gm.)  of  either  may  be  given 
every  two  or  three  hours,  freely  diluted,  because  water  itself  is  an  excellent 
diuretic;  from  five  to  ten  grains  (0.32  to  0.648  gm.)  to  children,  as  often. 
An  important  object,  too,  is  to  maintain  an  alkaline  urine,  which  tends  to 
dissolve  exudates.  For  this  purpose,  the  alkaline-mineral  waters  are  also 
useful,  or  what  is  commonly  known  as  cream-of-tartar  tea  may  be  drank 
instead  of  water.  A  teaspoonful  of  potassium  bitartrate  is  put  into  a  pint  of 
boiling  water,  and  taken  cold  as  drink  is  wanted. 


ACUTE  PARENCHYMATOUS  NEPHRITIS.  705 

Another  admirable  diuretic  combination,  including"  all  of  these  elements, 
is  Trousseavi's  diuretic  wine,  which  consists  of : 

IJ    Junip.  contus 3  x.     40  gm. 

Pulv.  digitalis, ,         ■      3  ij       8  gm. 

Pulv.  scilloB, .         .         •      3J        4  g™- 

Vin.  xerici, O^      %.  liter 

Macerate  for  four  days  and  add 
Potas.  acetatis 3  iij     12  gm. 

Express  and  filter. 

Sig. — Tablespoonful  three  times  a  day  for  an  adult. 

Infusion  of  digitalis  may  also  be  used  in  the  shape  of  fomentations. 
Cloths  wrung  out  in  hot  infusion  of  digitalis  and  laid  over  the  abdomen 
of  the  patient  have  been  known  to  produce  diuresis  when  all  other  measures 
have  failed. 

Theobromin  is  also  a  diuretic  which  should  not  be  forgotten  in  the 
treatment  of  renal  dropsy,  although  it  is  better  adapted  to  cardiac  dropsy. 
The  same  is  true  of  caffein.  For  the  method  of  administration  of  both  of 
these  see  treatment  of  cardiac  dropsy,  page  599. 

Treatment  of  Aeiite  Uremia. — The  alarming  and  dangerous  character 
of  the  symptoms  of  this  condition  demand  a  separate  consideration  of  the 
measures  required  in  their  treatment.  The  treatment  which  has  just  been 
described  is  such  as  would  be  called  for  by  an  ordinary  case  of  acute  nephritis" 
of  a  decided  character.  The  tendency  of  it  will  be  to  prevent  the  retention 
of  those  effete  matters,  whatever  their  precise  nature,  which  constitute 
the  cause  of  uremia.  But  all  efforts  in  this  direction  sometimes  fail,  and 
we  are  called  upon  to  contend  with  convulsions  or  coma,  or,  more  frequently, 
both  in  alternation.  How  shall  they  be  met?  The  indication  has  already 
been  explained.  Elimination  is  demanded.  The  kidneys  are  not  acting, 
and  the  secretion  of  urine  is  suppressed.  There  remain,  therefore,  but  the 
bowels  and  skin  to  operate  upon.  But  the  patient  is  unconscious  and  cannot 
swallow  voluntarily.  Such  remedies  must,  therefore,  be  used  as  do  not 
require  his  co-operation.  These  are  croton  oil  and  elaterium.  Of  the 
former,  two  drops,  slightly  diluted  with  plain  oil  or  glycerin,  may  be  carried 
into  the  back  part  of  the  throat,  or,  in  case  of  extreme  necessity,  undiluted, 
may  be  introduced  into  the  mouth,  whence  it  is  quickly  absorbed.  Its  oper- 
ation may  be  facilitated  by  a  rectal  injection.  Of  elaterium,  ?.  quarter  of  a 
grain  (0.Q165  gm.)  in  solution  may  be  administered  by  the  mouth. 

In  like  manner,  the  skin  may  be  made  to  substitute  the  action  of  the 
kidney.  The  vapor  or  hot-air  bath  or  hot  pack  should  at  once  be  availed  of. 
The  vapor  may  be  conveyed  by  a  pipe  two  or  three  inches  in  diameter, 
carried  from  a  vessel  containing  water,  under  which  a  spirit-lamp  is  placed, 
under  the  bed-clothing,  the  patient  being  well  covered  with  a  mackintosh 
and  blanket,  excepting  the  head.  An  ordinary  rain-spout  may  be  used. 
Hot  air  may  be  similarly  conveyed,  but  does  not  act  so  quickly.  Its  action 
may  be  favored  by  moistening  the  skin.  The  hot  pack  is  also  very  efficient 
and  perhaps  less  enervating. 

Jahorandi  or  its  active  principle,  piloearpin,  may  be  used,  the  latter 
preferably,  because  available  hypodermically.  One-third  grain  (0.02  gm.) 
of  the  muriate  may  be  thus  administered,  and  if  perspiration  does  not  set  in 
in  a  half  hour,  it  may  be  repeated.  Its  action  is  also  greatly  facilitated  by 
warmth  applied  to  the  patient.  A  freshly  prepared  infusion  may  be  injected 
into  the  rectum  with  almost  equally  prompt  results.  Four  ounces  (120  c.  c.) 
of  hot  water  should  be  poured  on  a  dram   (4  gm.)   of  jaborandi  leaves, 

45 


7o6  DISEASES  OF  THE  URIXARY  ORGANS. 

and,  when  sufficiently  cool,  strained  and  injected.  The  doses  here  mentioned 
are  intended  for  adults.  When  less  urgency  is  required,  a  fluid  dram 
(4  c.c.)  may  be  inspissated  and  made  into  a  suppository.  Should  edema 
of  the  lungs  occur,  it  may  be  overcome  by  the  hypodermic  injection  of 
atropin,  1-60  grain  (o.ooi  gm.). 

If  the  convulsions  continue,  blood-letting  may  be  practiced,  or  it  may 
be  done  at  once  if  the  patient  is  not  very  feeble.  Xo  one  doubts  the  effi- 
ciency of  bleeding  in  puerperal  convulsions,  and  if  puerperal  convulsions 
are  uremic,  as  they  are  with  few  exceptions,  then  bleeding  should  be  of 
service  in  the  uremic  convulsions  of  acute  Bright's  disease. 

The  hydrate  of  chloral  should  not  be  forgotten ;  indeed,  it  is  one  of  the 
most  valuable  remedies  for  the  convulsion  and  should  be  one  of  the  first 
measures  tried.  In  the  case  of  an  adult,  a  dram  (4  gm.)  in  solution  may  be 
injected  into  the  rectum  ;  fifteen  to  thirty  grains  ( i  to  2  gm.)  for  a  child.  Its 
use  is  sometimes  followed  by  the  promptest  favorable  results.  Chloroform 
may  also  be  used  to  control  the  convulsion  while  the  eliminating  measures  are 
acting. 

The  use  of  opium  requires  mention.  The  caution  w^hich  has  always 
been  suggested  in  its  use  I  believe  to  be,  in  the  main,  a  wholesome  one.  and  I 
should  prefer  to  produce  hypnotic,  sedative,  and  antispasmodic  effects  by 
chloral  and  the  bromids  whenever  it  is  possible.  At  the  same  time  there  can 
be  no  doubt  that  opium  is  less  harmful  in  acute  nephritis  than  in  chronic,  and 
especially  chronically  contracted  kidney,  and  when  other  measures  fail  to  con- 
trol convulsions,  it  may  be  used  cautiously.  It  was  in  the  convulsions  of 
acute  nephritis  that  the  late  Professor  Loomis,  of  Xew  York  City,  recom- 
mended it,  although  its  wider  use  has  grown  out  of  this  suggestion.  His 
practice  was  to  treat  cases  of  uremic  convulsions  in  acute  nephritis  with  hypo- 
dermic injections  of  large  doses  of  morphin — 1-2  grain  (0.033  g"^-)  or  more. 

The  same  measures  which  have  been  detailed,  excepting  the  general 
blood-letting  and  chloral,  may  also  be  employed  in  the  treatment  of  suppres- 
sion of  urine  or  of  obstinate  dropsy  without  uremic  symptoms,  with  such 
modifications  as  circumstances  may  suggest,  due  regard  being  paid  to  the 
strength  of  the  patient.  They  wall  be  further  referred  to  when  discussing 
the  treatment  of  the  chronic  forms  of  Bright's  disease. 

Sooner  or  later,  also,  in  the  treatment  of  acute  parenchymatous  nephritis 
supporting  measures  are  rendered  necessary  to  repair  the  losses  which  the 
blood  suffers  by  the  albuminuria,  and  to  some  extent  also  by  the  depleting 
measures  of  treatment.  These  effects  should  indeed  be  anticipated  by  proper 
diet,  tonics,  quinin,  especially  iron,  wine,  malt  liquors,  whisky,  or  brandy,  as 
indicated.  These  measures  will  also  be  more  particularly  alluded  to  in  the 
treatment  of  chronic  Bright's  disease. 

Treatment  of  Complications. — Complications  should  be  treated  by  reme- 
dies called  for  by  such  conditions  independent  of  the  renal  cause.  Effusions 
into  the  pleural  cavities  and  abdomen  are  often  best  relieved  by  paracentesis 
or  aspiration ;  pneumonia  and  bronchitis  by  counterirritation. 


CHRONIC  PARENCHYMATOUS  NEPHRITIS.  707 


CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

Synonyms. — Chronic  Diffuse  Nephritis;  Chronic  Tubal  Nephritis;  Chronic 
Catarrhal  Nephritis;  Large  White  Kidney. 

Definition. — A  chronic  diffuse  hyperplastic  process  in  the  kidney, 
involving  the  epithelium,  glomeruli,  and  interstitial  tissue. 

Etiology. — This  cannot  always  be  traced.  While  it  is  frequently  a  con- 
tinuation of  acute  nephritis,  more  frequently  it  originates  de  novo.  To  cases 
in  the  former  category  scarlatina  and  pregnancy  contribute  the  greater  num- 
ber. To  the  second  class  belong  insidious  cases,  the  cause  of  which  is  often 
not  traceable.  Habitual  exposure  to  cold  and  dampness,  such  as  residence 
in  damp,  cold  houses,  may  cause  some.  Tubercular  disease  of  the  lungs  is  an 
undoubted  cause.  Great  stress  is  laid  by  German  writers  upon  malarial  poi- 
soning as  a  cause.  In  this  country  it  is  not  a  frequent  cause.  One  or  two 
pretty  well-founded  cases,  with  others  of  more  doubtful  authenticity,  include 
my  experience  with  this  cause.  S.  C.  Busey,  I.  E.  Atkinson,  and  William 
Sydney  Thayer  have,  however,  also  assigned  this  as  a  cause  in  special  papers 
devoted  to  the  subject.  It  may  be  the  case  in  more  southern  parts  of  the 
United  States,  where  malarial  poisoning  is  more  intense  than  in  the  Middle 
States.  Alcohol  is  a  cause,  and  the  nephritis  of  confirmed  drunkards  and  the 
employees  of  breweries  may  be  thus  accounted  for,  though  it  cannot  be  denied 
that  the  exposure  to  which  some  of  the  former  class  are  subjected  may  be 
responsible.  Males,  and  of  these  young  adults,  are  the  more  frequent 
subjects.  Sepsis  in  prolonged  surgical  affections  may  produce  chronic 
nephritis. 

Morbid  Anatomy. — There  are  two  distinct  stages  in  the  morbid 
anatomy  of  chronic  parenchymatous  nephritis  if  the  disease  is  of  sufficient 
duration — viz.,  the  stage  of  enlargement,  represented  by  the  large  zvhite 
kidney,  and  that  of  contraction,  or  the  fatty  and  contracting  kidney.  A 
special  variety  is  chronic  hemorrhagic  nephritis. 

I.  Stage  of  Enlargement. — There  are  few  more  striking  objects  in 
morbid  anatomy  than  a  typical  example  of  the  large  zvhite  kidney.  The  kidney 
is  large  smooth,  white,  or  slightly  tinged  with  yellow ;  weighs  generally  from 
seven  to  ten  ounces  (217  to  310  gm.),  but  is  often  much  heavier.  It  is  usually 
doughy,  and  sometimes  elastic  in  consistence.  The  capsule,  which  may  be 
thinner  than  in  health,  strips  off  easily,  but  occasionally  drags  a  little  of  the 
parenchyma  with  it.  When  the  smooth  white  surface  thus  uncovered  is 
examined,  the  little  capillary  circlets  bounding  the  lobules  in  the  normal 
organ  are  in  some  places  indistinct,  in  others  conspicuous ;  the  same  is  true  of 
the  stellate  veins  of  Verheyn.  Numerous  yellow  specks  are  seen  scattered 
over  the  surface.  Hemorrhagic  extravasations  are  also  occasionally  present, 
but  very  much  more  rarely  than  in  the  acute  form.  Alongside  of  these  the 
greater  translucency  of  more  nearly  normal  areas  results  also  in  a  character- 
istic mottled  hue.  On  section,  it  is  evident  that  the  enlargement  resides  alto- 
gether in  the  cortex,  which  is  also  anemic,  its  intense  white  contrasting 
strongly  with  the  pink  hue  of  the  cones,r  which,  though  paler  than  in  health,  are 
much  less  so  than  the  cortex.  Closer  examination  of  the  cut  cortex  reveals 
the  same  yellow  specks  as  found  on  the  external  surface.  They  contribute, 
with  similar  less  decided  alterations,  to  form  a  series  of  dull  white  stri^  which 


7o8  DISEASES  OF  THE  URINARY  ORGANS. 

alternate  with  somewhat  broader,  transhicent  stride  radiating  toward  the  sur- 
face ;  the  former  correspond  to  the  area  of  the  convoluted  tubules  and  Mal- 
pighian  bodies, — the  labyrinth, — the  latter  to  that  of  the  medullary  rays. 

The  pelvis  of  the  kidney  in  chronic  parenchymatous  nephritis  is  the  seat 
of  catarrhal  swelling  and  a  slight  degree  of  hyperemia. 

Mimite  Change. — Microscopic  examination  of  thin  sections  shows  the 
involvement  of  both  tubes,  blood-vessels,  and  inter tiibidar  substance.  Of  the 
former,  many  are  found  choked  with  granular  cells  and  the  granular  debris 
of  cells,  causing  them  to  appear,  under  the  microscope,  as  black,  opaque  lines 
by  transmitted  light,  very  similar,  indeed,  to  the  tubes  in  acute  nephritis.  In 
other  situations  the  tubules  are  filled  with  fat  globules  and  fatty  cells.  In 
places  the  lumen  of  the  tubes  is  preserved,  in  others  not.  Other  cells  are 
the  seat  of  hyaline  change.  Others  still  are  nearly  normal.  The  parts  pre- 
senting a  yellow  tinge  are  those  in  which  the  fatty  elements  have  replaced  the 
normal,  and  this  is  the  composition  of  the  yellow  specks  already  alluded  to  as 
visible  to  the  naked  eye.  They  represent  a  coil  of  tubules  filled  with  oil  drops 
or  fatty  cells.*  Certain  tubules  contain  casts,  usually  of  the  waxy  kind. 
Sometimes,  indeed,  they  are  very  numerous.  Rarely,  hemorrhagic  extrava- 
sations are  also  found  in  the  tubules. 

The  'Capillaries  of  the  cortex  are  completely  or  nearly  empty  of  blood, 
which  has  been  expressed  from  them  by  the  distended  tubules.  To  this  and 
to  the  fatty  cells  is  due  the  extreme  whiteness  of  these  kidneys,  whence  the 
name  by  which  they  are  known.  Many  of  the  glomeruli  are  enlarged,  their 
capsules  thickened,  their  vessel-walls  thickened  and  hyaline,  their  capillary 
and  glomerular  epithelium  proliferated  and  degenerated. 

The  pyramids  in  chronic  parenchymatous  nephritis  are  more  changed 
than  in  the  acute  form,  but  the  changes  in  them  are  quite  secondary.  They  are 
sometimes  a  little  paler,  ov/ing  partly  to  a  granular  and  fatty  alteration  in  the 
cellular  lining  of  the  straight  tubules,  and  partly  to  the  presence  of  cells 
pushed  down  from  the  convoluted  tubules  above  them.  On  the  other  hand, 
they  may  be  congested  and  darker  in  color.  The  straight  tubes  of  the  cones 
as  well  as  the  looped  tubes  of  Henle  often  contain  waxy  casts. 

In  chronic  parenchymatous  nephritis  the  interstitial  tissue  is  always 
altered,  and,  it  may  be  said,  as  a  rule  in  proportion  to  the  duration  of  the  dis- 
ease. It  has  already  been  said  that  sooner  or  later  interstitial  overgrowth 
always  presents  itself,  although  it  is  difficult  to  say  when  this  overgrowth 
begins  in  any  given  case.  Langhans  reports  z  case  in  which  death  occurred 
five  weeks  after  the  appearance  of  the  first  symptoms,  directly  traceable  to  a 
thorough  wetting,  in  which  the  stroma  was  markedly  thickened.  And  in  a 
case  of  Dickinson's  already^  alluded  to,  intertubular  cellular  formation, 
"  though  approximating  as  much  to  pus  as  to  fiber,"  was  found  within  six 
weeks  of  the  onset.  Again,  cases  of  much  longer  duration  may  be  entirely 
without  it.  Interstitial  fibrosis  may,  however,  be  considered  as  a  superaddi- 
tion  of  chronicity,  and  whenever  a  case  is  distinctly  chronic,  it  may  be 
inferred,  with  tolerable  certainty,  that  it  is  present.  In  this  overgrowth  the 
quantity  of  the  connective  tissue  between  the  tubules  varies  extremely,  being 
sometimes  so  slight  as  to  be  discoverable  only  on  microsopic  examination  of 
thin  sections  ;  at  other  times  it  is  appreciable  to  the  naked  eye.  Minute  exami- 
nation shows  the  thickened  trabeculse  to  consist  of  numerous  round  and  oval 

*  No  satisfactory  explanation  has  yet  been  offered  of  the  great  dififerences  in  the  degree  of  fatty 
degeneration  in  the  different  kidneys  of  chronic  parenchymatous  nephritis  or  in  different  parts  of 
the  same  kidney.  Dickinson  says  the  cells  have  a  greater  tendency  to  be  fatty  when  cold  is  the 
cause. 


CHRONIC  PARENCHYMATOUS  NEPHRITIS.  709 

nuclei,  between  which  may  be  a  homogeneous  or  more  or  less  distinctly  fibril- 
lated  intercellular  substance. 

2.  The  Stage  of  Atrophy — The  Fatty  and  Contracting  Kidney  or  Small 
White  Kidney. — The  interstitial  new  formation  previously  referred  to  pos- 
sesses the  properties  usual  to  new  connective  tissue.  Produced  primarily  to 
replace  destroyed  tubular  structure,  it  shrinks  and  gradually  contracts  the 
previously  enlarged  organ,  while  obliterating  in  turn  a  certain  amount  of  the 
same  structure.  The  extent  of  contraction  varies  greatly,  increasing  with 
the  duration  of  the  process.  The  kidney  may  continue  as  large  and  even 
larger  than  the  normal  organ,  though  smaller  than  the  large  white  kidney, 
and  its  surface  is  uneven,  lobulated,  rough,  and  granular.  Its  capsule  does 
not  strip  ofif  easily,  as  from  the  large,  smooth  organ,  but  drags  with  it  con- 
siderable of  the  tubular  structure.  The  capsule  removed,  however,  the 
surface  of  the  kidney  exhibits  between  the  constrictions  the  same  pallid, 
speckled  appearance,  distinct  stellate  veins,  etc.,  already  described ;  and  on 
section  the  cortex  exhibits  the  same  anemic  appearance,  but  may  be  narrowed. 
Microscopically,  sections  exhibit  the  same  alternation  of  groups  of  normal 
and  choked  tubules  already  described,  alongside  of  other  places  in  which  the 
tubules,  together  with  the  Malpighian  bodies  at  their  extremities,  are  obliter- 
ated. Between  them  is  found  a  large  amount  of  interstitial  tissue,  and  the 
jNIalpighian  bodies  are  surrounded  by  concentric  layers  of  the  same.  Even 
minute  cvsts.  the  result  of  obstruction  of  tubules  by  the  constricting  tissue, 
are  found.  The  secondary  origin  of  this  form  of  kidney  is  not  conceded 
bv  everyone.     An  independent  primary  origin  is  claimed  for  it. 

3.  A  special  form  of  this  stage  is  chronic  hemorrhagic  nephritis.  In 
this  form  brown  hemorrhagic  foci  are  scattered  throughout  the  cortex  be- 
tween and  into  the  tubes.  The  organ  is  still  larger  than  normal,  and  pre- 
sents in  other  respects  the  histology  of  this  stage. 

It  not  infrequently  happens  that  along  with  the  changes  constituting 
chronic  parenchymatous  nephritis  are  found  also  those  of  lardaccous  disease. 
Thus,  in  a  large  white  kidney  the  Malpighian  bodies  will  often  strike  the 
mahogany-red  reaction  with  iodin  characteristic  of  this  condition,  although 
the  alteration  may  not  be  recognizable  by  the  naked  eye.  Occasionally  the 
change  may  even  affect  the  afferent  and  efferent  vessels. 

Symptoms. — There  are  few  distinctive  symptoms  of  chronic  parenchy- 
matous nephritis.  When  not  a  sequel  of  acute  nephritis  it  often  begins 
insidiously,  and,  after  a  variable  period  of  indescribable  ill  health,  including, 
however,  often  digestive  derangements,  an  anemic,  zvaxy  appearance 
develops,  with  puifincss  of  the  face  and  swelling  of  the  feet.  Ultimately,  the 
anasarca  may  become  general,  involving  the  face,  hands,  feet,  legs,  thighs, 
and  trunk.  The  serous  sacs  also  frequently  contain  fluid,  almost  always  in 
severe  cases.  The  swelling  may  be  confined  to  the  extremities  or  to  the  face, 
and  may  even  be  limited  to  more  unusual  situations,  as  the  scrotum.  Indeed, 
dropsy  is  often  entirely  wanting,  but  as  a  rule  it  is  manifest  sooner  or  later, 
and  no  symptom  gives  the  patient  so  much  inconvenience.  In  advanced 
degrees  his  legs  and  thighs  are  twice  their  normal  dimensions.  They  are  so 
heavy  he  cannot  lift  them,  while  they  are  often  excoriated  and  moist  with 
exuding  serum,  and  smarting  wdth  irritation.  Very  frequently,  as  the  result 
of  spontaneous  rupture  of  the  skin,  the  discharge  of  serum  is  profuse,  satu- 
rating the  bed-clothing  and  even  dropping  upon  the  floor ;  occasionally,  also, 
with  relief  to  the  patient. 

Another  very  constant  symptom  is  anemia,  producing  a  peculiar  translu- 


7IO  DISEASES  OF  THE  URINARY  ORGANS. 

cent  waxy  appearance,  quite  characteristic  and  often  alone  sufficient  to  suggest 
the  disease.  But  there  may  be  very  sHght  degrees  of  it  which  are  not  at  all 
peculiar.  Again,  the  debility  of  those  suffering  from  advanced  degrees  of 
this  condition  is  very  striking.  If  able  to  walk  at  all,  they  soon  get  out  of 
breath — are  soon  exhausted.  Dyspnea,  especially  on  exertion,  is  therefore 
a  frequent  symptom,  and  sometimes  is  extreme.  Locomotion  is  often  impos- 
sible in  consequence  of  the  extreme  swelling,  even  if  the  strength  otherwise 
permit  it. 

TJie  Urine. — The  urine  is  diminished  to  about  lo  to  40  ounces  (300  to 
1200  c.  c),  although  somewhat  variable  in  quantity.  It  is  often  turbid, 
reddish-yellow,  specific  gravity  normal  or  below,  highly  albuminous,  and 
deposits  often  bulky,  cloudy  sediment.  At  other  times  the  sediment  is 
scanty.  The  quantity  of  urine  also  increases  as  the  patient  improves  or  as 
the  stage  of  contraction  is  entered  upon,  so  that  it  may  even  exceed  the 
normal.  The  albumin,  while  also  large,  varies  as  to  its  percentage  amount 
with  the  quantity  of  urine  passed — from  0.5  to  2  per  cent.,  or  from  one-half 
to  three-fourths  of  the  volume  of  the  urine  tested.  The  amount  of  albumin 
lost  in  the  urine  is  sometimes  very  large.  It  has  even  occurred  that  the 
percentage  proportion  of  albumin  in  the  urine  has  exceeded  that  in  the  serum 
of  the  blood  from  the  same  patient.  The  quantity  of  albumin  has  very  little 
effect  upon  the  specific  gravity.  Indeed,  the  lighter  urines  are  generally 
those  which  have  the  larger  amount  of  albumin,  because  highly  albuminous 
urines  often  contain  little  area. 

The  sediment  is  made  up  of  variously  granular  casts,  among  which  the 
dark  granular  are  conspicuous  by  their  numbers  and  size,  and  especially  their 
width.  There  are  also  found  oil-casts  and  casts  containing  entire  and  frag- 
mentar}^  epithelial  cells,  which  are  likewise  granular  and  oily.  Finally,  yellow 
waxy  casts  are  found.  Casts  vary  in  number,  being  sometimes  scanty,  but  as 
a  rule  they  increase  with  the  development  of  the  disease  and  grow  less  as  it 
mends.  Occasionally  they  are  entirely  absent  for  a  time,  even  in  this  form 
of  Bright's  disease,  sometimes  as  the  result  of  treatment,  when  such  absence 
may  be  considered  a  favorable  sign.  Sometimes,  on  the  other  hand,  the 
tubules  are  choked  with  them,  and  they  do  not  descend  into  the  urine.  Com- 
pound granule  (granular  fatt}^)  cells  and  other  forms  of  fatty  renal  cells  are 
often  numerous.  Leukocytes  are  also  often  very  numerous,  while  red 
corpuscles  may  be  present  and  in  the  hemorrhagic  form  are  very 
numerous. 

The  normal  constituents  of  the  urine  are  generally  diminished  in  quan- 
tity. The  most  important  of  t^iese  is  urea.  To  the  reduced  amount  of  solids, 
and  particularly  of  urea,  the  reduced  specific  gravity  is  due. 

Notwithstanding  the  small  proportion  of  urea  which  is  excreted  in  this 
affection,  uremia  is  infrequent  in  chronic  parenchymatous  as  compared  zvith 
acute  nephritis  and  contracted  kidney.  It  is  more  frequent  after  the  stage  of 
contraction  is  reached. 

The  Stage  of  Contraction. — Are  there  any  symptoms  by  which  we  can 
recognize  the  stage  of  secondary  contraction,  which  takes  place  sooner  or 
later,  provided  the  patient  lives?  The  most  reliable  evidence  that  this  has 
occurred  is  the  presence  of  hypertrophy  of  the  left  ventricle  and  accentuation 
of  the  aortic  second  sound,  although  the  possibility  of  an  earlier  hypertrophy 
cannot  be  denied.  The  increased  vascular  tension,  mentioned  as  presenting 
itself  even  in  acute  nephritis,  continues  in  the  chronic  variety  to  stimulate  the 
heart  to  more  forcible  contraction,  which  must  sooner  or  later  result  in  hyper- 


CHRONIC  PARENCHYMATOUS  NEPHRITIS.  yu 

trophy.  As  already  stated,  time  is  required  to  reach  this  stage,  and  by  the 
time  hypertrophy  is  developed,  contraction  of  the  kidney  is  likely  to  have 
occurred.  Long  duration  of  the  disease  also  affords  presumptive  evidence 
that  contraction  has  taken  place.  If  a  case  of  undoubted  parenchymatous 
nephritis  continues  under  observation  for  a  year  or  more,  the  process  of  con- 
traction is  likely  to  have  commenced. 

The  dropsy  diminishes  and  may  disappear  as  the  stage  of  contraction  is 
entered  upon.  So,  also,  the  urine  changes  in  its  properties.  The  quantity, 
previously  small,  is  increased,  while  the  specific  gravity  falls  below  normal — 
loio  to  1015;  the  quantity  of  albumin  is  also  much  smaller  than  during  the 
stage  of  inflammation.  In  these  respects — absence  of  dropsy,  larger  amount 
of  urine,  and  smaller  amount  of  albumin — it  resembles  the  true  contracted 
kidney  of  interstitial  nephritis,  with  which,  indeed,  it  may  be  confounded  in 
the  absence  of  a  previous  history.  But  the  casts  continue  to  be  quite  nmrier- 
ous,  and  exhibit  much  the  same  character  that  they  do  in  the  stage  of  enlarge- 
ment, although  they  too  may  be  few ;  and  if  we  have  not  a  knowledge  of 
previous  history,  the  diagnosis  between  contraction  secondary  to  previous 
■enlargement  and  primary  contraction  the  result  of  interstitial  nephritis  may  be 
impossible.  Uremia  is  more  common  in  the  stage  of  contraction  than  that  of 
•enlargement. 

In  the  hemorrhagic  form  the  urine  almost  constantly  contains  blood. 
The  quantity  varies  somewhat  and  is  diminished  while  the  patient  is  in  bed, 
but  reappears  the  moment  he  arises. 

The  duration  of  chronic  parenchymatous  nephritis  is  variable.  Many 
cases  terminate  unfavorably  within  a  year  after  they  have  been  established, 
tut  I  have  one  case  now  under  observation  in  the  stage  of  contraction  which 
I  have  known  to  exist  for  sixteen  years  at  least.  Others,  especially  mild 
forms,  last  a  long  time,  causing  comparatively  little  inconvenience. 

Complications. — The  complications  of  chronic  parenchymatous 
nephritis  are  the  same  as  those  of  acute.  Edema  of  the  lungs,  bronchitis, 
pneumonia,  and  inflammation  of  serous  membranes  are  all  liable  to  occur. 
Hypertrophy  of  the  left  ventricle  is  more  common  than  in  acute  nephritis, 
for  the  reasons  already  referred  to,  but  still  very  much  less  so  than  in  inter- 
stitial nephritis.  Derangements  of  digestion  are  very  frequent,  probably 
due  to  a  more  advanced  stage  of  the  structural  changes  described  under  acute 
nephritis.  The  acute  blindness,  unattended  by  retinal  changes,  described  as 
occurring  in  the  uremia  of  acute  nephritis,  rarely  occurs  here,  while  retinal 
changes  are  rather  more  frequent,  but  still  uncommon  compared  with  inter- 
stitial nephritis,  under  which  they  wall  be  described. 

Diagnosis. — ^lany  cases  are  very  easy  of  diagnosis.  The  extreme 
pallor  of  the  patient,  the  diminished  urine  of  medium  specific  gravity,  the 
usually  large  amounts  of  albumin,  the  numerous  dark  granular,  oil,  and  waxy 
casts  of  large  diameter,  free  fatty  cells,  and  fatty  granular  cells,  especially  if 
we  are  able  to  trace  a  history  of  long  duration,  all  point  to  the  disease :  and  if 
there  is  an  antecedent  history  of  scarlatina  or  exposure  to  cold,  pregnancy,  or 
long  exposure,  probability  becomes  certainty. 

The  symptoms  of  amyloid  or  lardaceous  kidney  very  closely  resemble 
those  of  the  large  white  kidney,  and  it  has  been  mentioned  that  the  same 
causes  are  capable  of  developing  both.  It  is  often  impossible  to  say  which 
form  of  disease  is  present.  It  has  usually  been  considered  that  if  there  is 
enlargement  of  the  liver  and  spleen,  or  persistent  diarrhea,  and  the  cause  is 
•one  which  may  produce  lardaceous  disease,  it  is  certain  that  the  latter  condi- 


712  DISEASES  OF  THE  URINARY  ORGANS. 

tion  exists ;  but  observation  has  shown  that  the  first  two,  at  least,  may  be' 
present,  together  with  all  the  causes  and  other  symptoms  which  are  regarded 
as  favoring  lardaceous  disease,  and  yet  the  disease  be  parenchymatous 
nephritis  ;*  while  the  usual  causes  of  lardaceous  disease  may  operate  to  pro- 
duce it  in  the  liver,  leaving  the  kidney  intact.  As  a  rule,  there  is  not  so  much 
dropsy  in  lardaceous  disease,  casts  are  more  scanty,  and  generally  hyaline, 
granular,  and  waxy ;  hypertrophy  of  the  heart  and  uremia  and  albuminuric 
retinitis  do  not  occur.  Often,  too,  the  two  forms  of  disease  coexist,  either  as 
the  result  of  the  same  cause,  or.  the  amyloid  disease  may  be  the  result  of  long- 
continued  parenchymatous  nephritis. 

The  stage  of  contraction  is  more  difficult  of  recognition  unless  we  have 
had  the  case  for  some  time  under  observation  and  are  able  to  trace  its  con- 
tinuation with  the  stage  of  inflammation.  The  resemblance  to  the  contracted 
kidney  of  interstitial  nephritis  may  otherwise  be  very  close.  But  here, 
again,  the  albuminuria  is  likely  to  be  larger,  and  the  casts  more  numerous, 
and  to  include  the  numerous  varieties  mentioned  instead  of  the  scanty,  small 
hyaline  casts  which  attend  interstitial  nephritis.  In  the  latter  the  quantity 
of  urine  exceeds  the  normal,  while  in  the  former,  although  the  quantity  is 
larger  than  in  the  stage  of  enlargement,  it  is  still  less* copious  than  in  true 
interstitial  nephritis. 

Prognosis. — This  is  unfavorable  so  far  as  recovery  is  concerned.  Well- 
marked  cases  terminate  usually  within  two  years,  and  sometimes  within  a 
few  months.  Many  cases,  however,  may  be  very  much  prolonged  by  treat- 
ment, and  if  prolonged  to  the  stage  of  contraction,  the  patient  may  be  toler- 
ably comfortable  for  some  time — seems,  indeed,  to  have  another  lease  upon 
life.  But  sooner  or  later  the  dropsy  returns,  the  heart  fails,  and  the  patient 
dies  of  exhaustion,  or  some  one  of  the  complications  or  uremia  intervenes  to 
carry  him  off.  Of  the  former,  edema  of  the  lungs  or  of  the  glottis  and  pneu- 
monia are  particularly  dangerous.  In  the  stage  of  enlargement,  uremia, 
while  it  is  of  rarer  occurrence,  is  also  less  apt  to  end  fatally  than  in  the  stage 
of  contraction. 

On  the  other  hand,  it  is  to  be  remembered  that  there  are  many  mild 
cases  of  chronic  parenchymatous  nephritis  with  correspondingly  mild  symp- 
toms wherein  the  progress  of  the  disease  is  slow  and  may  extend  over  many 
years. 

Treatment. — While  it  occasionally  happens  that  spontaneous  recoveries 
from  acute  nephritis  occur,  this  is  not  the  case  with  the  chronic  form.  Here 
the  expectant  plan  of  treatment  does  not  suffice.  The  patient  with  chronic 
parenchymatous  nephritis,  if  left  alone,  grows  steadily  worse,  and  although 
measures  of  treatment  may  not  frequently  result  in  recovery,  they  often,  if 
judicious,  cause  marked  improvement  and  long  avert  the  fatal  end.  There 
is  always  an  intermediate  stage  between  that  of  acute  nephritis  and  the  con- 
dition of  the  large  white  kidney,  from  which  recovery  often  takes  place,  which 
calls  for  a  modification  of  the  treatment  described  for  the  acute,  or  some  addi- 
tions to  it. 

The  chief  indications  in  the  treatment  of  chronic  parenchymatous 
nephritis  are  two : 

1.  To  improve  the  quality  of  the  blood,  which  may  have  become  anemic 
and  contaminated  with  urea  and  allied  effete  matter. 

2.  To  depurate  the  blood  of  accumulated  excrementitious  matter,  and  to 

*  See  an  article  by  Dr.  Paul  Furbringer,  "Zur  Diagnose  der  amyloiden  Entartung  der  Nieren,'' 
'  Virchow's  Archiv,"  Bd.  Ixxi.,  1877,  S.  400. 


CHRONIC  PARENCHYMATOUS  NEPHRITIS.  713 

combat  the  symptoms  and  complications  which  form  a  source  of  great  incon- 
venience and  danger  to  the  patient. 

I.  The  first  of  these  indications  is  chiefly  fulfilled  by  the  use  of  iron, 
quinin,  and  strychnin,  nourishing  food  of  a  suitable  kind,  a  proper  hygiene. 
Iron  is  regarded  by  many  as  almost  a  specific  in  chronic  parenchymatous 
nephritis,  and  is  prescribed  constantly  in  the  most  reckless  and  thoughtless 
manner.  Large  doses  of  iron  should  not  be  given.  They  are  useless,  lock 
up  the  secretions,  cause  headache,  and  increase  the  danger  of  uremia.  The 
well-known  Basham's  mixture  is  a  great  favorite.  It  is  really  a  solution  of 
acetate  of  iron,  and,  being  made  by  adding  to  tincture  of  the  chlorid  of  iron 
acetic  acid  and  solution  of  the  acetate  of  ammonia,  has  the  advantage  of  at 
least  tending  to  diuresis,  while  it  is  also  a  roborant.*  But  the  tincture  of  the 
chlorid  of  iron  alone  is  an  efficient  preparation  which  is  always  accessible,  and 
when  combined  with  the  sweet  spirit  of  niter  and  freely  diluted,  is  perhaps  as 
efficient  as  Basham's  mixture.  Only  a  few  drops  should  be  given.  To  either 
one  the  quinin  and  strychnin  'may  be  added,  if  desired,  while  to  the  iron  the 
infusion  or  tincture  of  quassia  makes  a  compatible  addition. 

With  regard  to  diet,  while  it  is  true  that  a  sufficient  amount  of  food  of 
good  quality  is  desired,  those  articles  should  be  selected  which  contain  a  mini- 
mum of  nitrogen.  Experience  has  shown  that  when  the  appetite  is  good  and 
large  quantities  of  meat  are  eaten,  uremic  convulsions  have  been  more  fre- 
quent, whereas  when  the  appetite  has  been  bad  and  little  food  taken,  uremic 
convulsions  in  chronic  nephritis  are  very  rare.  While,  therefore,  it  is  not 
necessar}^  to  omit  all  such  food,  it  is  desirable  to  limit  it  to  moderation,  and, 
while  drawing  upon  the  vegetable  kingdom  for  food,  to  make  up  the  defi- 
ciency in  meats  by  the  free  use  of  milk.  The  good  results  of  the  milk  treat- 
ment in  cases  of  chronic  nephritis  are  now  generally  acknowledged  and  are 
evidenced  in  the  diminution  of  albuminuria,  decline  in  dropsy,  increase  in  the 
quantity  of  urine  passed,  and  general  amelioration  of  symptoms.  Of  the 
different  methods  of  employing  milk,  the  pure  milk  diet  has  been  most  satis- 
factory. From  2  1-2  to  3  1-2  quarts  (2.5  to  3.5  liters)  a  day  meet  the  require- 
ments of  an  adult  male,  and  less  is  often  sufficient.  The  milk  should  not  be 
skimmed,  but  diluted,  for  by  retaining  the  cream  the  casein  or  proteid  con- 
stituent is  maintained  in  smaller  proportion.  Rich  milk  is  not  desirable — 
indeed,  it  is  better  taken  diluted  with  Vichy  water  or  carbonated  water  and  at 
stated  intervals,  say  from  six  to  eight  ounces  every  two  hours.  It  is  not,  of 
course,  always  necessary  to  confine  the  patient  to  a  pure  milk  diet,  but  it 
should  at  all  times  constitute  a  large  part  of  the  food. 

Next  to  diet,  rest  is  a  most  useful  measure  to  ameliorate  the  symptoms 
of  chronic  nephritis,  and  an  albuminuria  reduced  to  a  minimum  while  the 
patient  is  up  may  often  be  further  reduced  by  putting  him  to  bed.  The  bene- 
ficial effect  of  rest  upon  edema  due  to  any  cause  is  too  well  recognized  to 
require  other  than  an  allusion.  The  advantages  of  rest  in  bed  are,  however, 
sometimes  more  than  counterbalanced  by  the  disadvantage  to  the  patient  of 
confinement  and  want  of  fresh  air  and  outdoor  life.  These,  of  course,  must 
be  weighed,  and  that  one  adopted  which  serves  the  patient  best. 

Under  hygienic  measures  is  included  suitable  clothing.  That  next  the 
body  should  be  of  wool,  for  it  must  be  remembered  that,  on  the  one  hand, 

*  The  more  usual  formula  for  Basham's  mixture  is  as  follows:  B  Tinct.  ferr.  chlorid.,  f  3ij  (7-4 
c.  c);  Acid.  acet.  destillat..  f  3ij  (7.4  c.  c);  Liq.  ammon.  acetatis,  f  siii  (go  c.  c);  Curagoae  or  syrupi 
simpl..  Aquae,  aa  q.  s.  ad  f  5  vj  CiSo  c.  c).  M.  et  Sig.  Teaspoonful  or  dessertspoonful  twice  a  day,  m 
ha,lf  a  tumbler  of  water.  If  the  mixture  becomes  turbid,  it  is  probably  because  some  of  the  acetic 
acid  has  evaporated,  when  a  few  more  drops  may  be  added  to  clear  it  up. 


714  CHRONIC  PARENCHYMATOUS  NEPHRITIS 

the  skin  is  a  powerful  adjuvant  to  the  kidney  in  its  eliminating  operations, 
and,  on  the  other  hand,  any  interference  with  or  suppression  of  the  action  of 
the  skin  must  throw  more  work  on  the  kidney.  Cold  is  the  agent  which  pro- 
duces such  suppression,  and  warmth  the  means  by  which  the  action  of  the 
skin  is  encouraged,  and  no  texture  prevents  the  former  or  secures  the  latter 
more  effectually  than  wool.  For  the  same  reason,  while  the  maximum 
amount  of  fresh  air  is  desirable,  cold  and  dampness  should  be  avoided  or  suffi- 
ciently guarded  against. 

2.  The  second  indication  is  to  depurate  the  blood  of  accumulated  impuri- 
ties, as  well  as  to  combat  the  symptoms  and  complications  which  cause  incon- 
venience or  jeopardize  life.  These  symptoms  are  those  of  dropsy,  effusions 
into  the  serous  cavities,  and  congestions.  The  patients  suffering  from  them 
are  usually  confined  to  the  house,  or  go  out  of  it  at  so  great  inconvenience  as 
to  make  it  intolerable  to  do  so.  Of  dropsy,  there  is  abundant  evidence  to  the 
naked  eye ;  but  of  the  necessity  of  depuration  there  is,  unfortunately,  no  direct 
means  of  estimation  except  by  a  volumetric  analysis  of  urine,  which  has  been 
rendered  very  much  easier  of  late  by  ready  methods  for  determining  urea. 
The  results  of  such  analysis  to  be  of  value  must  be  taken  in  connection  with 
the  kind  of  food  ingested.  Fortunately,  the  means  which  are  best  calculated 
to  relieve  the  one  are  most  likely  to  relieve  the  other.  These  measures  are, 
in  addition  to  diuretics,  such  as  promote  a  more  decided  action  of  the  skin 
than  any  yet  mentioned  and  certain  purgatives. 

With  regard  to  diuretics,  nothing  need  be  added  to  what  has  already 
been  said  under  acute  nephritis  (p.  704).  But  as  to  measures  which  promote 
a  decided  action  of  the  skin,  I  desire  to  add  the  warm  bath,  the  Turkish  bath, 
warm-pack  bath,  and  the  hot-air  or  vapor  bath  already  alluded  to.  Any  of 
these  may  be  used  as  convenience  or  the  patient's  choice  may  determine,  while 
the  frequency  with  which  they  should  be  used  depends  on  the  urgency  of  the 
case. 

The  "  warm  "  or  "  cold  pack  "  is  a  very  pleasant  form  of  bath.  The 
patient  is  wrapped  up  in  a  wet  sheet,  either  warm  or  cold,  and  further  envel  ■ 
oped  in  a  sufficient  number  of  blankets.  A  very  comfortable  sweat  generally 
ensues,  which  is  continued  for  an  hour.  In  the  use  of  the  warm  bath  the 
patient  is  immersed  at  a  temperature  of  about  104°  F.  (40°  C),  and  kept 
there  for  from  half  an  hour  to  an  hour.  He  is  then  removed  and  wrapped  in 
blankets.  It  has  been  said  under  the  treatment  of  acute  parenchymatous 
nephritis  that  these  effects  are  more  conveniently  and  as  efficiently  brought 
about  by  the  use  of  jaborandi  and  its  derivative,  pilocarpin.  The  directions 
for  their  use,  given  in  connection  with  acute  nephritis,  need  not  be  repeated. 
They  may  be  used  about  as  often,  as  the  baths,  usually  on  alternate  days,  occa- 
sionally daily,  with  advantage. 

The  judicious  use  of  aperients  is  an  efficient  means  of  depurating  the 
blood  and  reducing  dropsy.  The  selection  must  depend  on  the  urgency  of 
the  case,  as  sufficient  has  been  said  in  connection  with  acute  nephritis.  But 
in  many  cases  of  chronic  nephritis  a  stage  is  finally  reached  at  which  all  treat- 
ment of  the  kind  described  fails  to  relieve  the  dropsy,  which  becomes  eventu- 
ally the  sorest  burden  of  the  malady.  The  body  becomes  greatly  increased  in 
weight,  the  integument  of  the  extremities  is  stretched  almost  to  bursting,  and 
sometimes  it  does  rupture,  foUovv^ed  by  leakage,  which,  although  in  one  way 
inconvenient,  is  in  many  senses  a  great  relief  to  the  patient  by  diminishing 
the  tension  referred  to.  Acting  upon  this,  physicians  have  long  been  in  the 
habit  of  puncturing  the  swollen  parts  to  produce  the  required  leakage.     It  is 


DISEASES  OF  THE  URINARY  ORGANS.  715 

a  common  practice  to  make  a  number  of  minute  punctures  with  a  needle  or 
^harp-pointed  bistoury,  but  free  incisions  may  be  made  on  the  inner  or  outer 
side  of  the  ankle  of  each  leg.  Free  drainage  is  thus  secured,  often  with  great 
relief ;  or  Southey's  tubes  may  be  used  at  convenient  places.  They  are  intro- 
duced by  means  of  a  little  trocar  and  after  this  is  withdrawn  fine  india-rubber 
tubing  is  attached  to  the  little  cannula  and  carried  to  a  suitable  vessel  outside 
the  bed.  Some  remarkable  recoveries  have  followed  incisions.  Great  care 
should  be  taken  to  keep  the  tubes  clean,  as  they  are  liable  to  become  dirty  and 
clogged. 

The  treatment  of  the  complications  is  in  no  way  different  from  that  of 
the  same  conditions  under  other  circumstances.  The  point  to  be  impressed  is 
the  importance  of  being  constantly  on  the  lookout  for  them.  Effusions  into 
.serous  cavities  are  probably  the  most  important.  Edema  of  the  glottis 
requires  especial  allusion,  as  a  complication  most  alarming  and  threatening 
to  life.  Inhalations  of  steam  may  be  tried,  but  prompt  punctures  or  incisions 
are  the  only  certain  means  of  relieving  the  patient  and  saving  his  life. 

I  know  of  no  measures  directly  curative  in  acute  or  chronic  nephritis,— 
that  is,  remedies  which  by  their  direct  action  remove  the  morbid  state, — and 
I  believe  none  exist  unless  it  be  the  operation  to  be  next  described.  All  that 
can  be  done  is  to  place  the  patient  in  a  condition  most  favorable  for  nature's 
kindly  offices,  which  are  always  exerting  themselves  toward  cure.  This  is 
accomplished  by  the  measures  recommended,  which  also  eliminate  the 
mechanical  and  poisonous  products  which  interfere  with  recovery. 

Operative  Treatment. — Decapsulation  of  the  kidney  as  a  cure  for 
chronic  nephritis  was  proposed  by  Dr.  George  M.  Edebohls,  the  suggestion 
growing  out  of  some  results  of  operation  for  floating  kidney  in  persons  who 
happened  to  have  coincident  chronic  parenchymatous  nephritis.  His  results 
were  published  in  the  "  Medical  News,"  April  22,  1899.  His  first  thought 
was  that  the  cure  of  Bright's  disease  was  due  to  correction  of  the  displace- 
ment of  the  kidney,  and  it  was  not  until  three  secondary  operations  upon  kid- 
neys which  had  been  anchored  some  time  previously  demonstrated  to  him  the 
essential  conditions  underlying  the  cure  of  chronic  Bright's  disease  by  opera- 
tion, viz.,  decapsulation  or  decortication.  Edebohls  reported  in  the  "  New 
York  Medical  Record,"  December  21,  1901,  eighteen  cases,  all  of  whom 
recovered.  Two  died  of  other  causes,  one  after  an  operation  for  ruptured 
tubal  pregnancy  exactly  one  year  after  the  kidney  operation,  and  the  second 
after  hysterectomy  eight  years  after  Edebohl's  operation  on  the  right  kidney. 
Dr.  Edebohls  informed  me  November  8,  1902,  that  he  had  operated  up  to 
date  on  forty-five  cases  of  both  sexes,  and  the  results  continue  encouraging. 
In  twenty-seven  cases  he  operated  on  both  kidneys  at  one  sitting.  The  opera- 
tion consists  in  stripping  off  the  capsule  and  cutting  it  away  entirely,  close  to 
its  junction  with  the  pelvis  of  the  kidney. 

The  success  of  the  operation  is  seemingly  due,  as  Edebohls  suggests,  to 
arterial  hyperemization  of  the  kidney,  whereby  an  increased  and  adequate 
blood  supply  is  furnished  the  organ  which  permits  an  absorption  of  inter- 
stitial and  intertubular  inflammatory  products,  thus  relieving  the  tubules  and 
glomeruli  from  the  pressure  previously  interfering  with  function. 

My  experience  with  this  operation  has  been  limited  to  one  case,  but  that 
a  very  severe  one  of  chronic  diffuse  rrephritis  succeeding  upon  scarlet  fever. 
The  patient  was  a  little  girl  aged  ten.  The  case  had  lasted  over  four  years 
and  there  was  general  anasarca  as  well  as  ascites.  At  the  time  of  operation 
she  was  so  weak  that  mv  colleague,  Dr.  Frazier,  feared  to  operate  on  both 


7i6  DISEASES  OF  THE  URINARY  ORGANS. 

kidneys  at  the  same  time.  One  only  was  therefore  decorticated.  The  result 
may  be  truly  called  marvelous.  The  secretion  of  urine  which  under  the  most 
favorable  circumstances  before  operation  did  not  exceed  30  ounces  rose 
rapidly,  and  on  the  fourth  day  after  operation  over  100  ounces  were  secreted, 
and  in  ten  days  she  was  free  from  dropsy  and  ascites  and  a  month  later 
seemed  perfectly  well.  There  continued,  however,  to  be  a  large  albuminuria 
and  there  were  numerous  casts.  On  March  14,  1903,  the  second  kidney  was 
operated  upon.  She  did  well,  but  as  there  was  no  dropsy  there  did  not  suc- 
ceed the  large  increase  in  the  secretion  of  urine.  In  a  few  days,  however,  the 
quantity  of  albumin  diminished  decidedly  and  she  is  seemingly  well. 

CHRONIC  INTERSTITIAL  NEPHRITIS. 

Synonyms. — Contracted  Kidney;  Chronically  Contracted  Kidney;  Renal 
Cirrhosis;  Cirrhotic  Kidney ;  Gramdar  Degeneration;  Granidar  Kidney; 
Red  Gramdar  Kidney;  Gouty  Kidney;  Renal  Sclerosis. 

Definition. — Chronic  interstitial  nephritis  is  a  chronic  process  resulting 
ultimately  in  a  shrunken  kidney,  in  which  there  has  been  extensive  destruc- 
tion of  the  tubular  substance  and  overgrowth  of  int-erstitial  connective  tissue. 

Etiology. — Of  the  recognized  forms  of  Bright's  disease,  interstitial 
nephritis  shares  with  chronic  parenchymatous  nephritis  a  large  number  of 
instances  in  which  the  cause  is  undiscoverable.  There  are,  however,  some 
well-determined  causes.  Among  the  most  tangible  of  these  is  gout.  Gout 
is  associated  with  so  many  cases  of  contracted  kidney  that  the  term  gouty 
kidney  has  become  a  well-recognized  synonym  for  the  product  of  interstitial 
nephritis.  There  are  probably  no  cases  of  gout  which  have  continued  for  any 
length  of  time  v/hich  are  not  accompanied  by  interstitial  nephritis.  Uric  acid 
and  allied  substances  in  the  blood  are  probably  the  exciting  cause.  Another 
well-recognized  cause  is  lead  in  lead-poisoning,  the  absorbed  lead  acting  like 
the  poison  of  gout.  Hence  painters,  glaziers,  workers  in  lead  in  any  form, 
are  frequent  victims.  Dr.  Dickinson  considers  it  safe  to  assert  that  of 
painters  at  least  one-half  eventually  die  of  granular  degeneration  of  the  kid- 
neys. This  is  certainly  not  the  case  in  this  country.  It  is  true  that  alcohol 
has  always  been  assigned  an  important  role  in  the  production  of  chronic  in- 
terstitial nephritis.  It  is  probably  true,  especially  if  associated  with  a  habit 
of  overeating  proteid  foods.  The  latter  habit  alone  I  believe  to  be  a  fre- 
quent cause  of  chronically  contracted  kidney.  It  is  almost  incredible  how 
much  some  persons  eat, — persons,  too,  who  are  inactive  in  mind  and  body. 
Such  persons  must  overwork  the  kidney  and  gradually  bring  on  a  condition 
of  chronic  nephritis,  which  does  not,  however,  usually  appear  until  after 
middle  life.  On  the  other  hand,  I  believe  alcohol  alone  is  responsible  for 
more  cases  of  chronic  parenchymatous  nephritis.  The  late  Dr.  Henry  F. 
Formad,  who,  as  coroner's  physician  for  many  years  in  Philadelphia,  made 
an  enormous  number  of  autopsies  on  drunkards,  always  held  this  view,  and 
claimed  that  the  kidney  was  peculiar  enough  in  shape  to  be  called  the  "  pig- 
back  "  kidney. 

Long-continued  cystitis,  especially  following  gonorrhea,  is  a  cause  in 
a  few  instances,  the  inflammation  traveling  up  the  ureter  to  the  pelvis  of  the 
kidney  and  thence  to  the  intertubular  tissue.  The  more  usual  result  of 
such  extension  is  suppurative  nephritis. 

Among  the  causes  the  operation  of  which  cannot  be  so  directly  proved 


CHROXIC  IXTERSTITIAL  XEPHRITIS.  yi-j 

are  anxiety  or  business  care  and  z^'orry.  Dr.  Clifford  AUbutt.  quoted  by 
Dr.  Robert  T.  Edes,"^  goes  so  far  as  to  attribute  "'  twenty-four  out  of  thirty- 
two  cases  in  private  practice  to  some  long-continued  anxiety  or  great  grief." 
This  also  is  contrary  to  my  experience.  It  is  true  that  this  disease  very 
often  exists  for  a  long  time  undiscovered  in  business  men  who  have  lived 
under  a  state  of  constant  mental  tension.  The  eft'ect  of  this  cause  is  aug- 
mented if  its  subjects  combine  too  liberal  eating  and  drinking  with  the  hard 
work  and  axiety. 

Hereditary  influence  is  occasionally  a  cause  of  contracted  kidney.  A 
remarkable  instance  of  this  has  occurred  in  my  own  practice.  I  was  con- 
sulted by  a  man,  aged  thirty,  who  had  granular  kidneys.  His  father  and 
mother  both  died  of  Bright's  disease,  aged  fifty-six  and  sixty-three  years, 
respectively.  The  mother  had  convulsions.  A  brother  died  of  Bright's 
disease,  without  convulsions,  at  the  age  of  thirty-seven.  Two  children  of 
this  brother  had  Bright's  disease  when  four  and  seven  years  of  age,  re- 
spectively. A  second  brother  died  at  the  age  of  twenty-nine  with  convul- 
sions. A  third  and  fourth  brother,  aged  twenty-three  and  thirty-two  years, 
respectively,  have  had  Bright's  disease  for  six  years.  A  sister,  aged  thirty- 
six,  has  had  Bright's  disease  for  five  years.  A  brother,  aged  twenty-six, 
and  a  sister,  aged  thirty-four,  have  as  yet  exhibited  no  signs  of  Bright's 
disease.  A  maternal  cousin  died  of  undoubted  Bright's  disease,  and  other 
members  of  the  family  belonging  to  previous  generations  died  with  symptoms 
which  suggest  Bright's  disease.  The  patient,  himself,  has  undoubted  granti- 
lar  kidney,  discovered  in  August,  1880.  An  examination  of  his  urine  in  1876 
revealed  no  evidences  of  the  disease.  There  is  no  gout  in  the  family.  Dr. 
Dickinson  also  relates  the  histor\-  of  a  family  in  which  a  hereditary  albumi- 
nuria existed  independent  of  gout. 

Prolonged  passizr  congestion,  due  to  valvular  heart  disease,  may  become 
a  cause  of  granular  kidney.  The  same  may  be  said  of  stone  in  the  kidney 
causing  numerous  attacks  of  nephritic  colic.  I  have  known  typical  chronic 
interstitial  nephritis  ensue  on  such  attacks  of  nephritic  colic. 

Pregnancy,  so  frequently  a  cause  of  acute  parenchymatous  nephritis,  is 
rarely,  if  ever,  a  cause  of  interstitial  nephritis  or  chronic  parenchymatous 
nephritis.  It  is  true  contracted  kidney  is  sometimes  found  in  autopsies  of 
women  dving  of  puerperal  nephritis,  but  I  believe  it  more  frequently  pre- 
cedes than  folloAvs  the  pregnancy. 

Interstitial  nephritis  is  commonly  a  disease  of  middle  age.  the  majority 
of  persons  in  whom  it  is  discovered  being  past  forty.  A  few  cases  occur 
under  thirty.  The  youngest  patient  whom  I  have  ever  had  was  twenty-six. 
Still  younger  cases  are  reported. 

It  must  be  remembered  that  there  is  a  tendency  to  overgrowth  in  the 
interstitial  tissue  of  the  kidney,  as  of  other  organs,  in  old  age.  Hence  the 
term,  soiile  atrohJiy  of  the  kidney.  It  is  not  safe,  therefore,  to  call  every 
instance  of  atrophied  kidney  met  in  the  postmortem  room  a  case  of  inter- 
stitial nephritis.  The  clinical  history,  or  some  one  of  the  well-marked 
symptoms  of  the  disease,  as  albuminuria  or  uremic  symptoms,  should  have 
preceded  to  sustain  the  diagnosis. 

As  to  sex.  nearly  twice  as  many  males  have  the  disease  as  females, 
because  of  the  more  frequent  exposure  of  the  former  to  the  causes  of  the 
affection. 


*  Robert  T.  Edes,  "  Some  of  the  Symptoms  of  Bright's  Disease,"  "  Boston  Med.  and  Surg.  Jour.," 
vol.  ciii,  No.  2,  July  8,  1880. 


71 8  DISEASES  OE  THE  URINARY  ORGANS. 

Morbid  Anatomy. — In  interstitial  nephritis,  both  kidneys  are  involved^ 
but  there  is  often  a  marked  difference  in  the  extent  of  the  disease  in  each. 

Macroscopically,  the  organs  are  evidently  smaller  than  in  health,  often 
less  than  half  as  large.  I  have  seen  them  less  than  five  centimeters  (2 
inches)  in  length.  Next  to  this  reduction  in  size,  the  most  striking  feature 
of  the  contracted  kidney  is  its  uneven  or  granular  surface,  which  is,  how- 
ever, not  always  recognizable  until  after  the  capsule  is  removed.  Very 
characteristic  also  is  the  presence  of  cysts  with  more  or  less  clear  watery  or 
gelatinous  contents,  often  visible  through  the  capsule.  These  are  not  in- 
variably, but  quite  frequently,  present.  The  capsule,  itself  thickened,  strips 
off  with  difficulty,  dragging  portions  of  the  secreting  structure  with  it. 
Owing  to  the  resistance  which  the  blood  meets  in  its  passage  through  the 
kidney,  a  larger  portion  of  it  passes  out  of  the  organ  by  way  of  the  cap- 
sule ;  hence  ^  be  blood-vessels  of  the  latter  are  dilated,  as  are  also  the 
lymph-spaces. 

Bereft  of  its  capsule,  the  kidney  is  hard,  granular,  tough,  and  usually 
darker  than  in  health,  whence  one  of  its  names,  the  "  red  granular  kidney.'* 
This  color  is  in  strong  contrast  to  the  white  or  slightly  yellow  tinge  of  the 
fatty  and  contracting  kidney,  and  although  it  is  not  always  marked,  and 
sometimes  even  substituted  by  a  paleness,  it  is  still  easily  distinguished 
from  that  of  the  contracting  kidney  of  parenchymatous  nephritis.  The 
granules  on  the  surface  of  the  contracted  kidney  are  distinct  round  and 
oval  elevations  of  the  surface,  ranging  in  size  from  that  of  a  pin's  head  to 
that  of  a  pea,  or  from  1-25  to  1-5  inch  ( i  to  5  mm.).  Those  of  smaller  size 
are  most  numerous,  and  at  first  correspond  with  the  lobules,  the  bases  of 
which  are  visible  on  the  surface  of  the  normal  organ.  The  larger  ones 
result  from  the  coalescence  of  two  or  more  of  the  smaller.  The  granules 
themselves  are  of  a  lighter  color  than  the  depressed  circlets  between  them, 
which  are  tinted  with  vascularity  and  have  a  purplish  or  faint  red  hue.  The 
cysts  already  referred  to  are  now  more  distinct  (after  removal  of  the  cap- 
sule), and  vary  greatly  in  size.  While  equaling  in  minuteness  the  smallest 
of  the  granules,  some  of  them  are  as  large  as  a  walnut.  The  larger  are 
apt  to  be  ruptured  on  stripping  off  the  capsule. 

On  section,  it  is  at  once  evident  that  the  reduction  in  size  of  the  kidney 
is  largely  due  to  a  narrowing  of  the  cortex,  although  the  medulla  is  also 
contracted.  The  former  may  not  be  more  than  from  1-8  to  1-6  inch  (3  or  4 
mm.)  in  width,  and  exhibit  every  degree  between  this  and  the  normal. 
The  Malpighian  bodies  are  smaller,  less  numerous,  and  can  scarcely  be 
detected  by  the  naked  eye,  while  the  small  arteries  are  more  prominent 
from  the  thickening  of  their  ^alls.  Increased  density  and  firmness  of  the 
organ  are  apparent.  In  a  gouty  subject,  linear  chalk-marks  of  sodium 
urate  may  be  present,  more  particularly  in  the  pyramids  of  straight  tubules, 
and  are  contained  within,  as  well  as  between,  the  latter.  The  little  cysts 
referred  to  as  seen  on  the  surface  may  also  be  scattered  throughout  the 
section  from  cortex  to  papillae,  but  they  are  more  numerous  in  the  former. 
They  are  not  always  present.  The  pelvis  of  the  kidney  may  be  unaltered. 
It  is  sometimes  enlarged,  and  the  calices  are  elongated  from  retraction  of 
the  pyramids.  On  the  other  hand,  if  the  kidney  is  very  much  reduced  in 
size,  the  capsule  may  be  pursed  up  and  proportionately  smaller. 

Minute  Structure. — ]\Iinute  examination  of  thin  sections  through  the 
cortex  clearly  reveals  the  condition  to  be  an  excess  of  connective  tissue, 
with   destruction   of  the   tubules    and   blood-vessels.     The   process    is   best 


CHRONIC  INTERSTITIAL  NEPHRITIS.  719 

studied  if  the  sections  include  the  capsular  edge,  as  the  disease  progresses 
from  without  inward.  In  such  sections  may  be  seen  extensive  tracts  of 
connective  tissue  separating  the  tubules,  which,  in  healthy  kidneys,  are 
closelv  in  contact  without  appreciable  intertubular  substance.  The  tubules 
themselves  appear  in  places  quite  normal ;  in  others  they  are  represented  by 
fragmentary  portions  in  which  the  cells  are  still  unchanged ;  in  others,  again, 
the  cells  exhibit  a  granular  degeneration ;  some  tubes  are  evidently  dilated ; 
others  still  are  completely  shriveled,  while  it  is  evident  from  the  larger  areas 
of  connective  tissue  that  many  have  completely  disappeared.  In  a  few  tubules 
waxv  casts  are  present.  The  Malpighian  bodies  are  surrounded  by  con- 
centric lavers  of  nucleated  connective  tissue.  Many  of  them  are  shriveled 
and  atrophied,  and  an  attempt  to  inject  them  with  colored  injecting  fluids 
fails  either  partially  or  completely.  Some  thus  altered  lie  detached  from 
the  tubules,  with  which  they  should  be  continuous.  The  granules  on  the 
surface  of  the  kidneys  are  resolvable  by  the  microscope  into  tubules,  some 
of  which  are  in  a  tolerably  perfect  state,  some  decidedly  dilated. 

The  cysts  originate  partly  in  dilatations  of  obstructed  segments  of  the 
uriniferous  tubules  and  partly  in  dilated  ]\Ialpighian  capsules.  Proof  of  the 
latter  mode  of  origin  is  found  in  the  fact  that  compressed  capillary  tufts  are 
sometimes  found  lying  up  against  one  side  of  the  wall  of  the  cyst.  The 
same  overgrowth  of  connective  tissue  may  be  seen  in  the  pyramids,  but  it 
appears  later,  extends  more  slowly,  and  never  reaches  the  degree  found  in 
the  cortex. 

The  blood-vessel  of  the  contracted  kidney  is  the  seat  of  important 
changes.  In  the  first  place,  it  shares  with  the  tubules  the  compressing  effect 
of  the  contracting  new  formation.  As  the  result  of  this,  a  part  of  the  capil- 
lary system  is  destroyed,  and  in  the  part  thus  destroyed  are  many  capillary 
coils  in  the  Malpighian  bodies.  Hence,  as  many  afferent  arterioles  send 
their  blood  directly  into  the  second  capillary  network,  which  is  also  cut 
down  bv  the  pressure.  The  vessels  which  remain  are  often  sclerotic, 
dilated,  and  twisted,  and  in  consequence  of  the  destruction  of  numerous 
Malpighian  bodies  send  much  of  their  blood  out  through  the  capsule  of  the 
kidney.  The  intima  is  thickened,  and  the  media  and  adventitia  are  invaded  by 
hyperplastic  connective  tissue,  but  always  to  a  less  degree.  Even  arterioles 
whose  walls  have  thus  been  thickened  become  involved  in  the  atrophic 
processes  affecting  the  glandular  tissue  of  the  organ,  and  ultimately  disappear. 

Associated  with  these  changes  are  a  general  arteriosclerosis  and  hyper- 
trophy of  the  left  ventricle  of  the  heart,  sometimes  also  of  the  right.  The 
final  effect  of  these  alterations  is  to  produce  a  brittleness  in  the  arteriole 
walls,  which  disposes  them  to  rupture  on  very  slight  increase  of  intravascu- 
lar pressure.  Hence  the  frequent  fatal  termination  of  cases  of  interstitial 
nephritis  by  apoplexy,  also  the  frequent  nasal  and  retinal  hemorrhages 
which  characterize  the  disease. 

The  retinal  changes, — retinitis  albuminurica, — symptoms  of  which  form 
so  important  a  part  of  the  symptomatology  of  chronic  interstitial  nephritis, 
are  various  and  vary  with  the  stage  of  each  case.  Many  cases  are  first  diag- 
nosed by  the  ophthalmic  surgeon.  The  changes  include  serous  swelling 
of  the  disc  and  surrounding  retina,  hemorrhagic  extravasations,  dirty  white 
splotches,  representing  fatty  degeneration,  and  dilatation  of  the  veins 
and  capiltaries,  with  fatty  degeneration  and  sometimes  hyaline  thickening 
of  their  walls. 

Symptoms. — The  great  obscurity  as  to  the  origin  of  a  large  majority 


720  DISEASES  OF  THE  URINARY  ORGANS. 

of  cases  of  contracted  kidney  is  only  equaled  by  that  of  the  insidiousness 
of  their  approach.  The  beginning  of  the  disease  is  certainly  not  character- 
ized by  any  distinctive  symptoms ;  and  its  progress  is  often  unmarked  by 
any,  until  those  of  uremia  mark  the  beginning  of  the  end.  To  the  observing 
phvsician  some  obscure  symptom  may  suggest  an  examination  of  the  urine ; 
or  the  peculiar  tense  and  bounding  pulse  of  hypertrophy  of  the  left  ventricle, 
or  the  more  tangible  symptom  of  a  slight  swelling  of  the  feet  or  ankles, 
recognizable  only  at  night  or  through  the  unexpected  tightness  of  a  boot, 
may  lead  to  the  same  examination. 

Changes  in  the  Urine. — Attention  being  called  to  the  urine,  it  will  be 
found  to  present  characters  which  are  more  or  less  distinctive  and  lead  easily 
to  a  diagnosis.  When  freshly  passed,  it  is  acid  in  reaction,  copious,  often 
exceeding  the  normal  amount,  and  never  scanty,  except  in  the  last  stages  of 
the  disease.  The  quantity  is  often  sixty  (1800  c.  c),  and  may  reach  ninety 
ounces  (2700  c.  c).  The  patient  very  commonly  must  rise  at  night,  prob- 
ably not  more  than  once  or  twice,  to  pass  his  water.  There  may  be  corre- 
sponding thirst.  Consequently,  the  urine  is  light  in  color  and  of  low  specific 
gravity, — 1005  to  1015, — and  contains  a  trifling"  or  moderate  flocculent  sedi- 
ment. It  is  generally  albuminous,  but  the  albumin  is  small  in  amount  and 
may  be  temporarily  absent,  or  it  may  be  absent  before  a  meal  and  present 
after  it.  Later,  however,  the  albumin  becomes  corfstant.  It  seldom  exceeds 
one-tenth  the  bulk  of  fluid  tested,  and  is  very  constantly  a  great  deal  less, 
showing  a  delicate  line  of  white  by  Heller's  nitric  acid  test.  Tube-casts  are 
present,  but  not  usually  numerous.  They  are  almost  solely  hyaline  and  pale 
granular.  Some  of  the  hyaline  casts  are  delicately  so,  requiring  delicate 
illumination  for  their  detection ;  others  are  distinct  and  sharply  cut ;  others 
still  contain  two  or  three  glistening  oil  drops.  Casts  may  at  times  be  absent 
and  again  reappear,  as  is  the  case  with  albumin.  Toward  the  termination  of 
cases  of  •  interstitial  nephritis  the  urine  diminishes  in  quantity,  the  specific 
gravity  increases,  and  the  casts  become  much  more  numerous,  and  include 
among  them  highly  granular  or  dark  granular  and  occasionally  even  blood 
casts  in  addition  to  those  mentioned,  and  there  are  sometimes  a  few  blood 
discs  earlier.  The  urea  is  also  diminished,  sooner  or  later,  and  in  this  man- 
ner the  lower  specific  gravity  is  contributed  to.  This  fall  becomes  marked 
toward  the  close,  accounting  for  the  uremic  symptoms  which  often  first 
announce  the  disease.  It  may  be  as  low  as  fifteen  grains  (i  gm.),  and  may 
range  anywhere  between  this  and  the  normal  twenty-four  hours'  quantity, 
which  may  be  put  down  at  from  308  to  617  grains  (20  to  40  gm.)  in  an 
adult,  being  largely  influenced  by  the  kind  of  food  ingested.  All  the  re- 
maining normal  constituents  ftiay  be  said,  in  general  terms,  to  be  diminished. 

As  to  the  other  symptoms,  a  feeling  of  nnaceonntable  weakness  or  of 
being  tired  is  very  often  present,  but  it  is  a  symptom  which  occurs  in  many 
conditions,  and  should  only  be  considered  as  suggestive.  Slight  edema 
about  the  feet  and  ankles  is  often  present,  being  so  slight  as  to  escape  detec- 
tion, or  it  is  discovered  accidentally.  When  present  it  is  significant,  but  it 
is  often  entirely  wanting. 

Hypertrophy  of  the  left  ventricle  of  the  heart  without  valvular  disease  is 
so  constant  as  to  be  alone  suggestive  of  the  disease.  No  case  of  interstiti'^l 
nephritis  has  existed  for  any  length  of  time  without  this  condition  super- 
vening, and  as  few  cases  are  discovered  until  they  have  existed  for  some 
time,  few  are  found  without  hypertrophy.  In  more  than  one-half  of  cases, 
at  least,  there  is  evident  hypertrophy.     It  is  recognized  at  first  not  so  much 


CHRONIC  INTERSTITIAL  NEPHRITIS.  721 

by  the  resulting  enlarged  percussion  area  as  by  the  sharp  accentuation 
of  the  aortic  second  sound.  Corresponding  to  this,  the  pulse  is  hard  and 
resisting,  indicating  high  tension  and  thickening.  These  two  symptoms 
have,  therefore,  great  diagnostic  value.  Sclerosis  is  distinguished  from 
tension  by  obliterating  the  blood-current  by  pressure  and  feeling  the  artery 
beyond  this  point.  The  sclerosed  vessel  continues  tangible;  that  of  simple 
high  tension  disappears.  A  symptom  of  this  stage  is  often  an  uncomfort- 
able pulsation  felt  in  the  head  and  even  in  other  parts  of  the  body. 

The  causes  of  these  changes  in  the  vascular  system  will  be  considered 
when  treating  of  the  relation  of  heart  disease  and  kidney  disease. 

As  the  disease  becomes  more  advanced  there  are  added  cardiac  symp- 
toms, including  dyspnea,  palpitation,  and  reduplication  of  the  first  sound. 
The  last  is  probably  due  to  a  want  of  synchronism  in  the  systole  of  the 
two  ventricles.  There  is  usually  no  murmur,  because  there  is  no  valvular 
disease.  The  latter  may  be  present.  The  patient  may  have  had  valvular 
disease  prior  to.  the  renal  malady,  or  the  latter  itself,  by  its  long  continuance, 
may  have  produced  endocarditis  and  atheroma  with  an  aortic  systolic  mur- 
mur, or  there  may  be  a  mitral  murmur  due  to  relative  insufficiency.  Valvu- 
lar disease  is,  however,  unusual.  The  hypertrophy  of  the  heart  is  conserva- 
tive, and  all  goes  well  as  long  as  the  power  of  the  heart  lasts.  When  the 
latter  begins  to  fail  and  dilatation  appears,  the  blood  pressure  diminishes, 
and  with  it  begins  a  train  of  symptoms,  among  which  diminished  secretion 
of  urine  and  dropsy  are  the  most  conspicuous,  along  with  gallop  rhythm, 
dyspnea,  palpitation,  and  dizziness.  These  symptoms  may  again  be  averted 
for  a  time  by  hypertrophy  of  the  right  ventricle,  which  is  a  symptom  of 
disturbed  compensation.  Among  derangements  of  breathing  must  be  in- 
cluded Cheyne-Stokes  breathing,  commonly  toward  the  end  of  the  disease. 

Dimness  of  vision  due  to  retinitis  albuminurica,  already  described  on 
page  719  is  a  characteristic  symptom.  It  is  often  the  first  recognized,  and 
hence  the  diagnosis  is  frequently  first  made  by  the  ophthalmologist.  It  is 
a  serious  symptom,  generally  considered  a  sign  of  advanced  disease,  as, 
indeed,  it  usually  is.  Some  assign  two  years  as  the  limit  of  life  after  its 
recognition,  but  this  is  too  unfavorable  a  prognosis.  The  atheroma  of  the 
blood-vessels  is  the  cause  of  another  symptom  which  frequently  deter- 
mines the  mode  of  death — rupture  of  a  blood-vessel  in  the  brain :  in  a  word, 
apoplexy.  This  accident  is  more  usual  late  in  life,  but  Dickinson  reports 
a  case  in  which  cerebral  hemorrhage  occurred  in  a  girl  of  twelve.  The 
proportion  of  cases  of  recognized  interstitial  nephritis  in  which  this  happens 
is  not  large,  but  many  cases  of  apoplexy  are  directly  traceable  at 
autopsy  to  unsuspected  renal  cirrhosis.  Dickinson  believes  that  of  fatal 
cases  of  apoplexy,  one-half  are  preceded  by  this  form  of  disease.  Hemor- 
rhages in  other  situations  are  referable  to  this  same  altered  state  of  the 
blood-vessels,  as,  for  example,  into  the  retina,  from  the  nose,  and  even 
into  the  stomach.  Hence,  sudden  blindness,  in  addition  to  the  dimness  of 
vision  due  to  retinitis  albuminurica,  is  a  symptom  which  occasionally  pre- 
sents itself.  Amaurosis  and  amblyopia  also  occur,  and  may  disappear,  but 
dimness  of  vision  due  to  retinitis  albuminurica  is  a  permanent  symptom, 
though  I  have  seen  it  improve  under  treatment.  Auditory  disturbances 
also  occur,  such  as  ringing  in  the  ears,  with  dizziness  and  more  or  less 
deafness. 

The  termination  by  uremia  occurs  more  frequently  in  this  than  in  any 
other  form  of  Bright's  disease.     Bartels  says  that  nearly  all  the  patients  he 


^22  DISEASES  OF  THE  URINARY  ORGANS. 

has  seen  die  in  the  extreme  stage  of  atrophied  kidneys  sank  under  the 
symptom  of  chronic  uremia.  He  is  probably  correct,  and  it  is  frequently 
the  first  intimation  of  the  existence  of  any  derangement,  manifesting  itself 
in  any  one  or  more  of  the  forms  already  described  under  acute  nephritis. 
Headache,  drowsiness,  convulsions,  stupor,  delirium,  maniacal  excitement, 
renal  asthma,  restlessness,  nausea,  vomiting — any  one  of  these  symptom^ 
may  usher  in  the  dreadful  train  which  is  so  likely  to  be  fatal.  E.  C.  Seguin 
especially  has  called  attention  to  occipital  headache  as  a  symptom  of  uremia.''' 
\'on  Leube  considers  that  even  the  intermittent  headaches  which  occur  in 
this  disease,  and  which  very  closely  resemble  migraine,  are  probably  due 
to  uremia.  Temperature  follows  the  same  rule  in  uremia  as  in  other  forms 
of  nephritis.  The  convulsion  is  commonly  associated  with  a  rise  of  tem- 
perature. Dyspeptic  symptoms,  v.-ith  obstinate  vomiting,  particularly  in  the 
morning  on  rising,  are  apt  to  usher  in  a  chronic  uremia.  Diarrhea  is  less 
common,  but  also  sometimes  occurs  toward  the  close,  when  it  may  be  very 
difficult  to  control. 

The  duration  of  this  form  of  renal  disease  is  indefinite.  Always  a 
chronic  process,  it  may  last  for  years  undiscovered,  and  when  discovered 
before  it  is  too  far  advanced,  the  knowledge  of  its  presence  will  suggest 
measures  of  precaution  and  treatment  which  may  so  prolong  life  that  it  need 
only  be  determined  by  its  natural  limit  or  some  other  disease.  Yet  complete 
recovery  from  well-established  interstitial  nephritis  is  probably  unknown. 

Complications. — These  include  bronchitis,  pericarditis,  pleurisy,  pneu- 
monia, and,  more  rarely,  endocarditis,  peritonitis,  intertubular  gastritis, 
and  even  inflammation  and  ulceration  of  the  bowels.  But  all  inflammatory 
complications,  except  bronchitis,  pleurisy,  and  pericarditis,  are  less  frequent 
than  in  acute  nephritis.  Bronchitis  is  said  to  be  the  most  frequent  com- 
plication, while  pericarditis  is  the  most  dangerous,  being  almost  invariably 
fatal.  The  former  occurs  in  about  33  per  cent,  of  the  cases,  and  the  latter 
in  25  per  cent.,  according  to  W.  Howship  Dickinson,  and  7  per  cent,  ac- 
cording to  Sir  T.  Grainger  Stewart.  ]\Iy  own  experience  accords  more 
nearly  with  the  latter.  Pleurisy  and  pneumonia  are  also  of  tolerably  fre- 
quent occurrence.  Dr.  Stewart  finding  the  former  in  15  per  cent,  of  his 
cases  and  pneumonia  in  7  per  cent.  Acute  endocarditis  and  peritonitis 
occur,  but  very  seldom. 

Diagnosis. — The  diagnosis  of  an  interstitial  nephritis  is  usually  easy, 
if  in  any  way  an  examination  of  the  urine  is  suggested.  The  increased 
quantity,  the  low  specific  gravity,  small  albuminuria,  delicate  hyaline,  pale 
granular  casts,  and  hypertrop^hy  of  the  left  ventricle,  even  in  the  absence 
of  other  symptoms,  are  sufficiently  distinctive.  The  conditions  which 
should  suggest  such  an  examination  are  a  feeling  of  constant  weariness, 
slight  swelling  of  the  feet,  drowsiness,  frequent  headaches,  confused  intellect, 
dyspeptic  symptoms,  obstinate  nausea,  delirium,  coma,  and  convulsions. 
High  arterial  tension  should  aways  suggest  examination  of  the  urine. 

The  special  condition  from  which  it  is  most  difficult  to  distinguish  it  is 
the  milder  form  of  chronic  diffuse  or  parenchymatous  nephritis,  especially 
if  the  latter  has  reached  the  contracting  stage.  In  fact,  the  symptoms  are 
often  identical,  and  unless  the  history  helps  us,  it  may  be  impossible  to 
decide.  The  evidences  of  decided  fatty  change,  such  as  the  oil  cast  or  free 
fatty  renal  cell  in  the  urine,  settle  the  question  in  favor  of  chronic  diffuse 
nephritis. 

*  "  Archives  of  Medicine,"  vol.  iv.,  No.  i,  New  York,  August,  1880. 


CHRONIC  INTERSTITIAL  NEPHRITIS.  723 

Diabetes  insipidus  is  comparable  to  contracted  kidney  in  the  increased 
quantity  of  urine  of  low  specific  gravity,  but  there  is  no  albumin,  casts  are 
absent,  and  the  quantity  of  urine  is  much  greater. 

Prognosis. — The  prognosis  is  unfavorable  as  to  recovery,  but  favorable 
as  to  prolongation  of  life  if  the  diagnosis  be  made  sufficiently  early.  Cases 
with  casts  and  small  albuminuria  may  continue  under  observation  for  ten 
or  more  years.  If  not  made  previous  to  the  setting  in  of  uremic  symptoms, 
little  may  be  expected.  But  even  at  this  stage,  energetic  treatment  may  still 
avail  to  avert  the  immediate  danger  and  prolong  the  patient's  life.  The  pos- 
sible sudden  occurrence  of  convulsions  and  coma,  and  of  death  therefrom, 
should  always  be  remembered  and  impressed  upon  the  relatives  of  the 
patient.  These  constitute  unfavorable  symptoms,  to  which,  toward  the  end, 
Cheyne-Stokes  breathing  may  be  added. 

Treatment. — From  what  has  been  said  under  prognosis,  it  is  evident 
that  the  most  hopeful  result  to  be  expected  from  treatment  is  the  protection 
of  the  patient  from  the  consequences  of  his  malady,  rather  than  the  restora- 
tion of  the  kidney  to  its  normal  condition.  Our  power  in  the  former  respect 
depends  largely  upon  the  stage  at  which  the  disease  is  discovered.  If  de- 
tected at  a  period  in  which  the  urine  is  abundant,  the  albuminuria  small,  the 
casts  few,  and  there  is  no  edema,  the  indications  are : 

1.  To  maintain  the  integrity  of  the  blood,  by  preventing  the  accumula- 
tion of  urea  and  allied  compounds. 

2.  To  treat,  as  they  arise,  the  accidents  and  complications  which  are 
often  so  dangerous  to  the  patient. 

The  first  of  these  is  best  accomplished  by  dietetic  and  hygienic  measures, 
aided  by  the  use  of  a  few  remedies.  First,  as  to  food,  all  that  was  said 
under  chronic  parenchymatous  nephritis  is  applicable  to  interstitial  neph- 
ritis, because  the  appetite  is  still  good,  and  a  suitable  selection  can  be  exer- 
cised. As  the  urea  has  its  chief  source  in  the  azotized  elements  of  food, 
it  is  plain  that  the  larger  the  quantity  of  such  food  consumed,  the  larger 
is  the  accumulation  of  urea  to  be  eliminated  by  the  kidneys.  Now,  while 
it  is  not  possible  nor,  perhaps,  desirable  to  exclude  all  nitrogenous  food, 
it  may  be  largely  reduced.  This  is  accomplished  by  the  substitution  of  all 
or  a  part  of  animal  flesh  by  milk,  while  drawing  the  elements  of  a  mixed 
food  from  the  vegetable  kingdom.  The  so-called  vegetarians  have  proved 
conclusively  that  it  is  possible  to  live  and  maintain  good  health  upon  milk 
and  an  otherwise  exclusively  vegetable  diet,  and,  while  this  diet  may  not 
be  compatible  with  the  highest  mental  and  physical  development  of  which 
man  is  capable, "^^  which  is  not  at  all  proved,  the  resulting  life  is  perfect 
enough  for  all  its  objects,  and  will  doubtless  be  acceptable  to  those  who 
prefer  to  live.  On  such  a  system  I  have  known  the  patient  with  contracted 
kidney  to  maintain  apparently  perfect  health  for  many  years. 

With  regard  to  habitual  laeverages,  the  use  of  strong  alcoholic  drinks 
is  harmful,  and  brandy,  whisky,  champagne,  sherries  and  ports  should 
be  prohibited.  The  light  wines,  and  especially  the  red  wines  and  lighter 
alcoholic  drinks,  as  lager  beer,  porter,  etc.,  may  be  used  in  moderation. 
I  have  already  referred  to  the  very  great  value  of  the  alkaline  mineral 
waters,  such  as  those  of  Vichy,  Vals,  and  Kissingen ;  to  these  a  little  claret 
may  be  added  at  dinner.  ' 

What  has  been  said  of  clothing,  fresh  air,  and  exercise  in  connection 


*  See  Carpenter's  "  Physiology,"  seventh  English  edition,  1869,  p.  77. 


724  DISEASES  OF  THE  URIXARY  ORGAXS. 

with  chronic  parenchymatous  nephritis  is  even  more  apphcable  to  interstitial 
nephritis.  Warmth  of  the  body,  maintained  by  woolen  garments  next  the 
skin  to  encourage  its  action,  and  the  avoidance  of  damp  and  cold,  which 
check  it,  are  peremptory.  The  wetting  of  the  body  by  rain,  or  of  the  feet 
alone,  has  frequently  been  the  exciting  cause  of  a  fatal  uremic  attack.  India- 
rubber  overshoes  should  be  worn  in  damp  weather. 

In  this  connection,  sea-bathing  requires  mention.  It  is  well  known 
that  sea-bathing  sometimes  induces  albuminuria  in  normally  constituted 
persons,  or,  at  least,  in  individuals  at  other  times  free  from  albuminuria. 
This  is  probably  due  to  a  temporary  congestion  of  the  kidney,  from  intro- 
version of  the  blood  kept  up  by  the  duration  of  the  bath.  Still  more  mis- 
chievous, therefore,  must  be  the  effect  of  prolonged  sea-bathing  upon  one 
whose  kidneys  are  already  damaged  and  incompetent  to  perform  their  office. 
Sea-bathing,  therefore,  or  any  form  of  cold  bathing,  should  be  interdicted 
to  the  patient  with  contracted  kidney  or,  indeed,  with  any  form  of  chronic 
nephritis.  Sea-bathing  is  especially  mentioned  because  it  is  considered 
healthful,  and  persons  remain  in  the  water  so  long  at  a  time.  On  the  other 
hand,  a  daily  warm  bath  at  bedtime,  and  especially  an  occasional  Turkish 
bath,  is  advantageous. 

For  the  same  reason  residence  in  a  warm,  equable  climate  is  often  of 
signal  service  in  interstitial  nephritis ;  and  cases  are  reported  in  which  the 
albumin  has  disappeared  and  symptomatic  recovery  taken  place  during  such 
residence. 

Prolonged  bodily  or  mental  fatigue  should  also  be  avoided  by  these 
patients,  as  they  have  been  known  to  be  the  exciting  cause  of  uremia  and 
death  ;  especially  are  they  so  when  associated  with  free  eating  and  drinking. 
The  patient  should  live  a  life  as  easy  and  as  free  from  any  of  these  causes 
which  have  been  considered  as  his  circumstances  will  permit. 

As  to  drugs,  they  are  of  limited  utility.  The  moderate  use  of  tonics, 
including  quinin,  strychnin,  and  iron,  is  useful  to  combat  the  tendency  to 
anemia  and  weakness,  which  sooner  or  later  follows.  In  this  form  of 
Bright's  disease,  even  more  than  in  chronic  parenchymatous  nephritis,  is  the 
indiscriminate  use  of  iron  to  be  guarded  against.  Iron  in  contracted  kid- 
ney, as  often  used,  is  a  harmful  drug.  It  locks  up  secretions,  causes  head- 
ache, and  increases  the  danger  of  uremia.  Only  when  there  is  evident 
anemia  should  it  be  used,  and  then  only  in  very  small  doses.  I  hold  that 
so  long  as  iron  blackens  the  stools  or  constipates  the  bowels,  the  doses  are 
too  large,  and  they  should  be  reduced  until  the  effect  on  the  stools  is  very 
slight  or  not  noticeable.  Elimination  is  favored  by  stimulating  the  secretion 
of  the  skin,  and  this  is  best  accomplished  by  an  occasional  warm  bath,  or, 
especially,  a  Turkish  bath,  with  thorough  friction  and  protection  from  cold 
by  woolen  underclothing.  The  Turkish  bath  is  an  admirable  remedial 
measure,  especially  before  the  disease  is  too  far  advanced. 

Diuretics  are  not  indicated  in  the  earlier  stages,  because  the  secretion 
of  urine  is  already  free.  The  bowels  should  be  kept  regular  by  the  use 
of  the  natural  aperient  waters,  the  Hunyadi,  Friedrichshalle,  and  Rakoczy, 
or  an  occasional  blue  pill,  or  a  dose  of  magnesium  sulphate.  Of  course, 
later  in  the  disease,  when  the  heart  begins  to  fail  and  the  urine  is  scanty, 
both  diuretics  and  purgatives  are  indicated.  The  same  principles  are  to 
govern  us  in  using  them  as  have  already  been  laid  down  under  acute 
nephritis.  Very  high  arterial  tension  sometimes  demands  treatment.  A 
certain  amount  is  a  result  of  the  conservative  train  of  symptoms,  beginning 


CHRONIC  INTERSTITIAL  NEPHRITIS.  725 

with  hypertrophy  of  the  left  ventricle,  and  is  necessary ;  but  when  a  result- 
ing throbbing  is  unpleasantly  appreciable,  especially  if  there  is  throbbing 
headache  with  flashes  of  light  at  each  pulsation,  tension  should  be  low- 
ered. The  remedy  which  excels  all  others  is  nitroglycerin,  which  should 
be  given  in  doses  of  i-ioo  grain  (0.00066  gm.)  and  upward  every  three 
hours  or  oftener.  The  best  preparation  is  the  one  per  cent,  alcoholic  solu- 
tion, of  which  one  drop  represents  i-ioo  grain  (0.00066  gm.),  the  granules 
being  more  convenient,  but  less  reliable.  The  dose  should  be  rapidly  in- 
creased until  the  physiological  effect  is  obtained,  and  then  reduced  to  what 
is  found  best  to  effect  its  purpose.  Either  the  susceptibility  of  different 
persons  varies  greatly  or  the  drug  varies  greatly  in  quality.  I  have  re- 
peatedly given  it  every  two  hours  for  days  together  in  doses  of  i-ioo  grain 
(0.00066  gm.).  It  may  be  associated  with  digitalis,  with  which  it  co- 
operates by  relaxing  the  arteriolar  spasm  which  digitalis  produces,  and 
which  interferes  with  its  happiest  effects. 

The  second  indication  mentioned,  the  treatment  of  the  complications 
and  accidents  incident  to  the  condition,  resolves  itself  into  the  treatment 
of  the  bronchitis,  the  pericarditis,  the  pleurisy,  pneumonia,  endocarditis, 
gastric  and  intestinal  disorders,  which  have  been  named  as  occurring,  and 
especially  of  the  most  serious  calamity  of  all,  uremia.  The  treatment  of 
the  complications  is  that  of  the  same  conditions  under  other  circumstances. 
Paracentesis  is  a  measure  which  is  often  of  signal  service  in  effusions  into 
the  chest,  and  occasionally  of  the  pericardium. 

Dyspeptic  symptoms  are  best  treated  with  pepsin  and  acids,  and  such 
other  remedies  as  may  be  symptomatically  required.  Opium  should  be 
cautiously  employed,  if  at  all,  not  only  in  the  gastro-intestinal  disturbances, 
but  under  all  circumstances,  as  it  undoubtedly  increases  the  dangers  of 
uremia.  This  has  been  abundantly  proved.  It  need  not  be  discarded 
altogether,  for  there  is  sometimes  no  substitute  for  it  in  certain  bowel 
affections  and  conditions  of  severe  pain,  but  it  should  be  given  in  smaller 
doses  than  usual  and  its  effects  watched.  In  like  manner,  hypnotic,  sedative, 
and  antispasmodic  effects,  when  desired,  should  be  produced  by  sulphonal, 
trional,  chloral,  and  bromids,  if  possible. 

Finally,  as  to  the  treatment  of  uremia,  the  measures  described  in  the 
treatment  of  uremia  in  acute  nephritis  are  to  be  used.  Apoplexy,  which 
is  not  an  infrequent  termination  of  the  disease,  in  consequence  of  the 
atheromatous  state  of  the  blood-vessel  walls,  is  recognized  by  the  paralysis, 
general  or  partial, — most  frequently  hemiplegia, — v/hich  accompanies  the 
unconsciousness.  Remedies  are  here  generally  futile,  but  such  may  be 
used  as  are  indicated  for  apoplexy.  The  upright  position,  bleeding,  counter- 
irritation,  and,  if  the  patient  survives  the  immediate  accident,  iodid  of 
potassium,  with  a  view  to  promoting  absorption  of  the  extravasated  clot, 
may  be  used.  Hemorrhages  in  other  situations,  as  from  the  nose  or  ali- 
mentary canal,  are  treated  by  the  same  measures  as  when  they  occur 
under  other  circumstances.  The  close  resemblance  at  times  of  the  symp- 
toms of  uremia  to  those  of  apoplexy  should  be  remembered. 

As  to  special  treatment,  or  treatment  directed  to  the  removal  of  the 
interstitial  overgrowth  in  the  kidney,  there  is  none.  Theoretically,  the 
iodid  of  potassium  ought  to  be  of '  service.  Unfortunately,  the  peculiar 
requirements  of  its  administration — viz.,  the  length  of  time  during  which 
the  patient  must  take  the  remedy  before  any  results  may  be  expected,  and 
the  consequent  difficulty  in  accumulating  a  sufficient  number  of  cases — are 


'jie  DISEASES  OF  THE  URIXARY  ORGANS. 

such  that  it  is  ahnost  impossible  to  determine  whether  it  can  be  of  any  ser- 
vice or  not.  Owing  to  these  difficulties,  it  is  doubtful  whether  its  exact 
possibilities  have  as  yet  been  determined.  There  can  be  no  disadvantage  in 
administering  it,  if  the  dose  is  so  small  as  not  to  derange  the  stomach. 
A'erv  rarely  can  more  than  a  few  grains  daily  be  given.  I  believe  I  can 
sav.  however,  of  the  bichlorid  of  mercury,  that  I  have  seen  its  long-continued 
use  in  doses  of,  at  first.  1-24  grain  {0.0027  gm.).  and  later  1-50  grain 
(0.0013  gm.),  kept  up  a  long  time,  followed  by  improvement.  I  have  also 
seen  improvement  in  the  impaired  vision  of  albuminuric  retinitis  follow  its 
use.  Certainly,  in  the  event  of  a  clear  syphilitic  origin,  the  iodid  of  potas- 
sium should  be  used.  I  have  also  used  the  biniodid  of  mercury  with  apparent 
happy  results,  in  doses  of  1-24  gr.  (0.0027  gm.)  to  1-16  gr.  (0.0040  gm.) 
a  dav. 


LARDACEOUS  DISEASE  OF  THE  KIDXEY. 

Syxoxyms. — Amyloid  Disease:   Albuminoid  Disease;    JVaxy   Kidney; 

Depuratizr  Disease. 

Definition. —  A  morbid  state  of  the  kidney  'in  which  its  structural 
elements  are  more  or  less  infiltrated  with  a  substance  of  albuminous  com- 
position and  of  bacony  luster,  best  recognized  by  the  deep  mahogany-red 
color  it  strikes  when  treated  with  a  solution  of  iodin. 

Etiology. — The  most  frequent  cause  of  lardaceous  disease  is  profuse 
and  long-continued  suppuration,  such  as  occurs  in  chronic  bone  disease, 
whether  tubercular,  syphilitic,  or  traumatic  in  origin ;  or  such  discharge  as 
constitutes  the  expectoration  in  cases  of  chronic  phthisis  and  chronic  bron- 
chitis with  bronchiectasis.  Syphilis  itself,  independently  of  the  tertiary 
conditions  which  it  produces,  is  a  frequent  cause  of  lardaceous  disease. 
Cachectic  states  of  any  kind,  chronic  dysentery,  ulceration  of  the  bowels, 
and  chronic  albuminuria  are  possible  causes. 

Either  sex  is  equally  subject  to  lardaceous  disease,  but  as  men  are 
more  frequently  exposed  to  its  causes,  it  is  in  them  rather  more  common. 
Ver}^  young  children  are  rarely  affected,  for  evident  reasons,  but  in  young 
persons  from  eleven  to  thirty  it  is  most  frequent.  After  thirty  it  grows 
gradually  rarer.     Tubercular  hip  disease  in  children,  especially,  is  a  cause. 

Morbid  Anatomy. —  The  incipient  stages  seldom  present  alterations 
recognizable  by  the  naked  eye,  unaided  by  reagents.  But  if,  after  section 
of  the  kidney,  the  cortex  be  "treated  by  a  solution  of  iodin  and  iodid  of 
potassium.*  numerous  mahogany-red  points  make  their  appearance ;  or  if 
by  a  solution  of  violet  anilin,  as  many  red  or  pink  points.  These  are  the 
jXIalpighian  bodies,  whose  capillary  tufts  are  the  first  to  be  affected  by  the 
change.  The  kidney,  in  this  early  stage,  is  normal  in  size  or  very  slightly 
enlarged.  Its  capsule  strips  off  readily,  leaving  an  organ  which  exhibits 
no  changes,  or  a  paleness  or  translucency  which  readily  escapes  notice,  but 
mav  be  recognized  at  the  edges  of  a  thin  section.  \'ery  often,  too,  they 
are   completely  overshadowed  by  other  alterations,   for  amyloid   kidney  is 


*  77/1?  Iodin  Test  Solutions.— ^h^  best  test  solution  for  macroscopic  Durposes  is  one  made  by 
dissolving  2%  grains  (0.16  gm.)  of  iodin  by  the  aid  of  five  grains  (0.^2  gm.)  of  iodid  of  potassium  in  one 
fluid  ounce  (30  c.  c.)  of  water.  The  solution  contains  about  one-half  of  one  per  cent,  of  iodin.  For 
microscopic  preparations  a  solution  weaker  than  the  foregoing,  or  a  one-quarter  of  one  per  cent., 
of  iodin  dissolved  bj' twice  the  quantit3' of  iodid  of  potassium,  is  more  suitable,  and  sometimes  a 
solution  containing  as  much  iodin  as  water  alone  will  take  up  answers  best. 


LARDACEOUS  DISEASE  OF  THE  KIDNEY.  727 

most  frequently  a  superadded  event  in  the  course  of  chronic  diffuse  nephritis, 
while  the  same  event  may  happen  in  interstitial  nephritis.  The  large  white 
kidney  of  chronic  parenchymatous  nephritis  is  especially  apt  to  exhibit  a 
slight  degree  of  lardaceous  change,  which  may  altogether  escape  notice  imless 
iodin  is  used.  Hence,  iodin  should  he  tried  upon  all  kidneys  removed  at 
autopsy. 

In  a  more  advanced  stage  of  uncomplicated  lardaceous  change  the 
kidneys  are  both  enlarged,  usually  symmetrically,  but  the  extreme  degrees 
of  enlargement  are  commonly  associated  with  fatty  degeneration  of  the 
epithelium.  Such  organs  were  a  pair  weighing  twenty-three  ounces  (715 
gm.)  which  came  under  Dr.  Dickinson's*  notice.  Dr.  Johnson  f  refers  to 
a  case  in  which  the  two  kidneys  weighed  twenty-eight  ounces  (870  gm.). 
Rindfleisch  i  has  seen  a  single  instance  of  that  very  rare  condition,  complete 
lardaceous  infiltration, — that  is,  in  which  the  basement  membrane  of  the 
uriniferous  tubes,  as  well  as  the  capillaries,  was  infiltrated, — in  which  the 
kidney  was  enlarged  to  nearly  twice  its  normal  size.  In  the  uncomplicated 
forms  of  lardaceous  disease  the  capsule  is  not  adherent,  but  if  interstitial 
changes  coexist  to  any  extent,  it  is  adherent.  It  leaves  the  surface  of  the 
kidney  pale  and  anemic ;  occasionally,  the  stellate  veins  are  conspicuous.  The 
characteristic  translucency  may  even  be  recognized  in  the  organ  in  bulk,  but 
in  sections  it  is  more  striking.  When  the  change  is  present  in  high  degree, 
the  edges  of  a  thin  section  are  almost  as  translucent  as  a  similar  section  of 
bacon.  On  laying  open  the  kidney  the  cortex  is  seen  to  be  enlarged ;  it  is 
pale,  anemic,  waxy,  firm,  and  resisting.  The  pyramids  are  normal  in  hue 
and  area.  The  iodin  solution  added  to  such  a  kidney  produces  its  peculiar 
coloration  not  merely  in  the  Malpighian  capillaries,  but  also  in  the  afferent 
and  efferent  vessels  and  the  vasa  recta  of  the  pyramids.  In  a  still  later  stage, 
that  of  atrophy,  the  kidney  becomes  contracted,  diminished  in  size,  rough, 
and  even  distorted  in  shape.  The  capsule  is  adherent,  and  on  section  the  cor- 
tex is  found  narrowed,  sometimes  as  .much  so  as  in  the  contracted  kidney  of 
interstitial  nephritis. 

Microscopic  Changes. — To  microscopic  examination  in  the  first  stage,  in 
which  the  naked  eye  often  fails  to  detect  anything  abnormal  without  the  aid 
•of  iodin,  the  Malpighian  bodies  exhibit  a  lustrous  or  waxy  appearance.  They 
are  also  enlarged  and  the  capillary  walls  thickened.  At  this  stage  there  is 
no  visible  alteration  in  the  tubules  or  in  their  epithelium.  In  the  second  stage 
larger  vessels  are  involved,  the  vasa  afferentia  and  efferentia  in  the  cortex, 
and  also  the  vasa  recta  of  the  cones ;  also  the  second  capillary  network  of  the 
cortex,  and  an  exudation  occurs  into  the  tubules  of  a  glistening  material 
which  forms  casts.  This  is  undoubtedly  at  times  the  amyloid  material,  for 
such  casts  sometimes  strike  the  mxahogany  reaction.  At  other  times  they 
have  the  composition  of  ordinary  hyaline  casts.  It  is  to  be  remembered,  too, 
that  similar  waxy  casts  are  found  in  the  tubules  in  other  forms  of  chronic 
and  even  acute  renal  disease. 

The  arteriole  walls  are  thickened  by  an  involvement  of  both  interna  and 
media.  This  thickening  is  attended  by  an  extraordinary  distinctness  of  the 
muscular  fiber-cells  of  the  circular  coat.  Later,  the  basement  membrane  and 
epithelial  lining  m.ay  also  be  invaded,  the  cells  being  swollen,  translucent,  and 
apparently  fused.     It  is  also  quite  ugual  for  the  epithelium  of  the  cells  to  be 

*  Dickinson,  op.  ctt.,  p.  249. 

t  Johnson  op.  cit.,  p.  104. 

%  Rindfleisch,  "  Path.  Histology,"  "  New  Syd.  Soc.  Trans.,"  1873,  vol.  ii.  p.  167. 


;28  .      DISEASES  OF  THE  URINARY  ORGANS. 

fatty,  and  the  capillary  walls  to  contain  aggregations  of  fat  globules,  while 
the  urine  in  the  later  stages  contains  oil  casts  and  fatty  cells. 

In  what  has  been  called  the  third  or  contracting  stage  of  lardaceous  kid- 
ney, but  which  may  be  the  ordinary  contracted  kidney  on  which  the  amyloid 
change  has  been  ingrafted,  minute  examination  reveals,  in  addition  to  the 
appearances  described,  the  hypernucleated  intertubal  overgrowth.  Cysts  are 
occasionally  present  for  the  same  reason  that  they  are  found  in  the  granular 
contracted  kidney,  and  the  surface  assumes  also  a  certain  degree  of 
granulation. 

Symptoms, — An  individual  who  has  had  syphilis,  or  who  has  phthisis, 
bone-necrosis,  or  other  affection  causing  an  exhaustive  drain,  may  accjuire 
this  form  of  kidney  disease  without  appreciable  addition  to  his  symptoms. 
There  may  be  a  growing  frequency  in  micturition,  but  this  symptom  may  be 
totally  absent.  Accidentally,  it  may  be,  a  somewhat  copious  albuminuria  is 
discovered.  At  first  the  urine  may  be  quite  clear,  and  no  casts  are  met,  or 
they  are  exceedingly  scanty  and  hyaline  or  faintly  granular.  Later,  a  slight 
edema  of  the  feet  may  appear  while  the  patient  is  up  and  about,  but  it  disap- 
pears during  the  night  while  he  is  in  bed.  The  albuminuria  is  now  copious, 
but  still  varies,  and  casts  may  be  more  numerous,  or  may  still  be  scanty  and 
continue  hyaline  or  faintly  granular.  The  urine  is  now  decidedly  increased  in 
quantity — fifty-three  to  eighty  ounces  (1600  to  2500  c.  c.)  ;  its  specific 
gravity  is  low — 1005  to  1015.  More  rarely  the  urine  is  scanty.  A  cachectic 
anemic  condition  develops.  There  is  sometimes  a  peculiar  fetor  of  the 
breath,  but  it  is  doubtful  whether  this  is  characteristic  of  this  more  than  of 
other  forms  of  chronic  kidney  disease.  Still  later  all  these  symptoms  in- 
crease ;  the  dropsy  is  persistent,  the  urine  loaded  with  albumin,  and,  in  addi- 
tion to  the  ordinary  delicate  hyaline  casts,  it  may  contain  the  glistening  waxy 
casts. 

Senator  announced  some  years  ago  that  serum  globulin  is  increased  in 
the  urine  of  amyloid  kidney.  Some  winters  ago  I  was  enabled  to  make  some 
observations  which  make  me  confident  that  he  is  right  and  that  it  is  quite  a 
valuable  diagnostic  sign.  Fatty  casts  and  free  fatty  epithelium  from  the 
tubules  of  the  kidney  may  be  superadded,  as  well  as  free  oil  drops.  Epithelial 
casts  are  rare,  as  is  blood.  Edema  of  the  lungs  may  also  occur  as  a 
serious  complication.  Toward  the  close  of  the  disease,  the  urine,  which  had 
been  increased,  becomes  diminished  in  quantity,  but  is  seldom  suppressed.  Of 
the  chemical  constituents,  it  may  be  said  of  all  that  they  are,  as  a  rule,  slightly 
diminished,  but  not  sufficiently  to  influence  the  course  of  the  disease.  It  is 
in  consequence  of  this  that  uremia  is  almost  unknown  in  lardaceous  disease, 
the  urea  and  extractives  being  eliminated  in  sufficient  amount  to  avert  this  evil. 
Nor  do  we  find  hypertrophy  of  the  left  ventricle  or  high  arterial  tension. 

But  lardaceous  disease  of  the  kidney  almost  never  occurs  alone.  It  is 
always  accompanied  by  similar  changes  in  the  liver,  spleen,  and  often  of  the 
intestinal  canal.  Hence,  evidences  of  alterations  in  these  organs  are  more  or 
less  marked.  Thus,  the  percussion  areas  of  the  liver  and  spleen  are  almost 
always  enlarged,  and  the  blood-vessels  of  the  stomach  and  intestines  are  often 
involved.  In  the  former  event  obstinate  vomiting,  and  in  the  latter  equally 
obstinate  diarrhea,  results.     The  latter  is  far  more  frequent  than  the  former. 

As  to  duration,  the  disease  generally  runs  a  very  chronic  course,  which  is 
limited  only  by  the  malady  of  which  it  is  a  complication.  As  such  it  is  always 
of  shorter  duration  than  interstitial  nephritis,  and  may  be  shorter  than 
chronic  parenchymatous  nephritis,  although  the  latter  affection  and  lardaceous 


LARDACEOUS  DISEASE  OF  THE  KIDNEY.  729 

disease  more  closely  resemble  each  other  in  respect  to  duration.  When 
obstinate  diarrhea  and  vomiting  supervene,  the  end  is  usually  not  remote. 

Diagnosis. — There  are  some  instances  in  which  lardaceous  disease  is 
easily  recognized.  If  a  patient  has  had  syphilis  with  secondary  and  tertiary 
symptoms,  or  has  long  been  a  victim  to  phthisis,  and  he  is  discovered  to  be 
edematous  and  to  have  a  large  albuminuria,  with  waxy  hyaline  and  fatty  casts 
and  an  enlarged  liver  and  spleen  and  obstinate  diarrhea,  there  can  be  little 
doubt  but  that  lardaceous  disease  is  present.  But  when  neither  of  these  two- 
general  diseases  is  present,  or  the  phthisis  has  not  existed  a  very  long  time,  or 
there  is  not  decided  evidence  of  enlarged  liver  and  spleen,  we  cannot  be  certain. 
While  it  is  never  safe  to  diagnose  lardaceous  disease  without  the  presence 
of  enlarged  liver  and  spleen,  the  presence  of  these  enlarged  organs  along  with 
large  albuminuria,  and  the  other  symptoms  which  attend  it,  do  not  necessarily 
imply  amyloid  kidney.  The  symptoms  and  course  of  the  disease,  particularly 
in  its  latter  stages,  are  so  like  those  of  chronic  parenchymatous  nephritis  that 
it  is  often  impossible  to  distinguish  the  two.  Further,  there  is  every  reason 
to  believe  that  chronic  nephritis  is  sometimes  caused  by  the  same  dyscrasic 
conditions  as  produce  the  lardaceous  disease.  In  such  cases,  therefore,  a 
diagnosis  is  impossible.     Finally,  the  two  conditions  may  exist  jointly. 

The  only  other  form  of  renal  disease  which  it  is  at  all  possible  to  con- 
found with  lardaceous  disease  is  interstitial  nephritis.  But  in  this  we  have 
the  almost  total  absence  of  dropsy,  small  albuminuria,  and  scanty  sediment, 
in  which  granular  and  hyaline  casts  are  found.  While  the  quantity  of  urine 
is  increased  in  both  these  forms  of  chronic  Bright's  disease,  the  quantity  is 
larger  in  interstitial  nephritis.  Hypertrophy  of  the  left  ventricle,  an  almost 
invariable  symptom  in  contracted  kidney,  is  very  rare  in  lardaceous  disease, 
while  enlargement  of  the  spleen  and  liver  is  common  and  does  not  occur  in 
interstitial  nephritis.  Contracted  kidney  may  also  be  associated  with  larda- 
ceous disease. 

Prognosis. — In  the  matter  of  prognosis  much  depends  upon  the  presence 
or  absence  of  the  original  disease  causing  the  lardaceous  change  in  the  kid- 
neys. If  the  former  cannot  be  cured,  the  effect  of  the  latter  can  only  be  to 
hurry  on  the  unfavorable  termination,  although  it  is  subject  to  the  abatements 
as  well  as  exacerbations  of  that  affection.  If  the  original  disease  is  curable 
and  the  patient  young,  there  are  no  limits  to  the  possible  improvement, 
although  it  is  scarcely  likely  that  the  diseased  structures  are  ever  restored  to 
their  normal  state.  But  as  it  is  unlikely  that  all  the  renal  vessels  are  involved 
in  the  change,  and  the  organ  itself,  especially  before  its  complete  development 
is  attained,  is  one  capable  of  assuming  an  extraordinary  degree  of  supple- 
mental function,  it  is  not  impossible  that  there  may  be  a  complete  restoration. 
If  the  patient  is  past  middle  life,  even  if  it  should  happen  that  the  original  dis- 
ease has  disappeared,  the  probabilities  of  recovery  are  small,  while  a  decided 
degree  of  improvement  is  not  impossible.  If  the  stage  of  alteration  of  the 
blood-vessels  of  the  stomach  and  intestines,  as  attested  by  obstinate  vomiting 
and  diarrhea,  is  reached,  the  disease  is  necessarily  rapidly  fatal. 

Treatment. — Of  the  lardaceous  disease  it  may  be  said  with  greater 
emphasis  than  in  any  other  form  of  renal  disease,  "  an  ounce  of  prevention  is 
worth  a  pound  of  cure."  A  due  appreciation  by  surgeons  and  syphilog- 
raphers  of  the  causes  of  lardaceous  disease  would  prevent  the  occurrence  of 
many  cases,  the  timely  amputation  of  a  limb  long  the  seat  of  suppuration  and 
the  thorough  treatment  of  syphilis  being  all  that  is  necessary  to  accomplish 
this.     To  this  end  also  frequent  examinations  of  urine  should  be  made  by  the 


730  DISEASES  OF  THE  URIXARY  ORGAXS. 

surgeon  in  charge  of  cases  of  the  kind  so  often  referred  to^  and  the  sHghtest 
indication  of  albuminuria  should  be  the  signal  for  prompt  interference,  if 
such  'be  possible,  while  the  possibility  of  the  occurrence  of  this  renal  compli- 
cation should  always  be  before  the  surgeon's  mind.  Especially  watchful 
should  surgeons  be  who  are  in  charge  of  children  with  hip-disease. 

In  syphilis  the  faithful  and  persistent  use  of  remedies  for  a  sufficient 
time  after  all  the  symptoms  of  the  primary  and  secondary  affections  have  dis- 
appeared is  essential.  To  this  end  the  "  continuous,"  rather  than  the  "  inter- 
mittent," treatment  of  syphilis  by  small  doses  of  mercurials  long  continued 
is  the  plan  most  likely  to  secure  the  eradication  of  the  disease,  and  this  should 
be  kept  up  for  at  least  six  months  after  the  disappearance  of  all  syphilitic 
symptoms.  (By  small  doses  are  meant  doses  of  from  1-50  to  1-25  grain 
(0.0013  to  0.0026  gm.j  of  the  bichlorid.  j 

If  the  causing  disease  continues  to  exist,  the  treatment  of  the  amyloid  dis- 
ease is  the  treatment  of  the  former — if  it  is  s}-phili5,  iodid  of  potassium  and 
mercurials  ;  if  phthisis,  cod-liver  oil,  iron,  creasote  and  creasotal,  quinin,  an 
abundance  of  nourishing  food,  in  which  milk  and  cream  should  be  conspicu- 
ous, alcohol,  and  restorative  measures  generally,  together  with  fresh  air  and 
suitable  exercise.  Supposing  the  original  disease  to  have  disappeared,  the 
measures  of  treatment  indicated  are  precisely  those  of  chronic  parenchy- 
matous nephritis,  for  the  details  of  which  the  reader  is  referred  to  the  section 
on  that  disease. 


SUPPURATIVE   INTERSTITIAL   NEPHRITIS   AND 
PYELONEPHRITIS. 

Syxoxyms. — Septic    and   Pyoiiic   Xcpliritis;    Interstitial   Siippitratiz'e   Xe- 

pliritis:  Surgical  Kidney. 

Definition. — Suppurative  nephritis,  due  to  invasion  of  the  kidney  or  its 
pelvis  by  pathogenic  bacteria,  either  by  way  of  the  circulation  or  the  urinary 
tract. 

]\Iost  frequently  this  form  of  nephritis  starts  in  the  pelvis  of  the  kidney  as 
a  pyelitis,  and  thence  extends  into  the  interstitial  tissue  of  the  organ.  Such  a 
condition  is  pre-eminently  a  /'V^/onephritis.  It  may  also  happen  that  the 
nephritis  starts  in  the  interstitial  tissue  of  the  substance  of  the  organ  as 
the  result  of  infectious  embolism  or  traumatism  or  obstruction  of  the  tubules 
by  concretions.  In  either  ev^nt  both  the  kidney  and  its  pelvis  are  sooner  or 
later  involved,  and  it  is  scarcely  possible  to  separate  the  two  conditions  in 
diagnosis,  and  I  do  not,  therefore,  separate  the  two  diseases. 

Etiology. — The  most  frequent  medium  of  invasion  by  bacteria  is  retained 
decomposed  urine.  Retention  may  be  due  to  stricture  of  the  urethra  or 
even  phimosis,  to  stone  in  the  bladder  or  tireter  or  pelvis  of  the  kidney.  Per- 
haps there  are  always  bacteria  ready  to  avail  themselves  of  sufficiently  favor- 
able conditions,  but  a  favorite  route  of  introduction  is  by  unclean  catheters. 
In  many  of  these  cases  inflammation  of  the  bladder  is  an  intermediate  state. 
Calculous  concretions  in  the  substance  of  the  kidney  also  furnish  conditions 
favorable  for  the  action  of  bacteria  of  suppuration. 

Infections  emboli  cause  a  small  number  of  cases  of  suppurative  nephritis. 
The  emboli  are  usually  derived  from  the  valves  of  the  heart  in  cases  of  ulcer- 
ative endocarditis,  but  they  may  also  arise  in  putrid  wounds,  stumps,  or  other 


SUPPURATIVE  NEPHRITIS.  731 

seats  of  putrid  inflammation.  The  abscesses  found  in  the  kidney  in  common 
with  other  organs  in  pyemia  are  thus  produced.  Tubercle  bacilli  are  also 
causes,  entering  by  either  of  the  routes  named,  producing  tubercular  pyelo- 
nephritis. Among  the  organisms  found  in  the  urine  and  held  responsible  are, 
besides  the  tubercle  bacillus,  the  bacterium  coli  coinnnine,  the  protcus  Hauser, 
the  streptococcus  and  staphylococcus.  Parturition  is  a  most  infrequent 
medium  of  introduction  of  pathogenic  bacteria,  while  the  infectious  fevers 
are  recognized  causes. 

Traumatic  agencies  such  as  blows,  kicks,  or  penetrating  wounds  in  the 
neighborhood  of  the  kidney,  or  falls  from  a  distance  and  striking  upon  the 
sharp  edge  of  a  fence  or  similar  object,  may  also  cause  suppurative  nephritis. 

Suppurative  nephritis  may  occur  at  any  age  subject  to  the  operation  of 
the  cause.     The  youngest  patient  I  ever  had  was  two  years  old. 

Morbid  Anatomy. — The  appearances  vary  necessarily  with  the  stage  of 
the  disease  and  also  somewhat  with  the  cause.  In  an  earlier  stage,  if  the 
inflammation  pass  from  below  upward,  as  is  most  frequently  the  case,  the 
mucous  membrane  of  the  pelvis  is  first  affected,  being  swollen  and  dirty  gray 
in  color,  sometimes  visibly  congested.  Later,  the  pelvis  and  calices  may  be 
dilated  and  the  papillae  flattened.  The  distention  may  go  on  at  the  expense 
of  the  kidney  until  the  whole  organ  is  converted  into  a  pus-sac  bounded  by  a 
varying  remnant  of  renal  tissue.  Such  sac  may  be  a  constant  source  of  pus, 
or  if  complete  obstruction  occurs,  the  pus  may  become  inspissated  and  cheesy. 
The  ureter  is  also  often  dilated,  sometimes  resembling,  in  consequence  of  such 
extreme  dilatation,  the  intestine. 

In  tuberculosis  extending  z'ia  the  urinary  tract  the  apices  of  the  cones 
are  also  invaded,  it  may  be  from  the  mucous  membrane  by  continuity,  or  by 
direct  lodgment  of  the  bacillus.  Successive  portions  of  the  kidney  substance 
break  down,  and  the  ultimate  product  will  be  the  same — a  sac  filled  with 
liquid  pus  or  cheesy,  putty-like  substance. 

In  other  instances,  especially  when  the  kidney  is  invaded  by  way  of  the 
vascular  or  lymphatic  system,  as  in  pyemic  abscess,  foci  of  suppuration  a 
millimeter  and  upward  in  diameter  are  scattered  in  the  cortex  and  separated 
by  sound  renal  tissue.  They  are  surrounded  by  an  intensely  red  border,  are 
often  visible  through  the  cortex,  and  may  be  ruptured  by  dragging  of  the 
capsule.  On  section  at  an  early  stage,  linear  streaks  of  pus  may  be  found  in 
the  medulla. 

At  a  later  stage  these  little  collections  of  pus  unite  to  form  larger  ones, 
these  again  to  form  others  still  larger,  destroying  the  tubular  structure  of 
the  kidney  as  they  encroach  upon  it,  and  it  is  at  this  stage  that  cases  of  pyelo- 
nephritis not  infrequently  terminate  unfavorably  and  the  specimens  come 
under  observation.  At  first  each  of  the  abscesses  thus  formed  is  confined  to 
the  region  of  a  single  pyramid,  and  it  not  infrequently  happens  that  a  kidney 
is  partitioned  off  into  spaces  corresponding  with  these.  Before  this  occurs, 
however,  the  abscess  bursts  through  the  papilla  and  calyx  into  the  pelvis  of 
the  kidney.  Thus,  in  an  opposite  direction  from  that  first  described,  the  kid- 
ney may  again  be  converted  into  a  purulent  sac,  but  these  cases  generally  ter- 
minate fatally  long  before  this  stage  is  attained. 

When  the  abscess  is  embolic  in  origin,  its  seat  is  at  first  occupied  by  an 
area  of  intense  hyperemia,  resulting  nn  hemorrhagic  extravasation,  which 
takes  place  also  into  the  tubules,  causing  bloody  urine.  To  this  succeeds 
suppuration.  The  size  and  number  of  the  abscesses  depend  upon  that  of  the 
plug  obstructing  the  blood-vessels,  which  is  usually  one  of  the  interlobular 


732  DISEASES  OF  THE  URIXARY  ORGANS. 

arteries  or  a  vas  aft'erens.  The  embolic  abscesses  may  also  be  multiple,  in 
consequence  of  the  breaking  of  the  embolus  into  a  number  of  minute  frag- 
ments. When  the  cause  is  traumatic,  the  process  is  not  so  easily  defined. 
Circumscribed  abscesses  may  occur,  or  the  kidney  may  be  converted  into  a 
soft,  pulpy  mass,  a  mixture  of  pus,  blood,  and  broken-down  renal  substance. 

Symptoms. — The  symptoms  of  this  condition  are  not  numerous  and, 
apart  from  the  characters  of  the  urine,  are  not  very  distinctive.  In  milder 
degrees  of  pelvic  inflammation  before  the  kidney  is  invaded  there  may  be 
none.  Pain  and  tenderness  are  the  most  constant,  but  considerable  inroads 
may  be  made  upon  the  structure  of  the  kidney  before  pain  results.  On  the 
other  hand,  it  is  often  very  severe,  while  the  tenderness  over  the  region  of 
the  kidney  is  pronounced.  This  tenderness  is  the  most  distinctive  and  valu- 
able symptom.  Usually  the  severest  pain  is  in  the  renal  region,  whence  it 
radiates  toward  the  front  of  the  abdomen  and  groin,  and  may  be  accompanied 
by  retraction  of  the  testicle.  When  the  condition  is  the  result  of  impacted 
calculus,  the  seat  of  the  impaction  is  the  primary  seat  of  pain.  It  may  be 
between  the  umbilicus  and  the  pubis  when  the  stone  is  lodged  down  in  the 
ureter.  The  pain  is  always  intermittent  to  a  degree,  sometimes  totally  so,  but 
generally  it  is  more  or  less  constant,  increased  parox3'Smally.  Various  posi- 
tions are  assumed  by  the  patient  with  a  view  to  easing  the  pain,  among  which 
lying  on  the  face  is  not  infrequent. 

A  distinct  tumor  may  sometimes  be  discovered  in  the  region  of  the  kid- 
ney by  palpation  and  percussion.  This  implies  an  enlargement  of  the  organ, 
due  either  to  its  conversion  into  a  purulent  sac,  or  an  augmentation  of  its  size 
owing  to  the  distention  of  its  pelvis  with  pus  or  calculi  or  both.  Very  fre- 
quently it  is  due  to  perinephric  invasion. 

Fever  is  also  a  remittent  symptom.  Possibly  in  a  very  few  latent  cases  it 
may  be  altogether  absent,  but  except  in  these  there  is  always  elevation  of  tem- 
perature, with  corresponding  frequency  of  the  pulse.  These  latter  at  times 
become  decided,  and  in  advanced  stages  the  fever  is  septic,  being  followed  by 
profuse  sweats.  In  acute  cases,  especially  pyemic,  the  beginning  of  suppura- 
tion is  often  marked  by  a  chill  and  high  fever  or  succession  of  chills,  but  in 
other  instances  it  is  quite  impossible  to  recognize  the  beginning  of  the  sup- 
purative stage. 

The  characters  of  the  urine,  as  intimated,  are  more  distinctive.  Except 
in  acute  infectious  cases,  the  urine  almost  invariably  sooner  or  later  contains 
pus,  and  unless  it  does  contain  pus,  no  certain  diagnosis  can  be  made.  Blood 
is  also  a  very  constant  constituent  from  cases  of  suppurative  nephritis,  but 
while  such  urine  is  scarcely  eyer  examined  by  the  microscope  wdthout  dis- 
covering a  few^  blood  discs,  the  quantity  is  often  not  large  enough  to  be  recog- 
nizable to  the  naked  eye.  The  quantity  of  pus  varies  greatly.  While  it  may 
be  so  copious  as  to  produce  a  heavy  white  opaque  deposit  one-sixth  to  one- 
fifth  the  bulk  of  urine,  it  may  be  represented  by  little  more  than  a  trace.  This 
variation  will  occur  at  different  times  in  the  same  case.  Pus  from  the  kidney 
and  its  pelvis  is  usually  distinguished  from  that  formed  in  the  bladder  b}'  the 
absence  of  that  glariness  so  characteristic  of  the  latter,  due  to  admixture  with 
mucus  and  decomposition  products.  Pus  from  the  pelvis  of  the  kidney  is 
rarely  fetid,  as  compared  with  pus  from  the  bladder. 

The  urine  is  usually  diminished  in  quantity.  Complete  suppression  is 
not  uncommon  toward  the  close  of  cases  presenting  extreme  degrees  of 
destruction.  Notwithstanding  such  diminution,  the  color  may  be  pale  and 
the  specific  gravity  low,  owing  to  the  small  proportion  of  urea  present,  the 


SUPPURATIVE  NEPHRITIS.  733 

range  of  specific  gravity  in  a  single  case  being  from  1003  to  1016.  In  reac- 
tion the  urine  is  faintly  acid,  neutral,  or  alkaline,  and  though  often  prone  to 
rapid  decomposition,  this  is  a  much  less  characteristic  feature  than  in  cystitis. 
It  is  alzcavs  albuminous,  but  the  quantity  of  albumin  is  never  very  large,  and 
varies  generally  pari  passu  with  the  quantity  of  pus  and  blood.  When  more 
albumin  is  present  than  is  thus  accounted  for,  it  is  likely  that  the  parenchyma 
of  the  kidney  has  become  involved.  Such  cases  are,  therefore,  more  serious. 
In  such  cases,  too,  tube-casts,  ordinarily  rarely  found  in  suppurative  nephritis, 
may  appear. 

It  sometimes  happens  that  there  is  a  sudden  increase  in  the  quantity  of 
pus  in  the  urine,  followed  by  a  gradual  diminution,  or  the  urine,  previously 
clear,  may  suddenly  become  loaded  with  pus.  Such  occurrences  indicate  the 
probable  period  of  rupture  of  an  abscess  through  a  papilla  and  a  pouring  out 
of  its  contents  into  the  pelvis  of  the  kidney,  or  of  the  removal  of  a  temporary 
obstruction  to  the  descent  of  the  pus.  It  may  happen  that  a  small  portion  of 
the  substance  of  the  kidney  is  thus  discharged,  when  it  may  be  recognized  by 
microscopic  examunation,  which  will  discover  the  tubules  and  glomeruli  of 
the  kidney.  Occasionally,  also,  the  abscess,  instead  of  rupturing  into  the 
pelvis  of  the  kidney,  perforates  into  the  perinephric  tissue,  burrowing  in  dif- 
ferent directions  and  producing  fistulous  openings.  Perforations  may  thus 
take  place  posteriorly  in  the  lumbar  region,  or  anteriorly  at  the  groin,  into 
the  colon,  and  more  rarely  into  the  lungs  and  liver,  and  even  into  the  peri- 
toneal sac. 

The  course  and  duration  of  suppurative  nephritis  vary  greatly.  Trau- 
matic cases  are  comparatively  rapid,  either  toward  recovery  or  death. 
Pyemic  cases  may  run  their  course  in  forty-eight  hours,  and  are  invariably 
fatal.  But  cases  due  to  other  causes — viz.,  impacted  calculus,  tuberculosis, 
stone  in  the  bladder,  or  cystitis — may  be  prolonged  indefinitely,  while  some 
terminate  without  being  discovered.  Sooner  or  later  the  patient  generally 
succumbs  to  exhaustion,  but  life  may  be  sustained  for  years  with  paroxysms 
of  the  severest  suffering  and  a  surprising  degree  of  destruction  of  the  kidne3's. 
The  greatest  danger  to  those  thus  affected  is  intercurrent  illness,  which  is 
always  more  serious  and  more  apt  to  terminate  unfavorably.  It  is  then  that 
the  kidneys,  previously  surprisingly  sufficient  in  eliminating  power,  give  way 
in  this  respect,  the  symptoms  of  uremia  supervene,  and  the  patient  dies  of 
this  complication.  It  is  well  known  that  the  operation  for  stone  is  much  more 
likely  to  be  followed  by  a  fatal  result  when  the  patient  happens  to  have  a  sur- 
gical kidney. 

There  are  no  complications  peculiar  to  suppurative  interstitial  nephritis 
save  those  mentioned  as  causing  it ;  or  as  resulting  from  unusual  accidents, 
such  as  rupture  and  perforation  into  neighboring  organs,  or  uremia. 

Diagnosis. — The  diagnosis  of  suppurative  nephritis  ma}"  be  eas}^  or  diffi- 
cult. It  is  easy  when  there  is  the  history  of  a  traumatic  cause  followed  by 
hematuria,  and  later  purulent  urine,  with  tenderness  and  pain  over  the  region 
of  the  kidney.  On  the  other  hand,  Avhile  prolonged  inflammation  of  the  blad- 
der, stone  in  the  bladder,  nephrolithiasis,  or  other  causes  of  obstruction  and 
decomposition  of  urine  always  afford  good  reason  for  suspecting  that  sup- 
purative nephritis  exists,  it  is  not  safe  to  assert  its  presence  whenever  these 
conditions  exist.  If,  however,  the  urine  contains  pus  constantly  or  intermit- 
tently, and  in  addition  to  this  there  is  pain  or  tenderness  in  the  renal  region, 
suppurative  nephritis  may  be  averred  with  reasonable  certainty.  I  know  of 
no  distinctive  cellular  elements  from  whose  presence  in  the  urine  it  mav  be 


734  DISEASES  OF  THE  URINARY  ORGANS. 

asserted  that  pus  comes  from  the  pelvis  of  the  kidney  or  ureter,  for  though 
the  little  columnar  or  pear-shaped  cells  are  referred  to  these  sources,  they  also 
come  from  the  urethra  and  bladder. 

As  to  differential  diagnosis,  the  only  certain  means  of  recognizing  the 
tubercular  form  is  by  finding  the  bacillus  in  the  purulent  urine,  at  the  present 
day  greatly  facilitated  by  the  use  of  the  centrifugal  apparatus.  Should  the 
symptoms  described  occur  in  a  case  of  tuberculosis  of  the  lungs,  the  tubercular 
nature  of  the  nephropyelitis  becomes  quite  probable. 

Pxelonephritis  is  distinguished  from  paranephritis  by  the  more  circum- 
scribed shape  of  the  tumor,  the  absence  of  edematous  infiltration  of  the  lum- 
bar region,  and  by  the  presence  of  purulent  urine,  unless  it  happens,  as  it 
rarely  does,  that  the  paranephric  abscess  breaks  into  the  kidney  and  dis- 
charges by  the  ureter.  Pain  on  flexing  and  rotating  the  thigh  is  characteristic 
of  paranephric  abscess,  because  of  the  involyement  of  the  psoas  muscle. 
Pyemic  abscesses  of  the  kidney  may  be  suspected  if  a  pyemic  process  is 
present,  and  a  chill  supervenes,  follo\yed  by  any  or  all  of  the  renal  symptoms 
described. 

Prognosis. — Operation  has  done  much  to  improve  the  prognosis  of  late 
years.  Yet  so  far  as  recovery  is  concerned,  it  is  still  in  most  cases  unfavor- 
able. Traumatic  cases  may  recover  if  the  injury  is  not  too  extensive,  while 
very  grave  injuries  are  usually  rapidly  fatal.  Recovery,  too,  ensues  on  cases 
succeeding  infectious  fevers  and  pregnancy.  Cases  due  to  obstruction  of  the 
ureters  cannot  get  well  so  long  as  the  obstruction  and  irritation  continue,  and 
as  their  removal  is  often  impossible,  such  cases  gradually  grow  worse.  On 
the  other  hand,  their  fatal  termination  may  be  delayed  indefinitely.  It  is 
often  a  matter  of  astonishment,  on  viewing  the  postmortem  appearance  of 
cystic  purulent  kidneys,  that  the  patient  has  lived  so  long  with  such  extreme 
structural  changes  present,  the  barest  remnant  of  secreting  structure  being 
sometimes  found.  It  is  impossible  to  say  how  far  repair  may  take  place  if 
the  cause  can  be  removed.  Conditions  of  this  kind  occur  when  a  stone  has 
been  removed  after  having  been  long  present  either  in  the  bladder  itself  or  in 
the  kidney  or  ureter.  It  is  scarcely  necessary  to  say  that  such  persons  are  in 
imminent  danger  from  the  eft'ect  of  cold,  acute  disease,  or  other  cause  which 
tends  to  suppress  the  action  of  kidneys  already  crippled  in  function. 

Treatment. — As  operation  oft'ers  the  best  chance  of  cure  in  many  cases, 
a  surgeon  should  be  called  early.  There  is  no  curative  treatment  by  medi- 
cine for  suppurative  nephritis  without  a  removal  of  the  cause,  and  as  the  latter 
is  often  impossible,  it  follows  that  medicinal  measures  are  mainly  palliative. 
One  of  the  most  frequent  indications  is  the  relief  of  pain,  which  is  often  so 
severe  as  to  call  for  powerful  anodyne  measures — opium  and  its  alkaloids 
being  absolutely  essential.  Hypodermic  injections  of  morphin  in  doses  of 
from  1-8  to  1-3  grain  (0.008  to  0.022  gm.),  repeated,  if  necessary,  are  favorite 
and  effectual  methods  of  relieving  the  intense  pain,  which  is  often  due,  not 
so  much  to  the  inflammation,  as  to  the  impacted  calculus  or  other  cause  of 
obstruction.  Suppositories  of  from  one-half  to  two  grains  (0.03  to  0.13  gm. ) 
of  the  extract  of  opium  may  be  substituted.  Hot  fomentations  and  simple 
counterirritants,  such  as  mustard,  are  also  valuable  adjuvants. 

The  catarrhal  process  in  the  kidney,  its  pelvis,  and  the  ureter,  and  also 
in  the  bladder,  may  be  treated  with  varying  success.  Diluents  are  decidedly 
indicated,  and  for  this  purpose  any  one  of  the  numerous  negative  mineral 
waters  may  be  used.  The  alkaline  mineral  waters  are  contra-indicated,  as 
they  inspissate  the  pus  and  make  it  more  difficult  to  pass.     The  only  remedies 


PARANEPHRITIS.  735 

I  have  found  of  any  use  are  the  balsam  and  benzoic  acid.  Of  the  former,  I 
prefer  sandalwood  oil,  because  it  is  better  borne  by  the  stomach  than  copaiba. 
Given  in  gelatin  capsules,  each  containing  ten  minims  (0.65  c.  c),  of  which 
one  or  two  may  be  taken  three  times  a  day,  a  decidedly  beneficial  effect  upon 
the  catarrhal  inflammation  sometimes  ensues,  seen  in  the  diminished  amount 
of  pus.  Benzoic  acid  fulfills  another  indication,  that  of  securing  an  acid  reac- 
tion of  the  urine,  which  is  very  often  either  alkaUne  or  so  faintly  acid  that  it 
rapidly  becomes  alkaline,  and  thus  predisposes  to  decomposition.  The  ben- 
zoic acid  is  best  given  in  the  form  of  capsules.  For  an  adult  three  or  four 
five-grain  (0.32  gm.)  capsules  daily  are  usually  sufficient  to  keep  the  urine 
acid.  Larger  doses  than  these  may  be  given,  or  benzoate  of  sodium  may  be 
used  in  ten-grain  (0.6  gm.)  doses.  It  may  be  given  either  alone  or  in  con- 
junction with  the  sandalwood  oil,  the  former  being  given  before  and  the 
latter  after  a  meal.  To  children  smaller  doses  may  be  given.  To  them  one 
may  begin  with  one  grain  (0.006  gm.)  three  times  a  day  and  increase  the 
dose.  The  various  vegetable  diuretics,  as  buchu,  pareira  brava,  etc.,  are  of 
little  use  in  suppurative  nephritis  and  pyelitis. 

The  constant  and  inevitable  tendency  in  these  cases  to  run  down  in  gen- 
eral health,  in  consequence  of  the  drain  and  wear  and  tear  to  which  they  are 
subject,  demands  tonics,  such  as  quinin,  iron,  and  strychnin,  while  milk  and 
other  nutritious  articles  of  diet  are  always  indicated.  The  dangers  to  which 
the  patient  is  subject  from  exposure,  cold,  and  dampness  should  be  averted  by 
suitable  care  and  woolen  clothing. 

I  desire  to  repeat  that  many  of  these  cases  are  saved  at  the  present  day 
bv  a  timely  nephrotomy,  by  which  the  pus  is  discharged,  the  kidney  drained, 
and  calculi,  if  present,  removed.  I  look  back  upon  many  cases  that  were 
allowed  to  perish  whose  lives  would  at  least  have  been  materially  prolonged 
by  operation. 

Abscess  of  the  Kidney. 

Definition. — This  term  may  be  applied  to  a  kidney  which  is  more  or 
less  completely  converted  into  a  sac  of  pus. 

Symptoms. — These  are  tenderness,  swelling,  and,  in  extreme  cases, 
fluctuation,  commonly  associated  with  pyuria,  which  is  in  rare  instances 
absent.  It  may  be  intermittent,  and  the  tumor  caused  by  the  pus  collection 
may  also  disappear.     There  is  usually  fever  of  the  hectic  or  septic  type. 

Prognosis. — This  varies  with  the  cause,  though  often  favorable,  after 
operation. 

Diagnosis. — This  is  usually  early,  by  attention  to  the  symptoms  named. 

Treatment. — This  is  surgical, — operative, — and  is  usually  successful  in 
affording  great  relief,  if  not  curing  the  patient  completely. 

PARANEPHRITIS  OR  PERINEPHRIC  ABSCESS. 

Definition. —  Paranephritis  is  an  inflammation  invading  the  connective 
tissue  about  the  kidney,  terminating  almost  always  in  suppuration. 

Etiology. — A  number  of  causes  may  be  responsible  for  perinephric 
abscess.  Thus  there  may  be  rupture  of  a  nephric  abscess  through  the  cap- 
sule of  the  kidney ;  perforation  of  the  bowel,  most  frequently  seen  in  connec- 
tion with  appendicitis ;  extension  of  suppurative  disease  from  the  spine,  as  in 
caries  of  the  vertebrae,  or  from  a  burrowing  empyema ;  finally,  blows  and 
injuries  may  terminate  in  suppuration  about  the  kidney. 


736  DISEASES  OF  THE  URINARY  ORGANS. 

Morbid  Anatomy. — At  autopsy  the  kidney  is  found  surrounded  by  pus, 
\vhich  is  usually  posterior  to  it,  rarely  in  front  between  the  kidney  and  the 
peritoneum.  The  pus  has  often  a  fecal  odor  from  contact  with  the  large 
'  bowel.  It  may  burrow  in  various  directions,  and  even  burst  into  the  pleura 
and  be  discharged  by  the  lungs ;  or  it  may  work  its  way  to  the  groin  and 
appear  at  Poupart's  ligament.  In  turn  it  may  perforate  the  bowel  or  rupture 
into  the  peritoneum,  bladder,  or  vagina.  Occasionally  the  fatty  bed  of  the 
kidney  is  found  to  be  converted  into  a  fibrous  capsule  fused  more  or  less 
closely  with  that  of  the  true  kidney  capsule. 

Symptoms. — Alost  cases  are  secondary  to  disease  in  the  neighborhood. 
Fain  and  tenderness  in  the  region  of  the  kidney  are  the  most  constant  symp- 
toms. In  addition  there  is  a  peculiar  edematous  or  boggy  condition  in  the 
same  locality,  giving  rise  to  pitting  on  pressure.  The  position  assumed  is 
often  distinctive,  the  thigh  being  flexed  to  relax  the  psoas  muscle,  tension  on 
which,  especially  in  adduction,  increases  suffering.  The  patient,  if  able  to 
walk,  relies  as  much  as  possible  on  the  opposite  leg,  on  which  he  leans,  assum- 
ing also  a  stooping  posture  with  the  spine  fixed.  The  whole  attitude  and 
behavior  of  the  patient  remind  one  of  hip- joint  disease,  while  the  pain  may 
even  be  referred  to  the  knee,  as  in  this  disease.  These  symptoms  do  not,  how- 
ever, appear  at  once,  and  the  approach  is  often  insidious.  At  other  times 
suppuration  is  ushered  in  by  chills,  fever,  and  sweats.  The  plastic  form  of 
fibroid  paranephritis  is  without  distinctive  symptoms.  Various  directions  of 
burrowing  and  seats  of  perforation  were  mentioned  in  treating  of  the  morbid 
anatomy. 

Diagnosis. — The  diagnosis  from  ncpJiric  abscess,  with  which  it  is  most 
likely  to  be  confounded,  has  been  considered.  The  attitude  of  the  patient  in 
lying  or  standing  is  like  that  in  hip-disease,  but  the  history  elicits  that  in  its 
incipiency  the  pain  is  much  higher  up  in  perinephric  abscess,  while  examina- 
tion shows  that  the  swelling  and  tenderness  are  above  the  hip  and  not  over  the 
hip- joint  itself.  As  most  cases  except  those  due  to  injury  are  secondary  to 
disease  in  the  neighborhood,  it  is  not  necessary  to  separate  the  two  classes. 
Secondary  forms  are  more  sudden  in  their  onset,  though  this  is  not  always  the 
case.     Doubtful  cases  may  be  settled  by  the  exploring  needle. 

Treatment. — This  is  b}^  section  and  free  drainage,  for  though  spon- 
taneous rupture  sometimes  takes  place,  it  is  apt  to  be  preceded  by  destructive 
and  dangerous  burrowing,  which  should  be  anticipated  by  operation. 


NEPHROLITHIASIS  (  STONE  IN  THE  KIDNEY). 

Definition. —  Nephrolithiasis  means  "  stone  in  the  kidney,"  but  the  term 
is  a  general  one,  which  covers  the  presence  in  the  kidney,  its  pelvis,  or  ureter 
of  concretions  large  enough  to  justify  the  term  "  stone,"  of  smaller  masses 
appropriately  known  as  "  gravel,"  and  fine  particles  known  as  "  sand." 

Morbid  Anatomy, — Except  in  the  case  of  "  sand,"  which  includes  par- 
ticles made  up  either  of  pure  uric  acid  or  oxalate  of  lime,  gravel  and  stone,  as 
found  in  the  kidney  and  its  pelvis,  always  have  an  organic  basis  through 
which  are  distributed  the  mineral  matters  which  go  to  make  up  their  bulk, 
and  which  remains  as  a  framework  after  the  mineral  matters  are  dissolved 
out.  The  matters  thus  precipitated,  in  some  one  of  the  shapes  named,  in  the 
order  of  frequency  are  : 

(i)  Uric  acid  and  its  compounds  of  sodium,  ammonium,  and  potassium. 


NEPHROLITHIASIS  7^7 

(2)  Oxalate  of  lime.  (3)  The  phosphates  of  calcium  and  of  ammonium  and 
magnesium. 

Only  in  the  case  of  uric  acid  stones  of  small  size,  and  of  oxalate  of  lime 
stones  likewise  moderate  in  size,  do  we  have  the  bulk  of  the  stone  made  of  a 
single  constituent.  More  frequenth'  it  is  the  case  that  uric  acid  or  oxalate  of 
lime  stone  forms  the  nucleus,  and  about  this  aggregate  in  concentric  layers, 
the  phosphates,  which  make  up  the  great  bulk  of  all  large  stones  as  well  as 
some  stones  in  their  entirety.  More  rarely  a  uric  acid  nucleus  is  surrounded 
by  oxalate  of  lime  or  the  reverse.  Xot  only  may  the  sediments  become  the 
nuclei  of  large  stones,  but  foreign  matters,  such  as  a  clot  of  blood  or  a  frag- 
ment of  any  kind  of  matter  accidentally  reaching  the  urinary  passages,  may 
also  play  a  like  role. 

The  steps  for  determining  the  more  precise  composition  of  stones  will 
be  found  in  appropriate  manuals  on  the  examination  of  urine,  but  the  three 
principal  varieties  present  certain  physical  characters  by  which  they  can  with 
considerable  certainty  be  determined.  Thus,  nric  acid  stones  are  usually 
smooth  or  lobulated,  dark-red  or  reddish-brown  in  color,  hard  in  consistency, 
and  rarely  acquire  a  size  of  a  centimeter  (0.4  inch)  in  diameter,  while  many 
of  them  are  no  larger  than  a  lentil.  They  may  be  multiple.  Oxalate  of  lime 
■Stones  are  very  hard  and  uneven,  so  characteristically  so  that  they  have 
received  the  name  mulberry  calcuH,  from  their  resemblance  to  this  fruit. 
Their  hard-pointed  projections  produce  exquisite  pain  in  transit  from  the 
kidney  through  the  ureter  into  the  bladder.  They  attain  about  the  same 
maximum  size  as  uric  acid  stones,  and  are  also  often  multiple.  The  phos- 
phatic  stones  are  white  in  color  or  grayish-white,  quite  soft,  easily  disin- 
tegrated, may  often  be  crushed  between  the  fingers,  though  at  other  times 
they  are  much  harder.  They  attain  the  largest  size,  being  often  as  large  as 
a  hen's  egg.  When  stones  lie  in  the  ureter  rather  than  in  the  pelvis  of 
the  kidney,  they  are  apt  to  be  more  elongated,  or  sometimes  spindle-shaped, 
and  present  at  times  a  spiral  marking  which  is  characteristic.  Others 
are  molded  to  the  shape  of  the  pelvis  of  the  kidney  with  a  prolongation  for 
each  calyx,  which  may  be  further  branched — the  dendritic  or  coral  calculi. 
Rarer  forms  of  calculi  are  made  up  of  cystin,  xanthin,  carbonate  of  lime,  and 
urostealith. 

Etiology. —  The  rationale  of  the  precipitation  of  sediments  which  aggre- 
gate to  form  concretions  is  not  always  the  same,  and  is  perhaps  not  thor- 
oughly understood.  In  the  case  of  uric  acid  the  deposit  takes  place  either 
because  the  urine  contains  more  than  the  normal  quantity  of  uric  acid,  or 
because,  for  some  reason,  the  amount  of  water  secreted  is  abnormally  scanty. 
In  either  event  the  uric  acid  is  precipitated  in  the  excretory  tubes  of  the 
medullary  substance  or  in  the  pelvis  of'  the  kidney,  forming  minute  concre- 
tions made  up  of  from  five  to  ten  whetstone-shaped  crystals,  whence  they 
descend  in  the  form  of  sand  or  gravel  to  the  bladder.  At  times  the  sediments 
grow  by  successive  additions  in  the  pelvis  of  the  kidney,  forming  thus  true 
renal  concretions,  whose  descent  into  the  bladder,  if  at  all  possible,  is  accom- 
plished with  the  greatest  difficulty  and  pain.  The  method  in  which  such 
concretions  form  in  the  calices  of  the  kidney  around  a  papilla  is  well  shown 
in  Figure  yy. 

Oxalate  of  lime  calculi  form  similarly  by  the  precipitation  of  crystals  of 
this  substance  immediately  after  the  urine  is  secreted. 

Phosphatic  concretions  are  rarely  primary.  In  order  that  they  may 
form,  the  proportion  of  phosphates  must  be  largely  increased,  or  the  reactions 

47 


738 


DISEASES  OF  THE  URINARY  ORGANS. 


of  the  urine  must  be  permanently  alkaline.  More  frequently  phosphates  pre- 
cipitate around  nuclei  of  uric  acid  or  oxalate  of  lime,  or  foreign  bodies.  The 
effect  of  these  seems  to  be  to  cause  an  alkalinity  in  the  urine  immediately 
about  them  or,  in  cases  of  more  general  cystitis,  in  all  the  urine  in  the  bladder. 
This  alkalinity  causes  the  precipitation  of  phosphates  about  the  primary 
nucleus  and  formation  of  stone  of  various  sizes.  Rarely  layers  of  phosphates 
and  uric  acid  alternate. 

Symptoms. — ^It  sometimes  happens  that  a  stone  is  found  postinortem  in 
the  substance  of  the  kidney  or  in  the  pelvis  which  was  not  suspected,  but  it  is 
hardly  likely  that  even  in  these  cases  symptoms  were  not  present.  They 
were  simply  overlooked  or  ascribed  to  some  other  cause.  The  most  constant 
symptom  of  nephrolithiasis  is  pain  in  the  region  of  the  kidney  associated  with 


Fig-  77« — Hilus  of  Kidney  with  a  Large  and  Small   Renal  Calculus,  Showing  How 
Precipitation  and  Aggregation  Take  Place — {fro7ii  RindJleiscJi). 


more  or  less  tenderness.  Li^e  the  pain  of  stone  in  the  bladder,  it  is  aggra- 
vated by  motion,  especially  rough  motion,  and  there  are  certain  positions  of 
the  body  in  which  the  patient  is  made  more  or  less  uncomfortable.  Quite 
often  the  inflammation  caused  by  the  stone  proceeds  to  suppuration,  and  the 
whole  of  the  kidney,  more  or  less,  is  substituted  by  a  pus-sac.  The  pain  is 
often  suddenly  aggravated  when  a  large  stone  so  lodges  as  to  plug  up  the 
ureter  and  interfere  with  the  descent  of  urine,  or  a  small  one  descends  through 
the  ureter  into  the  bladder.  Under  these  circumstances  come  the  attacks  of 
so-called  nephritic  colic,  characterized  by  pain  which  may  equal  in  severity 
any  to  which  man  is  subject.  It  has  other  distinctive  features.  It  radiates 
downward  into  the  groin  and  the  neighborhood  of  the  bladder  and  down  the 
inside  of  the  thighs  and  into  the  testicle,  which  is  often  retracted.  Sometimes 
it  extends  upward  toward  the  diaphragm,  and  it  is  not  always  easy  to  sepa- 


NEPHROLITHIASIS.  739 

rate  the  pain  of  nephritic  colic  from  that  of  hepatic  colic  when  the  former  is 
on  the  right  side.  It  may  happen  that  both  kidneys  are  the  seat  of  impacted 
stone,  though  this  is  a  very  rare  event.  There  are  often  nausea  and  vomit- 
ing, a  cold  sweat  appears,  and  the  patient  may  collapse. 

After  the  pain  and  colic  the  changes  presented  by  the  iirine  may  be 
highly  distinctive,  aiding  greatly  the  diagnosis ;  at  other  times  the  urine  is 
absolutely  negative.  It  very  frequently  contains  blood,  though  the  quantity 
is  commonly  small,  and  may  be  demonstrable  only  by  the  microscope.  Espe- 
cially is  there  blood  in  connection  with  fresh  attacks  of  nephritic  colic.  Pus 
is  almost  always  present  in  small  or  large  amount.  Cylindroids  or  mucus- 
casts  may  be  found,  true  casts  rarely.  In  some  cases,  too,  uric  acid 
crystals  in  the  shape  of  red  or  brickdust-like  particles  either  before  or  during 
an  attack  of  nephritic  colic  point  to  the  uric  acid  nature  of  the  stone.  The 
same  is  true  of  oxalate  of  lime  crystals.  In  the  case  of  the  last  two  substances 
the  urine  is  acid  in  reaction.  Phosphatic  stones  may  be  suspected  if  the  urine 
is  alkahne  in  its  reaction,  as  it  is  only  possible  for  phosphatic  sediments  to 
form  in  the  presence  of  an  alkaline  or  neutral  urine  while  uric  acid  crystals 
can  only  remain  permanent  in  an  acid  urine.  Oxalate  of  lime,  the  most  in- 
soluble of  all  crystals,  occurs,  however,  in  either  acid  or  alkaline  urine.  In 
cases  of  gravel  or  sand,  as  contrasted  with  stone,  there  are  no  symptoms  as  a 
rule  between  attacks,  as  the  stone  must  reach  an  appreciable  size  before  it 
produces  the  constant  or  almost  constant  pain  characteristic  of  it.  In  some 
cases  there  is  complete  suppression  of  urine,  even  when  the  kidney  on  the 
opposite  side  is  normal,  though  more  frequently  when  it  is  diseased,  and 
death  from  uremia  may  occur  in  consequence.  ,  ^ 

Diagnosis. — It  has  been  intimated  that  nephritic  colic  may  be  con- 
founded  with  biliary  colic.  Usually  the  symptoms  of  each  are  sufficiently 
distinctive.  The  presence  of  jaundice  in  biliary  colic  is  invariable  and  comes 
on  very  soon  after  the  obstruction  begins.  The  stools  are  without  bile  and 
grayish-white  in  color.  Usually  the  pain  is  more  toward  the  epigastric  region 
as  a  center,  and  thence  through  the  upper  abdomen  and  perhaps  through  to 
the  right  shoulder-blade.  The  urine  is  also  bile-stained,  and  responds  to  the 
tests  for  the  coloring-matter  of  bile.  Other  substances,  however,  besides 
stone,  may  produce  nephritic  colic.  Thus,  clots  of  blood  may  obstruct  the 
ureter  and  give  rise  to  all  the  pahi  occasioned  by  an  impacted  stone,  and  in  the 
absence  of  a  history  of  stone  and  of  hemorrhage  there  are  no  symptoms  by 
which  the  two  causes  of  colic  can  be  separated.  In  the  case  of  hydatid  cysts 
of  the  kidney,  fragments  of  these,  too,  may  be  discharged,  and  in  suppurating 
kidney  inspissated  pits  may  occlude  the  ureter.  I  have  in  my  possession  some 
striking  molds  a  centimeter  in  diameter  and  several  centimeters  long,  com- 
posed of  inspissated  pus,  which  plugged  up  the  ureter  for  a  time  and  were 
subsequently  discharged.  Renal  colic  has  been  mistaken  for  intestinal  colic, 
but  such  confusion  is  dissipated  as  the  condition  continues.  Renal  colic  is 
also  produced  wdien  the  ureter  iS  compressed  by  any  cause  as  a  tzi'ist  in  the 
iircter  of  a  floating  kidney,  or  by  compression  of  a  tumor.  The  symptoms  of 
stone  in  the  kidney  sometimes  closely  resemble  those  of  stone  in  the  bladder, 
but  the  pain  in  the  latter,  though  it  may  be  felt,  to  the  back,  radiates  towards 
both  sides ;  in  stone  in  the  bladder  the  urine  contains  more  mucus  and  is 
alkaline  or  becomes  readily  so,  while  'In  nephrolithiasis  the  pus  is  purer  and 
the  urine  acid.  In  all  cases  pointing  to  the  presence  of  stone  in  the  bladder 
the  sound  should  be  promptly  used. 

The  most  invaluable  aid  to  the  diagnosis  of  stone  in  the  kidnev  is  the 


740  DISEASES  OF  THE  URINARY  ORGANS. 

X-ray  examination,  and  in  all  cases  of  suspected  stone  this  measure  should 
be  employed.  Almost  without  exception  a  stone,  if  present,  is  disclosed, 
and  many  times  stones  have  been  found  at  operation  after  such  examination 
has  disclosed  them  which  would  have  been  given  up  at  operation  but  for  the 
certainty  of  its  presence  thus  determined.  Rarely  it  has  happened  that  che 
X-rav  has  apparently  disclosed  a  stone  when  none  has  been  found  at  operation. 

Prognosis. — The  prognosis  of  stone  in  the  kidney  is  very  much  more 
favorable  now  than  it  was  fifteen  years  ago,  in  consequence  of  the  safety  with 
which  operations  can  be  performed.  The  kidney  may  be  exposed,  split  open, 
and  the  parts  reapposed  and  restored  with  perfect  recovery,  and  whenever  the 
diagnosis  of  stone  in  the  kidney  is  made,  an  operation  should  be  done. 
When  many  severe  attacks  occur  without  other  conclusive  evidence,  an 
exploratory  operation  is  sometimes  justified  for  the  sake  of  diagnosis.  When 
the  sand  or  gravel  is  so  small  as  to  pass  the  ureter,  the  suffering  terminates 
with  its  passage  into  the  bladder. 

Treatment. — It  is  needless  at  the  present  day  to  say  there  are  no  medi- 
cines which,  when  administered,  are  capable  of  producing  solution  of  a  stone 
if  it  be  of  any  size.  In  cases  in  which  there  is  no  such  formation  and  we  have 
simply  to  contend  with  gravel  or  sand,  therapeutic  measures  to  prevent  its 
further  formation,  and  even  in  some  cases  to  promote  solution,  may  be 
availed  of. 

It  is,  however,  a  matter  of  extreme  importance  before  treatment  is  insti- 
tuted to  know  exactly  the  kind  of  sediment  that  is  to  be  dealt  with,  and  to 
this  end  the  urine  should  be  carefully  studied.  Thus,  uric  acid  is  dissolved 
by  alkalies,  and  the  object  of  treatment  should  be  to  alkalize  the  urine  as  much 
as  possible,  with  a  view  to  keeping  the  uric  acid  in  solution.  On  the  other 
hand,  to  give  alkalies  to  the  patient  with  phosphatic  stone  or  sediment  is  only 
adding  "  fuel  to  the  flame."  As  to  oxalates,  they  are  equally  insoluble  in  both 
acids  and  alkalies,  but  there  is  reason  to  believe  that  they  are  produced  under 
the  same  conditions  which  produce  uric  acid  sediments,  and  the  treatment  is 
therefore  the  same  for  either. 

The  required  alkalinity  of  the  urine  for  the  solution  of  uric  acid  may  be 
produced  in  any  one  of  a  number  of  ways.  Perhaps  the  most  desirable  of  all 
is  the  free  use  of  alkaline  mineral  waters,  represented  by  the  foreign  waters  of 
Tarasp,  Vals,  Vichy,  and  Ems,  and  in  this  country  approximated  by  Saratoga 
Vichy  and  Saratoga  Geyser  waters,  which  may  be  termed  alkalo-saline  waters. 
It  is  unfortunate  that  in  this  country  we  have  no  native  sources  of  alkaline 
mineral  waters,  at  least  east  of  the  Rocky  Mountains,  and  the  alkaline  waters 
of  the  West  are  so  strong  that  it  would  not  be  possible  to  use  them  without 
dilution,  while  very  few  physicians  seem  to  have  had  any  experience  with 
them.  In  the  absence  of  true  alkaline  waters  the  numerous  negative 
mineral  waters  which  are  so  strongly  recommended  by  their  owners  may  still 
serve  a  useful  purpose  as  diluents  and  solvents.  They  are  almost  too 
numerous  to  mention,  but  the  Bedford,  Poland,  Waukesha,  Buffalo  lithia, 
Geneva  lithia,  and  Londonderry  lithia  waters  are  among  the  best  known. 
In  a  few  cases  they  alone  may  be  sufficient  if  used  freely  enough.  They 
may  be  rendered  more  active  by  combining  alkaline  salts,  such  as  the 
citrate  of  potassium  and  the  bicarbonate  of  potassium  and  lithia.  The 
lithia  waters  for  sale  in  this  country  contain  uncertain,  and  at  most  very 
small,  quantities  of  lithia.  I  think  it  much  better,  under  the  circumstances, 
to  add  a  definite  amount  of  lithium  carbonate  or  citrate  to  a  glass  of 
water — say  from  five  to  ten  grains   (0.3  to  0.6  gm.).     At  least  one  quart 


NEPHROLITHIASIS. 


7A^ 


(2  liters)  of  any  of  the  true  alkaline  waters  should  be  used  every  twenty- 
four  hours  by  an  adult  subject  to  uric  acid  sediments,  and  a  corresponding-  or 
larger  quantity  of  the  more  negative  waters  referred  to.  Liquor  potassii  of 
the  United  States  Pharmacopoeia  is  a  very  excellent  means  of  counteracting 
acid  tendencies.  It  may  be  given  in  doses  of  from  fifteen  minims  to  one-half 
dram  (i  to  2  c.  c),  and  milk  is  a  very  suitable  vehicle.  Piperazin,  a  com- 
paratively recently  introduced  solvent  for  uric  acid,  undoubtedly  possesses 
this  power  outside  of  the  body,  and  in  a  few  cases  it  has  also  seemed  to  me  of 
service  when  administered  to  patients  with  uric  acid  gravel.  Some  assert  and 
others  deny  its  efficacy.  Its  costliness  is  in  the  way  of  its  general  use  in  suffi- 
cient quantity  to  test  its  real  value.  All  that  has  been  said  of  treatment  of  the 
uric  acid  diathesis  may  be  applied  to  that  of  the  oxalate  of  lime: 

Much  also  may  be  accomplished  by  diet.  Persons  with  uric  acid 
diathesis  should  limit  the  amount  of  nitrogenous  food,  using  a  minimum  of 
meat  and  cultivating  the  use  of  milk  and  vegetables  as  a  diet. 

The  phosphatic  tendency  is,  unfortunately,  not  so  easily  combated,  as  our 
resources  for  the  purpose  of  acidifying  the  urine  are  very  limited.  Only  two 
drugs,  benzoic  acid  and  boric  acid,  have  this  reputation,  and  they  possess  it  to 
a  slight  degree  only,  while  large  doses  are  not  well  borne  by  the  stomach. 
From  five  to  ten  grains  (0.3  to  0.6  gm.)  of  each  may  be  given  three,  four,  or 
five  times  a  day,  as  borne  by  the  stomach.  Here,  too,  there  is,  of  course,  the 
same  indication  for  the  free  use  of  diluent  drinks,  and  in  these  cases  the  nega- 
tive mineral  waters  are  as  good  as  any,  while,  perhaps,  distilled  water  serves 
as  the  type  of  a  solvent.  When  the  composition  of  the  stone  is  unknown, 
it  is  best  to  use  this  class  of  waters  rather  than  alkaline  waters,  lest  the  stone 
happen  to  be  phosphatic,  in  which  event  alkaline  waters  would  cause  further 
deposit.  While  the  mineral  acids  cannot,  of  course,  be  given  in  such  dose 
as  to  produce  acidity  of  the  urine,  they  are  still  useful  in  counteracting  any 
tendency  to  higli  degrees  of  alkalinity. 

In  the, matter  of  diet,  too,  the  phosphatic  diathesis  requires  an  opposite 
treatment.  Meats  are  here  indicated,  while  milk  and  vegetables  may  form  a 
less  abundant  part  of  the  food  because  of  their  tendency  to  alkalize  the  urine. 

In  treating  the  uric  acid  diathesis  with  alkalies  it  is  possible  to  carry  the 
effect  too  far  and  cause  deposit  of  phosphates  where  uric  acid  sediments  were 
previously  precipitated.  It  is  important,  therefore,  to  watch  the  urine  care- 
fully and  to  avoid  such  an  administration  of  alkalies  as  will  cause  phosphatic 
sediments  to  make  their  appearance.  It  is  well  known  that  stones  are  found 
in  the  bladder,  which  exhibit  alternate  layers,  now  of  uric  acid  and  now  of 
phosphates,  although  the  latter  substance  almost  invariably  makes  up  the  bulk 
of  calculi  which  have  attained  any  size.  The  rationale  of  this  is  perhaps  as 
follows :  as  soon  as  the  uric  acid  gravel  or  oxalate  of  lime  gravel  becomes 
large  enough  to  act  as  an  irritant,  it  increases  the  organic  matter  in  the  urine 
in  the  shape  of  pus  and  mucus.  These  matters,  it  is  well  known,  favor  an 
alkaline  reaction,  so  that  the  little  stone  becomes  surrounded,  as  it  were,  by  a 
stratum  of  phosphate-precipitating  urine,  and  the  larger  it  grows,  the  more 
apt  is  this  to  be  the  case.  When  alternate  layers  exist,  it  may  be  inferred  that 
the  natural  acidity  reasserts  itself  and  throws  down  the  uric  acid  and  urates, 
which  in  turn  form  a  layer  about  the  stone. 

The  extreme  pain  of  attacks  of  nephritic  colic  must  be  combated  by 
anodynes,  and  for  this  purpose  rarely  is  anything  except  opium  and  its  alka- 
loids sufficient,  while  the  hypodermic  mode  of  medication  is  far  the  best,  both 
because  of  its  prompt  action  and  the  less  serious  effect  upon  the  stomach.     It 


742  DISEASES  OF  THE  URIXARY  ORGAXS. 

is  rarely  the  case  that  less  than  1-4  grain  (0.0 16  gm.)  of  morphin  thus  admin- 
istered is  sufficient,  and  very  frequently  this  dose  must  be  repeated  very  soon. 
It  has  happened  to  me  that  when  the  pain  was  less  severe,  I  could  control  it 
with  full  doses  of  phenacetin  and  acetanilid,  or  by  the  aid  of  these  substances 
render  smaller  doses  of  morphin  sufficient.  For  this  purpose  not  less  than 
fifteen  grains  (  i  gm.)  should  be  given.  Hot  poultices  are  useful  to  a  certain 
extent  in  relieving  pain  when  applied  to  the  lumbar  region  and  to  the  groins, 
while  hot  baths  are  of  great  service  in  relaxing  spasm  and  allaying  pain 
due  to  it. 

The  escape  of  the  stone  from  the  ureter  into  the  bladder  is  followed  by 
unspeakable  relief,  and  its  discharge  from  the  urethra  usually  follows  sooner 
or  later  with  little  or  no  pain,  although  a  stone  of  considerable  size  may  lodge 
in  the  urethra  and  require  extraction.  When  stones  are  not  discharged,  they 
are  likely  to  become  the  nuclei  of  larger  stones  in  the  bladder,  where,  of 
course,  the  majority  of  stones  acquire  their  growth. 

Stones  too  large  to  pass  per  vias  natiirales  should  be  cut  out  of  the  kid- 
ney. It  must  be  remembered,  however,  that  after  apparent  well-founded 
diagnosis  it  sometimes  happens  that  no  stone  has  been  found  on  section.  Yet, 
strange  as  it  may  seem,  it  frequently  happens  that  the  symptoms  do  not  return 
after  such  negative  operation.  Such  cases,  on  the  other  hand,  may  prove  to 
be  cases  of  tuberculosis  of  the  kidnev. 


TUMORS    OF  THE   KIDNEY. 

Definition  and  Application. — The  term  "  tumor  of  the  kidney  "  is 
applied  to  almost  any  enlargement  of  the  organ  due  to  morbid  growths. 
Yet  there  are  morbid  growths  of  the  kidney  which  are  not  suffi- 
ciently large  to  produce  appreciable  change  in  its  size.  Thus,  the  adenoma 
does  not  usually  exceed  4-10  inch  (i  cm.)  in  diameter,  though  it  may 
be  two  inches  (5  cm.)  or  more.  The  same  is  true  of  the  angiomata  and 
leukemic  tumors,  of  iihroma  and  lipoma,  which  sometimes  form  small  white 
nodes  in  the  fibrous  tissue  near  the  bases  of  the  pyramids.  Lymph-adenoma 
occurs  in  the  kidney  associated  with  similar  disease  of  lymph  glands,  liver, 
and  intestine.  Villous  papilloma  sometimes  grows  in  the  pelvis  of  the  kidney. 
Syphilitic  gummata  also  belong  to  the  group  of  moderate-sized  tumors  rarely 
producing  symptoms. 

Cysts,  single  and  multilocular,  acquire  larger  size,  producing  appreciable 
enlargement  of  the  kidney.  The  malignant  tumors,  sarcoma  and  carcinomu, 
belong  to  this  category,  and  with  cysts  are,  clinically  speaking,  perhaps  the 
chief  occasion  of  the  term  "  tumor  of  the  kidney."  On  the  other  hand,  renal 
abscess,  or  pyonephrosis,  does  not  usually  earn  for  the  kidney  involved  the 
name  "  tumor."  while  hydronephrosis  does. 

Symptoms. — Certain  local  symptoms  are  produced  indifferently  by  any 
one  of  the  tumors  large  enough  to  become  clinically  appreciable.  In  the  first 
place,  renal  tumors  grozv  for  the  most  part  fori^'ard  rather  than  backward, 
because  of  the  more  yielding  character  of  the  parts  in  front  of  them  than 
behind  them,  rarely  producing  posteriorly  much  more  than  a  fullness  of  the 
back,  in  the  course  of  which  there  is  obliteration  of  the  resonance  which  may 
be  present  between  the  kidney  dullness  and  the  vertebral  spines.  As  this  for- 
ward growth  proceeds,  a  special  effect  results  from  the  relation  of  the  bowel 
to  the  kidney ;  as  the  ascending  colon  on  the  right  side  and  the  descending 


TUMORS  OF  THE  KIDNEY.  743 

colon  on  the  left  lies  in  front  of  the  corresponding  kidney,  the  effect  of  en' 
largement  of  this  organ  is  to  push  the  bowel  in  front  of  it,  the  hollow  viscus 
being  recognized  by  the  tympanitic  percussion  note.  In  this  respect  renal 
tumor  differs  from  splenic  tumor,  and  less  invariably  from  that  of  the  liver, 
since  the  bowel  does  not  intervene  between  these  organs  and  the  abdominal 
wall,  though,  rarely,  the  small  intestine  may  float  between  the  liver  and  the 
parietes.  Commonly,  too,  the  hand  may  slide  between  the  renal  tumor  and 
the  liver  on  one  side  and  the  renal  tumor  and  the  spleen  on  the  other,  while 
it  never  loses  the  rounded  border  characteristic  of  the  kidney. 

By  bimanual  palpation  with  the  palm  of  one  hand  placed  in  the  lumbar 
region  and  the  other  in  front  below  the  ribs,  pressure  being  made  in  both 
directions,  the  tumor  may  be  recognized.  In  this  examination,  too,  it  will 
be  noticed  that  the  kidney  permits  a  much  more  limited  degree  of  mobility 
•during  breathing  than  does  the  liver,  although  it  is  not  totally  immobile. 
The  renal  tumor,  too,  commonly  resists  lateral  movement. 

Again,  pain  in  the  region  of  the  kidney  is  an  inconstant  symptom.  It  is 
•often  totally  absent,  at  other  times  exceedingly  severe,  especially  if  the  ver- 
tebrae and  spinal  cord  are  encroachd  upon.  It  sometimes  happens  that  in  con- 
sequence  of  the  pressure  of  the  kidney  upon  the  twelfth  dorsal  nerve  and 
branches  of  the  lumbar  plexus  neuralgic  pains  in  the  abdominal  walls  are 
produced. 

Diagnosis. — As  to  differential  diagnosis,  both  varieties  of  tumor,  viz., 
'Carcinoma  and  sarcoma,  produce  hematuria,  though  it  is  not  even  a  frequent 
symptom  with  them.  In  the  event  of  its  presence  the  blood  may  be  fluid 
or  clotted,  and  is  often  molded  in  the  pelvis  of  the  kidney  and  ureter,  an 
event  very  rare  in  the  blood  poured  into  the  pelvis  under  other  circumstances. 
Hematuria  is  more  frequent  in  carcinoma  than  in  sarcoma.  Both  conditions 
are  likely  to  produce  pain.  It  is  sometimes  extreme  and  boring,  when  it 
indicates  destructive  encroachment  on  the  vettebrge.  More  frequently  it 
is  dull,  radiating  over  the  flank  into  the  thighs.  These  tumors  also  produce 
cachexia.  Very  rarely  they  may  be  recognized  by  the  presence  of  distinctive 
histological  elements  in  the  urine.  This  occurred  in  my  experience  in  at 
least  two  instances.     Frequently  the  urine  is  altogether  negative. 

Of  sarcoma  and  carcinoma  between  which  no  distinction  was  made  until 
thirty  years  ago,  the  former  is  now  regarded  as  the  more  common.  Both 
may  be  primary  or  secondary,  more  frequently  secondary.  Sarcoma  is  a  dis- 
ease of  early  life,  in  fact,  it  is  often  congenital,  when  it  is  represented  by  that 
form  known  as  rhabdomyoma,  which  contains  striated  muscular  fibers.  In 
more  than  half  the  cases  it  affects  children  under  ten.  On  the  other  hand, 
renal  cancer  is  not  confined  to  later  life,  as  are  other  forms  of  cancer,  and  it 
may  even  occur  in  children.  May  not  these  tumors,  too,  have  been  sar- 
comata? More  usually  one  kidney  only  is  affected.  Such  organ  is  uneven, 
soft,  even  to  a  sense  of  fluctuation.  Carcinoma  also  selects  one  kidney 
whence  it  may  invade  the  pelvis  and  ureter.  It  affects  the  general  health 
more  rapidly,  hematuria  is  more  frequent  and  copious,  but  intermittent.  If 
there  be  a  superficial  primary  growth  elsewhere  and  a  renal  tumor  is  present, 
the  presumption  is  that  it  is  of  the  same  nature,  but  no  certain  diagnosis  can 
be  made  between  carcinoma  and  sarcoma  unless  the  rare  opportunity  occurs 
to  examine  fragments  discharged  witn  the  urine.  Unfortunately  for  diag- 
nosis, the  urine  is  too  often  quite  free  from  any  sediment,  even  of  pus.  Car- 
cinoma of  the  kidney  is  apt  to  invade  the  renal  veins  and  even  the  vena  cava, 
and  as  such  to  cause  metastasis  in  the  lunes  and  in  other  organs  as  well. 


744  DISEASES  OF  THE  URINARY    ORGANS. 

From  ovarian  tumors  renal  tumors  are  distinguished  by  the  fact  that  in 
the  former  the  intestines  He  in  the  flanks,  giving  resonance  on  percussion  in 
that  locality,  while  an  enlarging  kidney  pushes  the  bowels  in  front  of  it.  The 
ovarian  tumor  also  grows  from  below  upward  and  drags  with  it  the  uterus 
and  appendages,  as  can  be  recognized  by  vaginal  examination  and  by  rectal 
touch. 

Much  more  difficult  is  it  to  distinguish  the  renal  tumor  from  enlargement 
of  the  retroperitoneal  glands,  as  such  enlargement  also  pushes  up  the  intes- 
tines in  front  of  it,  giving  rise  to  a  tympanitic  percussion  note.  Hematuria 
is  never  in  retroperitoneal  tumor,  while  it  may  or  may  not  be  present  in  renal 
tumor.  The  retroperitoneal  tumor  may  press  upon  the  ureter  and  the  renal 
vessels  and  thus  produce  obstruction  to  the  descent  of  the  urine.  The  central 
situation  of  the  enlargement  in  retroperitoneal  tumors  contrasts  with  the 
lateral  growth  in  renal  tumors. 

From  tumors  of  the  liver  renal  tumors  differ  in  that  the  form  sooner  or 
later  cause  a  bulging  of  the  right  hypochondriac  region,  while  the  renal 
tumors  rarely  reach  as  high  as  to  alter  the  configuration  of  the  lower  thorax. 
The  sharper  border  of  the  liver  tumor  as  contrasted  with  the  rounded  edge 
of  the  kidney  tumor  is  characteristic,  while  the  freer  movement  of  the  liver 
with  the  breathing  is  also  of  value.  Splenic  tumors  are  not  likely  to  be  con- 
founded with  tumors  of  the  left  kidney.  Splenic  tumor  protrudes  from  above 
downward  and  toward  the  umbilicus  instead  of  from  the  lumbar  region  for- 
ward. It  moves  more  with  breathing,  and  its  sharper  edge  and  indentation 
may  be  recognized.     It  is  always  above  or  outside  of  the  colon. 

Treatment. — Renal  tumor  is  beyond  curative  treatment  by  the  physi- 
cian. As  soon  as  the  diagnosis  is  made,  a  surgeon  should  be  called  and  the 
question  of  operation  considered. 

Cysts  of  the  Kidney. 

Reference  is  here  made  only  to  such  cysts  as  produce  clinically  appre- 
ciable enlargement  of  the  organ.     They  include : 

1.  Retention  or  obstruction  cysts,  solitary  cysts  ranging  in  diameter  from 
a  centimeter  (0.4  in.)  to  10  centimeters  (4  in.)  and  larger.  They  may  be 
present  in  one  or  both  kidneys.  These  are  probably  primarily  the  result  of 
stenosis  of  a  uriniferous  tubule  behind  which  accumulates  first  urine,  which 
is  gradually  substituted  by  an  aqueous  fluid  in  which  may  be  found  traces  of 
urinary  constituents.  A  trace  of  albumin  may  also  be  present.  These  cysts 
rarely  give  rise  to  symptoms. 

2.  The  congenital  cystic  kidney,  in  which  both  organs  are  the  seat  of 
numerous  round  cysts  varying  in  size  from  1-5  inch  (5  mm.)  to  one  inch  (2.5 
cm.),  may  produce  tumors  of  large  size,  so  large,  in  fact,  that  they  have  inter- 
fered with  parturition.  They  contain  a  fluid  which  is  at  times  clear,  at  others 
again  turbid,  colloidal  in  consistence,  and  containing  albumin,  cholesterin, 
triple  phosphates,  rarely  urea  and  uric  acid,  and  sometimes  fat  drops.  Per- 
sons with  these  cysts  may  grow  to  adult  life,  and,  indeed,  such  cystic  kidneys 
have  been  found  postmortem  when  not  suspected.  Commonly,  the  subjects 
die  either  before  birth  or  shortly  after.  The  exact  mode  of  origin  of  these 
congenital  cysts  is  not  understood,  but  they  are  probably  the  consequence  of  a 
defect  in  development. 

There  may  be  no  symptoms  beyond  that  of  an  enlarged  organ,  or  they 
may  be  those  of  interstitial  nephritis  with  its  secondary  cardiovascular  con- 


TUMORS  OF  THE  KIDNEY.  745 

sequences.     There  may  be  a  small  albuminuria.     Blood  discs  may  be  found, 
but  no  casts. 

3.  Dermoid  cysts  are  also  occasionally  met  in  the  kidney,  while  a  general 
cystic  condition  invading  the  liver  and  spleen  as  well  as  the  kidney  is 
described. 

4.  Hydronephrosis  is  a  monocystic  degeneration  of  the  kidney  starting  in 
obstruction  of  the  ureter,  succeeded  by  dilatation  of  the  pelvis  and  gradual 
wasting  of  the  kidney  substance,  due  to  pressure  of  the  accumulating  fluid. 

The  obstruction  causing  this  condition  may  also  be  congenital.  As  such 
it,  too,  may  be  large  enough  to  impede  labor.  An  oblique  insertion  of  the 
ureter  at  such  angle  as  to  interfere  with  the  easy  discharge  of  the  secretion 
may  be  the  cause  of  its  retention  in  the  pelvis  of  the  organ.  Among  recog- 
nized causes  during  life  are,  also,  occlusion  of  the  ureter  by  cicatricial  adhe- 
sion, by  lithiasis,  tuberculosis  of  the  ureter,  by  pressure,  by  tumors,  by  a  retro- 
flexed  or  prolapsed  uterus,  by  bands  of  lymph  in  healed  peritonitis  and  by 
twists  in  the  ureter  of  a  movable  kidney.  Finally,  carcinoma  of  the  bladder 
and  even  hypertrophy  of  the  prostate  and  stricture  of  the  urethra  may  be 
causes. 

The  contents  of  the  tumor  may  be  purely  aqueous ;  more  frequently  they 
are  slightly  turbid ;  they  contain  a  few  pus-cells,  more  numerous  if  they  are 
the  seat  of  inflammation ;  also  uric  acid,  urea,  and  albumin. 

Its  symptoms  consist  of  those  already  described  as  common  to  benign 
renal  tumors  of  sufficient  size.  An  event  which  is  almost  pathognomonic  is 
the  occasionally  sudden  disappearance  of  the  tumor  simultaneously  with  the 
discharge  of  a  large  quantity  of  fluid  from  the  bladder,  followed  by  gradual 
refilling  of  the  sac  and  return  of  the  tumor.  This  intermittent  discharge  may 
be  kept  up  for  years.  Such  an  event  must  be  ascribed  to  a  valvular  obstruc- 
tion in  the  ureter  which  at  times  yields  to  the  pressure  of  the  accumulated 
fluid ;  or  it  may  be  due  to  the  undoing  of  a  twist  in  the  ureter  of  a  floating 
kidney. 

As  to  differential  diagnosis,  ovarian  tumor  is  the  condition  with  which 
it  is  most  frequently  confounded.  I  have  already  (p.  744)  called  attention  to 
the  different  relations  of  the  intestine  to  the  tumor  in  the  two  instances  and 
other  points  of  difference,  all  of  which  need  not  be  repeated.  The  relative 
immobility  of  the  renal  tumor,  as  contrasted  with  the  mobility  of  the  ovarian, 
may,  however,  be  mentioned ;  also  the  lumbar  origin  of  the  former,  as  con- 
trasted with  the  pelvic  of  the  latter,  as  determined  by  rectal  and  vaginal 
examination.  Should  the  tumor  disappear  simultaneously  with  a  copious 
discharge  from  the  bladder,  the  diagnosis  is,  of  course,  conclusive.  Aspira- 
tion may  also  be  brought  to  aid  the  diagnosis,  when  advantage  may  be  taken 
of  the  fact  that  the  characters  of  the  ovarian  fluid  and  that  of  hydronephrosis 
are  widely  different.  The  dense,  colloid  fluid  of  the  ovarian  cyst,  with  its 
numerous  cholesterin  plates,  fatty  granular  cells,  small  granular  cells,  and 
highly  albuminous  composition,  contrast  strongly  with  the  aqueous  con- 
sistence, the  low  specific  gravity,  and  the  general  negative  character  of  the 
hydronephrotic  fluid.  Too  much  stress  must  not,  however,  be  laid  upon 
these  differences,  as  they  do  not  always  exist.  The  history  in  the  case  of 
ovarian  tumor  will  develop  the  events  of  menstrual  and  sexual  derangement, 
which  are  absent  in  hydronephosis.'  Hydronephrosis  is  not  likely  to 
be  confounded  with  ascites.  The  changes  in  the  position  of  the  fluid  with 
that  of  the  patient,  characteristic  of  ascites,  and  its  bilateral  situation  dis- 
tinguish it  at  once  from'  hydronephrosis. 


746  DISEASES  OF  THE  URINARY    ORGANS. 

From  a  circniiiscribcd  peritoneal  exudate  hydronephrosis  is  distinguished 
by  the  different  history,  the  greater  tenderness  of  the  former,  and  tympany 
of  the  subjacent  intestine  eHcited  by  strong  percussion.  In  renal  abscess 
there  is  fluctuation,  but  there  are  also  fever  and  sometimes  chills.  The 
renal  retention  cyst  is  at  times  indistinguishable  from  hydronephrosis.  Both 
may  be  congenital  or  due  to  congenital  defects,  but  should  there  be  inter- 
mittent emptying  of  the  sac,  with  refilling,  hydronephrosis  may  be  suspected. 
The  diagnosis  from  hydatid  cyst^  so  far  as  is  possible,  follows  in  the  next 
paragraph. 

5.  Echinococcus  or  Hydatid  Cyst. — Hydatid  disease  of  the  kidney  is  a 
rare  affection,  and  when  the  enlargement  caused  by  it  is  sufficient  to  produce 
physical  signs,  they  do  not  differ  essentially  from  those  of  hydronephrosis 
and  cystic  kidney.  Only  in  the  event  that  the  microscope  recognizes  hook- 
lets  or  scolices,  or  fragments  of  the  cyst-wall  in  the  urine  or  in  the  fluid 
obtained  by  tapping  or  discharge  into  other  localities,  such  as  the  stomach, 
intestines,  or  bronchi,  can  a  diagnosis  be  made  with  certainty.  Such  dis- 
charge into  the  pelvis  of  the  kidney,  if  it  produce  obstruction,  may  also  cause 
acute  hydronephrosis.  The  presence  of  hydatids  elsewhere,  and  of  the 
hydatid  fremitus,  is  presumptive  evidence.  The  chemical  and  physical  char- 
acters of  the  fluid  from  hydatid  cysts  is  given  under  hydatid  disease  of  the 
liver  (p.  480).  Like  hydronephrosis  and  cystic  tumor,  the  hydatid  kidney 
differs  from  ovarian  tumor  by  its  immobility,  unless  the  disease  should  per- 
chance invade  a  movable  kidney. 

Treatment  of  Renal  Cysts. — The  treatment  of  the  whole  list  of  affec- 
tions included  under  cysts  of  the  kidney  lies  in  the  province  of  the  surgeon, 
the  chief  office  of  the  physician  in  these  cases  being  one  of  diagnosis  and 
relief  of  pain. 


ANOMALIES  OF  FORM  AND  POSITION  OF  THE  KIDNEY. 

Normal  Situation  of  the  Kidney. — The  normal  situation  of  the 
kidney  is  on  the  quadratus  lumborum  and  psoas  muscles,  the  inferior  end  of 
the  left  kidney  extending  a  variable  distance  below  the  edge  of  the  twelfth 
rib,  while  the  right  extends  about  3-4  inch  (20  mm.)  lower  down,  the  whole 
right  organ  being  lowered  by  the  position  of  the  liver.  The  outer  edge 
of  the  kidney  is  often  in  a  line  drawn  vertically  through  the  end  of  the 
twelfth  rib.  Both  kidneys  descend  about  1-2  inch  (12.5  mm.)  during  deep 
inspiration.  The  kidney,  if  in  its  normal  situation,  is  accessible  to  pressure 
just  below  the  last  rib  at  the  outer  edge  of  the  erector  spinse  muscle.  Some- 
times one  or  the  other,  more  frequently  the  left,  lies  on  the  lumbar  vertebra, 
on  the  sacrum,  or  in  the  inguinal  canal. 

Congenital  Absence  of  the  Kidney. — The  total  absence  of  both 
kidneys  is  possible  in  connection  with  extreme  abnormalities  and  defect  of 
development,  but  is  incompatible  with  life. 

Congenital  absence  of  one  kidney  is  not  very  rare,  the  absent  one  being 
usually  the  left.  Such  absence  may  be  suspected  when  over  the  normal 
situation  of  the  organ  a  tympanitic  note  only  .can  be  elicited  by  percussion. 
In  such  event,  the  remaining  kidney  supplements  the  work  of  the  absent 
one,  and  serious  consequences  only  follow  in  the  event  of  disease  or  lesion 
of  the  remaining  organ.     The  ureter  and  pelvis  of  the  absent  kidney  are 


FORM  AND  POSITION  OF  THE  KIDNEY.  747 

absent  also,  but  sometimes  the  remaining  organ  has  two  pelves  and  two 
ureters.     Occasionally    the    rudiment    of    a    ureter   is    present.     Congenital 

atrophy  of  one  kidney  is  even  more  common,  but  is  discoverable  only  at 
autopsy. 

LoBULATED  KiDNEY. — The  lobulatcd  kidney  is  the  most  frequent 
anomaly  of  form.  It  consists  essentially  in  the  persistence  of  the  lobulation 
natural  to  the  organ  in  the  fetal  state.  This  is  acquired  by  the  end  of  the 
eighth  week  of  fetal  Hfe,  after  which  it  gradually  disappears  in  normal 
development,  but  is  still  maintained  with  more  or  less  distinctness  through- 
out the  first  year  after  birth.  The  abnormal  lobulation  is  variously  distinct. 
Usually  partial  and  superficial,  the  fissures  are  sometimes  so  deep  as  to  divide 
the  organ  into  separate  reniculi,  of  which  there  may  be  from  seven  to  twenty. 
This  lobulation,  a  rare  event  in  man,  is  clearly  seen  in  the  kidneys  of  the 
lower  animals,  especially  in  the  sheep  and  ox. 

Horse-shoe  Kidney. — The  most  striking  of  the  anomalies  of  form  is 
the  horse-shoe  kidney,  in  which  usually  the  lower  ends  of  the  two  organs  are 
united  either  by  true  renal  tissue  or  by  a  band  of  fibrous  tissue.  ]\Iore  rarely 
it  is  the  middle  segments  which  are  united,  and  more  rarely  still  the  upper 
ends.  In  either  event,  this  coalescence  is  usually  associated  with  displace- 
ment of  the  organ,  which  is  then  lower  down  than  in  the  normal  condition, 
usually  just  above  the  promontory  of  the  sacrum,  more  rarely  in  the  pelvis, 
and  at  times  on  one  side  or  the  other  of  the  spinal  column.  In  the  fused 
kidney  there  are  usually  two  pelves,  with  from  two  to  four  ureters,  ^love 
rarely  there  is  but  one  pelvis.  The  ureters  pass  over  the  front  of  the  kidney. 
The  renal  arteries  spring  from  the  aorta  at  points  corresponding  to  the  situ- 
ation in  which  the  organ  is  found.  Thus,  when  above  the  sacrum,  the 
arteries  spring  from  the  back  of  the  aorta  near  its  bifurcation  or  from  one 
of  the  common  iliacs,  while  the  veins  enter  the  corresponding  parts  of  the 
vena  cava  or  iliac  veins. 

The  horse-shoe  kidney  is  generally  first  recognized  at  autopsy,  but 
rarely  it  may  be  recognized  in  its  abnormal  position  above  the  sacrum, 
especially  in  thin  persons. 

The  Movable  or  Floating  Kidney. 

Synonyms. — Ren  uiobilis:  Floating  Kidney;  Palpable  Kidney;  Nephroptosis. 

Description. — The  normal  kidney  is  commonly  quite  firmly  retained 
in  position  by  its  capsule  of  fat  and  by  a  covering  of  peritoneum.  The 
movable  or  floating  organ  exhibits  a  very  different  degree  of  mobility  in 
different  instances.  The  mobility  may  be  so  slight  that  it  can  be  recognized 
only  by  the  expert  manipulator,  or  so  great  that  the  organ  may  be  easily 
grasped  by  the  hand  through  the  abdominal  walls.  In  the  latter  condition 
there  is  a  mesonephron  or  peritoneal  fold  loosely  attaching  the  kidney  to 
the  spine. 

Etiology. — The  movable  kidney  is  more  common  in  thin  persons  than 
in  the  obese,  in  women  than  in  men.  Indeed,  it  has  been  said  that  one 
Avoman  out  of  every  four  has  a  movable  kidney.  It  is  six  times  as  frequent 
in  the  working-classes.  The  right  kidney  is  far  more  frequently  movable 
than  the  left.     Repeated  pregnancies  are  assigned   causes,   as   is  also  me- 


748  DISEASES  OF  THE  URINARY    ORGANS. 

chanical  violence,  as  a  fall  or  tight  lacing.  It  is  most  likely,  however, 
that  the  majority  of  floating  kidneys  are  congenitally  loose,  and  that  this 
looseness  may  be  increased  by  the  conditions  named. 

Symptoms, — The  floating  kidney  often  occasions  no  symptoms.  At 
other  times  it  is  responsible  for  a  remarkable  train  of  nervous  symptoms^ 
mainly  reflex  in  character.  These  include  obstinate  indigestion  of  every 
grade,  flatulence,  palpitation  of  the  heart,  cardialgia,  neuralgic  pain  almost 
anywhere  in  the  body,  but  especially  in  the  abdomen  and  cardiac  region. 
Gastric  crises  identical  with  those  characteristic  of  locomotor  ataxia  have 
been  ascribed  to  floating  kidney.  Irritable  bladder  and  dysmenorrhea  are 
also  consequences.  It  is  an  interesting  fact  that  where  the  degree  of  dis- 
placement and  the  mobility  are  most  marked,  the  reflex  symptoms  are  least 
so.  This  is  not  without  a  parallel  in  other  diseases,  and  in  illustration  may 
be  cited  the  well-known  fact  that  prolapsus  uteri  of  moderate  degree  often 
causes  decided  reflex  symptoms,  while  a  complete  procidentia  produces 
often  trifling  local  annoyance.  The  direct  result  of  the  displacement,  so  far 
as  appreciable,  is  a  sense  of  dragging  or  weight,  which  especially  manifests 
itself  while  standing,  walking,  riding,  or  dancing,  to  which  may  be  added 
a  variable  amount  of  pain.  More  serious  symptoms  sometimes  manifest 
themselves  as  the  result  of  torsion  of  the  ureter,  occasioned  by  complete 
rotation  of  the  kidney,  in  which  the  renal  vessels  and  nerves  are  also  involved. 
These  are  agonizing  pain,  associated  with  symptoms  of  collapse,  such  as 
nausea,  an  anxious  expression,  and  scanty  urination.  They  are  caused  in 
part  by  obstruction  to  the  ureter  and  the  backing  of  the  urine  on  the  kidney. 
Acute  hydronephrosis  may  also  be  the  result  of  such  strangulation,  which 
may  be  caused,  too,  by  inflammatory  bands.  This  condition  ends  sometimes 
as  suddenly  as  it  begins.  Both  hemorrhage  and  albuminuria  are  reported 
as  results.  Both  are  certainly  rare.  There  may  be  other  effects  of  dis- 
placement due  to  the  location  of  the  organ  at  times,  of  which  irritation  due 
to  pressure  upon  the  bladder  may  be  mentioned  as  one.  It  is  often  very 
uncomfortable  for  the  patient  to  lie  on  the  side  opposite  that  on  which  the 
displaced  organ  belongs. 

Diagnosis. — This  is  variously  difficult.  The  kidney  exhibits  some 
mobility  in  health,  descending  also  always  1-2  inch  (1.3  cm.)  with  each  deep 
inspiration.  Movable  kidneys  are  sometimes  so  loose  and  movable  that 
they  may  be  felt  with  ease  through  the  abdominal  walls.  Between  this 
ready  recognition  and  that  which  requires  the  highest  manipulative  skill  of 
the  examiner  there  is  every  degree.  At  the  present  day,  movable  kidney  is 
regarded  as  a  much  more  fi^equent  condition  than  was  formerly  believed. 
So  frequently  has  the  set  of  reflex  nervous  symptoms  described  been  found 
associated  with  movable  kidney  that  their  presence  should  always  suggest 
an  examination  for  the  presence  of  such  an  organ.  The  examination  may 
be  made  with  the  patient  in  the  standing  posture,  or  when  lying  on  the 
back.  In  the  first  he  bends  slightly  forward,  the  hands  being  placed  on  a 
table,  and  the  clothing  thoroughly  loosened.  The  right  hand  of  the  examiner 
is  then  placed  in  front  immediately  next  the  skin,  below  the  hypochondrium, 
while  the  left  is  placed  over  the  lumbar  region.  The  patient  is  directed  to 
respire  deeply  and  regularly,  and  to  relax  during  expiration.  The  region 
between  the  two  hands  is  carefully  palpated,  when,  if  there  is  any  marked 
degree  of  displacement,  or  rather  of  lowered  position,  the  organ  can  be  felt 
as  a  firm,  smooth,  oval  body,  somewhat  sensitive  to  pressure,  which  produces 
a  sickening  pain  which  is  quite  characteristic.     Most  rarely  the  pulsation 


IDIOPATHIC  HEMATURIA.  749 

of  the  renal  artery  can  be  felt.  The  right  kidney  naturally  moves  with 
breathing  more  than  the  left,  being  pushed  down  by  the  liver.  Sometimes 
the  manipulation  will  be  more  successful  in  the  knee-elbow  position.  When 
in  this  position,  the  movable  kidney  having  fallen  forward,  a  resonant  note 
may  be  obtained  by  percussing  over  the  normal  situation  of  the  organ ;  or  the 
patient  may  be  placed  on  the  back  with  the  side  to  be  examined  toward  the 
edge  of  the  bed,  on  which  the  physician  may  sit.  The  hands  are  applied  as 
in  the  standing  position,  and  manipulation  is  practiced  as  described. 

The  displaced  organ  is  hardly  likely  to  be  confounded  with  anything 
else.  The  spleen,  which  corresponds  nearly  in  size,  is  also  sometimes 
movable.  Its  shape  is.  however,  different.  Its  anterior  body  is  sharp 
and  often  notched.  Sometimes  both  the  left  kidney  and  the  spleen  are 
floating.  A  movable  pyloric  tumor  has  been  mistaken  for  a  movable  kidney. 
The  passage  of  a  stomach-tube  in  case  of  doubt  would  clear  it  up. 

Treatment. — As  may  be  inferred,  many  cases  of  movable  kidney  re- 
quire no  treatment.  In  a  few  instances  the  symptoms  are  relieved  by 
improving  the  general  health ;  in  others  the  patient  is  comfortable  while 
lying  on  the  back,  and  such  comfort  may  continue  for  a  time  after  rising. 
AVhen  decided  symptoms  attributable  to  the  kidney  are  present,  surgical 
treatment  for  fixing  the  kidney — nephrorrhaphy — is  alone  of  permanent 
value,  and  this  sometimes  fails.  I  have  known  an  operation  for  removal 
of  the  kidney — nephrectomy — to  be  necessary  after  nephrorrhaphy  had  been 
attempted  twice  unsuccessfully.  The  use  of  pads  and  supports  has  never 
proved  successful  in  my  cases.  Dr.  A.  Symons  Eccles,  however,  reported  * 
five  cases  of  nephroptosis  treated  by  an  abdominal  bell  and  pad,  massage  and 
exercise,  with  relief  of  all  symptoms. 


IDIOPATHIC  HEMATURIA.! 

Definition. — A  hematuria  the  origin  of  which  is  unknown.  In  ad- 
dition to  the  various  causes  of  bloody  urine  already  referred  to  in  treating 
diseases  of  the  urinary  organs,  and,  in  addition  to  malarial  hematuria,  there 
remains  a  form  of  renal  hematuria  of  not  very  infrequent  occurrence,  for 
which  none  of  the  causes  named  will  account.  To  this  the  term  idiopathic 
hematuria  is  appropriate. 

Symptoms. — The  characteristics  of  the  urine  in  this  form  of  hematuria 
are  in  no  way  different  from  those  of  renal  hematuria  from  other  causes. 
The  blood  is  intimately  admixed  with  the  urine,  and  is  not,  as  a  rule,  found 
in  the  shape  of  coagula,  as  is  so  often  the  case  when  the  blood  comes  from  the 
bladder  or  pelvis  of  the  kidney  or  in  malignant  disease  of  the  kidney.  There 
is  the  usual  smoke  hue  characteristic  of  acid  urine  containing  a  small  amount 
of  blood,  becoming  brighter  red  as  the  urine  becomes  alkaline,  and  darker 
red  as  the  quantity  of  blood  is  increased.  The  microscope  reveals  numerous 
blood-discs  recognizable  by  their  usual  characters,  and  often  blood-casts 
and  casts  filled  with  the  debris  of  red  discs,  or  red  discs  so  closely  packed 
as  to  make  it  impossible  to  distinguish  their  outline.  The  urine  is.  of  course, 
albuminous. 

Xext  to  the  change  in  the  urine,  die  most  striking  feature  is  the  absence 

"*■  "  Lancet,"  January-  2q,  i8c,8. 

+ 1  realize  that  the  siibjectshematuria,  hemoglobinuria,  and  chyluria,  next  to  be  considered,  are 

not  strictly  renal  affections,  but  it  is  difficult  to  classifj- them  otherwise. 


750  DISEASES  OF  THE  URINARY    ORGANS. 

of  other  symptoms.  The  subject  is  not  ill,  is  not  weak,  and  complains  of 
nothing.  Occasionall}-  a  dull  ache  in  the  back  is  felt  or  supposed  to  be  felt, 
perhaps  because  the  patient  thinks  that  since  there  is  bloody  urine,  there 
ought  to  be  pain  in  the  back.  The  same  may  be  said  of  weakness,  but  these 
symptoms  are  not  usually  complained  of,  though  they  may  be  present. 
Sir  William  Gull  spoke  of  such  hematuria  as  a  "renal  epistaxis."  With 
the  lapse  of  time,  however,  and  the  continuance  of  the  symptom,  positive 
weakness  gradually  supervenes. 

Treatment. — Rest  is  an  important  and  essential  condition  in  the  suc- 
cessful management  of  idiopathic  hematuria.  The  usual  astringents,  mineral 
and  vegetable,  known  to  be  efficient  in  the  treatment  of  hemorrhagic  condi- 
tions elsewhere,  are  often  without  effect  here,  though  these  substances,  in- 
cluding gallic  acid,  ergot,  the  persulphate  of  iron,  and  acetate  of  lead,  alum, 
catechu,  and  kino,  may  be  tried.  The  persulphate  of  iron  has  proved  of 
undoubted  value  in  my  hands,  in  doses  of  from  1-4  to  1-2  grain  (0.015  to 
0.32  gm.)  every  four  hours  in  a  pill.  The  astringent  mineral  waters,  espe- 
cially the  alum  waters,  as  those  of  the  Rockbridge  Alum  Springs,  in  Virginia, 
and  the  Jackson  Spring,  North  Carolina,  have  apparently  proved  curative, 
but  I  have  also  failed  with  them.  A  case  which  I  saw  in  consultation  with 
T.  Barry  Tyson,  of  Jenkintown,  resisted  all  measures  until  Dr.  Tyson  tried 
the  fluid  extract  of  hainainelis  virginica  in  doses'  of  twenty  minims  (1.32 
gm.)  every  three  hours,  and  in  thirty-six  hours  the  hemorrhage  ceased 
and  has  not  recurred.  As  hamamelis  contains  much  tannin  and  gallic  acid, 
it  may  owe  its  efficiency  to  this  constituent.  One  of  my  cases,  after  resist- 
ing every  other  form  of  treatment,  finally  yielded  to  electric  baths,  continued 
for  fifteen  minutes  every  other  day  for  one  month. 

Gelatin  has  also  been  recommended  in  hematuria,  in  common  with  other 
hemorrhages.  As  an  example,  Schwabe  injected  into  each  infra-clavicular 
region  25  c.  c.  (7  fo)  of  physiologic  salt  solution  containing  2  1-2  per  cent, 
of  pure  gelatin,  followed  by  the  daily  administration  by  the  mouth  for  a  week 
of  a  pint  of  10  per  cent,  gelatin  solution. 


HEMOGLOBINURIA. 

Definition. — In  this  interesting  condition,  the  coloring-matter  only 
of  the  blood  is  found  in  the  urine ;  very  rarely  a  few  blood  discs  or  their 
fragments.  In  their  absence,  other  criteria  of  the  presence  of  blood  coloring- 
matter  must  be  sought.  To"^  do  this,  one  may  make  Teichmann's  hemin 
crystals,  as  directed  in  the  footnote  on  page  79;  or  if  the  spectroscope  be 
available,  the  filtered  and  diluted  urine  produces  the  absorption  bands  of 
oxyhemoglobin  between  Fraunhofer's  line  D  and  E,  or  more  frequently  the 
three  bands  of  methemoglobin,  of  which  that  in  the  red  near  C  is  dis- 
tinctive. Sometimes  both  are  present.  The  urine  thus  stained  with  hemo- 
globin is  dark  brownish-red,  and  even  black  in  color.  It  is  also  albuminous, 
and  in  lieu  of  the  blood-discs  are  sometimes  found  yellowish-brown,  irregular, 
and  granular  flakes,  and  sometimes  cylindrical  masses  of  hemoglobin. 

Hemoglobinuria  is  always  associated  with  hemoglobinemia,  which  is, 
however,  less  easy  of  demonstration.  The  hemoglobin  is  set  free  from 
the  corpuscles  and  imparts  a  red  or  lake  hue  to  the  blood  plasma.  The 
discs   themselves   are  paler,   and   yellowish-brown   particles   of   hemoglobin 


HEMOGLOBINURIA.  751 

may  be  demonstrated  between  the  corpuscles.     The  number  of  corpuscles 
themselves  m.ay  be  reduced,  falling  to  4,000,000  and  less. 

Hemoglobinemia  and  hemoglobimiria  may  easily  be  separated  into 
two  divisions,  toxic    and  simple  paroxysmal. 

Toxic  Hemoglobinuria. — This  is  produced  by  toxic  substances,  which 
dissolve  out  the  hemoglobin  from  the  corpuscles.  Such  are  sulphuretted 
hydrogen,  arseniuretted  hydrogen,  carbon  monoxid,  carbolic  acid,  pyro- 
gallic  acid,  naphthol,  nitrobenzole ;  potassium  chlorate  in  large  doses,  and 
the  poison  of  certain  mushrooms ;  also  sometimes  the  poison  of  the  infectious 
diseases,  including  scarlet  fever,  diphtheria,  pyemia,  yellow  fever,  typhoid 
fever,  malaria,  and  even  syphilis.  The  last  has  sometimes  seemed  to  act 
as  a  predisposing  cause,  subsequently  to  which  so  trifling  a  thing  as  ex- 
posure to  cold  has  caused  it.  I  have  seen  it  associated  with  pregnancy  as  a 
probable  cause.  Hemoglobinemia  and  hemoglobinuria  sometimes  succeed  on 
extensive  burns  when  the  poison  is  probably  the  retained  excretions  of  the 
skin.  High  temperature  alone  is  said  to  have  caused  it.  In  malarial  poison- 
ing the  hemoglobinemia  may  be  the  direct  result  of  the  action  of  the  malarial 
Plasmodium.  The  blood  of  one  animal  transfused  into  the  vessels  of  another 
epidemically,  must  be  added  to  this  group. 

Prognosis. — This  depends  upon  the  dose  of  the  toxin  causing  it  and 
the  other  symptoms  produced.  Recovery  is  usual,  but  some  cases  are 
rapidly  fatal. 

Treatment. — This  is  that  of  the  disease  occasioning  it.  The  same 
astringent  measures  may  be  tried  as  in  hematuria,  and  restorative  medicines 
may  be  given  to  rebuild  the  blood.     Of  these,  iron  is  the  most  important. 


Paroxysmal  Hemoglobinuria. 

In  this,  intermittent  attacks  occur.  They  come  on  suddenly,  preceded 
by  chills  and  fever,  headache,  and  pain  in  the  limbs,  the  temperature 
often  reaching  104°  F.  (40°  C).  The  bloody  urine  follows  in  an  hour 
or  less,  and  may  last  four  or  five  hours,  or  there  may  be  two  or  three 
paroxysms  in  a  day.  At  other  times  there  is  no  fever  or  the  temperature 
is  even  subnormal.  Jaundice  is  associated  with  some  cases,  especially 
toward  the  end.  At  times,  instead  of  the  expected  hemoglobinuria,  there 
is  only  albuminuria.  Ralfe  explains  this  by  supposing  that  the  toxic  agent 
has  destroyed  only  a  small  number  of  corpuscles,  the  coloring-matter  from 
which  is  used  up  in  the  spleen  and  liver,  while  the  globulin  goes  ofl:  in  the 
urine.  Von  Leube  especially  calls  attention  to  a  swelling  and  tenderness  of 
the  liver  and  spleen,  and  says  he  has  met  these  symptoms  in  lieu  of  the 
expected  hemoglobinuria — in  lieu  even  of  albuminuria. 

The  occasional  association  of  hemoglobinuria  with  Raynaud's  disease 
is  very  interesting.  The  probability  is  that  in  most  cases  where  the  two 
conditions  are  associated,  the  preliminary  hemoglobinemia  is  due  to  a 
separation  of  the  hemoglobin  from  the  red  discs  in  the  peripheral  asphyxiated 
part  of  the  nose,  ears,  fingers,  or  other  parts. 

As  to  other  causes  of  the  paroxvsmal  form,  malaria  is  undoubtedly  one, 
though  perhaps  not  so  often  as  was  once  supposed.  Another  cause  is  ex- 
cessive muscular  exertion,  especially  when  associated  with  cold,  while 
cold  itself  is  perhaps  the  most  frequent  of  all  causes.     Mental  emotion  is 


752  DISEASES  OF  THE  URINARY  ORGANS. 

sometimes  a  cause.  It  must  be  admitted  that  for  the  cases  not  explainable 
by  toxic  agency  no  satisfactory  sohition  has  been  presented.''' 

Prognosis. — The  prognosis  of  the  paroxysmal  form  is  commonly  favor- 
able, though  it  may  continue  to  recur  for  a  long  time. 

Treatment. — This  depends  upon  the  cause.  If  it  be  malarial,  the 
condition  is  easily  curable  by  quinin.  To  seek  the  causes  in  many  cases 
is  to  seek  the  unattainable,  and  the  cases  must  be  treated  on  general  principles. 
Rest  and  warmth  are  essentials.  After  this,  the  same  astringent  remedies 
as  those  recommended  under  hematuria  may  be  tried.  As  cold  seasons  and 
cold  weather  favor  it,  a  residence  in  a  warm  climate  should  be  recommended 
when  the  condition  persists.  Nitrite  of  amyl  is  said  to  have  cut  short  and  to 
have  prevented  an  attack. 


CHYLURIA. 

Definition  and  Description. — A  state  of  the  urine  in  which  the  secre- 
tion is  admixed  with  fat  in  a  minute  state  of  division,  whereby  the  urine 
acquires  a  milky  or  chylous  appearance. 

The  proportion  of  fat  varies  greatly,  being  at  times  only  enough  to  impart 
a  mere  opalescence,  while  at  other  times  the  urine  is  scarcely  distinguishable 
from  milk,  even  the  characteristic  odor  and  taste  of  urine  being  wanting. 
The  fat,  on  standing,  often  rises  to  the  surface,  like  cream.  By  the  micro- 
scope, in  addition  to  this  molecular  fat  and  a  few  oil  drops,  numerous  blood 
discs  are  also  found.  These  are  sometimes  so  numerous  as  to  impart  a 
pinkish  tinge  to  the  fluid,  and  at  times  a  spontaneous  coagulation  takes  place, 
with  the  formation  of  a  slight  reddish  clot,  showing  the  presence,  also,  of 
fibrin. 

Etiology. — To  produce  chyluria  there  must  be  brought  about  in  some 
way  a  leakage  from  chyle  vessels  into  the  urinary  passages  somewhere 
between  the  kidney  and  the  neck  of  the  bladder.  Yet  no  such  communication 
has  ever  been  found,  so  far  as  I  know,  though  W.  H.  Mastin  noticed  the 
patulous  mouths  of  several  chyle  vessels  opening  into  the  serous  sac  of  a 
testicle  which  he  laid  open  for  the  cure  of  a  chylous  dydrocele  or  lymph 
scrotum.  Having  ligated  them,  no  recurrence  of  the  hydrocele  occurred. 
Supposing  such  a  communication  to  exist,  how  is  it  brought  about  ?  In  most 
cases  probably  by  the  blocking  of  lymph  channels  by  prematurely  discharged 
ova  or  embryos  of  the  ■fHaria  Bancrofti,  to  be  described  when  treating  of  ani- 
mal parasites.  Undoubtedly  there  occurs,  on  the  other  hand,  what  may  be 
termed,  under  the  circumstances,  an  idiopathic  chyluria,  the  most  searching 
examination  of  the  blood  during  life,  and  careful  dissection  after  death,  of 
lymph  glands  and  vessels  in  certain  cases,  failing  to  discover  either  ova  or 
embryos.  On  the  other  hand,  by  no  means  every  case  of  filariasis  is  attended 
by  chyluria. 

Symptoms. — Few  symptoms  other  than  those  of  the  chylous  urine 
are  present.  It  is  usually  intermittent,  but  may  be  persistent.  There  is 
sometimes  a  loss  of  strength  from  the  draining  ofif  of  fluid  which  is  un- 
doubtedly nutrient ;  at  other  times  there  is  some  pain  in  the  back,  and  at 
others  again  painful  urination  due  to  obstruction  of  the  urethra  by  coagula 
of  fibrin,  but  in  most  cases  the  patient  feels  well  and  would  not  know  there 

*  It  is  well  known  that  horses  are  subject  to  hemoglobinuria,  and  that  it  occurs  in  them  after 
exposure  to  cold,  especially  after  having  been  stabled  for  several  days. 


RELATION  OF  HEART  AND  KIDNEY  DISEASES.         753 

^vas  anything-  the  matter  with  him  had  not  his  attention  been  called  to  the 
urine. 

Treatment. — No  means  have  been  discovered  to  destroy  the  filaria  in 
parasitic  chyluria,  nor  to  check  the  leakage  in  the  idiopathic  form,  which 
often  persists  for  years  and  then  subsides  spontaneously.  Should  the 
mosquito  be  its  cause,  the  same  measures  which  will  ultimately  be  found 
for  its  eradication  will  apply  to  the  filarial  disease. 

See  also  article  on  Filariasis  in  section  on  Parasites. 


THE  RELATION  OF  HEART  DISEASE   TO   KIDNEY  DISEASE. 

Allusion  has  more  than  once  been  made  in  the  foregoing  pages  to  the 
relation  of  kidney  disease  to  heart  disease,  and  the  association  of  lesions  in 
the  two  organs.  Of  such  importance  is  a  proper  understanding  of  this 
relation,  that  a  few  pages  devoted  to  its  consideration  may  be  helpful  to  the 
student.     The  association  admits  of  classification : 

I.  Renal  Disease  Associated  with  Hypertrophy  of  the  Left  Ventricle 
withont  Valvular  Disease. — Modern  studies  have  made  it  quite  certain  that 
this  form  of  combined  heart  and  kidney  disease  ma}-  originate  in  two  ways : 
(a)  The  heart  affection  may  be  secondary  to  the  kidney  disease  as  its  direct 
consequence ;  or  (b)  both  conditions  may  result  from  one  and  the  same 
cause — viz.,  arterial  sclerosis. 

(a)  The  Renal  Condition  Precedes. — The  condition  which  precedes  is 
commonly  the  contracted  kidney  of  interstitial  nephritis,  and  its  result  is 
liypertrophy  of  the  left  ventricle. 

How  is  the  cardiac  hypertrophy  to  be  accounted  for?  I  will  first 
review  the  theories  which  have  been  given  from  time  to  time,  for  theories 
alone  they  must  be  acknowledged  to  be.  The  oldest,  which  may  be  termed 
the  "  retention  "  or  "  chemical  "  theory,  was  advanced  in  its  cruder  form  by 
Bright  himself,  whose  acute  observation  had  not  failed  to  notice  the  associa- 
tion of  cardiac  hypertrophy  without  valvular  disease  with  the  disease  so  de- 
servedly coupled  wath  his  name  since  1827.  Bright  suggested  two  alternative 
explanations :  "  Either  that  the  altered  quality  of  the  blood  affords  irregular 
and  unwonted  stimulus  to  the  organ  immediately,  or  that  it  so  affects  the 
minute  and  capillary  circulation  as  to  render  greater  action  of  the  heart 
necessary  to  force  the  blood  through  the  distant  subdivisions  of  the  vascular 
system."  The  late  Sir  George  Johnson  held  this  last  view,  and  his  pupil, 
Nestor  Tirard.  in  England,  and  Senator,  in  Germany,  still  entertain  it.  At 
one  time  Johnson  held  that  the  hypertrophied  state  of  the  muscular  coat  was 
the  result  of  an  effort  of  the  vessels  to  aid  the  onward  movement  of  the  blood. 
More  recently  he  ascribes  the  thickening  of  the  muscular  coat,  which  exists 
not  only  in  the  kidneys,  but  in  the  systemic  arterioles  generally,  to  a  con- 
stant exercise  of  the  normal  stop-cock  action  whose  object  is  to  resist  the 
passage  of  this  abnormal  blood ;  while  the  hypertrophy  of  the  left  ventricle 
is  ascribed  to  an  eft'ort  to  overcome  this  resistance.  Dr.  Johnson  maintained 
that  there  is  a  true  hypertrophy  of  the  muscular  coat  of  the  arteries  in  all 
the  tissues,  associated  with  thickening  of  the  intima  only,  in  the  kidneys, 
but  of  the  adventitia  also  in  the  hypertrophied  arterioles  of  other  tissues.* 
Recent  histological  studies,  made  for  Dr.  Johnson  under  the  direction  of  Dr. 

*  "  The  Pathology  of  the  Contracted  Kidney,"  by  Sir  George  Johnson,  London,  i8g6. 
48 


754  DISEASES  OF  THE  URINARY  ORGANS. 

Halliburton,  confirm  this  view.  Unfortunately,  other  recent  studies  by 
modern  methods,  notably  those  by  W.  T.  Councilman  and  Arthur  V.  Meigs, 
to  be  again  alluded  to,  do  not  find  the  changes  in  the  middle  coat  early  de- 
scribed bv  Johnson  and  now  again  by  Halliburton.  Until  lately,  experiments 
which  have  for  their  object  determining  the  effect  of  toxic  substance  intro- 
duced in  the  blood  on  the  heart  and  vessel  walls  have  proved  negative. 
More  recently  a  number  of  experimenters,  notably  Alfred  Croftan,  have 
succeeded  in  producing  increased  arterial  blood-pressure,  arterial  spasm, 
thickening  of  arteries,  and  hypertrophy  of  the  heart,  as  well  as  granular  and 
fatty  degeneration  of  renal-cells.  Croftan  used  the  alloxuric  bases  xanthin 
and  hypoxanthin,  while  Ustimovitsch,  Griitzner,  von  Cavazano,  and  Robus- 
tello  injected  urea  into  the  blood.*  It  is  to  be  regretted  that  a  histological 
question  seemingly  so  simple  cannot  be  settled  by  the  refinements  of  modern 
histology. 

The  so-called  "  mechanical  theory  "  of  cardiac  hypertrophy  was  ad- 
vanced by  Traube,  whose  researches  in  1856  gave  a  decided  impulse  to 
clinical  study  of  the  subject.  According  to  Traube,  the  increased  arterial 
resistance  was  caused  by  two  erroneously-supposed  states — the  first,  an  over- 
fullness  of  the  vessels  due  to  the  diminished  renal  secretion ;  second,  a  re- 
sistance to  the  admission  of  arterial  blood  into  the  kidney,  due  to  the  renal 
contraction  itself.  The  first  hypothesis  was  erroneous  for  contracted  kidney 
where  the  urinary  secretion  is  really  increased,  while  the  second  is  opposed 
by  the  fact  that  even  ligation  of  the  renal  arteries  fails  to  increase  arterial 
pressure.  This  is  because  of  the  ample  vascular  space  elsewhere  for  the 
blood  thus  diverted.  Nor  did  Cohnheim's  further  elaboration  of  the  me- 
chanical theory,  which  located  the  increased  resistance  more  precisely  behind 
the  wasted  glomerule,  give  any  more  permanent  life  to  it. 

I  incline  to  the  belief  that  we  should  not  lose  sight  of  the  possibility  that 
the  primary  changes  in  the  heart  may  be  compensatory  in  their  nature,  set 
up  with  a  view  to  supplementing  the  gradual  loss  of  renal  substance.  Such 
an  action  is  paralleled  everywhere  in  the  physiological  economy.  Nowhere 
do  we  meet  with  loss  of  function  which  is  not  at  once  met  by  an  attempt 
of  nature  to  compensate  it.  The  dependence  of  the  urinary  secretion  upon 
cardiac  pressure  is  well  understood,  and  an  increase  of  cardiac  power  is  the 
most  reliable  means  available  for  stimulating  the  action  of  the  kidneys,  when 
desired,  in  therapeutics.  The  diuresis  which  is  so  constant  a  symptom  of  the 
contracted  kidney  is  acknowledged  to  be  the  direct  result  of  a  supplemental 
contraction  of  the  left  ventricle,  which  it  is  reasonable  to  suppose  is  induced 
for  the  purpose  named,  and  results  in  hypertrophy. 

This  view  receives  confirmation  in  the  subsequent  course  of  the  disease. 
So  long  as  the  free  secretion  which  is  the  result  of  the  compensatory  action 
of  the  heart  is  kept  up,  so  long  the  patient  remains  tolerably  comfortable, 
and  perhaps  even  for  a  time  unconscious  of  the  presence  of  disease.  But  an 
organ  thus  overgrown  is  sure,  sooner  or  later,  to  sufifer  in  its  nutrition. 
Especially  is  this  the  case  if  its  arteries  be  the  seat  of  an  endarteritis,  inter- 
fering with  the  free  movement  of  the  blood  and  producing  also  fibromyo- 
carditis.  And  what  are  the  further  consequences?  The  strong  propulsive 
power  of  the  heart  declines,  the  pulse  falls  away  in  tension  and  power  and 
becomes  more  frequent  and   sometimes  irregular.     The  urine  secreted  di- 

*  See  Croftan's  paper  on  "The  Role  of  Alloxuric  Bases  in  the  Production  of  the  Cardio- vascular 
Changes  of  Nephritis."  published  in  the  "  American  Journal  of  the  Medical  Sciences,"  November, 
iQoo,  where  the  reader  will  find  references  to  papers  by  the  other  experimenters  mentioned. 


RELATION  OF  HEART  AND  KIDNEY  DISEASES.         755 

minishes  in  quantity  and  assumes  a  darker  hue.  Fortunate  is  the  patient  if 
the  specific  gravity  of  the  urine  rises  inversely  with  its  reduced  quantity,  as 
it  indicates  that  the  normal  excretion  of  solids  is  kept  up.  Too  frequently 
however,  this  is  not  the  case,  and  excrementitious  substances  accumulate  in 
the  blood,  laying  the  foundation  for  uremia.  Headache,  nausea,  a  foul  and 
even  a  urinous  breath  may  be  superadded,  and  uremia  sets  in,  preceded  by 
drowsiness,  or  it  may  be  ushered  in  suddenly  with  convulsions.  Or  another 
set  of  symptoms  may  supervene ;  the  patient  becomes  short  of  breath,  first  on 
slight  exertion,  and  later  this  very  distressing  symptom  occurs  without  such 
exciting  cause.  This  sort  of  asthma,  known  as  uremic  asthma,  has  been 
discussed  on  page  689.  For  a  time  this  symptom  may  be  averted  by  whip- 
ping up  the  heart  by  cardiac  stimulants,  and  the  right  ventricle  even  comes 
to  the  rescue  for  a  time  and  hypertrophies  in  its  effort  to  overcome  the  now 
disturbed  compensation.  Subsequently  this,  as  well  as  the  left  ventricle,  may 
become  dilated,  and  edema  of  the  lungs  sets  in,  with  annoying  cough  and 
serous  frothy  expectoration,  sometimes  blood-tinged.  Nor  does  general 
dropsy  continue  absent,  but  ensues  sooner  or  later  with  the  growing  heart 
failure.  Our  resources  are  now  almost  at  an  end,  but  are  not  exhausted, 
as  even  these  symptoms  sometimes  subside. 

It  should  be  stated  that  not  every  case  of  interstitial  nephritis  is  at- 
tended with  hypertrophy  of  the  left  ventricle.  In  addition  to  the  cases  of 
contracted  kidney  from  senile  endarteritis  already  referred  to,  cardiac  hyper- 
trophy is  apt  to  be  absent  in  the  interstitial  nephritis  of  the  weak  and 
cachectic. 

{h)  Both  the  HypertropJiy  of  the  Left  Ventricle  and  the  Contracted  Kid- 
ney are  the  Result  of  One  and  the  Same  Cause — Arterial  Sclerosis  or  Arterio- 
capillary  Fibrosis. — It  should  be  stated,  first,  that  a  certain  school  explains 
all  cases  of  contracted  kidney  in  this  way.  The  changes  described  in  the 
arteries  differ  chiefly  from  those  described  by  Dr.  Johnson  in  that  they  are 
held  to  be  degenerative,  so  far  as  the  muscular  coat  is  concerned. 

The  late  Sir  William  Gull  and  H.  S.  Sutton,  in  a  paper  which  has  become 
classic,  announced  in  1872*  that  the  changes  in  the  muscular  coat  were 
chiefly  of  an  atrophic  character,  and,  although  the  methods  of  these  ob- 
servers have  been  much  criticised,  the  most  recent  studies  on  this  subject 
by  W.  T.  Councilman  and  Arthur  V.  Meigs  go  to  confirm  their  conclusions 
both  as  to  the  seat  and  the  nature  of  the  changes.  Councilman  t  finds 
atrophic  changes  in  the  muscular  coat,  including  greater  or  less  destruction 
of  the  muscular  fiber-cells  and  the  formation  of  a  homogeneous  hyaline 
tissue  invading  both  coats,  but  especially  the  intima,  where  it  produces 
decided  thickening,  and  encroachment  to  a  varied  extent  upon  the  lumen, 
sometimes  amounting  to  occlusion.  The  capillary  walls  are  likewise  thick- 
ened, and  sometimes,  especially  in  the  glomerule  of  the  kidne3^  obliterated. 
Meigs'  X  studies  also  find  these  changes  for  the  most  part  confined  to  the 
intima,  which  is  decidedly  thickened.  To  a  less  extent,  the  intima  of  the 
veins  is  similarly  involved.  The  picture  of  the  changes  thus  briefly  described 
may  be  obtained  from  a  small  artery  taken  indifferently  from  any  tissue 
or  organ  of  the  body — for  example,  from  the  muscular  substance  of  the 
heart,  the  kidney,  or  the  liver.  It  is  this  diffuse  form  of  arteritis,  rather 
than  the  nodular,  which  is  the  link  between  the  hypertrophy  of  the  left 

*  "  Arteriocapillary  Fibrosis,"  "  Med.,  Chir.  Trans,"  London,  1872. 

t  "  On  the  Relations  Between  Arterial  Disease  and  Tissue  Change,"  "  Trans.  Assoc.  Amer.  Phys.,' 
vol.  v:.,  i8gi. 

J  "New  York  Record,"  July  7,1888. 


756  DISEASES  OF  THE  URINARY  ORGANS. 

ventricle  and  the  contracted  kidney.  In  the  nodular  form  of  arteritis  the 
changes  are  limited  to  small  areas  in  the  aorta  and  large  arteries — ather- 
omatous patches,  sometimes  calcareous  and  sometimes  fatty,  the  so-called 
senile  arteritis.  The  resistance  offered  the  free  movement  of  the  blood  is 
evidently  less  than  in  the  diffuse  form. 

Of  the  consequent  results  of  such  thickening,  the  hypertrophy  of  the 
ventricle  is  most  easily  explained.  The  resistance  in  the  blood-vessels  stimu- 
lates the  ventricle  to  increased  effort,  and  there  result  increased  arterial  ten- 
sion and  hypertrophy.  The  degree  of  cardiac  hypertrophy  is  sometimes 
enormous,  the  organ  weighing  as  much  as  850  grams  (28  ounces),  and  the 
average  in  twenty-seven  cases  studied  by  Councilman  being  over  400  grams, 
(13  ounces),  as  contrasted  with  the  normal,  10  to  12. 

According  to  this  view,  the  alterations  in  the  kidney,  which  vary  greatly 
in  extent,  being  sometimes  scarcely  noticeable  and  sometimes  extreme, 
are  the  direct  result  of  an  interference  with  its  nutrition.  The  blood 
supply  to  the  renal  elements  being  cut  off,  these  gradually  waste  and 
ultimately  disappear.  The  cells  and  tubules  thus  destroyed  are  gradually, 
but  irresistibly,  replaced  by  fibrous  connective  tissue,  in  obedience  to 
the  pathological  law  elaborated  by  Weigert,  but  which  was  announced, 
at  least  so  far  as  the  kidney  is  concerned,  fifty  years  ago  by  Dr.  John- 
son,* that  parts  destroyed  are  partially  replaced  by  cicatricial  connective 
tissue.  This  contrasts  and  reduces  the  size  of  the  kidney,  and  perhaps  also, 
in  this  contraction,  further  destroys  the  proper  kidney  structure,  and  thus 
increase  the  atrophy. 

It  has  been  said  that  in  this  form  of  combined  kidney  and  heart  disease 
there  is  no  cardiac  murmur.  Nor  is  there,  as  a  rule.  It  is  not  impossible, 
however,  for  the  endarteritis  of  which  we  are  speaking  to  creep  along  the 
walls  of  the  aorta  until  it  reaches  the  aortic  valves,  and  so  structurally 
changes  them  as  to  make  them  rough  or  incompetent  and  give  rise  to 
murmurs. 

The  causes  of  this  form  of  Bright's  disease  are,  therefore,  the  causes  of 
the  endarteritis,  which  have  been  discussed  on  page  624.  To  a  less  degree, 
probably,  the  specific  causes  of  all  the  infectious  diseases  must  be  included 
in  this  category — possibly  even  malaria.  The  subjects  are  usually  middle- 
aged  men,  between  the  ages  of  forty  and  fifty-five,  but  they  may  be  younger. 
Councilman  has  found  these  changes  more  common  in  the  negro  than  in  the 
white  race. 

Treatment. — The  treatment  of  this  form  of  combined  kidney  and  heart 
disease  is  not  different  from  that  of  interstitial  nephritis.  Even  greater 
rigidit}  is  necessary  in  eliminating  nitrogenous  food,  and  all  food  should  be 
reduced  to  a  minimum.  A  diet  of  milk  diluted  with  water  is  the  safest  of  all. 
Bread  and  butter  may,  however,  be  allowed,  and  even  succulent  vegetables 
easy  of  digestion,  such  as  rice,  potatoes,  peas,  and  string-beans,  while  simple 
fruit- juices,  as  those  of  oranges  and  lemons,  are  allowable.  Mental  excite- 
ment and  immoderate  muscular  exertion  must  be  avoided,  and  the  heart 
should  not  be  overworked  in  any  way. 

The  medicinal  treatment  especially  directed  to  the  arterio-sclerosis  may 
be  divided  into  that  intended  for  the  cure  of  the  endarteritis  and  that  directed 
to  the  relief  of  symptoms.  The  only  drug  from  w^hich  results  may  be 
expected  for  the  former  purpose  is  the  iodid  of  potassium,  which  should  be 

*  "Medico-Chirurg.  Trans.,"  1847. 


RELATION  OF  HEART  AND  KIDNEY  DISEASES.         757 

given  a  fair  trial  in  doses  as  large  as  can  be  borne  without  deranging  the 
stomach.  For  the  relief  of  the  symptoms  more  especially  due  to  the  scle- 
rosis,— viz.,  headache,  throbbing,  and  vertigo, — the  nitrites  are  often  useful. 
Nitroglycerin  should  be  given  in  doses  of  i-ioo  grain  (0.00065  gm.)  every 
four  hours  or  oftener,  rapidly  increased  to  1-50  grain  (0.0013  gm.)  if  the 
smaller  dose  is  without  effect.  The  aim  should  be  to  produce  the  physio- 
logical effect,  which  is  a  sense  of  fullness  or  a  flushing.  The  sodium  nitrite 
may  be  substituted  in  three-  to  five-grain  (0.19  to  0.32  gm.)  doses.  It  has 
the  advantage  of  being  more  permanent  in  its  effect,  although  it  is  slower  in 
its  action. 

2.  Valvular  Heart  Disease  Associated  zvith  Renal  Disease  in  which  the 
Heart  Disease  is  Primary. — The  heart  disease  is  commonly  disease  of  the 
mitral  valve.  The  kidney  involvement  does  not  occur  in  connection  with 
aortic  valvular  disease  until  mitral  insufficiency  is  superadded.  It  is  well 
known  that  in  mitral  regurgitation  as  soon  as  compensation  ceases  the  blood 
accumulates  first  in  the  lungs,  then  in  the  right  side  of  the  heart,  and  finall}' 
in  the  venous  system,  engorging  especially  the  liver,  stomach,  and  kidneys. 
The  effects  upon  the  first  two  were  discussed  in  treating  of  heart  disease. 
They  generally  manifest  themselves  sooner  than  the  renal  symptoms.  The 
result  in  the  case  of  the  kidney  is  the  kidney  of  passive  congestion  or 
cyanotic  induration,  already  described  on  page  694, 

Much  more  decided  are  the  clinical  phenomena  resulting  from  such  con- 
gestion. It  is  a  well-recognized  condition  of  copious  secretion  of  urine  that 
the  blood  should  move  freely  through  the  kidney.  A  stasis  is  followed 
immediately  by  diminished  filtration  of  water,  the  twenty-four-hours'  quan- 
tity being  reduced  to  from  thirty  to  twenty  ounces,  and  even  to  less.  The 
solids  at  first  at  least  remain  the  same,  the  urine  is  dark-hued,  the  specific 
gravity  is  high,  the  reaction  is  markedly  acid,  and  a  copious  sediment  of  urates 
and  uric  acid  makes  its  appearance  as  soon  as  the  urine  cools  off.  There  is 
almost  always  a  small  amount  of  albumin  found,  but  as  the  congestion 
increases,  albumin  becomes  copious.  Casts  are  sparsely,  if  at  all,  present, 
and  are  of  the  hyaline  and  faintly  granular  variety.  Both  red  and  white 
blood-corpuscles  are  also  sometimes  detected,  as  might  be  expected.  This 
condition  of  the  kidney  and  the  symptoms  are  the  direct  results  of  the  cardiac 
valvular  disease.  Yet  I  often  see  these  cases  diagnosed  as  Bright's  disease 
as  though  it  were  the  primary  and  principal  affection.  They  may  also 
be  produced  by  any  cause  producing  venous  stasis,  as  pulmonary  emph3'sema. 
chronic  pleurisy,  and  thrombosis  of  large  veins.  Their  effect  is  further  to 
augment  the  symptoms  of  the  cardiac  disease.  The  circulation,  already  every- 
where obstructed,  is  further  impeded,  there  is  dyspnea,  dropsy  increases, 
appetite  fails,  and  there  are  nausea  and  constipation.  Sleep,  already  disturbed 
by  dreams,  becomes  more  so,  and  a  more  distressing  picture  than  is  presented 
by  such  a  case  is  rarely  met. 

Treatment. — Yet  these  symptoms  are  often  easily  amenable  to  treatment 
so  long  as  the  heart  muscle  remains  capable  of  being  influenced  by  digitalis. 
I  have  seen  many  a  patient,  apparently  in  extremis,  gasping  in  orthopnea  and 
with  legs  heavy  and  almost  bursting  with  dropsical  effusion,  completely  re- 
lieved by  a  few  large  doses  of  this  drug.  But  they  must  be  large  doses — not 
less  than  from  eight  to  ten  minims  (0.5  c.  c.  to  0.6  c.  c.)  or  from  fifteen  to 
twenty  drops  every  three  hours  until  an  effect  is  produced.  If  digitalis  fails, 
the  tincture  of  strophanthus  may  be  given  in  the  same  doses,  or  caffein  citrate 
in  three-grain  (0.2  gm.)  doses,  each  every  four  hours,  or  spartein  sulphate  in 


758  DISEASES  OF  THE  URIXARY    ORGAXS. 

doses  of  from  1-4  to  1-2  grain  ( 0.016  to  0.03  gm. ).  Purgation  should  not  be 
omitted,  but  should  rather  be  pushed  to  the  production  of  watery  catharsis. 
The  ingestion  of  liuids  should  be  restricted,  and  Hay's  treatment  of  dry  diet 
with  purgatives  is  sometimes  useful.  But  I  have  found  a  restricted  milk  diet 
limited  to  two  ounces  every  two  hours,  associated  with  the  drugs  previously 
named,  equally  eflficient.* 

Such  a  kidney  is,  of  course,  more  liable  to  become  the  seat  of  an  acute 
or  a  chronic  nephritis  than  the  normal  organ. 

3.  Renal  Infarct  the  Result  of  Heart  Disease. — The  next  form  of  kidney 
involvement  secondary  to  disease  of  the  vascular  apparatus,  commonly  heart 
disease,  is  more  frequently  seen  on  the  postmortem  table  than  recognized  in 
the  living  subject.  It  is  onbolic  infarction,  produced  by  the  lodgment  in 
some  branch  of  the  renal  artery  of  an  embolus  derived  from  the  heart  or  a 
blood-vessel.  Its  most  frequent  source  is  a  fragment  of  vegetation  or  clot 
from  a  diseased  heart-valve,  commonly  the  aortic.  An  embolus  may  also 
arise  from  a  thrombus  in  a  vein.  If  from  the  latter,  it  must  be  carried  first 
to  the  right  heart,  and  thence  through  the  lungs  into  the  left  heart,  and  thence 
by  the  aorta  to  the  kidney,  and  must,  of  course,  be  small. 

The  effect  of  the  lodgment  of  an  embolus  in  the  kidney  is  a  wedge-shaped 
hemorrhagic  infarct  which  at  first  is  dark  red  in  color,  standing  out  above  the 
surface,  but  which  in  time  whitens,  contracts,  and  is  ultimately  absorbed, 
leaving  a  mere  cicatricial  mark. 

]\Iost  frequently  a  renal  infarct  occurs  without  noticeable  symptoms.  Its 
occurrence,  if  looked  for  by  reason  of  the  presence  of  valvular  heart  disease, 
may  be  suspected  if  there  is  the  sudden  appearance  of  blood  in  the  urine.  A 
sudden  pain  in  the  region  of  the  kidney  occurring  at  the  same  time  with 
hematuria  would  go  to  confirm  the  diagnosis.  Xo  treatment,  except  rest, 
is  indicated,  even  if  the  event  is  recognized. 

4.  Accidental  Coincidence  of  Renal  Disease  and  Heart  Disease. — Finally, 
kidney  disease  and  disease  of  the  vascular  apparatus,  and  especially  cardiac 
disease,  may  coincide  accidentally,  each  the  result  of  its  own  cause,  and  react- 
ing the  one  upon  the  other  in  various  degrees  and  variously  aggravating  the 
symptoms  of  each,  so  that  it  often  becomes  a  very  nice  question  to  determine 
which  is  the  preponderating  disease.  Fortunately,  this  difficulty  does  not 
always  extend  to  therapeutics,  the  same  remedies  which  are  useful  to  one 
affection  being  commonly  indicated  for  the  other.  A  careful  study  of  each 
case  should,  however,  be  made  on  its  own  merits,  and  due  weight  assigned 
to  each  factor  of  the  disease. 

*  See  some  cases  reported  by  the  autfibr  in  a  paper  "  On  the  Management  of  Obstinate  Dropsies," 
"Med.  News,"  June  21,  1890. 


CYSTITIS.  759 

DISEASES  OF  THE  BLADDER. 

CYSTITIS. 

Synonyms. — Catarrh  of  the  Bladder;  Vesical  Catarrh. 

Definition. — Cystitis  is  an  infectious  inflammation  of  the  bladder 
excited  usually  by  different  varieties  of  pathogenic  bacteria. 

Etiology. — Among  these  are  the  baeillus  coli  communis,  the  gonococcus, 
sfapliylocoecns  pyogenes  and  bacillus  tuberculosis.  The  typhoid  bacillus 
is  not  an  infrequent  cause.*  The  causes  formerly  assigned  to  such  inflam- 
mation, though  relegated  by  the  above  definition  to  favoring  causes,  are  still 
very  important.  They  include  foreign  bodies,  such  as  stone,  trauma,  obstruc- 
tion to  the  outflow  of  urine  by  enlarged  prostrate  or  stricture  of  the  urethra. 
A  frequent  medium  of  introduction  of  bacteria  was  formerly  catheters. 
The  number  of  cases  caused  by  catherization  has  diminished  because  of  the 
greater  precaution  taken  of  late  in  the  care  of  instruments.  Of  acknowl- 
edged bacterial  origin  is  also  gonorrheal  cystitis,  which,  succeeding  an 
attack  of  gonorrheal  urethritis,  invades  the  bladder  by  extension. 

Cold  was  formerly  recognized  as  a  cause  of  cystitis,  especially  in  women 
and  children,  but  it  is  subject  to  the  same  conditions  as  the  causes  just  named. 
On  the  other  hand,  cystitis  succeeds  upon  the  introduction  of  substances  in 
the  blood,  as  cantharides  and  capsicum.  Even  the  ingestion  of  certain  articles 
of  food  has  been  followed  by  it.  Traumatic  agencies  may  be  classed  among 
predisposing  causes  rather  than  exciting,  furnishing  the  conditions  favor- 
able to  the  operation  of  bacteria. 

Morbid  Anatomy. — The  bladder  of  cystitis  is  a  varied  picture.  There 
may  be  degrees  so  slight  as  to  produce  scarcely  appreciable  change  in  its 
appearance.  At  other  times  the  mucous  membrane  is  hyperemic  and  bathed 
with  a  mucoid  or  mucopyoid  secretion  of  dirty-gray  color.  In  many  cases 
only  the  neck  of  the  bladder  and  the  part  of  the  urethra  passing  through  the 
prostate  are  involved.  Again,  the  bladder  is  "  ribbed,"  a  result  of  straining. 
During  this  act  the  mucous  membrane  between  the  muscular  trabecule  yields, 
producing  depressions  bounded  by  the  more  unyielding  muscular  bands.  On 
the  other  hand,  in  chronic  cases  permanent  thickening  of  the  bladder-walls 
may  result.  Finally,  in  the  severest  forms  of  inflammation  due  to  pathogenic 
organisms,  such  as  those  associated  with  putrid  urine,  the  mucous  membrane 
may  be  covered  with  patches  of  false  membrane,  or  the  wall  of  the  bladder 
may  be  infiltrated  and  undermined  with  pus,  constituting  the  so-called  phleg- 
monous or  diphtheritic  cystitis,  from  which  there  may  result  urethral  and 
perineal  infiltration.  A  further  extension  of  the  cystitis  into  the  pelvic  con- 
nective tissue  about  the  bladder  is  known  as  paracystitis ;  this  belongs  to  the 
province  of  the  surgeon. 

Symptoms. — While  a  division  of  cystitis  into  acute  and  chronic  is 
justified  by  the  suddenness  and  severity  of  symptoms  in  certain  cases  as  con- 
trasted with  their  slow  development  in  others,  yet  the  conditions  so  constantly 
verge  into  each  other  that  a  separate  consideration  of  the  two  forms  is  not 
necessary.     The  first  symptom  is  usually  a  frequent  desire  to  pass  water. 

*  See  an  admirable  paper  by  Thomas  R.  Brown  on  "The  Bacteriology  of  Cystitis  Pyelitis,"  etc., 
"John  Hopkins  Hospital  Reports,"  vol.  x.,  1901. 


76o  DISEASES  OF  THE  URINARY     ORGANS. 

Such  frequency  varies  greatly  in  intensity.  It  may  be  every  few  minutes 
or  almost  incessant,  several  times  an  hour  or  once  in  two  hours.  After  the 
primary  frequency  of  disturbance  it  usually  diminishes  somewhat.  Such 
frequency  is  often  attended  by  painful  straining.  In  severe  cases  there  is 
always  tenderness  over  the  region  of  the  bladder  above  the  pubes,  and  in 
some  cases  there  is  constant  pain.  In  these  tenderness  can  also  be  elicited 
by  pressure  from  the  vagina  and  rectum,  while  catherization  is  especially 
painful.  In  calculous  cystitis  pain  is  excited  or  aggravated  by  motion, 
especially  such  as  is  communicated  to  one  riding  in  a  wagon  over  a  rough 
road. 

As  commonly  met,  there  is  rarely  fever  with  cystitis,  but  the  severe 
forms  are  attended  with  moderate  fever  and  sometimes,  in  the  diphtheritic 
variety,  with  high  fever.  Even  when  there  is  fever,  the  temperature  does  not 
exceed  ioo°  to  102°  F.  (37.8°  to  38.9°  C),  though  it  may  be  higher.  In  cer- 
tain acute  diphtheritic  cases  of  great  virulence  there  are  chills,  szveats,  and 
high  fever.  In  advanced  stages  there  may  be  sepsis,  due  to  absorption  of 
retained  putrid  matter  from  the  bladder. 

The  urine  presents  striking  changes,  from  which  alone  the  diagnosis  can 
be  made.  First,  it  contains  pus  in  varying  quantities,  but  it  is  especially  char- 
acteristic of  the  pus  of  cystitis  that  it  is  associated  with  mucus,  which  imparts 
a  glairy,  stringy  character  to  the  urine,  that  increases  the  difficulty  of  its  dis- 
charge from  the  bladder.  The  reaction  of  the  urine  when  passed  is  com- 
monly either  alkaline  or  faintly  acid,  and  if  acid,  it  promptly  becomes  alkaline. 
This  is  due  to  the  formation  of  ammonium  carbonate  out  of  the  normal  urea, 
the  result  of  the  operation  of  bacteria.  The  greater  alkalinity  thus  resulting 
reacts  upon  the  pus  and  converts  it  into  a  glairy  matter  resembling  mucus, 
thus  further  increasing  the  difficulty  of  micturition.  Under  the  circumstances 
the  pus  is  loaded  with  amorphous  phosphates  of  lime  and  glistening  crystals 
of  ammonio-magnesium  phosphate.  It  is  so  viscid  that  it  will  not  rise  in  the 
pipette,  and  must  be  cut  with  scissors  to  be  manipulated  for  microscopic  study. 
Blood  is  an  almost  constant  constituent  of  the  urine  in  calculous  cystitis,  and 
in  the  grave  diphtheritic  forms  shreds  of  gangrenous  bladder  tissue  may  be 
discharged. 

Diagnosis. — Ordinarily,  the  diagnosis  of  cystitis  is  easy,  yet  there  some- 
times occur  mild  forms  which  it  is  difficult  to  differentiate  from  mild  degrees 
of  interstitial  nephritis,  while  it  not  very  rarely  happens  that  the  two  condi- 
tions are  associated.  In  contracted  kidney  there  are  also  sometimes  a  good 
many  leukocytes.  The  presence  of  hyaline  casts,  even  when  scanty,  points 
to  nephritis,  while  hypertrophy  of  the  left  ventricle  and  increased  arterial 
tension  setttles  the  question.  Still  more  emphatic  is  the  diagnosis  if  there  is 
retinitis  albuminurica. 

The  question  as  to  whether  there  is  pyelitis,  separate  or  associated  with 
cystitis,  is  still  more  difficult.  It  is  true  that  the  pus  in  pyelitis  is  very  much 
less  glairy  and  viscid  than  that  of  cystitis  pure  and  simple.  I  know,  however, 
no  distinctive  cellular  elements  which  set-tie  this  question,  though  some  assert 
there  are.  Even  spasm  of  the  bladder,  commonly  regarded  as  peculiar  to 
cystitis,  may  be  present  in  pyelitis.  Rather  must  we  rely  upon  tenderness  in 
the  neighborhood  of  the  kidney  on  the  one  hand  and  in  that  of  the  bladder  on 
the  other.  Marked  intermission  in  the  purulent  discharge,  especially  if  asso- 
ciated with  attacks  of  nephritic  colic,  which  imply  an  obstruction  of  the  ureter, 
point  to  pelvic  involvement. 

Calculous  cystitis  may  be  suspected  when  pain  in  the  region  of  the  blad- 


CYSTITIS.  761 

(ler  is  excited  by  motion,  as  in  riding  over  a  rough  road,  or  at  the  end  of  the 
penis  after  micturition ;  also  when  there  is  blood  in  the  urine  or  when  the 
stream  of  urine  is  suddenly  interrupted.  These  symptoms  should  imme- 
diately suggest  the  use  of  the  sound,  negative  results  with  which  must  not, 
however,  be  accepted  without  qualification,  as  the  stone  may  be  concealed  in 
a  diverticulum. 

Prognosis. — The  medical  treatment  of  cystitis  does  not  furnish  a  very 
satisfactory  chapter  in  therapeutics.  It  includes  such  treatment  as  the  phy- 
sician is  called  upon  to  use,  supposing  the  exciting  cause,  such  as  a  stone  in 
the  bladder  or  obstruction  in  the  urethra,  to  have  been  removed,  whenever 
possible :  I  say  whenever  possible,  because  the  enlarged  prostate  which  is 
responsible  for  so  many  cases  of  cystitis  is,  in  the  vast  majority  of  cases,  not 
removable  even  in  these  days  of  brilliant  surgical  results.  Many  cases  get 
well;  others  are  only  partially  relieved.  Some  of  the  most  virulent  acute 
cases  terminate  favorably  with  rupture  into  the  vagina  or  rectum  if  the 
patient  resist  the  primary  attack  of  the  disease. 

Treatment. — Acute  Cystitis.- — Of  this  form  the  treatment  is  far  more 
satisfactory,  at  least  so  far  as  the  removal  of  the  acute  symptoms  is  concerned, 
than  that  of  the  chronic  form.  Rest  in  bed  is  a  primary  and  essential  condi- 
tion. Leeches  to  the  perineum  should  be  applied  more  frequently  than  they 
are.  A  poultice  to  this  same  region  and  over  the  lower  abdominal  region  is 
always  useful,  while  a  brisk  saline  cathartic  should  never  be  omitted. 

As  the  feverish  state  which  always  accompanies  cystitis  is  more  or  less 
constantly  associated  with  scanty  urine,  concentrated  and  irritating  to  the 
inflamed  mucous  membrane,  it  is  desirable  at  once  to  increase  the  secretion 
and  thus  dilute  it.  Copious  libations  of  pure  water,  to  which  the  citrate  or 
acetate  of  potassium  is  added,  in  fifteen  to  twenty-grain  (i  to  1.3  gm.)  doses 
for  an  adult,  should  be  allowed.  The  ordinary  spirit  of  nitric  ether  in  dram 
(3.4  c.  c.)  doses  every  two  hours  is  an  admirable  adjuvant,  and  may  be  com- 
bined with  the  official  liquor  potassii  citratis,  which  contains  about  twenty 
grains  (1.3  gm.)  of  citrate  of  potassium  to  1-2  ounce  (15  c.  c).  Formerly, 
the  mucilage  of  flaxseed  or  flaxseed  tea  was  much  used  as  a  diluent  men- 
struum for  the  diuretic  alkalies  indicated,  but  it  is  doubtful  whether  it  is  any 
more  efficient  than  a  like  quantity  of  water.  When  there  are  much  pain  and 
straining,  as  is  often  the  case,  especially  when  cantharides  is  the  cause  of  the 
inflammation,  opium  is  indispensable,  always  in  the  form  of  a  suppository, 
1-2  grain  (0.03  gm.)  to  one  grain  (0.065  g"^-)  of  the  extract,  or  a  correspond- 
ing amount  of  morphin.  Iced-water  injections  into  the  rectum,  or  pieces  of 
ice  similarly  applied,  are  very  efficient  in  allaying  the  pain  and  irritation  when 
additional  measures  are  needed.  I  have  recently  found  injections  of  cocain 
into  the  bladder  useful  in  allaying  the  intense  irritation.  Not  more  than  two 
grains  (0.13  gm.)  of  cocain  should  be  introduced  into  the  bladder  at  one 
time. 

Chronic  Cystitis. — The  successful  treatment  of  chronic  cystitis  is  a  much 
more  difficult  task,  for  three  evident  reasons : 

1.  The  constant  presence  in  the  bladder  of  the  urine  with  its  irritating 
qualities,  especially  so  to  an  inflamed  mucous  membrane. 

2.  The  difficulty  in  getting  remedies  to  reach  the  inflamed  surfaces. 

3.  The  pent-up  inflammatory  products,  which  in  their  decomposition 
often  make  the  urine  still  more  irritating  by  exciting  in  it  ammoniacal 
changes. 

There  is  no  doubt  that,  if  the  urine  could  be  kept  from  entering  the 


762  DISEASES  OF  THE   URIXARY     ORGAXS. 

bladder  during  the  existence  of  an  inflammation,  the  latter  would  rapidly  heal ; 
that  cure  would  be  facilitated  by  obtaining  ready  escape  for  the  pus  and 
mucus ;  while  happier  results  might  also  be  reasonably  expected  if  we  could 
secure  readier  access  for  remedies  to  the  inflamed  areas.  Xone  of  these  indi- 
cations can  be  met  entirely.  They  remain,  however,  the  conditions  to  be  ful- 
filled, and  while  none  can  be  thoroughly  fulfilled,  they  may  be  variously 
approximated. 

First,  the  irritating  qualities  of  the  urine  may  be  diminished  by  the  use 
of  diluents,  already  recommended  in  the  treatment  of  acute  cystitis.  Almost 
any  of  the  negative  mineral  waters,  so  highly  recommended  by  their  owners, 
are  useful  for  this  purpose.  Just  as  good  is  pure  spring  water,  and  even  bet- 
ter is  distilled  water.  From  one  to  two  quarts  should  be  taken  daily.  If  the 
kidneys  are  equal  to  their  office,  a  large  quantity  of  light-hued  urine  of  low 
specific  gravity  and  relatively  weak  in  solids  will  be  secreted. 

\\'hen  it  is  purposed  to  go  further  and  add  to  the  efficiency  of  diluents, 
mistakes  are  often  made,  \\'hile  one  can  scarcely  go  astray  in  adding  alkalies 
to  the  fluid  ingested  in  acute  cystitis,  it  is  very  different  with  the  chronic 
form.  In  this  the  urine  is  often  alkaline,  or  ready  to  become  so  on  the 
slightest  addition  of  alkali  to  the  blood.  Such  alkalinity  of  urine  in  turn 
favors  decomposition,  the  effect  of  which  is  to  convert  the  pus,  if  present, 
into  a  tenacious,  glairy  fluid  which  the  bladder  cannot  evacuate.  Notwith- 
standing this  tendency,  liquor  potassae  and  other  alkalies  are  sometimes  ad- 
ministered under  precisely  these  conditions — adding  "  fuel  to  the  flame." 
The  indication  under  these  circumstances  is  to  render  the  urine  acid,  if 
possible,  although  the  means  to  this  end  are  unsatisfactor}'.  Benzoic  acid 
has  the  reputation  of  doing  this,  and  it  is  probably  true  of  it  when  adminis- 
tered in  sufficient  doses.  It  may  be  given  in  the  shape  of  a  five-grain  (0.32 
gm.)  capsule,  of  which  at  least  six  must  be  given  in  a  day  to  produce  any 
eff'ect.  Benzoate  of  sodium  may  be  given  in  ten-grain  doses  (0.6  gm.) 
e\'ery  two  hours.  The  same  property  has  been  assigned  to  citric  acid,  but 
this  is  a  mistake,  as  all  of  the  vegetable  acids,  when  ingested,  are  eliminated 
as  alkaline  carbonates. 

The  second  indication  is  to  medicate  the  inflamed  surface.  Two  ways 
suggest  themselves : 

1.  By  the  internal  administration  of  drugs. 

2.  By  the  injection  of  medicated  liquids  into  the  bladder. 

To  carry  out  the  first  method,  an  enormous  number  of  infusions,  decoc- 
tions, and  fluid  extracts  of  vegetable  substances  have  been  suggested,  the  vast 
majority  of  which  are  absolutely  useless,  except  as  they  serve  by  their  quan- 
tity to  act  as  diluents.  Among  the  best  known  of  these  are  buchu,  pareira 
brava,  uva  ursi,  and  triticum  repens.  I  have  never  known  any  beneficial 
results  to  be  obtained  from  any  of  them,  except  perhaps  buchu,  and  seldom 
prescribe  them  except  as  vehicles. 

The  remedies  heretofore  most  efficient  in  cystitis  through  their  internal 
administration  are  the  balsams.  Of  these,  the  balsam  of  copaiba  is  practically 
unavailable,  because  not  one  stomach  in  a  hundred  will  bear  it  in  sufficient 
doses  or  for  long  enough  time  to  permit  it  to  be  of  any  use.  Sandalwood  oil 
is  more  easily  borne,  and  is  also  an  eflficient  remedy.  It  is  best  administered 
in  capsules  containing  ten  minims  (0.6  gm.).  Contrary  to  the  usual  custom 
of  giving  these  and  like  remedies  after  meals,  I  have  given  them  on  an 
empty  stomach  before  meals.  They  are  as  well  and  even  better  borne  than 
when  given  after  food,  and  they  pass  into  the  blood  much  more  quickly.     It 


CYSTITIS.  ,  763 

is  desirable  to  impre^rnate  the  blood  and  to  impart  a  balsamic  odor  to  the 
urine.  This  is  scarcely  possible  with  less  than  eight  capsules  a  day — two 
before  each  meal  and  two  at  bedtime.  They  should  be  followed  by  a  little 
milk  rather  than  water. 

A  valuable  addition  to  drugs  useful  in  the  treatment  of  cystitis  is  uro- 
tropin  or  formin,  and  it  has  been  in  my  hands  most  efficient.  It  has  seemed 
to  me  to  be  most  indicated  in  subacute  and  chronic  stages.  The  dose  is  5  to 
7  1-2  grains  (0.3  to  0.5  gm.)  in  a  capsule  three  times  a  day.  I  have  not  found 
it  always  superior  to  sandalwood.    Occasionally  this  balsam  is  more  efficient. 

Both  boric  acid  and  benzoic  acid  are  useful  adjuvants  to  the  treatment 
of  chronic  cystitis  through  their  antiseptic  effect  on  the  urine,  each  in  five- 
grain  (0.32  gm.)  doses,  rapidly  increased  to  ten  grains (0.65  gm.).  They 
may  be  given  jointly,  as  in  the  following  prescription: 


IJ     Sodii  biborat., 


-aa      .        .        .        .        .        .        .        .     gr.  X  (0.65  gm.) 


Ac  benzoic,     ) 

Infus.  buchu .     f  §  ij  (60  c  c). 

Three  times  a  day. 

Resorcin  in  five  to  ten-grain  (0.32  to  0.65  gm.)  doses  and  naphthalin  in 
two-grain  (0.13  gm.)  doses  are  recommended  for  the  same  purpose.  Salol 
has  become  a  popular  remedy,  very  large  doses  being  advised, — from  fifteen 
to  thirty  grains  ( i  to  2  gm.)  every  three  hours, — but  in  my  experience  these 
doses  are  not  well  borne,  ten  grains  being  a  maximum  dose. 

The  application  of  remedies  to  the  bladder  by  injections  is  best  con- 
sidered in  connection  with  the  third  indication — the  getting  rid  of  inflamma- 
tory products,  the  pus  and  mucus,  and  the  matters  resulting  from  their  decom- 
position. The  latter  are  not  always  present,  but  all  who  have  had  much 
experience  with  cystitis  are  familiar  with  the  tenacious,  glairy,  mucoid  mat- 
ter, which  will  not  drop  or  rise  up  in  a  pipette,  glistening  with  large  crystals 
of  triple  phosphate,  and  exhaling  a  stinking,  ammoniacal  odor  which  quickly 
contaminates  an  entire  apartment.  There  is  only  one  way  to  get  rid  of  this, 
and  that  is  to  wash  out  the  bladder,  and  often  this  is  too  long  deferred.  Tepid 
water  should  be  used  first,  and  the  injection  made  through  the  soft,  flexible 
catheter.  Sir  Henry  Thompson  is  very  emphatic  in  his  directions  that  no 
more  than  two  ounces  should  be  thrown  in  at  a  time,  and  that  this  should  be 
allowed  to  run  out,  a  like  quantity  again  injected  and  allowed  to  run  out,  and 
this  repeated  until  the  water  comes  out  as  clear  as  it  enters.  But  double  this 
quantity  may  be  used  with  entire  safety,  and  with  such  quantity  used,  a  much 
shorter  time  is  necessary  to  cleanse  the  bladder  thoroughly.  After  the  capacity 
of  the  bladder  has  been  determined,  even  more  may  be  thrown  in,  because  it 
is  sometimes  useful  to  distend  the  viscus  a  little,  in  order  to  reach  the  depres- 
sions and  inequalities  always  present  in  advanced  bladder  inflammations. 
These  simple  injections,  practiced  once  a  day,  or  in  severe  cases  twice  a  day, 
often  result  most  happily.  After  a  few  injections  with  plain  water  some 
medication  may  be  added.  Salicylate  of  sodium,  in  the  proportion  of  a  dram 
(4  gm.)  to  the  pint  (1-2  liter),  is  one  of  the  best.  Its  disinfecting  qualities 
are  undoubted.  Boric  acid,  in  the  proportion  of  a  dram  (4  gm.)  to  the  pint 
(1-2  liter),  is  also  very  satisfactory.  Sir  Henry  Thompson's  soothing  lotion 
— of  biborate  of  sodium  an  ounce  (30fC.  c),  glycerin  two  ounces  (60  c.  c), 
water  two  ounces  (60  c.  c),  and  of  this  mixture  1-2  ounce  (15  c.  c.)  to  four 
ounces  ( 120  c.  c.)  of  tepid  water — mav  also  be  used.  Nitrate  of  silver  of  the 
strength  of  1-4  grain  (0.016  gm.)  to  the  ounce  (30  c.  c),  increased  to  1-2 


764  DISEASES  OF  THE  URINARY    ORGANS. 

grain  (0.03  gm.)'  is  often  very  efficient  in  diminishing  pus.  The  bladder,  if 
previously  washed  out  by  boric  acid  solution,  should  be  irrigated  with  plain 
warm  sterilized  water  in  order  to  avoid  chemical  reaction  between  the 
nitrate  of  silver  and  the  boric  acid. 

Alum  is  an  astringent  which  has  been  too  often  overlooked  of  late  in  sup- 
purating processes  in  mucous  membranes,  and  may  be  substituted  for  the 
salicylate  with  advantage  when  the  pus  does  not  disappear  so  rapidly  as  is 
desired.  It  should  be  more  cautiously  used  than  the  salicylate  of  sodium. 
Sufficient  of  the  powdered  alum  should  be  first  added  to  a  pint,  of  water  to 
give  it  a  distinctly  astringent  taste,  when  the  bladder  should  be  washed  out 
as  described,  while  a  small  quantity  may  be  allowed  to  remain  after  the  last 
injection. 

When  there  is  a  foul  odor  present,  the  bichlorid  of  mercury  may  be  used 
in  exceedingly  dilute  solution, — not  more  than  i  to  25,000  at  first, — gradu- 
ally increasing  the  strength  if  it  is  well  borne.  Carbolic  acid  may  also  be 
used  in  weak  solution, — 1-4  to  1-2  per  cent., — also  peroxid  of  hydrogen,  one 
part  to  four  or  five  of  water.  Among  other  remedies  recommended  for  use 
in  the  same  way  are  acetate  of  lead,  one  grain  (0.06  gm.)  to  four  ounces 
(120  c.  c.)  ;  dilute  nitric  acid,  one  or  two  minims  (0.06  or  0.12  c.  c.)  to  the 
ounce  (30  c.  c). 

Anodynes  are  indispensable  in  many  cases  of  cystitis  to  relieve  the 
patient  of  extreme  pain  and  of  the  frequent  desire  to  pass  water,  which  are  the 
result  of  the  same  cause.  Opium  and  its  alkaloids  are  the  most  efficient,  and 
they  are  best  introduced  by  the  rectum.  There  appears  to  be  no  absorbing 
power  in  the  bladder  for  opium,  and  there  is  no  use  in  attempting  to  admin- 
ister anodynes  by  that  channel.  Cocain,  from  which  so  much  might  reason- 
ably be  expected,  is  disappointing,  though  it  should  not  be  overlooked.  I 
have  injected  as  much  as  two  ounces  (60  c.  c.)  of  a  one  per  cent,  solution  into 
the  bladder,  representing  eight  grains  (0.5  gm.),  without  effect,  except  to 
produce  some  of  the  symptoms  of  cocain  poisoning.  Disappointing,  too,  has 
been  the  use  of  cocain  to  remove  the  exquisite  tenderness  of  the  urethra  which 
sometimes  attends  this  condition,  and  is  a  serious  drawback  to  the  use  of  the 
catheter ;  yet  it  may  be  tried  for  both  purposes.  For  catheterizing,  a  two  per 
cent,  solution  may  be  injected  into  the  urethra,  allowing  two  or  three  minutes 
to  elapse  before  the  catheter  is  introduced.  Then,  through  the  soft  catheter 
itself,  a  few  drops  of  this  solution  may  be  injected  in  advance  of  the  catheter, 
which  is  again  pushed  a  little  further ;  then  a  few  more  drops  are  instilled,  the 
catheter  is  introduced  a  little  further,  and  so  on  until  the  instrument  enters 
the  bladder. 

When  there  is  greatly  enlarged  prostate,  catheterization  is  indispensable, 
and  is  often  attended  with  the  most  happy  results.  It  is  often  too  long 
deferred  because  of  the  natural  repugnance  to  the  use  of  the  instrument.  The 
patient  or  his  friends  should  be  taught  to  use  the  catheter  and  to  wash  out  the 
bladder.  In  these  days  of  refined  antisepticism  it  is  scarcely  necessary  to 
say  that  the  greatest  precautions  should  be  taken  to  cleanse  the  catheter  after 
its  use,  in  order  to  avoid  sepsis.  There  is  nothing  better  for  this  purpose 
than  the  bichlorid  solution,  i  to  1000,  in  which  the  catheter  should  be  allowed 
to  lie  for  a  short  time  after  being  cleansed  with  boiling-hot  water. 

How  much  can  be  accomplished  by  such  treatment  as  that  just  described  ? 
An  absolute  and  total  cure  in  chronic  cystitis  is  a  rare  event.  On  the  other 
hand,  a  life  of  sufifering  may  be  converted  into  one  of  comparative  comfort, 
and  I  have  many  times  seen  it.     It  occasionally  happens,  of  course,  that  all 


NEUROSES  OF  THE  BLADDER.  76s 

treatment  of  this  kind  fails,  and  yet  the  patient  Uves  to  be  tortured  by  the  dis- 
comfort of  the  situation.  In  such  cases  perineal  section  may  be  recom- 
mended, and  I  have  had  the  operation  done  several  times  with  some  relief  to 
the  patient,  although  with  less  than  was  hoped  for.  Of  late  years  suprapubic 
cystotomy  has  come  into  favor.  The  operation  of  castration,  strongly  advo- 
cated by  J.  William  White,  offers  some  prospect  of  relief  in  cases  due  to 
enlarged  prostate.  It  recommends  itself  by  its  comparative  freedom  from 
danger.  Vasectomy  is  even  a  much  simpler  operation,  but  less  effectual. 
Excision  of  a  portion  of  the  prostate  itself  is  becoming  more  common. 


STONE  IN  THE  BLADDER. 

All  that  has  been  said  in  a  general  way  of  stone  formation  and  the  treat- 
ment of  its  tendency  when  treating  of  nephrolithiasis  may  be  applied  to  stone 
in  the  bladder. 

Symptoms. — The  symptoms  of  stone  in  the  bladder  are  practically  those 
of  cystitis,  already  described,  aggravated  by  motion,  especially  riding  over 
rough  roads.  As  further  distinctive  of  stone  in  the  bladder  may  be  mentioned 
pain  at  the  end  of  the  penis  immediately  after  micturition.  The  only  proof, 
however,  of  the  presence  of  stone  is  its  recognition  by  the  sound,  which  should 
be  used  in  every  case  of  cystitis. 

Treatment. — For  removal  of  stone  in  the  bladder  medicinal  treatment 
is  even  less  efficient,  and  operative  treatment  is,  if  possible,  more  imperative. 


NEUROSES  OF  THE  BLADDER. 

Physiology  of  the  Bladder  and  Its  Derangements. — A  proper  under- 
standing of  nervous  derangements  of  the  bladder  will  be  facilitated  by  a 
review  of  its  physiology.  The  control  of  the  bladder  over  the  urine  is  partly 
reflex  and  partly  voluntary.  The  reflex  center  is  in  the  lumbar  enlargement 
of  the  cord ;  the  voluntary,  in  the  cortex  of  the  brain.  In  the  lumbar  cord 
seem,  however,  to  be  lodged  two  reflex  centers,  one  for  the  detrusor  vesica: 
and  the  other  for  the  sphincter.  If  the  bladder  be  partly  filled  and  at  rest, 
its  control  is  given  over  to  the  sphincter,  whose  striated  fibers  are  reflexly 
active.  As  the  bladder  becomes  more  nearly  full,  the  unstriped  fibers  of  the 
•detrusor  muscle  are  more  and  more  stimulated,  and  a  time  arrives  when  the 
sphincter  can  maintain  itself  only  by  the  assistance  of  the  will  if  the  subject 
he  in  a  normal  state.  In  such  state,  too,  under  suitable  circumstances,  the 
will  suspends  its  control  over  the  sphincter  and  the  bladder  is  emptied. 

Paralysis  of  Bladder. 

If  the  spinal  cord  is  cut  above  the  lumbar  enlargement,  voluntary  power 
to  aid  or  suspend  the  action  of  the  sphincter  is  lost,  the  bladder  is  given  over 
to  the  lumbar  cord  as  a  pure  reflex  center.  The  urine  accumulates  as  long  as 
the  action  of  the  sphincter  prevails,  but  as  soon  as  a  sufficient  amount  accumu- 
lates to  stimulate  the  extrusor,  the  bladder  is  emptied  more  or  less  completely. 
Thus  is  produced  one  of  the  forms  of  incontinence,  as  when  there  is  exten- 
sive lesion  of  the  cord  above  the  lumbar  region. 

If,  on  the  other  hand,  there  is  paralysis  of  the  detrusor  muscle  and  the 


766  DISEASES  OF  THE  URINARY    ORGANS. 

sphincter  remain  intact,  there  will  be  retention  of  urine.  If,  however,  com- 
munication with  the  brain  remains  intact,  by  an  act  of  the  will  the  reflex  con- 
traction of  the  sphincter  may  be  suspended  and  the  bladder  partially  emptied 
by  a  straining  effort,  at  least  so  far  as  pressure  can  be  exerted  by  the  abdom- 
inal muscles.  Should  the  afferent  or  sensory  nerves  of  the  reflex  arc  be  para- 
lyzed either  alone  or  in  conjunction  with  the  efferent  to  the  detrusor,  the 
bladder  will  become  enormously  distended ;  but  if  the  distention  continue,  a 
point  is  reached  when  the  sphincter  is  paralyzed  by  overstretching,  when  in- 
continence occurs  and  the  urine  dribbles  away.  There  is  the  same  effect  if 
there  be  destruction  of  the  cord  at  its  lumbar  enlargement.  So  long  as  the  cord 
is  intact  the  patient  may  partially  empty  the  bladder  by  abdominal  pressure. 
Again,  if  paralysis  of  the  sphmcter  i^esiccc  occurs,  incontinence  succeeds  as 
soon  as  urine  has  accumulated  sufficiently  to  overcome  the  elastic  closure  of 


Fig.  78.— Diagram  Showing  Probable  Plan  of  the  Center  for  Micinviiion— {Cowers). 

MT.  Motor  tract.  ST.  Sensory  tract  in  the  spinal  cord.  MS,  Center,  and  7ns 
motor  nerve  for  sphincter.  MD,  Center,  and  ?nd  motor  nerve  for  detrusor,  i- 
Afferent  nerve  from  mucous  membrane  to  S,  sensory  portion  of  center.  B.  Blad- 
der. At  r  the  position  during  rest  is  indicated,  the  sphincter  center  in  action,  the 
detrusor  center  not  acting.  At  a  the  condition  during  action  is  indicated,  the 
sphincter  center  inhibited,  the  detrusor  center  acting. 

the  bladder  orifice.  It  may  also  be  slightly  delayed  by  voluntary  innervation 
of  the  sphincter,  but  is  unrestrained  during  sleep.  Hence  at  such  time  the 
patient  wets  the  bed.  Such  incontinence  is  also  manifested  when  the  patient 
coughs  or  when  in  any  way  sudden  pressure  is  brought  to  bear  on  the 
bladder.  It  is  often  seen  in  women  who  are  said  to  have  "  weak  "  bladders. 
Combined  detrusor  and  sphincter  paralysis  is  followed  by  dribbling  away  of 
urine  as  soon  as  enough  accumulates  to  overcome  the  elastic  closure  of  the 
urethra,  because  there  is  no  contraction  of  the  bladder,  and  the  outflow  is  a 
mere  overflow. 

Muscular  Spasm  of  the  Bladder — Cystospasm. 

Symptoms. — In  detrusor  spasm  sudden  evacuation  of  the  bladder  takes 
place.  This  occurs  in  hyperirritability  of  the  mucous  membrane  of  the  blad- 
der or  of  the  reflex  center  in  the  cord  as  soon  as  a  small  amount  of  urine  accu- 


NEUROSES  OF  THE  BLADDER.  767 

mulates  in  the  bladder.  It  may  be  controlled  to  a  degree  by  a  voluntary 
impulse  to  the  sphincter,  but  at  other  times  it  is  irresistible,  and  is  especially 
prone  to  occur  during  sleep.  To  this  class  of  cases  belong  many  of  the 
instances  of  incontinence  in  children. 

In  spasm  of  the  sphincter,  on  the  other  hand,  the  orifice  is  kept  forcibly 
closed,  though  this  closure,  too,  may  be  intermitted  by  action  of  the  will,  per- 
mitting thus  a  small  quantity  of  urine  to  be  discharged  at  a  time.  As  the 
urine  accumulates  the  discomfort  increases  still  further,  when  an  attempt  is 
often  made  to  empty  the  bladder  by  straining  efforts.  This  sometimes  reacts 
on  the  sphincter,  producing  further  contraction,  which  may  extend  to  the 
bulbo-urethral  and  sphincter  ani  muscles,  causing  painful  spasm.  Such 
spasm,  too,  forcibly  resists  the  introduction  of  a  catheter.  It  may  be  due  to 
hyperexcitability  of  the  sensory  reflex  center  or  to  irritation  directly  in  the 
neighborhood  of  the  sphincter,  such  as  intense  inflammation. 

A  combination  of  spasm  of  the  detrusor  and  sphincter  muscles  may  exist, 
giving  rise  in  high  degrees  to  intense  suffering.  It  may  be  caused  by  a  simul- 
taneous irritation  of  the  two  reflex  centers  in  the  cord  or  by  intense  irritation 
of  the  mucous  membrane  of  the  bladder  reflected  to  both  sets  of  muscles. 

In  addition  to  the  nervous  affections,  chiefly  of  the  cord,  which  may 
occasion  these  symptoms,  modifications  in  the  sensibility  of  the  mucous  mem- 
brane of  the  bladder,  deeper  urethra,  and  prostate  may  also  occasion  them. 
These  changes  may  be  associated  with  inflammation  or  they  may  be  purely 
neurotic.  R.  Ulzmann  has  refined  the  subject  of  neuroses  of  the  genito- 
urinary system  to  a  high  degree,  referring  many  symptoms  of  the  kind 
described  to  an  "  exalted  reflex  excitability  "  caused  by  "  overstrained  physi- 
cal, but  especially  by  exciting  mental  activity,"  long  kept  up.  Among  these 
he  mentions  fright,  pain,  grief,  loss  of  property,  and  the  like,  as  well  as  the 
"  gonorrheal  process,"  excess  in  venery,  and  masturbation,  apart  from  the 
organic  processes  of  hyperemia,  and  even  inflammation,  which  may  be  due  to 
gonorrhea.  The  pure  neurotic  representatives  of  this  class  are  unattended 
with  changes  in  the  urine,  which  is  normal  in  every  particular.  These-  are 
not  very  uncommon,  and  they  are  often  extremely  difficult  to  treat  success- 
fully. 

A  comparatively  frequent  representative  of  this  class  is  due  to  a  hyper- 
esthesia of  the  vesical  mucous  membrane,  as  the  result  of  which  the  presence 
of  the  smallest  quantitv  of  urine  gives  rise  to  a  pressing  desire  to  emptv  the 
bladder,  which  is  accomplished  with  spasm,  pain,  or  other  discomfort.  As 
the  result  of  this  the  patient  must  empty  his  bladder  often— several  times  an 
hour,  but  much  less  frequently,  if  at  all,  at  night.  The  urine  is,  as  a  rule, 
normal,  and  though  sometimes  concentrated,  with  a  proportionate  specific 
gravity,  is  still  no  more  so  than  that  which  is  commonly  retained  with  perfect 
comfort.     This  occurs  also  sometimes  in  women. 

Occasionally  there  is  absolute  loss  of  sensation  in  the  vesical  mucous 
membrane,  apparently  also  functional,  in  consequence  of  which  the  urine 
accumulates  without  exciting  the  attention  of  the  patient,  and  the  bladder 
becomes  thus  overdistended. 

Treatment. — Of  Incontinence  or  Eneuresis. — Previous  to  instituting 
treatment  for  these  conditions  the  most  careful  inquiry  must  be  made  as  to  the 
cause,  and  its  removal  sought.  This  is  often  impossible,  and  treatment  must 
then  be  empirical. 

Incontinence  most  frequently  calls  for  treatment.  If  due  to  disease  of 
the  cord,  it  is  amenable  to  treatment  so  far  as  such  disease  is,  and  in  the  mean- 


768  DISEASES  OF  THE  URINARY    ORGANS. 

time  the  patient  must  be  protected  by  catheterization  from  the  overdisten- 
tion  which  is  so  apt  to  precede  incontinence.  Incontinence  due  to  weak- 
sphincters  demands  that  this  weakness  should  be  treated  by  full  doses  of 
strychnin,  which  may  be  advantageously  given  in  gradually  ascending  doses. 
Tincture  of  nux  vomica  may  be  substituted  in  ascending  doses  until  fifteen- 
minim  (i  c.  c.)  doses  are  attained.  Electricity  has  lately  been  highly  com- 
mended for  this  form  of  incontinence,  in  the  shape  of  faradization,  one  pole 
being  applied  to  the  lumbar  part  of  the  spine  and  the  other  in  the  urethra,  in 
the  vagina,  or  to  the  perineum,  the  sittings  being  continued  for  a  few  minutes 
each  day  or  every  other  day.     Cold  douches  to  the  perineum  are  also  useful. 

If  incontinence  is  due  to  hyperesthesia  of  the  mucous  membrane  or  to 
irritability  of  the  bladder,  belladonna  is  the  accepted  remedy.  It  should  be 
given  in  ascending  doses,  and  toward  evening  if  it  be  nocturnal  incontinence, 
so  common  in  children.  The  physiological  effect  of  the  belladonna  should  be 
produced.  The  bromids  may  be  combined  with  it  or  used  separately.  If 
there  is  irritability  of  the  lumbar  cord,  ergot  commends  itself  through  its 
effect  of  diminishing  congestion  of  the  cord.  The  urine  should  receive  atten- 
tion, since  a  high  degree  of  acidity  or  the  presence  of  sediments  of  uric  acid 
and  of  oxalate  of  lime  may  become  the  exciting  causes  of  incontinence. 

Incontinence  in  children  (which  is  the  most  frequent  variety  met  in  prac- 
tice) is  a  source  of  great  annoyance,  but  in  the  majority  of  cases  it  subsides 
spontaneously  not  later  than  the  twelfth  year.  In  its  treatment  in  addition  to 
the  measures  suggested,  close  investigation  should  be  made  for  causes  which 
should  be  removed. 

Habit  is  sometimes  a  cause  of  incontinence  in  children,  and  encourage- 
ment of  a  cautious  practice  of  holding  the  water  may  gradually  correct  the 
evil.  Children  should  not  be  punished  for  incontinence,  as  the  nervous  appre- 
hension excited  only  serves  to  make  matters  worse.  General  ill-health  and 
irregular  habits  are  sometimes  responsible,  and  when  these  are  corrected 
the  patient  recovers.  Phimosis  is  sometimes  a  cause,  and  should  be  cor- 
rected if  present. 

Of  Retention. — An  overfull  bladder  should  always  be  relieved  by  the 
catheter,  and  catheterization  should  be  repeated  as  often  as  necessary  to  pre- 
vent recurring  distention  while  the  cause  is  being  treated.  When  the  re- 
tention is  due  to  weakness  of  the  detrusor  muscle,  strychnin  will  be  of 
service.  Electricity  may  also  be  used — one  pole  being  placed  behind  the 
pubes  and  the  other  applied  to  the  lumbar  region. 

If  retention  is  due  to  spasm,  the  cause  should  be  carefully  sought. 
The  same  irritations  referred  to  as  causes  of  incontinence  may  produce 
spasm,  and  some  of  the  same^remedies  are  useful  to  relieve  it,  as  belladonna 
and  the  bromids.  Warm  sitz-baths  and  full  baths  and  enamas  of  warm 
v^ater  may  be  used  at  a  temperature  of  95°  F.  (35°  C.)  two  or  three  times 
a  day.  In  the  event  of  failure  with  these  measures,  more  powerful  anod3mes 
may  be  used,  including  opium  and  morphin.  These  are  best  administered 
in  the  shape  of  a  suppository  containing  from  1-2  grain  to  one  grain  (0.033 
to  0.0066  gm.)  of  extract  of  opium,  and  1-4  grain  (0.0165  gm.)  of  morphin. 
Ultzmann  recommends,  in  cases  of  frequent  micturition  due  to  hyperesthesia 
of  the  prostate,  injections  through  the  prostatic  urethra  by  a  catheter  which 
just  reaches  the  membranous  portion  of  the  urethra.  The  solutions  used  are 
a  1-4  to  1-2  per  cent,  of  carbolic  acid  and  a  1-2  per  cent,  solution  of  sulphate 
of  zinc,  increasing  the  strength  as  it  is  borne  to  three,  four,  and  five  per 
cent.     These  should  be  used  once  a  day  with  a  syringe  holding  four  ounces 


MORBID  GROWTHS  OF  THE  BLADDER.  769 

(100  gm.),  and  the  whole  quantity  should  be  thrown  into  the  bladder  in  the 
manner  prescribed. 

Other  forms  of  spasm  must  also  be  treated  by  sedatives,  and,  strange 
as  it  may  seem,  the  passage  of  a  sound  will  sometimes  relieve  such  spasms. 

Unfortunately,  the  causes  of  either  of  these  conditions  cannot  always 
be  ascertained,  and  a  cure  must  be  secured  by  passing  from  one  remedy  to 
another  until  the  correct  one  is  arrived  at. 


HEMORRHOIDAL  VEINS   OF   THE   BLADDER. 

Excluding  all  other  causes  of  hemorrhage  of  the  bladder  heretofore 
considered,  such  as  villous  cancer,  stone,  and  tuberculosis,  there  remains  a 
cause  of  hemorrhage  which,  by  exclusion,  resolves  itself  into  a  hemor- 
rhoidal state  of  the  veins.  Its  subjects  are  only  older  persons,  rarely  under 
sixty ;  it  is  rather  copious  and  yet  rarely  fatal, — in  my  experience  never  so, — 
though  fatal  cases  are  reported. 

Great  care  should  be  taken  in  the  study  of  cases  of  this  kind  in  order 
to  make  sure  that  the  hemorrhage  is  not  due  to  the  more  serious  causes 
already  considered,  otherwise  a  grave  mistake  in  prognosis,  as  well  as  in 
diagnosis,  may  occur.  The  bladder  should  be  carefully  explored  by  the 
sound  and,  if  necessary,  by  the  endoscope. 

Treatment. — Hemorrhages  from  this  source  may  occur  and  not  be 
repeated,  and  it  is  this  favorable  termination,  in  the  absence  of  stone  or 
malignant  disease,  on  which  we  are  sometimes  unfortunately  compelled  to 
rely  for  the  diagnosis.  Should  the  hemorrhage  continue,  astringent  solu- 
tions— 1-2  per  cent,  and  upward  of  alum  and  sulphate  of  zinc — may  be 
injected  into  the  bladder,  always  using  the  soft  catheter.  Absolute  rest 
in  bed  should  also  be  insisted  upon.  At  the  same  time,  the  astringent 
drugs  and  mineral  waters  recommended  under  the  treatment  of  hematuria 
may  be  tried,  but  it  is  hardly  to  be  expected  that  astringent  effects  can  be 
produced  in  the  bladder  through  the  route  of  the  circulation  by  medicines 
administered  by  the  mouth.  In  some  cases,  ergot  appears  to  have  been 
efficient  in  controlling  these  hemorrhages. 


MORBID    GROWTHS    OF    THE    BLADDER. 

The  bladder  is  subject  to  myoma,  myxoma,  sarcoma,  and  carcinoma, 
especially  the  variety  known  as  villous  cancer  or  papilloma ;  also  to  tubercu- 
losis. Carcinoma  may  be  primary,  but  is  commonly  secondary.  The  sim- 
plest hisioid  tvimors  are  not  clinically  recognizable,  one  from  the  other. 

Symptoms. — Carcinoma  of  the  bladder  may  be  suspected  if,  in  addition 
to  the  usual  symptoms  of  cystitis,  hemorrhage  is  copious  and  persistent,  if 
there  is  carcinoma  elsewhere,  and  if  there  is  rapidly-developed  cachexia,  and 
especially  if  there  are  other  signs  of  secondary  cancer  in  the  vicinity.  Occa- 
sionally villi  of  the  papillomatous  growth  are  passed  in  urine  and  easily 
recognized.  Unless  thus  fortunate,  the  only  certain  means  of  diagnosis  in 
the  male,  though  not  always  to  be  reMed  on,  is  the  endoscope,  which,  in  the 
hands  of  a  skillful  manipulator,  affords  valuable  assistance.  In  the  case  of 
the  female  it  is  easier  and  quite  as  satisfactory  to  dilate  the  urethra  under 
ether  and  explore  with  the  finger,  though  the  endoscope  may  also  be  used. 

49 


770  DISEASES  OF  THE  URINARY  ORGANS. 

The  symptoms  of  tuberculosis  of  the  bladder  are  those  of  cystitis,  and 
the  recognition  of  the  bacillus  of  tuberculosis  by  microscopic  examination 
affords  the  only  sure  means  of  differential  diagnosis  between  it  and  other 
forms  of  inflammation  of  the  bladder.  It  is,  however,  relatively  easily 
found  when  present,  especially  if  the  urinary  centrifuge  is  used. 

Treatment. — If  the  diagnosis  of  villous  cancer  can  be  made  early,  the 
life  of  the  patient  may  be  prolonged  by  scraping  the  bladder,  but  in  my 
experience  the  growth  returns,  sooner  or  later.  In  a  few  instances  in 
which  I  have  had  surgeons  operate  for  me  in  true  cancer  of  the  bladder,  the 
result  has  been  unfortunate — the  patient  perishing  soon  after  the  operation. 
The  palliative  treatment  is  that  of  cystitis.  At  the  same  time  the  counsel 
of  a  surgeon  should  be  promptly  sought. 

The  local  treatment  of  tuberculosis  of  the  bladder  is  that  of  cystitis. 
It  demands  the  same  general  treatment  as  tuberculosis  occurring  elsewhere. 


SECTION  VIII. 

CONSTITUTIONAL  DISEASES, 

RHEUMATISM. 

Historical. — The  term  rheumatism  was  originally  used  to  indicate  morbid  con- 
ditions associated  with  mucous  discharges  (Gr.  pev/ua,  a  flux),  conditions  to  which  the 
term  catarrh  was  later  applied  and  for  which  this  term  is  still  used.  Rheumatism  and 
gout  were  originally  confounded  under  the  name  apGinng,  first  applied  to  gout  and  so 
used  by  Hippocrates  (b.  c.  460-357)  and  Aretaeus  (the  latter  half  of  first  and  beginning 
of  second  century  A.  d.),  Sydenham  (1633)  was  the  first  to  separate  the  two  conditions 
and  to  describe  them  intelligently. 

Acute  Articular  Rheumatism. 
(See  Infectious  Diseases). 

Muscular  Rheumatism. 

Synonyms — Rheumatic  Myositis;  Myalgia. 

Definition. — A  painful  condition  of  voluntary  muscles  and  their  apo- 
neurotic coverings,  especially  aggravated  by  motion  and  pressure.  It  affects 
especially  large  muscles,  such  as  those  of  the  neck,  the  shoulders,  the  arms, 
the  back,  the  thighs,  and  the  calves  of  the  legs,  and  the  intercostal  muscles. 

Etiology  and  Pathology. — Exposure  to  cold,  and  especially  to  drafts 
of  cool  air,  as  from  an  open  door  or  window,  is  the  most  frequent  cause. 
The  acute  form,  at  least,  does  not  move  about,  but  persists  in  the  muscles 
primarily  attacked  until  relieved. 

Its  true  nature  is  unknown,  and  whether  it  is  an  affection  of  muscular 
substance,  or  of  the  intermuscular  connective  tissue,  or  of  the  minute 
branches  of  sensory  nerves  distributed  throughout  the  muscles  is  also 
unknown.  Certain  forms  of  muscular  rheumatism,  especially  that  of  the 
back,  are  ascribed  to  gout.  An  infectious  origin  has  been  suggested.  It 
is  sometimes  associated  with  articular  rheumatism,  but  has  probably  a 
different  etiology,  though  like  exciting  causes  operate  to  produce  it.  Simi- 
lar pain  often  succeeds  muscular  strain,  but  it  is  doubtful  if  this  should  be 
called  muscular  rheumatism. 

The  division  of  muscular  rheumatism  into  acute  and  chronic  is  based 
upon  the  duration  of  the  pain  and  upon  its  disposition  to  recurrence.  The 
terni  chronic  is  justified  by  those  forms  which  recur  with  changes  in  the 
weather,  and  are  either  excited  or  relieved  by  them.  It,  too,  is  less  localized 
than  the  acute.  On  the  other  hand,  it  is  not  inaptly  at  times  called  wander- 
ing. It  is  more  common  in  men  than  in  women,  because  of  their  more  fre- 
quent exposure  to  its  cause. 

Symptoms. — The  only  invariable  symptom  is  pain,  aggravated  by  mo- 
tion or  pressure.  Sometimes  there  is  swelling.  It  is  usually  rather  sudden 
in  its  onset,  requiring  at  most  but  a  few  hours,  and  often  less,  to  develop 
it.  It  is  never  accompanied  by  ma,rked  constitutional  disturbance.  The 
pulse  may  be  somewhat  accelerated,  and  the  temperature  may  approach 
100°  F.  (37.8°  C),  but  more  often  there  is  no  fever  at  all. 

771 


-j-ji  CONSTITUTIONAL  DISEASES. 

]\Iuscular  rheumatism  is  especially  named  according  as  it  involves 
special  muscles.  Thus,  hunhago  is  a  painful  affection  of  the  lumbar  muscles 
and  their  tendinous  attachments.  The  attacks  come  on  under  the  condi- 
tions already  named,  but  sometimes  suddenly  without  discoverable  cause. 
The  suddenness  of  its  occurrence  under  these  circumstances — as.  for  exam- 
ple, subsequent  to  a  simple  twist  or  stooping — has  given  rise  to  the  term 
"  kink  in  the  back,"  or,  among  the  Germans,  to  the  word  Hcxenschuss,  or 
"  witches"  shot."  It  has  seemed  to  me  that  this  sudden  pain  was  really  a 
"  cramp,"  being  entirely  analogous  to  the  cramps  which  seize  the  muscles 
in  other  localities.  The  strain  in  most  cases  is  altogether  too  insignificant 
to  cause  laceration.  As  a  consequence,  the  body  is  at  times  immovable  as 
in  a  vice,  so  excruciating  is  the  pain  caused  by  motion. 

Stiif  neck,  or  torticollis,  is  an  affection  of  the  side  and  back  of  the  neck, 
forcing  the  patient  to  hold  his  neck  to  one  side  as  the  situation  of  least  dis- 
comfort, and  when  he  desires  to  turn  his  head  he  is  forced  to  turn  the  whole 
body.  Sometimes  it  becomes  chronic  and  is  rather  difficult  to  cure.  It  is 
more  frequently  met  in  children  and  young  adults.  Omalgia  is  a  similar 
condition  of  the  muscles  of  the  shoulder  and  upper  ami,  making  motion 
exquisitely  painful.  Ankylosis  of  the  shoulder  joint  may  be  caused  by  de- 
layed motion.  Pleurodynia  affects  the  intercostal  muscles  and  makes 
breathing  and  coughing  very  painful,  while  a  deep  breath  becomes  impossible 
and  sneezing  an  agony.  The  pectoral  and  serratus  muscles  may  also  be 
involved  when  the  pain  is  higher  up.  It  occurs  more  frequently  on  the 
left  side. 

Cephalodynia,  or  rheumatism  of  the  muscles  of  the  scalp,  scapitlodynia, 
and  dorsodynia  are  all  forms  of  muscular  rheumatism  which  explain  them- 
selves. It  also  affects  the  abdominal  muscles,  and  a  most  interesting  instanc*'.' 
of  this  form  simulating  peritonitis  was  published  by  myself  in  the  "  Phila- 
delphia Aledical  Times,"  volume  x.,  1880. 

The  duration  of  the  acute  form  is  brief,  seldom  lasting  for  more  than  a 
few  days,  though  there  may  be  a  tendency  to  relapse.  The  chronic  forms 
are  indefinite  in  duration. 

Diagnosis. — This  is  easy  for  the  coarser  acute  forms  of  omalgia,  stiff" 
neck,  and  lumbago.  Muscular  rheumatism  may,  however,  be  confounded 
with  neuritis  and  neuralgia.  In  muscular  rheumatism  the  pain  is  more  dif- 
fuse ;  in  neuritis  there  are  pain  and  tenderness  more  localized  and  along  the 
course  of  large  nen^e  trunks.  Muscular  rheumatism  and  neuritis  are  dis- 
tinctly worse  on  motion ;  neuralgia,  less  so.  Rheumatism  is  commonly 
relieved  by  the  warmth  of  the  bed ;  neuritis  may  be  aggravated,  while  neu- 
ralgia is  uninfluenced  by  this  cause,  while  increased  by  cold  winds.  Pleuro- 
dynia is  sometimes  difficult  to  distinguish  from  intercostal  neuralgia,  but 
attention  to  the  points  named  will  prevent  mistakes.  Neuritis  of  the  brachial 
nerve  trunks  resembles  omalgia,  but  the  former  is  early  followed  by  atrophy, 
while  muscular  rheumatism  is  not.  From  pleurisy,  pleurodynia  is  easily  dis- 
tinguished by  the  absence  of  fever  and  of  physical  signs.  The  lancinating 
pains  of  locomotor  ataxia  and  the  pains  of  incipient  disease  of  the  z'crtehrce 
resemble  at  first  those  of  lumbago,  bu':  the  special  symptoms  of  these  dis- 
eases are  soon  superadded. 

Treatment. — The  acute  form  of  muscular  rheumatism  is  occasionally 
amenable  to  treatment  by  the  salicylates  and  salicin.  Some  phenomenally 
good  results  sometimes  follow  the  use  of  these  remedies.  They  are,  however, 
inconstant,  and  if,  after  a  fair  trial,  such  results  are  not  promptly  attained, 


RHEUMATISM.  773 

the  drugs  should  be  omitted.  If  efficient,  the  same  rules  as  to  their  continued 
use  in  reduced  doses  after  relief  has  been  obtained  apply  as  in  acute  articular 
rheumatism.  The  group  of  muscles  treated  must  be  placed  at  absolute  rest, 
and  in  the  case  of  the  thorax  this  is  best  accomplished  by  strapping  the 
side  with  adhesive  plaster.  Rest  may,  however,  be  overdone,  and  in  the 
case  of  muscles  like  those  of  the  shoulder,  atrophy  may  result  from  too 
prolonged  a  rest.  Another  measure  of  great  value  is  dry  heat,  applied  by 
means  of  a  hot-water  bag  covered  with  flannel,  or  by  a  warm  flat-iron.  To 
use  a  popular  expression,  a  muscular  rheumatism  may  thus  be  sometimes 
"  ironed  out."  A  flannel  cloth  should  be  interposed.  With  these  measures 
may  also  be  associated  massage.  Sometimes  a  single  efficient  treatment 
by  massage  is  enough  to  "  rub  out  "  such  a  rheumatism.  Of  less  permanent 
utility  are  hot  poultices,  although  they  allay  pain,  at  least.  The  same  effect 
is  accomplished  by  moist  hot-air  or  vapor  (steam)  baths,  which,  in  special 
establishments,  can  be  localized. 

The  chronic  form  is  also  treated  by  massage,  passive  motion,  and  elec- 
tricity, either  the  induced  or  direct  current.  Counterirritation  by  liniments, 
such  as  those  made  with  chloroform,  ammonium  hydrate,  or  turpentine, 
have  long  enjoyed  a  reputation,  but  at  the  present  day  it  is  beginning  to  be 
cjuestioned  as  to  whether,  after  all,  it  is  not  the  friction,  rather  than  the 
liniment  itself,  which  produces  the  good  effect.  Some  efficiency  in  the 
liniment  itself,  I  think,  must  still  be  admitted,  and  I  would  advise  its  use  as 
determined  by  circumstances.  Acupuncture,  consisting  in  the  puncture  by 
needles  thrust  deeply  into  the  skin,  is  a  measure  which  has  some  advocates, 
especially  in  the  treatment  of  lumbago.  My  experience  with  it  is  limited. 
Hydrotherapy  is  more  likely  to  be  useful,  and  here  the  warm  or  cold  pack 
is  the  better  method  of  application.  Dry-cupping  is  also  often  of  service. 
Small  blisters  should  not  be  forgotten. 

General  treatment  should  not  be  neglected :  cod-liver  oil,  iron,  strychnin, 
quinin,  and  good  food  are  necessary  measures  when  the  patient  is  run  down. 
Among  diseases  which  need  nutritious  food,  chronic  muscular  rheumatism  is 
pre-eminent. 

Chronic  Articular  Rheumatism. 

Definition. — A  term,  often  vaguely  applied,  which  should  be  restricted 
to  chronic  inflammatory  swelling  involving  the  soft  tissues  of  the  joint,  not 
due  to  sepsis  or  traumatism. 

Etiology. — Occasionally  a  sequel  of  acute  rheumatism,  it  is  more  fre- 
quently of  independent  origin  in  those  subject  to  prolonged  exposure  to 
cold  and  dampness  or  to  changes  in  the  weather.  It  is  often  a  sequel  of 
the  subacute  form,  as  the  subacute  is  of  the  acute.  On  the  other  hand, 
it  sometimes  precedes  the  acute  and  subacute  forms.  It  is  a  disease  usually 
of  middle  life,  and  is  more  frequent  among  the  poor  and  the  working 
classes. 

Morbid  Anatomy. — This,  superficially,  is  similar  to  that  of  acute  rheu- 
matism, but  the  internal  joint  changes  are  more  marked.  The  joint  is 
enlarged  chiefly  because  the  capsule  and  tendons  are  thickened,  as  are  also 
the  sheaths  of  the  tendons,  explaining  the  difficulty  of  motion  and  the  stiff- 
ness. The  cartilages  may  be  involved  and  eroded  in  chronic  cases.  On 
the  other  hand,  the  joint  tissues  may  be  unaltered.  In  protracted  cases, 
especially  when  there  is  neuritis,  atrophy  of  the  muscles  covering  the  joints 


774  CONSTITUTIONAL  DISEASES. 

takes  place,  producing  marked  deformity.  In  these  cases,  too,  there  may  be 
ankylosis.  At  other  times  there  is  distention  of  the  joint  with  effusion, 
the  pressure  of  which  upon  the  muscles  themselves  or  on  the  vessels  leading 
to  them  may  be  responsible  for  the  atrophy. 

Symptoms. — These  are  chiefly  stiffness  and  pain  in  the  joints,  including 
their  muscular  and  fibrous  coverings.  The  latter  pain  is  characteristically 
increased  on  motion,  while  the  stiffness  is  often  diminished  by  exercise. 
There  may  be  little  swelling,  but  marked  tenderness  to  the  touch,  though 
not  always.  All  the  symptoms  are  aggravated  by  cool  and  damp  weather, 
and  often  by  other  unknown  meteorological  influences.  They  are  almost 
invariably  improved  by  warm  weather.  There  is  rarely  slight  fever,  nor 
is  the  pulse  much  altered.  The  stiffness  may  pass  into  actual  immobility 
due  to  ankylosis,  and  there  may  be  distortions  of  the  joints,  as  described 
under  morbid  anatomy.  Cardiac  lesions  as  the  direct  result  of  the  cause 
do  not  occur,  but  the  valves  may  gradually  be  sclerosed,  and  fibroid  changes 
may  take  place  in  the  muscle. 

Diagnosis. — This  is  not  usually  difficult.  The  age  of  the  patient,  the 
family  history,  the  varying  amount  of  the  pain,  the  multiple  joint  affection, 
and  the  large  size  of  the  joints  involved,  the  effect  of  motion,  and  the  slight 
fever  are  sufficient  to  distinguish  it  from  gout  and  surgical  monarthritis. 

Prognosis. — This,  as  to  cure,  is  unfavorable,  unless  the  patient  can  be 
removed  to  a  warm  climate.  Generally,  in  spite  of  treatment,  the  symptoms 
gradually  grow  worse  as  the  patient  ages,  though  his  life  is  rarely  shortened. 
Yet  unaccountable  improvement  sometimes  takes  place. 

Treatment. — The  remedies  useful  in  acute  rheumatism  are  not  usually 
efficient  in  the  chronic  form.  Occasionally  acute  exacerbations  are  relieved 
by  the  salicylates.  Of  drugs  sometimes  serviceable,  the  iodid  of  potassium 
and  bichlorid  of  mercury  may  be  named.  Cod-liver  oil,  iron,  and  tonics  are 
often  useful  by  building  up  the  strength  of  the  patient.  Guaiacum  is  a  drug 
which  still  maintains  some  reputation  in  the  treatment  of  chronic  rheumatism. 
It  is  usually  given  in  the  form  of  the  tincture  or  ammoniated  tincture,  five 
to  thirty  minims  (0.3  to  2  c.  c),  four  times  a  day,  preferably  in  milk. 

Local  treatment  is  more  important  than  internal  medication.  Counter- 
irritation  by  iodin  or  blisters  persistently  kept  up  is  sometimes  useful.  En- 
casing the  joints  in  red-flannel  bandages  occasionally  gives  relief  and  is  a 
convenient  adjuvant.  Massage  is  undoubtedly  an  efficient  measure,  though 
its  effects  are  not  always  permanent.  It  is  especially  useful  when  there 
is  atrophy  of  muscles,  in  which  condition  it  may  be  combined  with  electricity 
and  passive  motion. 

Hot  baths,  which  should  always  be  taken  at  night,  give  temporary 
relief,  but  in  my  experience  it  is  not  always  permanent.  Even  the  systematic 
baths  at  the  various  hot  springs,  as  those  of  Virginia,  Arkansas,  St.  Catha- 
rine's and  Banf,  in  Canada,  and  elsewhere,  which  are  undoubtedly  service- 
able, are  apt  to  be  followed  by  relapses.  ]\Iore  satisfactory  is  permanent 
residence  in  a  warm  climate  for  those  who  can  afford  it. 

In  some  of  the  obstinate  forms  of  this  affection,  the  Tallerman-Sheffield 
hot  dry-air  treatment  may  reasonably  be  expected  to  be  of  service,  and 
should  be  tried.  In  this  treatment  the  affected  part  is  exposed  to  a  tem- 
perature of  250°  to  300°  F.  (121°  to  148.7°  C). 

See  also  treatment  of  rheumatoid  arthritis. 


ARTHRITIS  DEFORMANS.  775 


Joint  Affections  Simulating  Rheumatism. 

These  include  numerous  joint  inflammations  of  septic  origin,  such  as 
occur  in  septicemia,  scarlet  fever,  diphtheria,  and  the  hke.  They  have  all 
been  appropriately  referred  to  when  treating  of  the  infectious  diseases. 


ARTHRITIS  DEFORMANS. 

Synonyms. — Chronic  Rhcinnatk  Arthritis;  RJicuniatoid  Arthritis;   Osteo- 
arthritis; Rheumatic  Joint. 

Definition. — A  deforming  disease  of  the  joints,  regarded  by  most 
authorities  as  distinct  from  gout  and  rheumatism,  and  characterized  by  de- 
structive changes  in  the  synovial  membranes,  cartilages,  and  bone,  and  by 
bony  outgrowths  restricting  the  motion  of  the  joint. 

Historical. — Sydenham  (1633),  Musgrave  (1763),  Haller  (1764),  and  de  Sauvages 
{1768)  allude  to  the  characteristic  changes  in  the  bone  due  to  arthritis  deformans,  but 
the  first  correct  description  was  read  by  Landre  Beauvais  before  the  Paris  Academy 
of  Medicine,  August  3,  i8co,  under  the  name  "  Goute  Asthenique  Primitive."  AYilliam 
Heberden,  Sr.  (1710-1801),  of  England,*  was,  however,  the  first  to  recognize  its  true 
clinical  position  as  something  distinct  from  gout  and  rheumatism  on  the  terminal 
finger-joints,  since  known  as  Heberden's  nodosities.  Haygarth's  paper  on  "  Nodosity 
of  the  Joints,"  in  1805,  describes  the  disease  clinicalh".  and  he  remarked  upon  the 
peculiar  liability  of  its  occurrence  in  the  female  sex.  Robert  Smith  (1835),  R.  Adams, 
and  Charcot  (1868)  contributed  to  its  morbid  anatomy;  Trastour  (1853),  Vidal  (1853), 
and  Charcot  to  its  clinical  aspects.  Charcot  and  Trastour  regarded  it  as  a  variety  of 
chronic  rheumatism,  as  do  Mitchell  Bruce  of  England,  and  Kahler  of  Vienna,  at  the 
present  day.  H.  "W.  Fuller  (1852)  and  A.  B.  Garrod  (1859)  described  the  disease  ac- 
curately as  something  distinct  from  gout  and  rheumatism,  basing  their  views  on  the 
absence  of  the  visceral  complications  of  these  two  diseases.  Jonathan  Hutchinson 
and  others  at  the  present  day  still  hold  that  the  disease  is  the  product  of  a  blending 
of  gout  and  rlieumatism.  J.  K.  Mitchell  suggested  a  nervous  origin  for  the  multiple 
form,  and  this  idea  has  been  developed  bv  Senator  (1877)  and  R.  Wichmann  (1890)  in 
Germany,  W.  M.  Ord  (1884)  and  Dyce  Duckworth  (1884)  in  England,  L.  Weber  (1884) 
in  America,  and  others,  until  at  the  present  day  this  neurotrophic  view  seems  to  be 
the  most  popular.  Arbuthnot  Lane  (1891)  attaches  much  importance  to  mechanical 
wear  and  tear  in  the  production  of  the  lesions.  Archibald  E.  Garrod  contributed 
an  exhaustive  paper  to  volume  ii.  of  the  "  Twentieth  Centurj-  Practice  of  Medicine," 
1895,  from  which  the  facts  of  this  historical  sketch  are  mainh"  drawn.  In  1897,  James 
Stewart  of  Montreal  read  before  the  Section  on  Medicine  of  the  British  Medical  As- 
sociation, a  paper  in  which  an  infectious  origin  of  the  disease  was  supported. 

Etiology. — Although  in  the  clinical  features  of  its  incipiency  arthritis 
sometimes  closely  resembles  the  mild  form  of  acute  rheumatism,  its  inde- 
pendence of  rheumatism  and  gout  and  their  causes  is  generally  conceded. 
Heredity,  however,  plays  a  likely,  if  not  an  important,  role.  Some  relation 
to  gout  is  still  claimed.  Thus,  the  late  J.  M.  DaCosta  said  rheumatoid 
arthritis  is  the  form  assumed  by  hereditary  gout  in  the  female.  Females 
are  much  more  liable  to  the  disease  than  males,  especially  sterile  women 
and  those  who  have  had  uterine  or  ovarian  disease.  A.  E.  Garrod  collected 
500  cases,  of  which  411  were  females  and  only  89  males.  It  is  a  disease 
said  to  be  as  common  in  the  rich  as  in  the  poor,  though  I  have  seen  man}'' 
more  of  the  latter,  perhaps  because  of  hospital  practice.  It  usually  begins 
between  the  ages  of  twenty  and  thirty,  but  it  may  occur  in  children  under 
. f — 

*  "  Commentaries  on  the  History  and  Cure  of  Diseases  "  by  William  Heberden,  Sr..  a  posthu- 
mous work,  edited  by  his  son.  W.  Heberden,  Jr.,  was  published  in  English  and  Latin  in  London  in 
1802  by  T.  Payne.  It  was  arranged  in  1782  by  the  elder  Herberden,  who  was  born  in  1710  and  died  in 
1801.  On  page  14S  of  the  English  edition  appears  the  short  article  on  "  Nodes  of  the  Fingers.'' in 
which  he  says:  "They  have  no  connection  with  the  gout,  being  found  in  persons  who  never  had  it." 


776  CONSTITUTIONAL  DISEASES. 

twelve  and  as  late  as  fifty.  The  beginning  of  the  menstrual  period  in 
women  is  a  favorite  time  for  its  incipiency. 

Traumatism,  often  assigned  by  the  subjects  of  the  disease  as  a  cause, 
has  commonly  no  well-sustained  relation,  but  must  be  allowed  as  a  factor  in 
monarthritic  cases.  Exposure,  cold,  and  dietetic  errors  are  ruled  out  at  the 
present  day  as  exciting  causes,  yet  sometimes  it  seems  impossible  to  exclude 
them.  Certainly,  insufficient  food  seems  to  favor  the  disease.  Uterine 
disease,  shock,  worry,  care,  and  grief  are  alleged  causes. 

Nature  of  the  Disease. — The  neurotrophic  theory  of  the  disease  sug- 
gested by  the  late  J.  K.  ^Mitchell,  and  additionally  supported  by  Charcot's 
studies  of  the  arthropathies,  certainly  explains  the  phenomena  better  than 
any  other.  According  to  this  view,  there  must  be  allowed  a  lesion  of  the 
spinal  cord,  either  primary  or  secondary  to  peripheral  irritation,  the  result 
of  uterine  or  traumatic  disease.  The  reasons  in  favor  of  it  are,  briefly,  the 
symmetrical  distribution  of  the  articular  dystrophies  in  the  multiple  form, 
the  primary  invasion  of  peripheral  joints,  and  the  centripetal  extension  of 
the  disease ;  its  etiology,  the  atrophy  of  muscles,  the  contractures,  the 
occasional  skin  dystrophies  manifested  by  pigmentation  and  local  sweating. 
All  these  are,  however,  offset  by  the  absence  of  anatomical  evidence  of 
spinal  cord  lesion,  without  which  evidence  the  theory  must  still  be  regarded 
as  not  proved.  The  reflex  origin  of  the  cord  lesion  is  especiallv  supported 
by  W.  M.  Ord.* 

Morbid  Anatomy. — All  three  of  the  structures  w^hich  enter  into  the 
formation  of  the  joint,  share  in  the  process,  but  the  changes  probably  begin 
in  the  cartilages.  These  consist  in  a  proliferation  of  the  cartilage  cells, 
succeeded  by  fibrillation  of  the  intercellular  substance,  which  subsequently 
undergoes  mucous  degeneration,  liquefaction,  and  absorption.  Thus,  the 
bone  ends  are  laid  bare.  These  subsequently  become  atrophied,  smooth, 
and  eburnated.  The  bone  ends  and  joint  cavities  are  alike  distorted ;  con- 
cavities may  become  convexities,  and  convexities  concavities.  The  edges 
of  the  cartilages,  where  overlapped  by  synovial  membranes,  thicken  and 
form  outgrowths,  which  subsequently  ossify  and  become  the  osteophytes 
which  contribute  to  the  deformity  of  the  bone,  sometimes  also  forming 
rims  or  lips.  The  eft'ect  of  the  latter  is  to  impair  motion  without  producing 
actual  ankylosis,  except  in  very  rare  instances,  which  may  include  even 
vertebrae.  The  synovial  membranes  also  become  thickened  and  the  fringes 
hypertrophied.  Eft'usion  is  sometimes  present  in  the  joints  and  in  the 
bursse.  Fragments  of  cartilage  may  be  attached  to  the  tufts,  or,  becoming 
detached,  they  may  lie  loose  in  the  joint.  Muscular  atrophy  also  makes  a 
conspicuous  part  of  the  morbid  changes. 

Symptoms. — If  the  joint  lesions  be  made  the  criterion  of  the  presence 
of  arthritis  deformans,  any  remaining  difference  in  symptoms  depends 
mainly  upon  the  grouping  and  extent  of  these  lesions.  Hence  it  is  more 
convenient  to  subdivide  them  into  clinical  varieties.  Two  such  are  easily 
made: 

1.  ^Multiple  arthritis  deformans,  including  (a)  Heberden's  nodosities 
on  the  small  joints  and  {h)  the  progressive  form,  in  which  large  joints  are 
successively  invaded  in  an  acute  or  a  chronic  manner. 

2.  The  monarthritic  or  partial  form,  in  which  one  or  two  joints  are 
alone  attacked. 

*  "Trans,  of  the  Clinical  Societ}-,"  1879,  xiii. 


ARTHRITIS  DEFORMANS. 


777 


I.  Multiple  Arthritis  Deformans. 

(a)  Heberden's  Nodosities. — These  are  prominences  or  nodules  which 
develop  gradually  on  the  sides  and  ends  of  the  distal  phalanges,  especially 
of  the  fingers  and  sometimes  also  of  the  toes.  Women  are  the  most  frequent 
subjects,  and  the  development  begins  usually  between  the  thirtieth  and 
fortieth  years,  and  gradually  increases  with  age,  but  varies  also  at  times  and 
seasons  independently  of  this  gradual  increase.  The  pain  and  tenderness 
also  vary,  being  usually  worse  when  the  hands  become  cold,  and  especially 
when  accidentally  struck.  At  other  times  they  are  insensitive.  These  same 
nodosities  occur  in  gout,  and  are  especially  attributed  by  tl  .  laity  to  gout, 
but  this  is  an  error.  They  may  be  considered  of  probable  gouty  nature 
when  they  are  aggravated  by  errors  of  diet.  They  are  quite  independent 
of  the  tophaceous  deposits  of  gout,  which  are  altogether  absent  in  arthritis 


Fig.  79. — Heberden's  Nodosoties. 
From  a  photograph  of  the  hand  of  a  patient  of  the  author. 


deformans.  Persons  in  whom  they  are  permanently  present  rarely  have 
the  large  joints  invaded,  and,  indeed,  are  said  to  have  promise  of  long  life. 
Subcutaneous  nodules,  similar  to  those  characteristic  of  acute  rheumatism, 
are  also  found  in  rheumatoid  arthritis. 

{b)  The  Progressive  Form. — This  may  be  acute  or  chronic.  The 
acute  form  simulates  in  its  beginning  a  mild  form  of  rheumatic  fever  in 
young  women  of  from  twenty  to  thirty  years,  but  it  may  occur  also  in  chil- 
dren. There  are  SAvelling  of  the  joints,  tenderness,  and  fever.  These  may 
continue  without  material  change  for  weeks,  or  may  abate  to  recur  with  in- 
creased severity ;  on  the  whole,  however,  growing  worse,  until  the  perma- 
nentlv  enlarged  and  distorted  state  to  be  described  is  established. 

In  the  chronic  form  the  s^me  changes  develop  more  slowly  and  without 
fever,  maintaining  with  remarkable  constancy  a  symmetrical  order  of  devel- 
opment, the  order  of  frequency  being  the  hands,  knees,  feet,  ankles,  wrists, 


y7^  CONSTITUTIONAL  DISEASES. 

elbows,  shoulders,  jaws,  cervical  spine,  hips,  and  dorsal  spine.  The  most 
striking  changes  are  seen  in  the  knees,  which  become  enlarged  and  so  fixed 
that  the  legs  are  constantly  flexed  on  the  thighs,  and  the  thighs  on  the  trunk. 
These  flexions  may  be  contributed  to  by  contractures,  which  may,  however, 
arise  secondarily,  subsequent  to  the  flexion,  or  form  pari  passu  with  it. 
They  are  seen  in  the  upper  extremity  as  well  as  in  the  lower,  producing  the 
"  seal-fin  "  deflection  at  the  wrist  and  a  rectangular  bend  at  the  elbow. 
The  actual  enlargement  is  exaggerated  in  appearance  because  of  wasting 
of  the  adjacent  muscles  and  thickening  of  the  capsular  ligament.  Its  sur- 
face becomes  hard  and  shining.  There  may  also  be  some  effusion  in  the 
joint,  though  the  condition  has  been  called  by  the  French  arthrite  seche. 
Motion  grows  more  and  more  difficult,  until  the  joint  is  almost  locked, 
and  grating  and  crackling  attend  attempt  at  motion.  Pain  varies  greatly: 
at  times  it  is  very  severe,  at  others  it  is  quiescent,  but  it  is  always  excited 
by  attempt  at  motion.  Tingling,  numbness  of  the  hands  and  feet,  and  local 
szveating  and  skin  pigmentations  are  not  uncommon  among  the  early  symp- 
toms, and  are  regarded  as  trophic  in  origin.  Day  by  day  the  patient  be- 
comes more  helpless  and,  in  the  absence  of  fresh  air,  wan,  weary,  and  anemic. 
Fortunately,  in  many  cases  the  fingers  are  unencumbered,  and  the  patient 
may  be  able  to  occupy  himself  or  herself  in  some  handiwork,  such  occupation 
serving  to  make  more  bearable  a  life  of  virtual  imprisonment.  Weather  has 
its  influences ;  diet  rarely.  The  condition  is  singularly  free  from  complica- 
tions of  all  kinds. 

2. .  The  Partial  or  Monarthritic  Form. 

This  affects  men  more  frequently  than  women,  and  of  these,  elderly 
men.  The  hip- joint  is  a  frequent  site,  constituting  the  morbus  coxce,  or 
chronic  rheumatic  arthritis  of  Adams,  whose  studies  of  this  subject  have 
added  so  much  to  our  knowledge  of  the  morbid  anatomy.  The  other  joints 
affected  are  the  knee,  the  shoulder,  and  the  vertebral  articulations.  It  is 
often  traced,  rightly  or  wrongly,  to  injury.  It  is  not  always  unassociated 
with  disease  in  other  joints,  as  there  may  be  Heberden's  nodosities,  or  the 
disease  may  involve  in  a  less  degree  the  corresponding  joint  on  the  other  side. 
Wasting  of  the  muscles  of  the  buttock  and  thigh  is  a  conspicuous  associated 
symptom.  The  knee-jerk  is  commonly  increased  on  the  affected  side.  An 
interesting,  though  unusual,  symptom,  when  the  hip  is  affected,  is  the  presence 
of  a  large  cyst  at  some  distance  from  the  joint,  ascribed  by  W.  Morrant 
Baker  *  to  an  outflow  of  the  serum  from  an  overfilled  joint  to  a  point  at 
which  it  is  restrained  by  the  rrwiscular  and  other  tissues  of  the  part. 

Diagnosis. — This  is  rarely  difficult.  Arthritis  deformans  differs  widely 
from  gout  in  the  total  absence  of  tophaceous  deposits,  and  from  acute  rheu- 
matism in  the  absence  of  fever,  though  in  the  incipiency  of  the  progressive 
multi-articular  form  there  is  a  certain  resemblance  to  acute  rheumatism, 
while  in  the  more  advanced  stage,  a  stage  in  which  the  joint  lesions  are 
conspicuous,  it  resembles  also  chronic  articular  rheumatism.  This  will  be 
appreciated  when  it  is  remembered  that  some  regard  it  as  only  a  further 
development  of  chronic  rheumatism.  The  lapse  of  time  may  be  necessary 
to  determine  which  it  is.  The  atrophied  shoulder  of  omoneuritis  also  some- 
what resembles  the  monarticular  form,  but  the  greater  tenderness  and  pain- 
fulness,  as  well  as  acuteness,  of  this  affection  distinguish  it.     The  arthro- 

*  "St.  Bartholomew's  Hospital  Reports,"  1877,  xiii.;  1885,  xxi. 


ARTHRITIS  DEFORMANS.  779 

pathies  attending  locomotor  ataxia  and  syringomyelia  are  distinguished  by 
the  symptoms  pecuHar  to  them  and  by  the  absence  of  osteophytes. 

Treatment. — This  is  not  generally  promising,  and  the  usual  remedies 
for  rheumatism  are  of  little  avail.  Yet  treatment  is  by  no  means  unavailing, 
especially  if  instituted  early,  and  we  may  always  hold  out  to  the  patient 
the  hope  of  arrest  at  some  stage.  The  principle  of  treatment  consists  in 
efforts  to  improve  nutrition  by  means  of  good  food  and  tonics,  of  which 
cod-liver  oil,  iron,  iodin,  and  arsenic  are  the  most  efficient.  A  systematic 
course  of  these  remedies,  continuous,  except  so  far  as  judicious  intermission 
may  be  necessary,  will  sometimes  accomplish  surprising  results  if  instituted 
early  and  continued  perseveringly.  The  iodid,  either  in  the  form  of  the 
pill  or  syrup,  is  the  best  preparation  of  iron.  A  grain  (0.066  gm.)  of  the 
former  and  fifteen  minims  (i  c.  c.)  of  the  latter  are  suitable  doses  three  times 
a  day.  Massage  is,  perhaps,  the  single  measure  calculated  to  be  of  most  use, 
and  if  cod-liver  oil  and  iron  be  used  in  connection  with  it,  further  benefit 
may  be  expected.  Disappointing  as  the  treatment  often  is,  in  a  few  cases 
surprising  results  may  be  obtained.  One  of  the  most  serious  drawbacks 
in  certain  cases  is  the  difficulty  in  securing  outdoor  life  and  the  advantage 
of  exercise.  One  of  the  objects  of  massage  must  be  to  substitute  the 
latter,  while  every  possible  effort  should  be  made  to  have  the  patient  in  the 
open  air  as  much  as  possible,  and  when  his  means  will  permit  it,  to  take 
advantage  of  residence  in  warm  but  dry  climates.  It  is  very  important  to 
avoid  the  use  of  anodynes  altogether,  if  possible.  The  relief  aft'orded  by 
them  is  but  temporary,  they  militate  against  the  eft'ort  at  securing  an 
improved  nutrition,  and,  above  all,  there  is  danger  of  forming  the  morphin 
habit.  Simple  support  by  splints  is  sometimes  a  comfort  to  patients.  The 
treatment  by  hydrotherapy,  as  carried  out  at  Aix-les-Bains  and  Aix-la-Cha- 
pelle  in  Europe,  undoubtedly  affords  temporary  relief.  The  same  may  be 
said  of  the  treatment  at  the  Hot  Springs  of  Arkansas,  Virginia,  and  North 
Carolina  in  this  country,  and  at  St.  Catharine's  in  Canada.  While  general 
steam  baths  are  contra-indicated  by  reason  of  their  debilitating  effect,  local 
vapor  baths  applied  to  separate  limbs  or  portions  of  limbs  by  a  specially  con- 
structed apparatus  are  sometimes  useful.  Some  mention  should  be  made  of 
the  electric  bath.  Like  so  many  remedies,  it  is  often  of  service  at  first,  but  I 
have  yet  to  see  any  permanent  good  results  follow  its  use.  It  may,  however, 
be  tried  in  cases  which  have  resisted  other  treatment.  The  bath  should  be 
given  under  intelligent  supervision  and  the  current  should  be  weak  at  first. 

Much  was  expected  first  from  the  hot  dry-air  or  Tallerman-Sheffield 
treatment  of  this  disease.  Temporarily  it  does  produce  relief  of  pain,  but  I 
have  been  unable  to  learn  that  any  permanent  benefit  has  been  secured. 

The  bowels  should  receive  close  attention,  the  body  should  be  frequently 
bathed,  preferably  in  warm  water,  and  all  measures  desirable  to  secure  the 
most  perfect  personal  hygiene  should  be  practiced.  This  is  another  of  the 
few  diseases  with  an  abundance  of  good,  nourishing  food  is  necessary.  This 
is  the  more  important  when  we  remember  that  many  cases  originate  among 
the  poor  and  badly  fed.  The  use  of  wine,  porter,  stout,  and  ale  should  be 
encouraged. 

Having  a  highly  intelligent  friend  afflicted  for  many  years  with  rheu- 
matoid arthritis  whose  circumstances^  permitted  him  to  seek  every  available 
means  of  relief,  I  asked  him  to  give  me  the  benefit  of  his  experience.  He 
replied  in  a  letter  so  sensible,  and  which  appeared  to  me  to  contain  the  truth 
so  well  condensed,  that  I  append  it  with  the  belief  that  it  will  be  useful. 


78o  CONSTITUTIONAL  DISEASES. 

"  I  received  no  benefit  at  any  of  the  following  places :  Aix-les-Bains/== 
Bourboule,  Royat,  Wiesbaden,  Homburg,*  Carlsbad,^  Gastein,*  Wiltbad,'- 
Acqui,*  Montesumano,  Richfield  (N.  Y.),  Green  Sulphur  (Fla.).  In 
all  the  places  marked  with  an  *  there  were  people  to  all  appearances  affected 
similarly  to  myself  who  did  receive  benefit,  and  at  the  same  time  there  were 
others  also  so  afflicted  who  were  made  worse.  In  short,  I  am  convinced  from 
my  experience  that  no  physician  can  definitely  settle  what  spring  will  be  of 
the  greatest  service  to  any  patient,  and  that  the  only  chance  of  finding  this  out 
will  be  for  him  to  select  those  which  he  thinks  will  be  of  the  most  service  and 
let  the  patient  try  them  in  turn.  In  this  way  the  patient  will  perhaps  find  one 
which  will  either  materially  alleviate  or  absolutely  cure  him.  I  found  that 
the  mud  baths  of  Battaglia,  Italy,  did  me  the  most  good,  but  they,  at  the  same 
time,  nearly  cost  me  my  life.  I  am  also  convinced  that  rheumatoid  arthritis 
cannot  be  successfully  treated  by  giving  the  same  remedies  to  different  people 
suffering  from  it.  There  must  be  variations  in  our  general  make-up  as  there 
are  in  our  features.  In  my  judgment,  therefore,  each  patient  must  be  a  law 
to  himself.  He  must  find  out  for  himself  by  judicious  experiments  the  food 
and  drink  that  he  can  best  assimilate,  and  confine  himself  to  them,  even  if  the 
usual  practice  would  indicate  that  they  ought  to  injure  him.  I  also  think  that 
no  patient  ought  to  take  any  hot  baths  anywhere  without  ample  nourishment 
of  some  kind,  for  a  depleted  diet  and  terrific  perspiration  have  done  me  great 
harm,  for  it  was  like  '  burning  my  candle  at  both  ends.'  My  experience  has 
convinced  me  that  careful  attention  to  diet,  outdoor  exercise,  freedom  from 
anxiety,  and  good  digestion  are  much  more  serviceable  than  any  springs  in 
the  world." 


GOUT. 

Synonym. — Podagra. 

Definition. — An  acute  and  chronic  constitutional  affection,  due  to  an 
abnormal  accumulation  of  uric  acid  in  the  blood  and  tissues,  causing  various 
symptoms,  of  which  arthritis  is  the  most  distinctive  and  significant. 

Historical. — With  the  exception  of  the  classic  work  of  Thomas  Sydenham, 
"  Traciatus  de podagra  et  hydrope"  published  in  1683,  and  based  upon  his  own  case, 
he  having  been  himself  a  victim  for  forty  years. — the  history  of  our  knowledge  of 
gout  is  the  history  of  the  development  of  its  pathology,  which  begins  with  Wollaston's 
discovery  in  1797  that  the  deposits  in  the  joints  and  vicinity  in  this  disease  are  largely 
composed  of  uric  acid.  Previous  to  this  time  a  humoral  view  of  the  nature  of  gout 
was  accepted,  though  without  tangible  foundation.  In  1784  Cullen  promulgated  the 
nervous  theory  of  gout  which  was'adopted  from  G.  E.  Stahl.  CuUen's  theory  did  not 
entirely  exclude  the  humoralistic,  since  he  allowed  that  a  morbid  substance  appeared 
in  the  blood  of  some  gouty  persons  after  a  time,  but  as  the  effect  of  the  disease  rather 
than  as  its  cause.     (See  also  Pathology.) 

Etiology. — The  tendency  to  gout  is  more  frequently  inherited,  but  is  also 
acquired.  Between  50  and  60  per  cent,  of  all  cases  of  gout  can  be  traced  to 
ancestry,  parents  or  grandparents.  More  men  are  gouty  than  women,  and 
it  is  the  male  line  through  whicli  the  tendency  is  most  frequently  transmitted. 
It  is  not  usually  manifested  until  after  forty  years  of  age,  sometimes  later, 
but  the  signs  which  are  almost  sure  to  eventuate  in  gout  may  show  them- 
selves before  the  twelfth  year.  While  overeating,  especially  of  meats,  and 
intemperate  drinking,  associated  with  the  luxurious  habits  which  grow  out  of 
the  possession  of  wealth,  are  the  most  frequent  causes  of  acquired  gout,  these 


GOUT.  781 

last  are  by  no  means  essential.  Sir  Dyce  Duckworth's  studies  of  gout  in 
what  is  probably  the  richest  field  in  the  world,  London,  go  to  show  that  many 
of  the  peasantry  of  Ireland,  among  whom  gout  is  unknown,  became  gouty 
after  having  lived  for  a  time  in  London.  On  the  other  hand,  not  every  per- 
son who  inherits  a  tendency  to  gout  becomes  gouty,  since  the  fostering  causes 
previously  mentioned  may  be  wanting.  In  others  this  tendency  is  so  great 
as  not  even  to  require  the  favoring  condition. 

While  alcohol  is  an  acknowledged  cause  of  gout,  it  has  been  observed  that 
something  depends  on  the  shape  in  which  it  is  presented.  ]\Ialt  liquors,  espe- 
ciallv  the  "  heavy  "  English  ales  and  beers,  strong  in  alcohol,  are  more  active 
in  the  production  of  gout  than  the  lighter  beers  consumed  in  Germany  and 
this  countn,'.  The  same  is  trtie  of  the  strong  and  the  sweet  wines,  of  which 
port  and  sherry  are  the  type,  while  pure  whisky  is  less  harmful.  The  glyco- 
genic substances  in  the  malts  and  sweet  wines  are  probably  responsible  as 
sources  of  acid  fermentation  products  in  the  stomach,  which,  after  absorption, 
reduce  the  alkalinity  of  the  blood  and  impair  its  solvent  power  over  uric  acid. 

An  interesting  exciting  cause  of  gout  is  lead-poisoning.  This  is  seen 
particularly  in  England  and  especially  in  London,  as  pointed  out  by  Sir 
Alfred  Garrod  in  1854.  It  is,  however,  rare  in  other  parts  of  Great  Britain 
and  Ireland,  and  is  growing  more  infrequent  in  London;  for  in  1870,  accord- 
ing to  Garrod,  33  per  cent,  of  people  who  suffered  from  gout  had  been 
poisoned  by  lead,  while  Sir  Dyce  Duckworth,  up  to  1890,  fotmd  only  18  per 
cent,  in  hospital  cases.  It  is  a  rare  cause  also  in  France  and  Germany.  It 
may  be,  as  suggested  by  Alexander  Haig,  that  the  effect  of  plumbism  is  to 
diminish  the  alkalinity  of  the  blood.  In  this  country  the  combination  is 
comparatively  rare. 

Injuries  and  blows  on  susceptible  parts,  and  so  slight  a  cause  as  pressure 
by  a  boot,  are  often  predisposing  causes. 

Pathogeny. — It  cannot  be  claimed  that  the  pathology  of  gout  is  thor- 
oughly established,  although  so  many  facts  bearing  on  it  are  well  determined. 
In  this  respect  it  resembles  its  sometimes  congener,  diabetes  mellitus.  It  is 
commonly  admitted  that  uric  acid  is  in  some  way  causative.  A^'hether.  how- 
ever, the  uric  acid  thus  responsible  is  the  result  of  increased  formation  or 
diminished  excretion,  or  both,  is  not  so  generally  acknowledged.  As  early  as 
1797  Wollaston  show^ed  that  the  deposits  in  the  joints  and  vicinity  were  a 
compound  of  uric  acid.  About  1838  Sir  Henry  Holland  suggested  that  the 
peccant  material  was  uric  acid  in  the  blood.  This  was,  indeed,  suspected  by 
others,  but  it  was  not  until  1848  that  Sir  Alfred  Garrod  furnished  the  first 
demonstrative  evidence  of  such  accumulation  by  his  well-known  thread  test.* 

Alexander  Haig  r  claims  that  there  is  "'  almost  never  "  an  excessive  for- 
mation of  uric  acid  at  any  time,  and  that  its  accumulation  in  the  blood  and 
body  is  generally  due  to  retention  or  failure  of  excretion  :  that  uric  acid  is,  on 
the  whole,  continuously  formed  in  the  proportion  of  i  to  2)Z  of  urea.  In  cer- 
tain states  of  the  blood,  consisting  essentially  in  increased  alkalinity,  uric 
acid  is  held  in  solution  in  larger  quantity,  constituting  uric  acidemia.  At 
such  times,  too.  it  is  eliminated  in  increased  quantity  in  the  urine,  by  which  it 
is  also  readily  held  in  solution  because  of  the  alkalinity  of  this  secretion.  In 
opposite  states  of  the  blood  the  uric  acid  is  driven  out  of  this  fluid  and  depos- 


*  This  is  done  as  follows  :  To  two  drams  (3  gm.^i  of  serum  from  a  blister  add  five  or  six  minims 
(o.-^r^  to  0.306  srm.)  of  acetic  acid  in  a  watch-srlass.  A  thread  immersed  in  this  will  in  a  few  hour.s  show 
an  incrustation  of  uric  acid.  This  reaction  is  not  confined  to  gout.  It  occurs  in  chlorosis  and 
leukemia. 

+  "  Uric  Acid  as  a  Factor  in  the  Causation  of  Disease,"  by  Alexander  Haig,  London,  1892. 


7^2  COXSTITUTIOXAL  DISEASES. 

ited  in  the  tissues  of  the  joints.  Haig  holds,  also,  that  these  opposite  condi- 
tions, which  are  tiuctuations  in  secretion  only,  can  be  artificialh"  produced  by 
drugs,  food,  temperature,  and  other  conditions  influencing  the  reaction  of  the 
blood.  Thus,  alkalies,  alkaline  foods,  and  warm  weather  favor  the  former, — 
i.  e.,  solution, — while  acids  and  cold  weather  favor  precipitation,  and  it  is 
under  influences  like  these  that  uric  acid  in  the  form  of  urates  is  stored  up  in 
the  body.  He  further  says  that  the  blood  never  becomes  loaded  with  uric  acid 
except  as  the  result  of  previous  imperfect  excretion,  and  such  imperfect  excre- 
tion or  retention  is  sufficient  to  account  for  the  largest  quantities  he  has  ever 
seen  in  the  human  body,  and  that  it  is  not  necessary  to  suppose  excessive  for- 
mation in  explanation.  Further,  that  he  does  not  assert  that  such  formation 
never  occurs,  only  that  he  has  never  met  any  conclusive  proof  of  its  occur- 
rence, while  all  the  phenomena  of  disease  can  be  explained  without  postulat- 
mg  the  excessive  formation  of  a  single  grain. 

The  ultimate  result  is,  however,  the  same.  Whether  it  be  from  dimin- 
ished excretion  or  increased  formation,  or  both,  there  is  an  accumulation  of 
uric  acid  in  the  blood  which  is  responsible,  first,  for  certain  premonitory  symp- 
toms of  gout,  and,  second,  for  certain  local  symptoms.  The  latter  are  of  an 
inflammatory  nature,  and  consist  essentially  of  pain,  swelling,  and  redness  of 
the  joints,  preferably  of  the  smaller  ones,  and  especially  of  the  metatarso- 
phalangeal articulation  of  the  great  toe:  more  frequently,  perhaps,  of  the 
left  great  toe. 

As  to  the  relation  of  the  uric  acid  compounds  to  the  local  inflammation, 
it  is  scarcely  necessary  to  say  that  uric  acid  does  not  exist  in  the  blood 
in  an  uncombined  state,  even  in  pathological  conditions.  The  normal  urates, 
as  originally  shown  by  Bence  Jones,  and  confirmed  by  Sir  William  Roberts, 
are  quadri-urates.  Such  is  the  composition  of  the  urate  sediments  in  urine.  In 
the  pathological  state  these  are  converted  into  the  less  soluble  biurates,  which 
make  up  the  local  deposits.  It  has  all  along  been  considered  that  these 
deposits  are  the  direct  cause  of  the  gouty  inflammations.  Haig,  as  the  result 
of  his  recent  researches,  reasserts  this  view^  in  the  following  graphic 
language  :* 

"  Then  I  also  noticed  that  in  curing  a  headache  by  giving  an  acid  to 
diminish  the  excretion  of  uric  acid,  I  always  produced  a  certain  amount  of 
pricking  and  shooting  pain  in  my  joints  (generally  in  those  which  had  been 
most  used  on  the  day  in  question),  and  it  naturally  occurred  to  me  that  the 
uric  acid  was  held  back  in  these  joints  and  produced  the  pains.  The  uric  acid 
which  had  failed  to  appear  in  the  urine  must  have  gone  somewhere.  \\'hat 
more  natural  than  to  suppose  that  it  had  been  retained  in  the  joints  (where  in 
gout  it  is  found),  and  that  the  pricking  pains  were  the  evidence  of  its 
presence?  Then,  on  turning  to  Sir  Alfred  Garrod,  I  find  that  he  had  de- 
scribed precisely  similar  joint  pains  as  occurring  in  gouty  subjects  imme- 
diately after  the  ingestion  of  beer  or  wine,  and  a  very  little  investigation 
sufficed  to  prove  that  all  wines  and  beers  are  strongly  acid,  so  that  a  very 
simple  explanation  could  be  given  of  the  facts. 

E.  Pfeififer  holds  that  both  gout  and  gravel  are  due  to  the  fact  that  in 
these  conditions  uric  acid  is  produced  and  excreted  in  a  form  difficult  of  solu- 
tion. As  such  patients  excrete  on  an  average  less  uric  acid,  the  blood  becomes 
overcharged  with  it  and  the  uric  acid  salts  are  deposited  in  different  parts  of 
the  body  unnoticed  and  wdthout  symptoms  of  irritation.     Then,  according  to 

*  op.  cit.,  p.  2. 


GOUT.  783 

Pfeiffer,  the  attacks  of  gout  occur  when  from  any  cause  the  alkaHnity  of  ihe 
blood  becomes  so  great  as  to  dissolve  the  deposited  urates,  which  then  give 
rise  to  irritation  and  inflammation.  Xot  the  precipitated  uric  acid,  therefore, 
but  the  dissolved  uric  acid,  according  to  this  view,  must  be  regarded  as  the 
irritating  agent;  while  an  acute  attack  is  the  result  of  a  re-solution  in  the 
blood  of  previously  deposited  uric  acid,  due  to  an  increased  alkalescence  of  the 
blood  and  body- juices,  while  a  deposit  is  the  result  of  diminished  alkalescence. 
Pfeiffer,  in  further  support  of  this  view,  calls  attention  to  the  fact  that  the 
most  recent  chemical  analyses  by  Lecorche,  Ebstein,  and  himself  show  that 
the  excretion  of  uric  acid  during  an  attack  of  gout  is  increased  and  not  dimin- 
ished, as  taught  by  Gar  rod.  Pfeiffer  further  cites  in  support  of  this  view  the 
fact  that  acids,  especially  salicylic,  in  large  doses  promptly  relieve  the  pain  in 
gout,  while  it  is  increased  by  the  administration  of  alkalies. 

The  most  recent  studies  on  this  subject — those  of  Sir  William  Roberts  * 
— reaffirm  the  older  view,  that  the  "  mechanical  theory  offers  a  natural  and 
complete  explanation.  The  crystalline  urate  precipitated  in  the  cartilag- 
inous and  fibrous  structures  of  the  joints  necessarily  act  as  foreign  bodies ; 
they  excite  irritation,  clog  the  lymph  channels,  exercise  pressure  on  the  tissue 
elements,  and  impede  their  nutritive  operations.  These  effects  sufficiently 
account  for  the  inflammation,  pain,  and  swelling  which  ensue,  and  explain  the 
remoter  degenerative  changes  which  follow."  While  admitting  that  old 
tophaceous  deposits  are  not  always  painful,  my  experience  is  that  of  Sir 
William  Roberts,  and,  I  believe,  of  most  clinicians,  that  coincident  with  a 
fresh  deposit  of  sodium  biurates  there  is  always  pain,  while  the  salicylates 
or  alkalies  are,  in  my  experience,  the  promptest  means  to  relieve  the  pain  of 
gout. 

Of  modern  authorities  Ebstein  t  is  the  most  eminent,  who  ascribes  the 
excess  of  uric  acid  in  the  blood  to  an  abnormal  foiiiiation  of  this  substance  in 
the  body,  in  parts  also  which  do  not  normally  produce  it,  as  bone-marrow  and 
cartilage.  The  lymph  and  blood  becoming  surcharged,  a  balance  is  com- 
monly restored  by  increased  renal  excretion  or  perhaps  by  decomposition  of 
the  uric  acid.  When,  however,  from  any  cause  the  lymph  moves  slowly,  the 
so-called  premonitory  symptoms  of  gout  occur, — viz.,  a  "  tired  feeling''  vague 
pains,  etc.  If  an  actual  stasis  occurs,  the  acute  attack  appears.  This  con- 
centrated solution  of  uric  acid  acts  like  a  chemical  poison  on  certain  tissues, 
giving  rise  to  necrobiotic  changes,  and  when  these  reach  a  certain  stage,  char- 
acterized by  an  acid  reaction,  the  uric  acid  is  deposited  in  them  as  sodium 
biurate.  If  this  stage  is  not  reached,  the  local  symptoms  disappear  and  the 
joints  return  to  their  natural  state.  So  much  of  Ebstein's  view  as  makes  a 
previously  degenerated  state  of  the  tissues  a  necessary  condition  of  the  deposit 
of  uric  acid  is  commonly  admitted  by  modern  authorities,  as  represented  by 
Ord  and  Sir  Dyce  Duckworth.  The  nervous  theory-  of  gout  promulgated  by 
Cullen  in  1873  was  to  the  eft'ect  that  it  is  a  mixed  neurohumeral  rather  than  a 
purely  neural  disease.  Of  modern  authors.  Sir  Dyce  Duckworth  has  taken 
the  most  pains  to  elaborate  and  establish  the  theory  that  gout  is  a  neuro-  • 
humeral  disease.     The  sum  of  his  conclusions  may  be  stated  as  follows : 

The  diseased  states  recognized  as  of  undoubted  gouty  nature  are  pri- 
marily dependent  on  a  functional  disorder  of  the  nervous  system,  and  thus 
gout  is  a  primary  neurosis.  This,  Hk^  others,  may  be  inherited  or  acquired, 
modified,  or  even  repressed,  and  may  be  associated  with  other  neuroses.     A 

*  "  Uric  Acid,  Grave],  and  Gout."  1892,  p.  iii. 
f'Beitrag-e  zur  Lehre  von  der  Harnruhr-Diathese,"  1891. 


784  COXSTITUTIOXAL  DISEASES. 

large  part  of  the  symptoms  known  as  gouty  is  due  to  perverted  relations  of 
uric  acid  and  sodium  salts  caused  by  the  neurosis. 

Morbid-  Anatomy. — As  will  be  further  evident  in  treating  the  svmptom- 
atology  of  gout,  there  is  scarcely  a  tissue  which  may  not  be  affected  bv  it.  but 
the  morbid  conditions  which  are  more  distinctive  are.  first,  the  characteristic 
inflamed  great  toe  of  acute  gout — the  true  podagra.  The  angry,  swollen, 
dark-red  or  mottled  appearance  of  such  a  toe  once  seen  is  not  forgotten. 
Similar  though  less  striking  changes  are  sometimes  seen  in  the  metacarpo- 
phalangeal articulation  of  the  thumb. 

The  superficial  changes  in  chronic  gout  are  less  distinctive,  and  are  often 
not  different  from  those  of  chronic  rheumatism.  But  wherever  uratic 
•deposits  are  present  in  the  tissues,  there,  by  universal  consent,  is  gout.  They 
are  found  most  often  in  joints  and  in  the  parts  around  them :  first,  the  carti- 
lages of  the  movable  joints,  then  the  ligaments,  tendons,  bursae,  and,  finallv, 
the  connective  tissue  and  skin,  this  being  the  order  of  feebleness  in  vascularitv 
and  nutritive  activity.  Frequent  situations  are  the  digital  joints  and  carti- 
lages of  the  ear :  more  rarely  the  cartilages  of  the  nose,  the  vocal  cords,  the 
cornea,  kidneys,  marrow  of  bone,  and  expectoration.  Cartilages  impreg- 
nated with  urates  present  the  appearance  of  being  smeared  with  whitewash 
or"  white  paint,  and  when  preserved  in  pure  alcohol,  maintain  it  for  a  long 
time.  ^Minutely  examined,  cartilages  are  infiltrated  on  the  peripheral  surface, 
more  rarely  beneath,  with  acicular  crystals  of  sodium  urate.  Rarely  they  are 
found  in  the  bone  under  the  cartilage.  The  cartilage  cells  are  for  the  most 
part  free,  and  after  the  urates  are  dissolved  out,  the  tissue  appears  natural  or 
slightly  granular.  The  tophaceous  deposits  are  the  best  known  and  most 
characteristic  lesion  of  gout.  About  the  digital  joints,  especially  the  knuckle.= 
of  the  hands,  they  sometimes  ulcerate  through  the  skin,  making  the  oft- 
repeated  story  of  the  go«ty  subject  who  chalked  his  games  of  whist  with  his 
knuckles  a  not  unlikely  one.  The  deposits  are  often  associated  with  deflec- 
tion of  the  fingers  to  the  ulnar  side — "  seal-fin  "  type  of  hands — and  of  the 
toes  outward,  a  late  symptom  not  confined  to  gout — in  fact,  more  common  in 
rheumatoid  arthritis.     It  is  due  to  stronger  action  of  the  abductor  muscles. 

The  nodular  gouty  tophi  are  not  to  be  confounded  with  Heberden's 
nodosities,  also  characteristic  of  rheumatoid  arthritis.  Indeed,  Heberden  him- 
self denied  their  gouty  nature,  though  they  do  occur  in  gout  also.  Their 
gouty  nature  must  be  determined  by  other  symptoms  more  essential  to  gout. 
They  are  irritable  nodular  outgrowths  on  the  distal  ends  of  the  phalangeal 
bones.  They  vary  in  prominence  and  tenderness  at  different  times,  being 
worse  in  gout,  especially  after  errors  of  diet,  but  on  the  whole  they  slowly 
increase  with  the  age  of  the  patient  and  the  persistence  of  other  symptoms. 

Of  undoubted  gouty  nature  are  the  little  vesicles  over  the  nodosities, 
called  "  crab's-eye  "  cysts.  To  these  are  to  be  added  certain  exostoses  and 
ecchondroses.  or  "  lippings."  ueneath  the  synovial  membrane,  at  the  edges  of 
the  cartilages,  and  round  the  heads  of  the  phalanges,  and  even  of  larger  bones 
like  the  femur,  patella,  and  tibia. 

Changes  in  the  internal  organs  are  most  often  confined  to  the  kidneys 
and  vascular  system.  Uratic  deposits  have  been  referred  to.  They  are  not 
constant,  and  are  found  usually  in  the  interlobular  tissue  toward  the  apices. 
but  also  more  rarely  in  the  tubules.  Ultimately  the  gouty  subject  acquires 
an  interstitial  nephritis,  the  well-known  gouty  kidney ;  though  the  term 
"  gouty  kidney  "  has  also  been  applied  to  kidneys  the  straight  tubules  of  which 
are  found  filled  with  uratic  sediments,  as  is  the  case  sometimes  at  necropsy. 


GOUT. 


/^:> 


Arteriosclerosis  is  almost  always  present,  and  must  now  be  ascribed  to  the 
xanthin  bases,  which  are  toxic  while  uric  acid  is  not.  The  heart  is  hyper- 
trophied  in  its  left  ventricle.  There  may  be  deposits  of  urate  of  sodium  on  its 
valves.  Changes  in  the  lungs  are  mainly  confined  to  emphysema,  which  is 
found  in  many  cases  of  long  standing. 

Symptoms. — Of  Typical  Acute  Gout. — Persons  subject  to  attacks  of 
gout  sometimes  have  premonitory  symptoms  suggesting  the  approach  of  an 
attack.  These  vary  with  the  individual  and  are  significant  only  in  each  case. 
They  may  be  headache,  neuralgia,  any  one  of  the  numerous  manifestations  of 
deranged  digestion,  irregularity  of  the  heart's  action,  palpitation,  high  tension 
of  the  pulse,  depression  of  spirits,  drowsiness,  a  disposition  to  yawn,  a  tired 
feeling — in  fact,  any  symptom  which  the  patient  learns  to  associate  wdth  the 
attack.  Attacks  are  apparently  also  invited  or  determined  by  anything  which 
lowers  the  vitality  of  the  patient.  On  the  other  hand,  a  supper  with  wine  or 
a  single  glass  of  champagne  will  often  produce  an  attack. 

The  first  actual  symptom  of  the  typical  attack  is  articular  pain,  commonly 
in.  the  great  toe,  at  the  metacarpo-phalangeal  joint,  and  with  its  appearance 
the  premonitory  symptoms  usually  pass  away.  The  pain  is  extremely  severe, 
sharp,  shooting,  and  sudden,  often  arousing  in  the  middle  of  the  night  a 
patient  who  has  gone  to  bed  apparently  well  and  least  expecting  an  attack. 
With  this  pain  are  the  szcelling,  heat,  and  discoloration  already  described 
under  morbid  anatomy.  Rarely,  the  attack  begins  with  a  slight  chill.  On 
the  other  hand,  there  may  be  pain  without  heat,  redness,  or  swelling,  and  all 
the  typical  local  anatomical  features  of  an  attack  without  pain.  In  some 
instances  the  attack  develops  more  slowdy.  At  times  the  first  attack  is  so  little 
distinctive  that  it  is  assumed  to  be  something  much  more  trifling,  such  as 
rheumatism  or  some  slight  injury,  while  the  personal  peculiarities,  natural  or 
acquired,  always  more  or  less  influence  the  symptoms.  After  the  outburst 
at  night  the  extreme  pain  diminishes  as  morning  advances,  but  it  may  recur 
the  next  night,  and  this  goes  on  for  four,  five,  or  six  days,  when  the  attack 
terminates. 

Some  fe-'ccr  usually  accompanies  the  onset  of  acute  gout.  The  tem- 
perature promptly  rises  to  ioo°  F.  (37.8'  C),  but  does  not  far  exceed  it,  102° 
F.  (38.9°  C.)  being  the  usual  maximum  attained.  As  in  other  acute  diseases, 
the  temperature  is  higher  in  the  evening.  The  local  temperature,  notwith- 
standing the  sensation  of  heat,  is  five  or  six  degrees  below  that  of  the  axilla 
at  the  same  time.  The  attack  terminates  with  desquamation  of  the  epidermis 
over  the  inflamed  joint. 

Changes  in  the  urine  are  almost  distinctive.  It  is  scanty,  acid,  highly 
colored,  and  of  high  specific  gravity.  It  deposits  uric  acid  and  urates  on 
standing,  and  often  contains  a  small  quantity  of  albumin.  It  sometimes 
contains  sugar  in  small  or  even  decided  quantity,  but  I  am  certain  that  at 
other  times  the  reaction  of  uric  acid  on  copper  oxid  is  mistaken  for  that  of 
glucose.  During  or  preceding  an  attack  the  uric  acid  excreted  may  be 
diminished;  later  it  may  be  increased,  but,  as  elsewhere  stated,  a  relative 
increase  in  uric  acid  is  often  mistaken  for  an  absolute  increase  in  the  twenty- 
four-hours'  amount.     The  probabilities  are  that  these  changes  are  inconstant. 

A  recognized  symptom  of  acute  gout,  and  sometimes  the  only  one,  is 
pharyngitis,  and  now  the  term  "  gotvty  sore  throat  "  is  one  in  common  use, 
though  it  is  doubtless  also  often  used  carelessly.  There  seems  no  way  oi 
distinguishing  it  locallv  from  other  forms  of  sore  throat  in  which  there  is  no 
decided  swelling. 


786  COXSTITUTIOXAL  DISEASES. 

Gout  is  said  to  be  rctroccdcnt  or  metastatic  when  it  disappears  suddenly 
from  its  external  site  and  there  are  substituted  for  the  outward  symptoms 
derangements  of  some  internal  organ,  especially  the  heart  or  stomach  or 
brain  or  urinary  bladder.  In  the  first  there  appear  cardiac  symptoms  of  vary- 
ing severitv.  including  pain,  shortness  of  breath,  and  irregularity  in  the  heart's 
action ;  in  the  second,  gastro-intestinal  pain,  a  sinking  sensation,  vomiting  or 
diarrhea,  often  associated  with  intense  mental  excitement  or  depression ;  in 
the  third,  meningeal  symptoms ;  and  in  the  fourth,  cystitis  and  prostatitis. 
]More  rare  events  are  gouty  orchitis,  parotitis,  and  urticaria,  or  other  fugitive 
skin  affections.  ^letastasis  is  more  prone  to  occur  in  atonic  cases.  Sudden 
death  has  supervened  in  some  instances,  but  postmortem  lesions  of  a  definite 
kind  seem  to  be  wanting,  at  least  lesions  which  can  be  held  responsible  for 
the  symptoms. 

Of  Irregular  or  Atypical  Gout. — This  includes  a  set  of  symptoms  not 
so  distinctive  in  themselves  as  peculiar  in  this,  that  they  occur  only  in  persons 


Fig.  So. — Tophaceous  Gout. 
Both  hands  were  symmetrical!}^  affected,  man  aged  sixty  (after  Duckworth.) 

who  have  had  gout  or  who  have  a  decided  hereditary  tendency  thereto. 
These  conditions  being  fulfilled,  there  is  scarcely  any  superficial  or  visceral 
symptom  which  may  not  be  of  gouty  origin,  but  among  them  may  be  named 
cutaneous  eruptions,  gastro-infestinal  disorders,  various  forms  of  headache 
and  neuralgia,  hot  and  itching  palms  and  soles,  especially  at  night,  a  similar 
condition  of  the  eyeballs,  lumbago  and  other  muscular  pains,  arteriocapillary 
fibrosis  and  its  consequences,  iritis,  bronchitis,  pericarditis,  cystitis  with 
hemorrhage  into  the  bladder,  and  others. 

Some  affections  of  the  teeth  occurring  under  the  same  conditions  may  be 
regarded  as  gouty.  Such  are  the  so-called  pyorrhcea  alveolaris  and  "  dental 
erosion." 

All  that  was  said  of  the  general  physical  and  chemical  characteristics  of 
urine  in  acute  and  chronic  gout  may  be  true  of  it  in  irregular  gout. 

Among  other  orgns  the  eye  in  its  blood-vessels,  retina  and  optic  ner^^e 
falls  heir  to  changes  w^hich  are  ascribable  to  gout,  but  the  same  law  as  to 
their  necessarv  relation  holds,  bv  which  I  mean  that  identical  conditions  occur 


GOUT.  ;87 

which  are  not  due  to  gout,  and  the  conclusion  that  they  are  thus  related 
depends  upon  a  definite  knowledge  of  the  previous  existence  of  gout  in  the 
patient.  An  exception  to  this  exists  in  the  rare  cases  of  actual  uratic  deposits 
in  certain  situations,  as  the  cornea,  the  crystalline  lens,  vitreous  humor,  and 
even  the  retina. 

Many  conditions  are  called  gority  on  insufficient  foundation. 

Of  Chronic  Gout. — As  repeated  attacks  of  gout  occur  and  the  patient 
grows  older,  there  gradually  accumulate  the  morbid  changes  described  under 
morbid  anatomy  as  more  or  less  characteristic — the  joints  deformed  by  toph- 
aceous and  other  deposits,  the  lipping,  the  seal-fin  hand,  the  renal  and  arterio- 
vascular  changes,  interstitial  nephritis,  etc.  The  urine  now  is  in- 
creased, lighter  hued,  and  contains  albumin  and  a  few  hyaline  and  granular 
casts. 

Some  further  allusion  should  be  made  to  the  deformities  thus  resulting 
as  symptoms  of  chronic  gout.  They  appear  especially  in  connection  with 
the  toes  and  fingers,  causing  swellings,  deflections,  and  torsions  which  pro- 
duce the  most  fantastic  shapes.  Among  these  are  deflected  and  abducted  toes. 
Heberden's  nodosities,  the  seal-fin  hand,  and  the  deformities  caused  by 
tophaceous  deposits.  It  is  important  to  remember  that  any  of  these  except 
the  tophaceous  deposits  may  be  due  to  rheumatoid  arthritis  as  well  as  gout. 
Bursal  cysts  or  crabs'  eyes  on  Heberden's  nodosities  are  said  to  point  to 
iheir  gouty  origin.  The  appended  cut  from  Duckworth  illustrates  the 
ai)pearance  of  enormous  tophaceous  deposits  undoubtedly  of  gouty  origin  as 
contrasted  with  Heberden's  nodosities. 

Treatment. — The  treatment  of  gout  easily  divides  itself  into  two  parts : 
iirst,  that  of  the  gouty  diathesis ;  second,  treatment  of  the  paroxysm  or  of  the 
acute  attack. 

I.  Treatment  of  the  gouty  diathesis. — It  is  plain  that  we  may  diminish 
the  quantity  of  uric  acid  in  two  ways :  first,  by  confining  the  gouty  per- 
son to  such  food  as  produces  a  minimum  of  uric  acid ;  second,  by  admin- 
istering such  medicines  as  will  promote  its  solution  and  elimination.  The 
first  of  these  constitutes,  in  the  main,  the  dietetic  treatment,  the  second  the 
medicinal. 

I.  The  Dietetic  Treatment. — This  is  by  far  the  most  efficient  of  the  treat- 
ments of  gout,  without  which  all  else  is  only  palliation.  It  consists  essentially 
in  the  elimination,  from  the  dietary,  as  far  as  possible,  of  all  nitrogenous  or 
albuminous  principles,  the  complete  combustion  of  which  results  in  urea, 
and  the  incomplete,  in  uric  acid.  I  say  as  far  as  possible,  for  it  is  prac- 
tically impossible  to  eliminate  them  altogether.  The  foods  which  are  the 
type  of  this  class  should,  however,  be  altogether  omitted.  Such  are 
the  meats  of  the  butcher-shops,  the  albumen  of  eggs,  and  the  cheeses.  The 
first  include  beef,  veal,  mutton,  lamb,  and  pork,  whether  salt  or  fresh,  and 
for  the  most  part  fish.  As  to  cheese,  as  one-half  pound  of  this  contains 
almosc  as  much  nitrogenous  matter  as  a  pound  of  beef, — 27  per  cent,  when 
made  of  the  whole  milk,  and  28  per  cent,  when  made  of  skimmed  milk, — it  is 
plainly  contra-indicated.  If  we  consider  only  the  edible  parts  of  beef, — i.  e., 
meat  deprived  of  the  refuse  represented  by  bones,  skin,  etc., — it  contains 
according  to  its  source,  from  17  to  23fper  cent,  of  proteids ;  mutton,  from  15 
to  18  per  cent.  Of  fish,  flounder  contains  13.8  per  cent.;  mackerel,  18  per 
cent.;  halibut,  15  per  cent.;  and  salmon,  21  per  cent.,  or  quite  as  much  as 
beef  and  more  than  mutton.     Salt  codfish  contains  15  per  cent. ;  smoked  her- 


788  COXSTITUTIOXAL  DISEASES. 

ring,  20  per  cent. ;  and  canned  sardines,  24  per  cent.  Poultry  contains  from 
14  to  15  per  cent,  of  albuminates,  and  game  22  per  cent.  The  hen's  egg, 
including  albumen  and  yolk,  contains  13.7  per  cent,  of  proteid,  whence  it  is 
plain  that  it  is  a  less  objectionable  food  than  meat. 

On  the  other  hand,  milk  contains  but  from  3  per  cent,  to  4  per  cent,  of 
protein  ;  butter,  i  per  cent. ;  and  oleomargarine,  0.6  per  cent.  The  fat  oyster 
contains  8  per  cent.,  the  lean,  4.2  per  cent.,  and  the  lobster,  5.5  per  cent. ;  fish 
other  than  those  previously  mentioned,  from  5  to  10  per  cent. 

Of  vegetable  foods,  wheat  bread  contains  8.9  per  cent,  of  protein ;  wheat 
flour,  II  per  cent.,  and  Graham  flour,  11.7  per  cent. ;  rye  bread,  6.7  per  cent. ; 
buckwheat  flour,  the  same;  corn  (maize),  9  per  cent.;  rice,  7.4  per  cent.; 
sugar.  0.3  per  cent. ;  potatoes,  2  per  cent. ;  sweet  potatoes,  1.5  per  cent. ;  tur- 
nips and  carrots,  i  per  cent.;  cabbage,  1.9  per  cent.;  melons,  i  per  cent.; 
apples  and  pears,  0.4  per  cent. ;  and  bananas,  2  per  cent.  Again,  beans  con- 
tain 23.2  per  cent,  and  oatmeal  from  12  to  15  per  cent.,  large  proportions  of 
proteids. 

Thus,  the  typical  foods  permissible  from  the  standpoint  of  composition 
are  milk,  butter,  fruits,  and  succulent  vegetables,  except  beans,  and  oat- 
meal. To  these  oysters  and  lobster  may  be  added,  moderately;  fish,  except 
that  containing  a  large  amount  of  protein,  and,  when  extreme  rigidity  is  not 
required,  poultry  in  moderate  amount;  but  all  "butcher's  meat  should  be 
strictly  forbidden. 

It  is  usual,  also,  to  inderdict  the  use  of  carbohydrates, — /.  e.  starches 
and  sugars, — as  well  as  the  hydrocarbons, — fats  and  oils, — but  I  have  never 
been  able  to  see  any  reason  for  this.  There  is  absolutely  none  from  the 
standpoint  of  chemical  composition,  since  they  are  totally  without  nitrogen, 
and,  so  far  as  my  own  experience  goes,  none  from  the  clinical  standpoint. 
Only  in  the  event  of  their  producing  indigestion  and  fermentation,  with  the 
generation  of  acids,  can  they  become  a  cause  of  gout,  and  then  only,  I  should 
say,  an  exciting  cause.  I  am  in  the  habit,  therefore,  of  permitting  the  use  of 
rice,  potatoes,  and  other  farinacea,  and,  to  a  reasonable  extent,  sugar.  I  am 
glad  to  be  able  to  say  that  I  am  sustained  in  this  view  by  Sir  William  Roberts, 
who,  in  the  brochure  quoted  on  page  771,  says  also:  "  The  most  trustworthy 
experiments  indicate  that  fat,  starch,  and  sugar  have  not  the  least  direct  influ- 
ence on  the  production  of  uric  acid,  but  as  the  free  consumption  of  these 
articles  naturally  operates  to  restrict  the  intake  of  nitrogenous  food,  their  use 
has  indirectly  the  effect  of  diminishing  the  average  production  of  uric  acid." 
Basing  his  conclusions  upon  experiments  with  solutions  of  blood-serum 
impregnated  with  common  salt  (o.i  per  cent.),  in  which  he  found  the  precipi- 
tation of  crystalline  biurate  always  appreciably  hastened,  Sir  William  Roberts 
for  some  years  past  has  directed  the  gouty  to  restrict,  as  far  as  possible,  the 
use  of  common  salt  at  meals.  On  the  other  hand,  he  recommends  that  the 
subjects  of  uric  acid  gravel  should  be  advised  to  take  habitually  with  their 
meals  as  much  culinary  salt  as  their  palates  will  tolerate. 

There  are,  however,  other  sorts  of  ingesta,  also  entirely  or  almost  free 
from  nitrogen,  acknowledged  to  be  both  a  predisposing  and  an  exciting  cause 
of  gout — namely,  malt  liquors  and  zcincs.  These  are  composed  of  water, 
alcohol,  carbohydrates,  and  a  trace  of  miner'al  matters,  but  no  nitrogen.  It 
is  not  easy  at  first  to  understand  why  these  substances  should  be  harmful. 
Experience,  however,  shows  that  the  stronger  wines,  such  as  port,  ]\Iadeira, 
and  sherry,  by  their  continued  use,  are  very  likely  to  produce  gout,  while  the 
lighter  wines, — the  clarets,  hocks,  and  Moselle  wnnes, — if  taken  in  modera- 


GOUT.  789 

tion,  rarely  produce  it.  After  these,  stout,  porter,  and  the  strong  ales  induce 
gout.  Even  lager  beer,  which  contains  but  3  per  cent,  of  alcohol,  is  capable 
of  acting  similarly,  and  I  know  many  men  who  have  been  forced  to  give  up 
this  beverage  because  of  this  effect.  Cider  and  perry  least  of  all  beverages 
predispose  to  gout.  On  the  other  hand,  distilled  spirits,  especially  whisky, 
are  almost  entirely  without  effect  in  producing  gout.  Why  is  this?  Appar- 
ently, the  amount  of  alcohol  is  not  the  measure  of  the  effect,  for  whisky,  gin, 
brandy,  and  rum  all  contain  more  alcohol  than  any  of  the  wines  named.  If 
reference  is  made  to  the  wines  most  likely  to  produce  gout,  it  will  be  found 
that  they  are  those  which  contain  a  considerable  quantity  of  both  sugar  and 
alcohol.  Such  are  port,  sherry,  and  Madeir'a,  all  of  which  contain  more  than. 
15  per  cent,  of  alcohol  and  much  sugar  ;  also  sweet  champagnes  containing  11 
per  cent,  of  alcohol.  On  the  other  hand,  some  very  sweet  wines,  as  Tokay,. 
Malaga,  and  the  higher  Sauternes,  which  contain  much  sugar,  are  said  to 
produce  gout  less  rapidly.  It  would  seem  that  those  Uquors  which  contain 
alcohol  in  combination  with  other  substances,  especially  sugar,  are  potent  in 
producing  gout,  particularly  when  they  excite  indigestion,  probably  by 
restricting  elimination  rather  than  producing  more  uric  acid. 

As  to  the  acidity  of  alcoholic  drinks,  their  influence  is  pretty  clear  as 
exciting  causes.  In  this  way  act  the  beers,  in  which  both  alcohol  and  sugar 
are  present  in  small  amount,  but  which  are  highly  acid.  An  explanation  of 
this  fact  is  less  ready  from  the  standpoint  that  the  acute  attack  of  gout  is  due 
to  a  reabsorption  of  the  deposited  uric  acid  by  alkaline  blood,  than  on  the 
supposition  that  the  attack  is  due  to  the  irritative  effect  of  uric  acid  deposited 
in  the  joints,  because  of  the  diminished  alkalinity  of  the  blood  induced  by  the 
absorbed  acid.  Whatever  be  the  explanation,  few  facts  in  the  clinical  history 
of  gout  are  better  established  than  that  the  ingestion  of  acid  may  be  an  excit- 
ing cause  of  attacks. 

In  the  same  way  act  acid  fruits,  such  as  strawberries,  acid  oranges,  and 
lemons.  On  the  other  hand,  to  such  influence  I  have  known  the  most  diver- 
gent response.  Thus,  a  gouty  patient  of  my  own  could  bring  on  an  attack 
by  drinking  a  single  glass  of  lemonade,  while  a  gouty  friend  would  drink  a 
pitcher  of  lemonade  at  dinner  without  any  ill  effect  whatever.  It  is  to  be 
remembered  that  the  otherwise  harmful  effects  of  the  strong  distilled  spirits, 
such  as  are  well  borne  in  gout,  are  no  less  serious  in  gouty  subjects  than  in 
others,  and  are  often  induced  by  the  careless  prescription  of  whisky  because 
less  harmful  than  wines  in  gout. 

A  most  valuable  adjuvant  to  the  dietetic  treatment  are  the  natural 
mineral  waters.  The  waters  which  have  heretofore  received  almost  universal 
approval  are  the  alkaline  and  alkaline-saline  water's,  although  those  possess- 
ing purgative  properties  also  enjoy  a  good  reputation.  In  America,  however, 
few  alkaline  waters  are  native,  while  those  which  are,  are  so  far  inferior  to  the 
foreign  waters  that  they  do  not  serve  the  purpose.  On  the  other  hand  the 
costliness  of  the  foreign  w^aters  constitutes  a  very  serious  obstacle  to  their 
general  use.  Most  of  the  native  waters  which  have  been  employed  and  highly 
vaunted  by  their  owners  are  of  the  kind  known  as  negative  waters — that  is, 
they  have  no  mineral  ingredients  in  any  quantity  to  justify  their  classification 
in  any  of  the  five  principal  varieties  of  mineral  waters — viz.,  the  alkaline,  the 
saline,  alkaline-saline,  the  purgative  and  sulphurous — or  on  which  to  base 
any  therapeutic  results  except  by  their  diluent  effect.  At  the  same  time  it 
has  been  noticed  that  these  waters  are  not  without  effect  in  relieving  gouty 
symptoms.     Reasoning  from  these  facts,  we  may  prescribe  such  native  nega- 


790  CONSTITUTIONAL  DISEASES. 

tive  waters  as  are  accessible  to  the  patient,  or  distilled  water,  with  this  end  in 
view — the  simple  diluent  and  solvent  effect  which  comes  from  an  increased 
proportion  of  water  ingested.  The  further  propriety  of  such  a  course  is 
found  in  the  fact  that  gouty  and  lithemic  patients  are  often  moderate  water- 
drinkers,  never  drinking  water  between  meals  and  very  little  at  meals.  To 
such,  eight  ounces  of  water  ordered  on  rising,  between  meals,  and  at  bedtime, 
will  often  clear  off  a  dark-hued  urine  of  high  specific  gravity  and  substitute 
a  light-hued,  clear  urine,  without  any  sediment. 

The  mineral  waters  which  have  actually  acquired  the  greatest  reputation 
in  the  treatment  of  gout  are  those  of  which  sodium  bicarbonate  is  the  chief 
ingredient,  to  which  the  calcium  bicarbonate  is  regarded  a  valuable  adju- 
vant. Such  are  the  alkaline  waters  of  Vals  and  Vichy  in  France,  Evian-les- 
Bains  in  Switzerland,  Neuenahr  and  Fachingen  in  Prussia,  Contrexville  and 
Vittel  in  the  Vosges  (France),  and  Dax  in  France.  Other  waters  possessed 
of  reputation  in  the  treatment  of  gout,  in  which  the  quantity  of  alkaline  bi- 
carbonate is  smaller,  owe  it  to  their  combined  alkaline  and  aperient  properties, 
chiefly  due  to  sodium  sulphate  and  magnesium  sulphate,  and  belong  in  the 
second  category  of  remedies  for  the  treatment  of  gout.  Such  are  the  alkaline 
and  saline  waters  of  Carlsbad  and  Marienbad  in  Bohemia,  Kronthal  in 
Nassau,  and  Brides-les-Bains  in  Savoy.  Then  there  are  the  saline  waters 
represented  by  Baden  Baden,  Ems,  Homburg,  Kissingen,  Wiesbaden,  and  our 
own  Saratoga  waters.  In  saline  waters  we  are  much  more  fortunate  in  this 
country,  the  Saratoga  waters  furnishing  all  that  can  be  desired.  Finally, 
there  are  the  bitter  acidulated  and  bitter  purgative  waters — Hunyadi  Janos, 
Friedrichshalle  and  Rakoczy  in  Hungary,  Piilna  in  Bohemia,  and  Rubinat  in 
Spain — rarely  resorted  to  for  gout,  but  useful  as  eliminating  agents.  Among 
the  weaker  aperient  waters  are  those  of  Bedford  Springs,  Pa.,  in  this  country. 

The  use  of  these  mineral  waters  is  especially  indicated  in  a  continuous 
manner  between  the  attacks,  with  a  view  to  averting  them.  Especially  useful 
are  the  thermal  waters  in  the  chronic  arthritic  complications,  in  which  their 
internal  use  is  combined  with  bathing.  In  this  connection  may  be  mentioned 
Calrsbad  and  Marienbad  (at  both  of  which  the  mud-baths  are  employed). 
Baden  Baden,  Ems,  Wiesbaden,  Hammon  RTrha  in  Algeria,  available  in 
winter,  Plombieres  in  the  Vosges,  and  Dax  in  France.  Homburg  and  Kis- 
singen are  also  resorted  to  for  their  baths,  although  the  waters  are  cold. 

Sulphurous  waters  also  have  some  reputation  in  gout.  Especially  is 
this  the  case  with  the  waters  of  Aix-la-Chapelle  in  Rhenish  Prussia  and  Aix- 
les-Bains  in  Savoy,  Harrogate  in  England,  Richfield  Springs,  Sharon,  and 
St.  Catherine's  in  Canada  and  Mt.  Clemens  in  Michigan,  U.  S.  A.  In  all 
these  places  the  bath  treatrrrent  is  an  important  adjuvant.  America  is  also 
more  fortunate  in  sulphur  waters. 

The  remedies  in  the  second  category — the  aperients — are  decidedly  useful 
in  gout,  both  as  eliminators  of  toxic  substances,  and  to  prepare  the  way  for 
the  absorption  and  prompt  action  of  the  alkaline  bicarbonates.  They  are  not, 
however,  used  at  the  present  day  so  freely  as  they  were  a  century  ago,  and 
they  are  commonly  reserved  for  the  acute  attack. 

Hygienic  measures  are  also  of  importance  in  the  treatment  of  gout.  The 
patient  should  bathe  daily,  using  the  cool  bath  in  the  morning  or  the  warm 
in  the  evening  on  retiring,  as  experience  may  determine  to  be  the  best.  The 
skin  should  be  thoroughly  groomed,  and  daily  exercise  should  be  practiced,  an 
open-air,  outdoor  life  being  desirable  whenever  possible. 

II.  The  Medicinal  Treatment  and  the  Treatment  of  the  Acute  Attack. — 


GOUT.  791 

As  a  rule,  the  use  of  medicines  is  reserved  for'  the  acute  attack.  From  the 
earliest  history  of  the  disease  practice  has  recognized  two  classes  of  remedies 
in  the  treatment  of  gout, — alkalies  and  purgatives.— the  object  of  both  being 
to  eliminate  the  offender,  the  first  by  producing  soluble  combinations  which 
pass  off  readily  by  the  kidneys,  and  the  second  to  carry  it  off  by  the  bowels. 
It  is  plain  that  a  combination  of  the  two  principles  might  be  expected  to  be 
more  efficient  than  either  one  alone. 

First,  as  to  alkalies  and  alkaline  combinations.  ]\Iy  experience  places 
the  salicylate  of  sodium  easily  at  the  top.  and  while  it  is  not  so  rapid  in  its 
effect  in  relieving  the  pain  of  an  acute  attack  of  gout  as  it  is  in  rheumatism, 
it  is  nevertheless  an  invaluable  remedy,  excelling  all  others.  During  an 
attack  it  should  be  given  in  doses  as  large  as  can  be  borne.  As  a  fule,  adult 
men  easily  bear  fifteen  grains  (i  gm.)  four  times  a  day,  or  ten  grains  (0.65 
gm.)  may  be  administered  every  two  hours.  Even  larger  doses  may  be 
given  with  advantage,  if  borne  by  the  stomach.  With  relief  to  the  acute 
symptoms  the  dose  should  be  reduced :  but,  as  in  rheumatism,  the  remedy 
should  not  be  discontinued,  and  between  attacks  smaller  doses  should  be  kept 
up  for  some  time.  These,  however,  may  be  substituted  by  the  natural 
mineral  waters  to  be  presently  alluded  to.  The  efticiency  of  the  salicylates  is 
explained  by  the  fact  that  their  prolonged  internal  use  is  attended  with  an 
.increased  elimination  of  uric  acid. 

After  the  salicylates,  the  alkaine  carbonates  have  alwys  held  a  high 
position  in  the  treatment  of  gout.  Half  an  ounce  (  15  gm.)  a  day  in  divided 
doses  should  be  the  initial  treatment,  continued,  but  in  smaller  doses,  when 
relief  comes  to  the  acute  symptoms.  It  may  be  combined  with  a  little  lemon- 
juice  to  improve  the  flavor,  or  the  citrate  of  potassium  may  be  given  in  the 
same  doses. 

Among  the  eliminating  remedies  is  the  time-honored  colchicum,  a  drug 
which  is  of  undoubted  value  in  gout,  but  which,  in  my  experience,  must  yield 
the  palm  to  salicylic  acid.  For  a  long  time  its  action  was  inexplicable,  and 
it  came  to  be  known  as  a  specific  in  gout  as  quinin  is  in  chills  and  mercury 
in  syphilis.  ^Modern  studies  have,  apparently,  solved  this  problem.  Pro- 
fessor Rutherford  has  shown  that  it  is  one  of  the  most  powerful  cholagogues 
known.  This,  taken  in  connection  with  what  we  now  know  of  the  office  of 
the  liver  in  urea  formation,  simplifies  very  much  the  solution  of  the  problem. 
It  explains,  too,  why  colchicum  produces  its  sedative  and  anesthetic  effect 
without  necessarily  causing  purgation.  Indeed,  some,  as  Sir  Alfred  Garrod. 
considef  that  its  eifects  are  best  attained  without  purgation,  and  Garrod 
says  that  if  cathartic  action  is  required,  it  is  better  to  combine  some  aperient 
with  the  colchicum,  as  when  much  purging  and  vomiting  results  from  col- 
chicum, nervous  and  vascular  depression  follows.  I  confess  I  like  to  see 
a  mild  action  on  the  bowels  by  increasing  the  dose  gradually,  and  it  is  not 
necessary  to  produce  either  violent  purging  or  vomiting.  \Miatever  its  mode 
of  action,  it  sometimes  operates  in  the  most  magical  manner  in  relieving  pain. 
The  preparation  commonly  used  is  the  wine.  In  this  country  the  wine  of 
the  seeds  is  no  longer  official,  so  that  if  the  wine  is  ordered,  that  of  the  root 
is  dispensed.  This  is  more  powerful  than  the  wine  of  the  seeds.  The  dose 
of  the  latter  is  from  1-2  to  i  1-2  drams  (2  to  6  c.  c.)  ever}-  three  hours  dur- 
ing the  attack,  but  of  the  root  from  fifteen  to  thirty  minims  (i  to  2  c.  c), 
reducing  the  dose  when  nausea  or  purgation  ensues.  The  acetic  extract  of 
colchicum  was  a  favorite  preparation  of  the  older  physicians,  especially 
Scudamore,  who  introduced  it,  and  who  considered  its  action  milder  than 


792  CONSTITUTIONAL  DISEASES. 

that  of  anv  other  form.  It  is  still  sometimes  used,  and  has  the  advantage 
that  it  may  be  put  into  pill  form.  Its  dose  is  from  one  to  two  grains  (0.065 
to  0.13  gni-)-  Scudamore's  gout  remedy  consisted  of  magnesium  sulphate, 
four  drams  (15  gm.)  ;  magnesia,  eighty  grains  (5  gm.)  ;  vinegar  of  col- 
chicum,  four  fluid  drams  (15  c.  c.)  ;  syrup  of  crocus,  four  fluid  drams  (15 
c.  c.)  ;  mint  watef,  five  fluid  ounces  (150  c.  c).  From  one  to  three  table- 
spoonfuls  are  given  every  two  hours  until  from  four  to  six  evacuations  are 
produced  in  twenty-four  hours.  The  fluid  extract  of  colchicum  may  be 
administered  in  doses  of  from  two  to  six  minims  (0.12  to  0.30  c.  c). 

Colchicin,  the  active  principle  of  colchicum,  is  also  employed.  Its 
dose  is  1-50  grain  (0.0013  gm.j.  The  same  dose  may  be  employed  hypoder- 
micallv.  A  favorite  modern  remedy  is  the  salicylate  of  colchicin  in  doses 
of  5  minims  (0.31  c  c),  given  in  pearls  or  capsules.  The  other  aperients 
commonly  used  in  gout  are  the  sulphates,  of  which  magnesium  sulphate  is  the 
favorite.  Sodium  sulphate  is  also  used,  and  it  is  the  constituent  of  the  most 
actively  purgative  mineral  waters  already  mentioned,  viz.,  the  Hunyadi 
Janos.  Rakoczy,  and  Friedrichshalle,  now  largely  used  instead  of  the  pure 
salt.  It  is  also  the  largest  constituent  of  the  Carlsbad  waters.  A  favorite 
combination  of  the  older  physicians  was  magnesium  sulphate  two  drams, 
magnesium  carbonate  a  scruple  suspended  in  an  ounce  of  cinnamon  water, 
given  two  or  three  times  a  day  until  active  purgation  resulted.  These  two 
substances  may  be  combined  with  colchicum.  and  with  it  make  one  of  the 
forms  of  Scudamore's  mixture,  alluded  to.  Another  of  the  older  remedies, 
also  purgative  should  not  be  lost  sight  of.  It  is  Warner's  gout  cordial,  essen- 
tially the  tincture  of  rhubarb  and  senna  of  the  pharmacopeia  of  the  present 
day. 

Colocynth  is  also  employed  as  an  aperient  in  gout,  and  advantage  has 
been  taken  of  this  fact  in  the  preparation  of  the  secret  remedy  known  as 
Laville's  tincture,  which  is  very  largely  used  by  the  laity,  and  which  undoubt- 
edly has  a  very  prompt  efifect  in  many  cases  of  acute  gout.  The  following 
has  been  published  *  as  the  composition  of  Laville's  remedy,  as  determined 
by  analysis : 

Quinin,  5      parts. 

Cinchonin 5. 

Colocynthin,  .     ' 2.5 

Lime  salts, 5. 

Water,  82.5 

Alcohol,  .........  100 

Port  wine,  .........  800 

The  lithium  compounds — the  carbonate  and  citrate — have  not  proved  so 
■jseful  as  to  cause  me  to  prefer  them  to  salicylic  acid.  Indeed,  the  early 
results  of  Garrod  with  them  cannot  be  said  to  have  been  realized  in  modem 
therapeutics.  Sir  Dyce  Duckworth  says  of  lithia  that  it  is  a  remedy  better 
adapted  to  the  chronic  than  to  the  acute  phases  of  gout,  and  so  I  have  been 
using  it.  Five  grains  (0.3  gm.)  four  times  a  day,  freely  diluted,  is  the  dose 
usually  administered,  and  with  this  the  potassium  salts  are  sometimes 
combined. 

Another  modern  remedy  asserted  to  be  efficient  in  the  treatment  of  gout 
is  piperazin.  I  regret  to  say  that  I  have  been  disappointed  in  it.  In  my 
early  trials  I  thought  it  useful,  but  soon  learned  that  it  was  less  efficient  than 
the  salicylates  and  colchicum.    While  an  acknowledged  solvent  for  uric  acid 

*  "Druggist's  Circular,"  October,  1889. 


LIT  HEM  I  A.  793 

when  dissolved  in  water,  it  seems  to  be  incapable  of  dissolving  uric  acid  in 
the  system.  It  still  has  some  stanch  adherents,  and  may  be  tried.  From 
fifteen  to  thirty  grains  ( i  to  2  gm. )  daily  are  advised,  dissolved  in  water  or 
in  some  one  of  the  numerous  mineral  waters. 

Local  Applications. — For  the  relief  of  the  acute  attack  of  gout,  leeches, 
blisters,  and  cold  have  all  been  discontinued  of  late  years,  not  only  because 
they  are  useless,  but  also  because  their  use  has  been  followed  by  fatal  at- 
tacks of  the  so-called  internal  gout.  Warmth  and  moisture  do,  however, 
have  a  mollifying  effect,  which  is  increased  if  the  liquid  preparations  of 
opium  be  associated.  Cocain,  which  might  be  expected  to  be  useful,  operates 
only  through  surfaces  whence  the  epiderm  is  removed.  Should  such  be  pres- 
ent, a  five  per  cent,  solution  may  be  applied  on  lint. 

It  often  happens  that  the  pain  in  a  paroxysm  of  gout  is  so  severe  that  it 
is  impossible  to  wait  until  the  effect  of  the  foregoing  remedies  is  secured, 
and  a  hypodermic  injection  of  morphin  is  absolutely  necessary  to  relieve 
the  sufferings  of  the  patient.  I  must  remind  the  reader,  however,  that  as 
many  old  subjects  of  gout  have  contracted  kidneys,  the  use  of  morphin 
under  these  circumstances  is  attended  with  some  danger,  and  the  drug 
should  be  used  with  great  caution. 

All  pressure  by  boots  on  joints  disposed  to  gout  should  be  carefully 
avoided,  as  well  as  injuries,  as  such  influences  undoubtedly  act  as  predis- 
posing causes.  Muscular  and  mental  fatigue  are  exciting  causes  of  acute 
attacks,  and  should  be  avoided  by  the  gouty. 

Treatment  of  Retrocedent  Gout. — The  true  nature  of  a  metastatic  attack 
having  been  determined,  it  must  be  relieved  symptomatically,  while  efforts 
to  stimulate  a  true  external  attack  may  be  made  by  the  hot  mustard  foot- 
baths, sinapisms,  and  the  like.  It  has  even  been  suggested  that  a  pint  of 
champagne  may  be  advised,  this  being  the  wine  most  frequently  responsible 
for  acute  attacks. 

LITHEMIA. 

Synonyms. — Uricacidemia;  Uricemia;  American  Gout. 

Definition. — A  condition  of  imperfectly  determined  anatomical  and 
chemical  nature,  but  probably  the  result  of  an  accumulation  in  the  blood  of 
partly  oxidized  products  of  food  metamorphosis,  of  which  uric  acid  is  the 
type.  It  differs  from  gout  chiefly  in  the  absence  of  joint  deposits  and  joint 
inflammation.  In  England  the  name  of  Murchison  is  inseparably  associated 
with  lithemia,  and  in  this  country  that  of  J.  M.  Da  Costa.  The  former 
ascribed  the  accumulation  to  inactivity  of  the  liver.  It  has  been  called  Amer- 
ican gout,  because  it  has  been  thought  to  take  in  this  country  the  place  that 
gout  occupies  in  England. 

Etiology. — The  accumulation  referred  to  is  the  result  of  intemperate 
eating  and  drinking,  especially  if  associated  with  the  lack  of  exercise  suffi- 
cient to  oxidize  the  food  ingested.  In  either  event  the  income  is  greater 
than  the  output,  accumulation  results,  and  morbid  phenomena  follow. 
Heredity  also  plays  a  part  at  times. 

Symptoms. — Among  symptoms^  tolerably  constant  are  manifestations 
of  indigestion,  including  fullness  and  discomfort  after  meals,  an  unpleasant 
taste,  at  times  nausea,  and  at  others  acidity :  a  tendency  to  constipation  and 
absence  of  bile  from  the  discharges;  also  a  tendency  to  aphthous  ulcers  in 


794  COXSTITUTIOXAL  DISEASES. 

the  cheeks  and  hps,  with  punctiform  ulcers  on  the  end  and  sides  of  the 
tongue.  Extreme  nervous  irritability  is  also  often  associated  or  may  be  the 
most  striking  symptom,  while  vertigo  and  headaehe  are  among  the  most  con- 
spicuous and  annoying.  While  vertigo  is  often  associated  with  a  fullness 
and  throbbing,  the  vertigo  and  severe  headache  are  rarely  associated.  A 
further  characteristic  is  the  slozv  pulse,  which  may  beat  at  the  rate  of  but 
iiftv  or  sixtv  times  a  minute  and  even  less,  and  exhibits  a  correspondingly 
increased  tension,  with  sharp  accentuation  of  the  aortic  second  sound.  On 
the  other  hand,  if  the  patient  be  an  alcoholic  or  addicted  to  tobacco,  the 
lirst  sound  of  the  heart  may  be  feeble.  Curious  paresthesias  are  also  often 
present,  of  which  tingling  and  a  sense  of  numbness  are  conspicuous.  There 
may  be  anesthesia.  In  contrast  to  this  muscular  pain,  shooting  or  aching 
may  occur  anywhere  in  the  body.  Last,  but  by  no  means  least,  is  depression 
of  spirits,  most  inveterate  and  unpleasant,  the  patient  imagining  he  is  the 
subject  of  every  known  disease,  while  suicide  is  sometimes  sought  for  relief. 

There  is  almost  invariably  alteration  in  the  quality  and  quantity  of  the 
urine.  It  is  scanty,  Jiighly  colored,  of  high  specific  gravity,  depositing  on 
standing,  especially  at  a  slightly  lower  temperature,  a  large  bulky  sedi- 
ment composed  of  mixed  urates  or  uric  acid  or  both.  In  this  sediment  also 
are  sometimes  included  oxalate  of  lime  crystals.  Yet  though  almost  invari- 
ably present,  this  state  of  the  urine  cannot  be  regarded  as  essential,  and 
cases  occur  with  the  tout  ensemble  of  symptoms  while  the  urine  is  in  a 
natural  condition. 

Diagnosis. — This  hinges  very  largely  upon  the  condition  of  the  urine, 
as  described,  and  upon  the  habits  of  the  patient.  It  has  already  been  stated 
that  lithemia  differs  from  gout  in  the  absence  of  joint  symptoms,  but  it  cannot 
be  denied  that  the  two  conditions  often  occur  conjointly.  Less  frequently, 
if  at  all,  is  lithemia  the  result  of  heredity,  and  it  demands  as  an  essential 
condition  the  overeating  and  drinking  with  defective  oxidation  referred  to, 
which,  while  exciting  causes  of  gout,  are  by  no  means  always  necessary  to 
its  production,  especially  when  there  is  a  decided  hereditary  tendency  to  the 
same.  As  intimated  in  the  definition,  uricacidemia  is  rather  a  condition  in- 
ferred than  actually  demonstrated — inferred  from  the  disproportionate 
amount  of  uric  acid  excreted  as  compared  with  urea. 

Prognosis. — It  may  be  said,  too,  of  lithemia,  as  distinguished  from 
irregular  gout  and  from  gout,  that  the  prognosis  is,  on  the  whole,  more  favor- 
able, and  a  cure  may  be  generally  promised  the  patient  if  he  comply  with  the 
physician's  instructions. 

Treatment. — The  indications  are  evident.  The  overeating  and  over- 
drinking must  be  feduced,  and"  active  outdoor  exercise  must  be  practiced  in 
order  to  burn  up  the  remnant  of  unoxidized  food.  The  restriction  which 
Avould  be  required  depends  somewhat  upon  the  severity  of  the  case,  but  in 
all  instances  may  be  covered  by  the  injunction  to  the  patient  to  become  a 
vegetarian  rather  than  carnivor.  The  juicy  green  vegetables,  such  as  peas, 
beans,  spinach,  asparagus,  cauliflower,  celery,  onions,  cabbage,  lettuce,  and 
an  abundance  of  milk,  are  allowed.  The  free  use  of  water,  preferably  the 
alkaline  mineral  waters  referred  to  in  treating  of  gout,  and  the  omission  of  all 
alcoholic  drinks  should  be  enjoined.  A  quart  (a  liter)  of  Vichy  or  Vals  daily, 
or  in  their  absence  any  one  of  the  indifferent  mineral  waters,  with  the  addi- 
tion of  lithium  or  sodium  carbonate,  should  be  drunk.  When  urgency  is  re- 
quired, a  diet  of  diluted  milk  or  of  milk  and  \'ichy  may  be  insisted  upon  until 
such  symptoms  pass  away. 


DIABETES  MELLITUS.  795 

Of  meats  which  may  be  permitted  in  moderate  quantity  along  with 
vegetable  food  are  oysters,  fish,  the  white  meat  of  chicken,  and  game.  The 
question  of  the  carbohydrates  is  a  mooted  one.  I  have  never  seen  such  food  as 
rice  and  potatoes  do  harm,  nor  bread — if  of  good  quality  and  not  too  freshly 
baked.  Sugar  is  best  restricted,  because  of  its  tendency  to  produce  acid 
fermentations  and  acidity.  There  is  no  chemical  contra-indication.  H)^dro- 
carbons,  on  the  other  hand,  are  not  well  borne,  and  all  fats  should  be  for- 
bidden, including  butter,  as  well  as  the  fat  of  meat. 

As  to  medicines,  the  most  important  are  the  alkalies,  which  may  be 
added  to  the  negative  mineral  waters  if  they  are  used  instead  of  the  more 
truly  alkaline  waters.  Aperients,  and  of  these  again  the  salines,  are  espe- 
cially indicated,  and  above  all  the  natural  mineral  purgative  waters,  such  as 
Saratoga  waters  in  this  country,  Hunyadi,  Friedrichshalle,  and  the  like. 
Phosphate  of  sodium  is  a  favorite  aperient  in  these  conditions  on  account 
of  its  supposed  action  upon  the  liver.  The  usual  dose  is  one  dram  (4  gm.) 
in  the  morning,  on  rising,  dissolved  in  hot  water.  The  lithium  salts 
may  be  used,  and  while  I  have  not  been  able  to  trace  any  very  direct 
results  to  their  action,  they  serve  as  an  excuse  for  the  administration  of 
liquids,  since  they  are  usually  given  dissolved  in  water— say  five  grains 
(0.3  gm.)  of  the  carbonate  or  citrate  in  a  glass  of  water  before  meals. 
Pleasant  effervescing  tablets  containing  these  doses  are  now  made  by  many 
manufacturing  chemists.  The  stomachics  and  bitter  tonics,  of  which  nux 
vomica  and  strychnin  are  the  types,  may  form  useful  adjuvants,  and  pepsin 
with  hydrochloric  acid  after  meals  is  often  useful.  The  salicylates,  if  well 
borne,  are  useful  remedies  to  hold  in  solution  the  uric  acid  and  favor  its 
elimination.  Extremely  painful  attacks  may  require  the  use  of  opiates,  but 
the  doses  should  be  as  small  as  possible,  and  their  use  should  be  discouraged 
under  all  circumstances  excepting  in  extreme  urgency. 


DIABETES  MELLITUS. 

Definition. —  A  condition  characterized  by  copious  secretion  of  a  urine 
charged  with  glucose  and  due  to  some  as  yet  imperfectly  understood  de- 
rangement of  the  glycogenic  and  glyco-destructive  functions  of  the  organism. 

Historical. — Diabetes  is  one  of  the  oldest  diseases  known,  being  referred  to  by 
the  Roman  Celsus  and  the  Greek  Aretaeus,  both  of  whom  lived  in  the  first  century  of 
the  Christian  era;  also  by  the  early  East  Indian  physicians  as  a  condition  character- 
ized by  copious  secretion  of  urine,  extreme  thirst,  and  emaciation.  Little,  if  any- 
thing, was,  however,  added  to  the  subject  until  the  latter  part  of  the  seventeenth 
century,  when  Thomas  Willis  (1622-75)  in  England  first  inferred  from  its  sweetness 
the  presence  of  sugar  in  the  urine.  Moreover,  it  was  not  until  a  century  later,  1775, 
that  Matthew  Dobson,  also  an  Englishman,  actually  obtained  sugar  from  urine. 
Among  other  early  students  of  this  subject  were  Cowley  (1788),  Frank  (1704),  John 
Rollo  (i7q7),  W.  Prout  (1825)  in  England,  and  Bouchardat  and  Mialhe  in  France. 
Inseparably  associated  with  the  subject  is  Claude  Bernard,  who  first  discovered  that 
glycosuria  could  be  produced  by  puncturing  the  floor  of  the  fourth  ventricle.  Since 
that  time  there  is  perhaps  no  subject  in  medicine  to  which  has  been  contributed  so 
much  knowledge  from  an  experimental  side  as  this  one,  and  yet  no  subject  as  to  the 
true  pathology  and  etiology  of  which  we  possess  proportionately  less  accurate  infor- 
mation. 

Other  names  associated  with  the  clinical  and  experimental  investigation  of 
diabetes  are  Briicke,  Cantani,  Dickinson,  Pavy,  Ebstein,  Frerichs,  Kiilz,  Lecorche, 
von  Mehring,  Minkowski,  Naunyn,  Seegen,  C.  C.  von  Voiht,  Senator,  F.  Voit,  and 
Carl  von  Noorden.  ' 

Geographical  and  Racial  Distribution. — Diabetes  is  not  a  common  dis- 
ease anywhere,  and  it  is  variously  frequent  in  different  countries  and  races. 


796  CONSTITUTIONAL  DISEASES. 

Thus  it  is  less  common  in  the  United  States  than  in  Europe,  where  there  are 
said  to  be  from  five  to  nine  cases  among  100,000  inhabitants,  while  according 
to  the  last  United  States  Census  there  are  but  2.8  in  100,000.  According  to 
Dickinson,  the  disease  is  more  widely  prevalent  in  the  agricultural  counties 
of  England  than  in  the  cities.  It  is  common  in  Sweden,  on  the  one  hand,  and 
in  southern  Italy  and  India,  especially  in  Ceylon,  on  the  other,  while  espe- 
cially rare  statistically  in  Holland.  Russia,  and  Brazil. 

It  is  much  more  frequent  among  Hebrews  than  among  Christians  in 
the  experience  of  almost  everyone,  yet  for  what  reason  I  have  been  unable 
to  discover.  One  of  my  Hebrew  friends  suggested  that  it  is  due  to  the  in- 
tensification of  hereditation  by  intermarriage.  It  is  rare  in  the  negro  race, 
though  I  have  met  several  cases.  It  is  a  disease  especially  frequent  among 
the  rich  and  well-to-do,  though  the  poor  are  not  exempt.  It  is  also  a  disease 
of  adults,  yet  it  has  occurred  in  infants  at  the  breast.  In  the  reports  of  the 
Registrar-General  of  England  for  the  years  1851-60,  ten  deaths  are  regis- 
tered under  the  age  of  one  year  and  thirty-two  under  the  age  of  three.  The 
youngest  patient  I  ever  had  was  a  little  girl  aged  twenty-two  months,  who 
was  delivered  prematurely  because  of  nephritis  in  the  mother,  though  the 
child  was  healthy  up  to  one  year.  Albuminuria  was  associated  with  the  dia- 
betes. The  disease  is  most  frequent  between  the  ages  of  thirty  and  sixty. 
It  is  more  serious  in  the  young,  recovery  in  very  young  subjects  being  almost 
unknown.  It  is  much  more  frequent  in  males  than  in  females,  in  the  pro- 
portion of  nearly  three  to  one,  though  Senator's*  statistics  show  that  under 
the  age  of  twenty  more  females  are  affected  than  males.  This  has  been  my 
own  experience.  Little  is  known  of  the  effect  of  occupation,  though  it  is 
thought  that  occupations  taxing  the  mind  favor  it.  It  has  happened  to  me  to 
treat  a  number  of  physicians  and  farmers.  Heredity  has  in  my  experience 
been  less  conspicuous  than  European  writers  find  it.  From  10  to  25  per 
cent,  are  thus  traced  by  different  Continental  observers.  On  the  other  hand, 
it  may  occur  in  several  members  of  a  family.  It  is  not  unusual  to  find  dia- 
betes mellitus  in  some  members  of  a  family  and  gout  in  others. 

Pathology  and  Pathogenesis, — The  etiology  of  diabetes  is  so  inti- 
mately united  with  its  patholog}'  that  it  is  scarcely  possible  to  separate  their 
consideration.  What  is  known,  therefore,  of  its  immediate  causation  will 
be  developed  in  connection  with  the  pathology,  while  its  more  remote  causes 
will  be  briefly  considered  in  the  ensuing  paragraph.  Inseparably  connected, 
also,  with  the  pathology  of  diabetes  are  the  phenomena  of  sugar  formation 
in  the  economy.  A  brief  statement  of  the  latter  seems,  therefore,  justifiable. 
During  life  there  is  constantly  being  produced  and  stored  in  the  liver  of 
man  and  the  lower  animals  an  amyloid  substance,  which  was  named  by  its 
discoverer,  Claude  Bernard,  glycogen.j  Its  formula  is  C^,  H,„,  O  5,  that  of 
starch,  and  the  term  ^oaiiiyliir,  or  animal  starch,  was  at  one  time  suggested 
for  it.  The  glycogen  formation  takes  place  whether  animal  or  vegetable 
food  be  taken,  but  it  is  much  larger  upon  a  vegetable  diet.  It  is  commonly 
held  that  it  does  not  occur  at  all  with  a  diet  of  pure  fats,  but  Salomoni: 
claims  that  it  is  produced  in  the  livers  of  rabbits  fed  on  olive  oil.  C.  von 
Noorden  also  considers  that  fat  is  converted  into  sugar  in  the  liver. §  All 
physiologists  agree  that  this  amyloid  substance  is  derived  mainly  from  the 

*  See  Senator's  article  on  "Diabetes  ^Mellitus  "  in  "  Ziemssen's  Cyclopagdia  of  Medicine."  vol. 
xvi.  p.  866,  ad  fin. 

+  Bernard,  "  Xov.  Fonc.  du  Foie,"  Paris.  1S53. 

X  "  Yirchow's  Archiv,"  vol.  Ixi.,  part  3.  1874.  18. 

^  Article  "Diabetes  Mellitus,"  in  "Twentieth  Century  Practice  of  Medicine,"  New  York,  iSgs^ 
vol.  ii.  p.  42. 


DIABETES  MELLITUS.  797 

starchy  and  saccharine  principles  of  food,  but  partly  also  by  a  splitting  up 
and  rearrangement  of  the  elements  of  nitrogenous  food.  This  possibly  takes 
place  in  the  liver,  resulting  in  the  production  of  urea  and  glycogen,  the 
latter  being  stored  in  the  liver-cells.  The  muscles  are  also  favorite  reservoirs 
for  glycogen  storage.  The  most  important  property  of  glycogen  is  its  ready 
convertibility  at  the  temperature  of  the  body  into  glucose,  or  grape-sugar ; 
for  this  a  glycolytic  ferment  is  probably  required.  By  means  of  these  storage 
reservoirs  the  blood  is  kept  supplied  with  0.12  to  0.18  per  cent,  of  grape- 
sugar  in  health,  the  oxidation  of  which  contributes  to  the  forces  of  the 
economy. 

In  diabetes  mellitus  some  derangement  of  this  balance  takes  place,  as 
the  result  of  which  more  or  less  of  the  glucose  delivered  to  the  blood  is  not 
utilized,  in  a  word,  is  wasted.  This  may  be  brought  about  in  several  ways : 
(i)  It  may  be  that  the  glucose  arising  by  a  reconversion  of  the  glycogen 
stored  in  the  liver  is  contributed  to  the  blood  too  rapidly  to  be  oxidized; 
(2)  It  may  be  that,  although  the  glucose  is  delivered  in  normal  quantity,  it 
is  still  not  consumed  because  of  some  defect  in  the  oxidizing  mechanism, 
some  deficiency  in  the  glycolytic  ferment;  (3)  It  may  be  that  the  glucose 
arising  from  sugar  and  starch  digestion  in  the  intestine  is  not  first  con- 
verted into  glycogen  as  in  health,  but  passes  directly  through  that  organ  to 
the  vena  cava  too  rapidly  or  in  too  large  quantity  to  be  utilized,  or  lacking 
some  molecular  quality  which  permits  its  oxidation.  One  or  the  other  of 
these  alternates  will  explain  all  cases  of  glycosuria  when  the  non-utilized 
glucose  is  derived  only  from  the  carbohydrates  of  the  food.  These  are  the 
milder  cases  and  include  also  those  cases  of  glycosuria  clearly  traceable  to 
overingestion  of  sugars  and  starches.  Those  bad  cases  of  diabetes,  however, 
which  Dr.  Pavy  calls  "  composite  diabetes,"  in  which  the  glucose  arising 
from  proteid  foods,  and  finally  even  from  proteid  tissues,  is  not  utilized,  are 
less  easy  of  explanation.  For  it  would  seem  that  not  only  is  the  glucose 
normally  arising  unconsumed,  but  that  there  is  also  an  increased  formation 
of  glucose  from  these  sources,  and  it  may  be  even  from  the  "  fixed  proteids  " 
of  the  body.  Whichever  of  these  it  is,  the  excess  of  sugar  thus  resulting  in 
the  blood  is  eliminated  by  the  kidneys,  and  thus  glycosuria  becomes  an  essen- 
tial symptom  of  diabetes  mellitus. 

Etiology. — What  causes  this  deranged  mechanism?  I  have  already 
said  that  there  is  no  disease  concerning  which  so  much  accurate  knowledge 
has  been  arrived  at  and  of  the  true  pathology  of  which  we  are  so  thoroughly 
in  the  dark.  It  is  not  a  kidney  disease,  as  was  once  supposed  in  its  early  his- 
tory, although  this  impression  still  prevails  among  the  laity,  and  naturally  so, 
because  the  essential  evidence  of  its  existence  is  found  in  the  urine.  We 
know,  further,  that  diabetes  occurs  under  very  different  circumstances.  We 
can  produce  diabetes  in  an  animal  by  irritating  the  floor  of  the  fourth  ven- 
tricle, as  was  originally  done  by  Claude  Bernard  in  his  celebrated  piqiire 
experiment.  There  are,  however,  also  other  parts  of  the  nervous  system,  the 
irritation  of  which  will  produce  diabetes,  from  the  cerebellum  down  to  the 
point  of  emergence  of  the  sympathetic  nerves  to  the  viscera.  It  is  commonly 
admitted  that  this  experimental  glycosuria  is  caused  by  a  centrifugal 
stimulus  from  the  nervous  centers  to  the  liver,  through  the  vasomotor  system. 
We  know,  also,  that  tumors  impinging  on  the  floor  of  the  fourth  ventricle, 
and  lesions  of  this  part  of  the  brain,  including  abscesses,  are  attended  by 
diabetes  mellitus ;  also  injuries  to  the  spinal  cord. 

Relatively  remote  from  the  nervous  centers  is  an  organ,  the  pancreas, 


798  CONSTITUTIONAL  DISEASES.      - 

the  diseases  of  which  are  often  associated  with  diabetes  melHttis,  and  whose 
extirpation  is  followed  by  glycosuria.  On  the  other  hand,  we  know  that  in 
a  large  number  of  the  gravest  forms  of  diabetes  autopsies  have  failed  to 
disclose  any  lesion  whatever ;  in  fact,  the  most  unmanageable  and  serious 
cases  are  those  in  which  we  find  no  lesion.  Therefore,  while  we  must  admit 
that  both  the  nervous  system  and  the  pancreas  have  something  to  do  with  the 
causation  of  diabetes,  we  are  not  able  to  trace  a  nervous  or  pancreatic 
lesion  in  every  case.  It  is  further  likely  that  the  sympathetic  nerve  is  an 
important  channel  for  nervous  influence,  regulating  as  it  does  the  opening 
and  the  closing  of  the  blood-vessels. 

A  word  more  as  to  the  relation  of  the  pancreas  to  diabetes.  I  have  said 
such  relation  is  proved  from  the  experimental  as  well  as  from  the  clinical  side, 
and  I  myself,  in  a  few  cases  at  autopsies,  have  found  a  pancreatic  lesion. 
Hanseman  claim  pancreatic  lesions  in  50  per  cent,  of  cases.  From  the  experi- 
mental side  it  is  found  by  von  Mehring  and  Minkowski  that  extirpation  of 
the  pancreas  is  immediately  followed  by  diabetes ;  and,  although  there  are 
some  differences  in  results,  it  is  one  of  the  best  determined  facts  that  glyco- 
suria follows  such  extirpation.  Sometimes  such  a  diabetes  has  been  tran- 
sient, but  then  it  has  been  found  also  that  a  fragment  of  the  pancreas  was 
left  behind.  I  repeat  that  while  we  must  admit  that  the  pancreas  has  some- 
thing to  do  with  a  large  number  of  cases  of  diabetes,  we  cannot  say  so  of  all, 
as  there  are  some  in  which  no  lesion  is  found. 

The  rationale  of  this  relation  of  the  pancreas  is  not  settled.  It  has  been 
alleged  that  the  absence  of  the  pancreatic  secretion  is  responsible,  but  it  has 
been  shown  that  simply  cutting  off  the  secretion  from  the  intestine  does  not 
cause  diabetes.  It  has  been  suggested  that  extirpation  of  the  pancreas  really 
operates  by  disturbing  the  sympathetic  nerves  in  the  vicinity ;  but  this  has 
also  been  experimentally  refuted,  and,  with  this,  the  view  of  Klebs,  accepted 
by  Senator,  that  the  coexistence  of  diabetes  mellitus  and  disease  of  the  pan- 
creas is  primarily  or  secondarily  due  to  lesions  of  the  celiac  plexus.  The 
researches  of  Lepine,  which  have  been  confirmed,  ascribe  the  glycosuria  to 
the  absence  of  a  glycolytic  ferment  furnished  in  health  by  the  pancreas  to  the 
blood.  This  explanation  certainly  accounts  for  the  facts.  It  is  evident  that 
it  is  impossible  to  explain  all  cases  of  diabetes  from  any  one  standpoint  to  the 
exclusion  of  another. 

An  important  relation  has  recently  been  established  between  the  supra- 
renal gland  and  glycosuria,  by  the  studies  of  Blum,*  Herter,  and  Croftan. 
The  first  showed  that  glycosuria  ensued  upon  the  subcutaneous  injections  of 
animals  with  freshly  prepared^  suprarenal  extract,  even  when  the  diet  was 
free  of  carbohydrates.  This  was  confinned  by  G.  Suelzer  f  and  A.  C.  Crof- 
tan.$  Reasoning  thence  Croftan  announced  that  the  suprarenal  capsules 
contain  a  substance  which  either  causes  the  formations  of  sugar  or  inhibits 
the  normal  destruction  of  sugar. 

Herter  §  does  not  accept  Croftan's  conclusion,  but  concludes  rather  that 
many  and  perhaps  most  forms  of  glycosuria  and  diabetes  are  due  to  the  action 
of  substances  or  conditions  which  interfere  with  normal  oxidation  in  the  cells 
of  the  pancreas.     He   adduces   in  proof,  the   fact   shown   by  himself  that 

*  "  Ueber  Nebennieren  Diabetes."  "  Archiv  f.  klin.  Med  ,"  iqoi,  Bd.  Ixxi.,  Heft  2  u.  3,  S.  146. 

t"  Zur  Frag-e  der  Nebennieren  Diabetes,"  "  Berlin,  klin.  Wochenschrift,"  iqoi,  No.  48.  S.  i2oq. 

t"  Concerning  a  Sugar-forming  Ferment  in  Suprarenal  Extract,"  "  American  Medicine,"  Janu- 
ary 18,   iqo2. 

§  With  A.  N.  liichards,  "  Preliminary  Communication,"  "  Med.  News."  February  i,  iqo2.  Also 
"  Experimental  Glycosuria  from  Adrenalin  Chlorid  and  its  Relations  to  other  Forms  of  Glycosuria, 
Dependent  on  the  Action  of  Reducing  Substances  on  the  Cells  of  the  Pancreas,"  "Trans.  Assoc. 
Amer.  Physicians,"  igoz. 


DIABETES  MELLITUS.  799 

glycosuria  results  from  subcutaneous  injection  of  adrenalin  chlorid,  and 
moreover  that  painting  the  pancreas  with  the  same  solution  is  followed  by  a 
transitory  glycosuria  with  corresponding  glycemia,  while  no  such  effect  fol- 
lows a  similar  application  to  the  liver  or  spleen;  while  after  adienalin  chlorid 
undergoes  oxidation  it  loses  its  ability,  when  thus  applied,  to  cause  glycosuria. 
Thus  is  laid  at  the  door  of  the  suprarenal  capsule  interference  with  the  cell 
activities  in  the  pancreas  which  are  concerned  with  the  production  of  an 
oxidizing  enzyme  whose  function  it  is  to  oxidize  glucose.  Closer  than  this 
we  have  been  unable  to  come.  Deranged  suprarenal  function  is  of  course 
not  the  only  cause  which  interferes  with  the  normal  function  of  the  pancreas. 

Any  agency,  direct  or  reflected,  which  is  capable  of  influencing  normal 
cell  activity  of  the  pancreas  may  becoine  a  cause  of  diabetes.  Hence  a 
variety  of  causes,  some  of  which  seem  but  rem.otely  connected  with  the  dis- 
ease, may  operate  to  cause  diabetes.  In  illustrations  of  traumatic  agency  by 
which  the  pancreas  is  indirectly  affected  I  may  refer  to  cases  of  movable 
kidney  causing  pancreatic  diabetes,  cured  by  nephropexie  reported  by  Sher- 
man Thompson  Brown.*  As  instances  of  such  influence  may  be  mentioned 
the  rare  instances  of  diabetes  associated  with  pregnancy.  Operating  through 
the  nervous  system,  in  addition  to  nervous  lesions  already  named,  may  be 
worry,  gastro-intestinal  derangements,  disorders  of  the  liver,  sexual  excesses, 
and  the  like.  Among  more  remote  causes  recently  suggested  are  toxic 
agencies  introduced  from  without  or  originating  in  the  alimentary  canal, 
such,  as  instanced  by  Williamson, f  may  be  the  explanation  of  many  cases 
otherwise  unaccountable. 

Morbid  Anatomy. — Diabetes  can  hardly  be  said  to  have  an  essential 
morbid  anatomy,  for,  except  in  the  instances  mentioned,  the  morbid  lesions 
which  are  found  after  postmortem  examination  to  have  been  associated  with 
diabetes  are,  in  the  main,  such  as  are  the  consequence  of  the  continued  pres- 
ence of  the  condition,  rather  than  such  as  cause  the  symptoms.  Sometimes 
there  are  absolutely  no  alterations  discoverable,  either  by  the  unaided  eye  or 
with  the  microscope. 

To  begin  with  the  organ  which  has  so  much  to  do  with  the  glycogenic 
function  of  the  body, — the  liver, — it  frequently  presents  the  appearances  of 
a  hyperemic  organ — that  is,  it  is  darker  and  harder  than  the  normal  organ, 
while  it  is  also  enlarged,  sometimes  considerably,  at  other  times  only  slightly. 
Corresponding  to  this,  the  microscope,  by  very  moderate  amplification,  shows 
enlarged  and  distinct  acini,  with  capillaries  dilated  and  distended  in  various 
degree  with  blood.  Higher  magnifying  powers — 300  to  400  diameters — show 
the  liver-cells  to  be  enlarged,  distinctly  nucleated,  rounded,  and  disposed  to 
fuse.  If  a  weak  solution  of  iodin  is  added,  they  may  strike  a  wine-red  color, 
which,  according  to  Rindfleisch,  is  confined  to  the  nucleus ;  but,  according  to 
Senator,  may  extend  to  the  whole  of  the  cell.  Klebs  ascribes  this  reaction 
to  postmortem  changes  in  the  glycogenic  substance.  The  minute  changes 
described  are  said  by  Rindfleisch  to  be  mote  striking  in  the  peripheral  zone 
of  the  lobule  than  in  that  of  the  portal  vein,  while  the  intermediate  zone,  or 
that  of  the  hepatic  artery,  is  fatty,  and  the  central  part,  including  the  rootlets 
of  the  hepatic  vein,  is  nearly  normal.  Incidental  morbid  states  are  hyper- 
trophic cirrhosis  and  atrophic  cirrhosis.  An  interesting  fact  in  this  connec- 
tion is  that  the  most  serious  organicf  disease  of  the  liver  appears  never  to 
cause  glycosuria. 

*  "Philadelphia  Medical  Journal,"  April  4,  1902. 
t  "The  Practitioner,"  July,  igoo. 


8oo  CONSTITUTIONAL  DISEASES. 

As  to  the  pancreas,  about  which  so  much  has  already  been  said,  it 
may  be  well  to  mention  the  changes  found  at  different  times.  They 
include  calculi  found  in  the  pancreas  of  a  diabetic  as  early  as  1778  by 
T.  Cowley,  cancer  by  Bright  at  a  comparatively  early  date  and  atrophy 
by  Griesinger,  who  had  found  the  pancreas  atrophied  in  one  of  the 
five  diabetics  whose  bodies  he  examined  after  death,  yet  believed  that  this 
lesion  was  of  no  significance  whatever.  But  the  observations  which  have 
been  published  in  great  numbers  (Hartsen,  Fles,  von  Recklinghausen, 
Frerichs,  Klebs,  Harnock,  Kiilz,  Schaper,  Lancereaux,  Senator,  and  others) 
allow  us  to  assume  that  diseases  of  the  pancreas  are  present  in  about  one-half 
of  all  the  cases  of  diabetes.  The  statement  of  Senator  *  that  this  organ  "  is 
found  diseased  with  surprising  frequency,  in  particular  either  atrophied  or, 
in  addition,  degenerated,"  is  in  the  main  correct.  Among  nine  cases  Frerichs 
saw  atrophy  or  fatty  degeneration  of  the  gland  five  times,  and  in  the  Vienna 
dead-house  the  pancreas  was  found  strikingly  small,  soft,  and  anemic  in 
thirteen  out  of  thirty  diabetics  (Seegen).  Other  coincident  diseases  of  the 
pancreas  already  mentioned  are  cancer  and  impacted  calculus.  Reference 
should  not  be  omitted  to  the  important  work  of  Eugene  L.  Opie,  who  has 
shown  minute  changes  in  the  island  of  Langerhaus  in  certain  cases  of  diabetes 
mellitus.t 

The  kidneys,  primarily  unaffected,  are  in  many  cases  sooner  or  later 
influenced  by  the  constant  hyperemia  to  which  they  are  subjected  in  eliminat- 
ing the  sugar.  The  appearances  commonly  met  are  those  of  hyperemia  and 
overgrowth  of  epithelium — in  a  word,  those  of  catarrhal  nephritis.  Occa- 
sionally the  changes  are  more  advanced,  and  the  epithelium  is  fatty.  More 
rarely  granular  contracted  kidney  is  present,  contributing  a  more  serious 
significance  to  the  albuminuria.  These  changes  are  not  necessarily  attended 
by  albuminuria  previous  to  death.  In  most  other  cases  I  believe  nephritis  to 
be  an  accidental  coincidence.  There  occurs  also  sometimes  a  vesicular  swell- 
ing of  the  epithelium  in  the  straight  tubes,  hyaline  changes  in  the  descending 
limb  of  Henle's  loop,  as  well  as  a  hyaline  change  in  the  vessels  of  the  Mal- 
pighian  tubes.  As  to  the  proportion  of  cases  in  which  the  kidneys  reveal 
morbid  alterations,  it  is  a  decided  majority. 

The  hings  are  often  the  seat  of  tubercular  deposits  and  cavities  resulting 
from  their  softening ;  also  of  bronchopneumonia  and  croupous  pneumonia, 
which  may  terminate  in  gangrene.     The  heart  is  sometimes  hypertrophied. 

Symptoms. — Almost  invariably  the  earliest  symptoms  noticed  by  the 
diabetic  are  thirst  and  polyuria.  One  or  the  other  of  the  two  may  be  noticed 
first,  or  the  patient's  attention  may  be  called  to  both  simultaneously.  It  occa- 
sionally happens  that  a  dryness  of  the  fauces  and  a  glutinous  viscid  character 
of  the  saliva  attract  attention  before  any  other  symptom.  Sometimes  it  is 
observed  that  a  drop  of  urine  falling  upon  the  boots  or  clothing  and  evaporat- 
ing there,  leaves  a  persistent  white  or  yellowish  spot  due  to  sugar.  Dryness 
and  harshness  of  the  skin,  due  to  absence  of  perspiration,  soon  make  their 
appearance  and  early  attract  the  attention  of  those  who  ordinarily  perspire 
freely,  and  occasion  varying  amounts  of  discomfort.  Itching  of  the  skin  is 
also  sometimes  present.  The  temperature  of  the  body  is  not  increased,  at  this 
stage  scarcely  altered,  although  later  in  the  disease  it  may  be  decidedly 
lowered.     If  the  further  progress  of  the  disease  is  not  arrested,  a  voracious 


*  Senator,  loc.  cit..  p.  8S7. 

f'On  the  Relations  of  Chronic  Insterstitial  Pancreatitis  to  the  Islands  of  Langerhaus  anc 
Diabetes  Mellitus,"  "Jour,  of  Experimental  Medicine,"  vol.  v.,  1900-1901,  p.  396. 


DIABETES  MELLITUS.  ■     8oi 

appetite  becomes  the  next  symptom,  notwithstanding  which  the  patient 
observes  that  he  slowly  loses  in  zueight  and  grows  daily  tveaker.  Extreme 
languor  and  zveakness  are  characteristic.  The  rapidity  with  which  these 
symptoms  succeed  one  another  varies.  Sometimes  the  course  is  very  rapid, 
constituting  an  acute  form  ;  at  other  times  the  successive  stages  are  exceed- 
ingly slow  in  developing  chronic  diabetes. 

Boils  and  carbuncles  in  the  skin  are  also  of  frequent  occurrence,  favored 
\)y  the  malnutrition  growing  out  of  diabetes,  and  the  former  are  occasionally 
the  first  symptoms  recognized.  The  latter  never  occur  early,  but,  when 
present,  are  frequently  the  immediate  cause  of  death. 

Gangrene  of  various  parts  of  the  body  is  another  of  this  class  of  symp- 
toms. It  is  sometimes  spontaneous,  but  more  frequently  is  immediately 
caused  by  some  trifling  injury  which,  under  other  circumstances,  would  be 
without  result.  It  has  been  known  to  start  from  a  blister  and  from  the  cut- 
ting of  a  corn.  Beginning  most  frequently  in  those  parts  of  the  body  most 
remote  from  the  center  of  the  circulation,  as  the  toes,  its  progress  and  appear- 
ances are  like  those  of  senile  gangrene.  Sometimes,  however,  the  gangrene 
is  moist. 

Eczema,  with  itching  and  burning  of  the  labia  and  vicinity,  is  a  frequent 
and  troublesome  symptom  in  women  incident  to  the  extremely  frequent  mictu- 
rition. In  the  male  the  meatus  urinarius  is  sometimes  the  seat  of  a  similar  irri- 
tation.    Eczema  elsewhere,  as  on  the  palms  of  the  hands,  is  also  a  symptom. 
The  early  loss  of  sexual  desire  is  characteristic. 

Dyspeptic  symptoms  may  appear  at  various  stages,  seldom  very  early. 
Acid  eructations,  flatulence,  and  epigastric  pain,  or  an  indescribable  sensation 
described  as  "  sinking  "  of  the  epigastrium,  are  among  them.  Constipation 
is  sometimes  a  very  troublesome  symptom,  and  adds,  in  my  experience,  to  the 
seriousness  of  the  case ;  on  the  other  hand,  diarrhea  is  occasionally  present. 
The  foregoing  category  includes  all  the  symptoms  which  present  them- 
selves in  the  milder  form  of  the  disease.  But  unless  averted,  all  these  symp- 
toms become  intensified.  The  patient  complains  of  constant  burning  thirst, 
is  continually  urinating,  and  as  constantly  drinking  w^ater  to  quench  his  thirst, 
and,  while  often  eating  enormously,  grows  emaciated,  although  at  the  onset 
of  the  disease  he  may  have  been  a  robust,  vigorous  man. 

As  the  disease  advances  there  is  a  peculiar  vinous  or  acetous  odor  of  the 
breath,  which  has  been  compared  to  that  of  stale  beer,  and  by  Sir  Thomas 
Watson  to  the  odor  of  a  place  in  which  apples  ar'e  kept.  This  is  believed  to 
be  due  to  acetone  and  diacetic  acid,  both  of  which  exist  in  the  blood  of  severe 
cases  of  diabetes. 

Later,  cough  often  sets  in,  owing  to  bronchitis  and  tubercular  phthisis, 
and,  with  the  copious  expectoration  incident  to  them,  adds  to  the  debilitating 
agencies  already  at  work.  Roberts  thinks  phthisis  occurs  in  one-half  the 
■cases.  I  am  sure  not  so  many  die  of  it  in  this  country.  C.  von  Noorden 
says  one-fourth  of  all  diabetic  subjects  in  Germany  have  the  disease,  and 
Lancereaux,  that  victims  of  pancreatic  diabetes  are  especially  prone  to  tuber- 
culosis. The  consumption  thus  induced  sometimes  rapidly  hastens  the  fatal 
termination,  while  at  other  times  it  appears  to  have  but  a  trifling  influence  in 
this  respect.  The  other  symptoms  characteristic  of  pulmonary  consumption 
are  also  present,  not  excepting  hectic  sweats.  The  perspiration  thus  arising 
may  contain  sugar. 

Diabetic  coma,  first  described  by  Kussmaul  in  1874,  is  a  form  of  coma 
which  often  comes  on  in  advanced  stages  of  diabetes  and  almost  as  often  ter- 

51 


8o2      ■  COXSTITUTIOXAL  DISEASES. 

minates  in  death.  The  condition  is  one  of  suddenly  or  gradually  superven- 
ing unconsciousness,  with  or  without  previous  irritability  or  uneasiness, 
anxiety,  vertigo,  or  symptoms  resembling  alcoholic  intoxication.  Sometimes 
it  is  preceded  by  obstinate  constipation  or  intestinal  catarrh  or  severe  colicky 
and  muscular  pain.  Convulsions  do  not  occur,  but  the  eyes  are  half  open, 
the  pupils  dilated,  and  the  eyeballs  wandering.  In  addition  to  coma  there  are 
frequent  and  feeble  pulse,  deep  inspiration,  with  short  expiration,  more  or 
less  frequent  than  in  health,  and  gradually  invading  cyanosis.  The  tem- 
perature, at  first  slightly  elevated,  is  subsequently  subnormal.  The  condition 
lasts  for  from  twenty-four  to  forty-eight  hours,  when  death  usually  super- 
venes. Over  one-half  of  all  deaths  in  diabetes  are  ascribed  to  diabetic  coma 
by  Frerichs,  but  others  assign  a  much  smaller  number  to  it.  The  odor  of  ace- 
tone may  issue  with  the  breath.  The  coma  has  been  variously  ascribed  to 
acetone  and  diacetic  acid,  to  oxybutyric  acid,  and  by  Professor  Saunders  and 
D.  J.  Hamilton  *  to  slow  carbonic  acid  poisoning  due  to  fat  embolism  of  the 
pulmonary  vessels,  the  result  of  lipemia.  All  views  are  speculative. 
Acetone  and  diacetic  acid  are  very  often  present  for  a  long  time,  and  yet  no 
diabetic  coma  supervenes.  There  would  seem  to  be  better  reason  for  ascrib- 
ing the  condition  to  "  acid  intoxication,"  as  held  by  Stadelmann  and  ]SIin- 
kowski,  since  the  continued  presence  of  oxybutyric  acid  is  always  followed, 
sooner  or  later,  by  coma  unless  the  patient  dies  from  some  other  cause. 
Diabetic  coma  must  not  be  confounded  with  other  forms  of  coma  which  may 
occur  in  diabetes,  as  true  apoplexy  and  uremia. 

Alore  Unusual  Symptoms. — The  previously  recorded  symptoms  occur 
sooner  or  later  in  most  cases,  the  thirst  and  saccharine  polyuria  being  essen- 
tial. There  are  many  others  which  occur  more  or  less  frequently,  but  not 
constantly.  Among  the  rarer  symptoms  is  cataract,  the  association  of  which 
with  diabetes  was  long  ago  noticed  by  Prout.  It  develops  rapidly  and  is 
nearly  always  symmetrical,  involving  both  eyes  simultaneously,  but  not  to  the 
same  degree.  It  is  sometimes  a  very  nice  point  to  determine  whether  cata- 
ract is  due  to  diabetes  or  to  the  usual  causes.  The  earlier  the  age  at  which 
it  occurs,  the  more  probably  is  it  due  to  diabetes. 

Other  visual  defects  may  occur.  Among  these  are  myopia,  amblyopia, 
presbyopia,  and  loss  of  accommodating  power  from  defect  of  the  cilian,' 
muscle.  George  E.  de  Schweinitz  informs  me  that  a  sudden  development  of 
myopia  between  the  fortieth  and  sixtieth  years  without  apparent  lesion  is 
characteristic  of  diabetes.  It  may  be  due  to  a  fine  edema  of  the  choroid,  or  a 
choroiditis  which  in  turn  determines  an  elongation  of  the  axis  of  the  eyeball 
and  thus  produces  myopia. 

The  ophthalmoscope  may  "reveal  dilatation  of  the  retinal  vessels.  The 
late  Albert  G.  Heyl  f  described  a  condition  which  he  called  intra-ocular 
lipemia,  in  which  the  light  salmon  color  of  the  blood  contained  in  the  branches 
of  the  retinal  vein  and  artery  contrasted  with  the  cinnabar-red  of  the  vein  and 
yellow-red  of  the  artery,  also  by  the  greater  width  of  these  vessels  and  the 
lighter  yellow  of  the  fundus.  Finally,  atrophy  of  the  retina  and  hemorrhagic 
and  inflammatory  affections  of  the  eye  have  been  described,  and  total  blind- 
ness has  been  ascribed  to  the  first  named. i  Derangements  of  other  special 
senses  said  to  attend  diabetes  are  impairment  of  hearing,  roaring  in  the  ears, 
and  derangement  of  smell  and  taste. 

A  spongy  state  of  the  gums,  with  recession  and  excavation,  is  an  occa- 

*  "Edin.  Med.  Jour.,"  July,  1879. 

t  "Lipemia  and  Fat  Embolism  in  Diabetes  MelHtus,"   "  N.  Y.  Med.  Rec,"  vol.  xvii.,i88o,  p.  477. 

X  Dufresne,  "  De  1'  Amblyopic  Diabetique,"  "  Gaz.  Heb.,"  November,  1861. 


DIABETES  MELEITUS.  803 

sional  symptom,   resulting  in  extreme  cases  in   absorption  of   the  alveolar 
processes  and  falling-out  of  the  teeth. 

Severe  neuritis  in  the  brachial  and  crural  nerves  is  not  infrequent.  In 
grave  cases  the  tendon  reflexes  are  diminished  or  absent.  Unilateral  szveat- 
ing  has  been  observed.  Senator  refers  to  three  cases — two  of  the  left  half 
of  the  face  and  one  of  the  right.  Edema  sometimes  appears  late  in  the  dis- 
ease, and  is  not  necessarily  the  result  of  renal  complication. 

Alterations  in  the  Blood. — It  has  already  been  mentioned  that  in  diabetes 
the  blood  becomes  highly  charged  with  glucose,  which  increases  from  a 
normal  of  0.05  to  0.15  per  cent,  to  0.2,  and  in  extreme  cases  to  0.57,  per  cent, 
and  from  this  abnormal  glycemia  comes  glycosuria.  From  the  presence  of 
the  first  we  should  naturally  expect  a  higher  specific  gr'avity  of  the  blood- 
serum,  which  has  been  found  as  high  as  1033,  as  contrasted  with  the  normal 
1028.  On  the  other  hand,  the  serum  has  been  found  thinner  than  normal, 
containing,  according  to  different  analyses,  from  80.2  to  84.8  of  water  instead 
of  the  normal  78  to  79  per  cent.  The  red  blood  discs  are  often  diminished, 
and  the  alkalinity  of  the  blood  is  also  lowered.  As  such  diminution  is  at  a 
maximum  when  oxybutyric  acid  is  being  excreted,  it  has  been  ascribed  to 
this  substance. 

An  abnormal  amount  of  fat  in  the  blood,  producing  the  technical 
lipemia,  was  observed  by  the  earliest  students  of  diabetes,  and  is  attested  by 
many  analyses,  as  well  as  by  the  milky  appearance  of  the  serum  and  the  intra- 
ocular appearances  described  by  Albert  G.  Heyl.  The  analyses  of  Simon 
show  from  2  to  2.4  per  cent,  instead  of  the  normal  1.6  to  1.9  per  cent. 

Changes  in  the  Urine. — The  peculiarity  of  diabetic  urine  most  noticeable 
to  the  patient  is  its  enormous  quantity,  which  has  been  known  to  exceed 
seventy  pounds  (31.78  kilos)  in  twenty-four  hours,  while  apocryhal 
accounts  of  larger  amounts  are  extant.  Frank  records  52  pounds  (23.6 
kilos)  ;  Bardsley  *  36  pints  (20.4  liters)  and  32  pints  (18.6  liters)  ;  Bence 
Jones  found  56  pints  (31.78  liters)  ;  Sir  Thomas  Watson  and  Dr.  Dickinson 
26  pints  (14.77  hters),  and  Dr.  Pavy  32  pints  (18.16  liters).  From  70  to 
100  ounces  (2100  to  3000  c.  c.)  are  frequent  quantities.  The  quantity  of 
urine  passed  is  limited  by  the  amount  of  fluid  ingested,  for  while  it  is  pos- 
sible that  the  amount  of  the  former  secreted  may  exceed  for  a  very  short 
period  the  quantity  of  the  latter  ingested,  it  is  evident  that  this  cannot  con- 
tinue for  any  length  of  time,  and,  in  point  of  fact,  it  is  found  to  be  almost 
invariably  a  little  less,  the  remainder  being  removed  by  the  lungs,  skin,  and 
bowels.  It  is  said  that  in  health  the  lungs  exhale  fully  one-fourth  as  much 
water  as  the  kidneys  secrete.  Should  it  be  proven  that  cases  do  occur  in 
which  the  amount  of  water  secreted  exceeds  that  ingested  by  the  mouth  for 
any  considerable  period,  it  must  then  be  admitted  that  absorption  of  water 
from  the  air  by  the  skin  is  possible.  On  the  other  hand,  it  was  early  observed 
by  Th.  Cowley  t  (1788)  that  the  quantity  of  water  occasionally  is  not  at  all 
or  but  slightly  increased.  To  this  condition  Frank,!  another  old  author, 
gave  the  name  of  diabetes  decipiens.  It  is  well  known,  also,  that  intercur- 
rent diseases,  especially  febrile  affections,  sometimes  diminish  the  quantity  of 
urine  as  well  as  the  amount  of  sugar  excreted ;  while  the  same  diminution  of 
urine  and  sugar  also  occasionally  occurs  toward  the  fatal  termination  of  the 
disease.  ' 


*  Bardsley,  article  on  "Diabetes  "  in  the  "Cyclopedia  of  Prac.  Med.,"  Philadelphia,  1845,  P-  ^°7- 
tTh.  Cowley,  "London  Medical  Journal,"  1788.  .     .. 

t  J.  P.Frank,  "  De  Curandis  Horn.  Morbis  Epitome,"  lib.  v.,  "  De  Profluviis,"  Pars  i,  Manheimn, 
1794. 


804  CONSTITUTIONAL  DISEASES. 

But  the  most  important  change  is,  of  course,  the  presence  of  glucose. 
Of  this,  the  quantity  varies  greatly  in  different  cases  and  at  different  times 
in  the  same  case.  Every  case  of  trifling  and  temporary  glycosuria  should 
not,  however,  be  considered  a  case  of  diabetes.  The  sugar  should  be  easily 
recognizable  by  the  ordinary  tests  and  should  be  constant.  From  what  may 
be  indicated  as  "  evident  traces  "  the  proportion  of  sugar  may  reach,  it  is  said, 
as  much  as  15  per  cent.  I  have  never  found  more  than  10  per  cent.,  though 
I  often  hear  reports  of  the  finding  of  larger  quantities  which  I  can  scarcely 
credit.  The  twenty-four-hours'  quantity  varies  similarly.  The  maximum 
quantity  secreted  in  this  time  appears  to  be  that  reported  by  Dickinson, 
wherein  a  man  twenty-five  years  of  age  voided  50  ounces  (1500  gm.)  of 
glucose  in  twenty-four  hours.  But  the  more  usual  quantity  is  from  10  to  80 
milligrams  to  the  cubic  centimeter,  or  from  20  to  25  gm.  in  twenty-four  hours ; 
this  corresponds  nearly  to  from  5  to  30  grains  to  the  fluid  ounce  of  the  Eng- 
lish system,  or  from  300  to  3800  grains  in  the  twenty-four  hours. 

The  effect  of  muscular  exercise  in  diminishing  the  quantity  of  sugar  in 
the  urine  of  diabetics  was  early  confirmed  by  Kiilz  and  others,  while  it  is 
scarcely  necessary  to  say  that  accidental  as  well  as  intentional  changes  in  diet 
are  followed  by  consequent  variations.  So,  too,  urine  passed  after  fasting, 
as  on  rising  in  the  morning,  contains  generally  less  sugar  than  that  passed 
after  a  meal,  and  in  the  clinical  study  of  cases  of  diabetes,  where  a  part  of  the 
twenty-four  hours'  urine  is  not  obtainable,  it  is  important  to  bear  this  in 
mind.  As  the  difficulties  in  obtaining  a  part  of  the  twenty-four  hours'  urine 
regularly  are  very  great,  it  is  often  preferable,  in  my  experience,  to  take  for 
examination  two  samples,  one  passed  in  the  morning  on  rising,  and  represent- 
ing the  fasting  urine,  and  another  on  going  to  bed,  representing  the  day  urine. 

Consistently  with  the  increased  solid  matter  thus  added,  the  specific 
gravity  of  diabetic  urine  is,  as  a  rule,  high,  1040  being  very  common,  while 
Bouchardat  found  it  as  high  as  1074  in  one  instance.  The  well-known  dis- 
position of  diabetic  urine  to  become  frothy  on  shaking,  and  to  maintain  this 
frothy  condition,  is  a  natural  physical  result  of  its  increased  density.  Urine 
may,  however,  have  a  low  specific  gravity  and  yet  contain  sugar.  I  have 
found  it  as  low  as  loio  and  lower.  Such  low  specific  gravities  of  glucose,  if 
present  in  any  decided  degree,  must  depend  on  the  low  proportion  of  other 
normal  ingredients.  Sugar  sometimes  disappears  very  rapidly  from  urine  by 
fermentation,  thus  reducing  also  the  specific  gravity. 

Concurrent  with  the  increase  in  quantity  of  urine  is  an  absence  of  color, 
which  in  extreme  degrees  is  almost  total,  so  that  the  urine  may  be  as  clear  as 
spring-water.  Almost  all  diabetic  urine,  sooner  or  later  after  exposure  at  a 
moderate  temperature,  becomes  cloudy  from  the  development  of  fungi 
coincident  with  fermentation.  The  odor  of  the  urine  is  usually  normal  when 
first  passed,  but  sooner  or  later,  in  consequence  of  fermentation  setting  up, 
it  may  acquire  an  acetous  odor.  The  latter  change  also  increases  the  degree 
of  the  normal  acid  reaction  and  maintains  it  much  longer  after  exposure  to 
the  air  than  is  the  case  with  normal  urine.  This  acetous  odor  is  ascribed  to 
acetone  and  diacetic  acid.  The  urine  may  have  a  sweetish  odor  when  passed, 
which  has  been  compared  to  "  sweet  brier."  Diabetic  urine  is  sometimes  quite 
free  from  sediment.  At  other  times  there  is  a  copious  sediment  of  uric  acid. 
In  the  sediment  may  also  be  included  the  pencilinm  fungus,  common  to  acid 
urine,  as  well  as  the  more  characteristic  yeast  or  sugar  fungus,  or  the  torula 
cerivisia;.     This  also  sometimes  appears  as  a  mold  on  the  surface  of  the  urine. 

Of  the  normal  chemical  constituents  of  the  urine,  iirea  is  almost  invari- 


DIABETES  MELLITUS.  805 

ably  increased.  This  is  contributed  to  by  two  causes.  The  first  is  the  inges- 
tion of  large  amounts  of  nitrogenous  food,  whether  to  appease  the  appetite 
or  by  the  physician's  advice.  The  second  cause  is  the  destruction  of  the 
tissues  themselves  which  characterizes  the  severest  cases  in  the  last  stages  in 
spite  of  the  enormous  food  consumption.  In  such  event  the  nitrogenous 
tissues  are  split  up  into  urea  and  sugar. 

As  regards  uric  acid,  it  is  either  normal  or  slightly  increased.  Of  the 
other  constituents  of  the  urine,  creatinin  is  increased ;  sulphuric  acid  is  sub- 
ject to  its  normal  variations;  chlorin,  phosphoric  acid,  lime,  and  magnesia 
are  said  to  be  increased;  phosphoric  acid  and  lime  especially  so.  Ammonia 
is  sometimes  largely  increased. 

Of  abnonnal  constituents,  albumin  is  often  present — perhaps  m  one- 
third  of  all  cases  ;  some  make  it  a  larger  proportion,  some  less.  The  albu- 
minuria is  not  generally  larger  and,  in  my  experience,  is  not  often  a  serious 
symptom.  Albuminuria  does  not  necessarily  imply  renal  change.  It  is 
scarcely  necessary  to  say  that  the  urine  may  become  albuminous  from  any  of 
the  causes  of  albuminuria  independent  of  diabetes,  as  pus  from  pyelitis, 
cystitis,  etc. 

Inosit,  or  muscle-sugar,  occasionally  replaces  the  grape-sugar  in  dia- 
betes, but  more  frequently  accompanies  it.  Gallois  '■'  found  it  in  five  out  of 
thirty-five  diabetics. 

Finally,  acetone,  diacetic  acid,  and  beta-oxybntyric  acid  are  all  fre- 
quently met  in  diabetic  urine.  It  is  now  conceded  that  the  source  of  these 
substances  is  albumin  either  of  the  food  or  body  tissues,  diacetic  or  aceto- 
acetic  acid  being  probably  first  formed  and  rapidly  transformed  into  acetone. 
\Mien  but  little  diacetic  acid  is  produced,  it  is  all  converted  into  acetone ; 
when  much  is  formed,  both  substances  appear  in  the  urine.  The  conversion 
takes  place  mainly  in  the  urine,  but  doubtless  also  in  the  tissues  or  the  blood, 
since  acetone  may  be  present  in  the  expired  air.  To  acetone  is  ascribed  the 
vinous  odor  sometimes  present  in  the  urine.  Acetone  is  produced  in  health 
in  a  slight  amount  in  the  normal  decomposition  of  albumin,  freely  in  certain 
diseases  other  than  diabetes.  According  to  von  Xoorden,  these  substances 
are  formed  in  the  disintegration  of  the  albumin  of  the  body  and  not  of  the 
food — in  a  word,  when  the  patient  is  "  consuming  his  own  proteids." 

Beta-oxybutyric  acid  is  believed  by  many  to  be  the  first  stage  in  the  for- 
mation of  diacetic  acid.  Von  Noorden  also  thinks  this  possible,  but  he  claims 
for  it  a  certain  "  clinical  independence,"  and  considers  it  probable  that 
oxybutyric  acid,  on  the  one  hand,  and  aceto-acetic  acid,  on  the  other,  arise 
from  qualitatively  different  disintegration  processes.  While  acetone  in  the 
urine  does  not  add  to  the  seriousness  of  diabetes,  the  presence  of  oxybutyric 
acid  is  of  the  gravest  prognostic  significance.  It  is  said  never  to  disappear 
permanently  after  being  once  present,  and  to  be  almost  always  followed  in 
a  few^  days  or  weeks  by  diabetic  coma  and  death.  Diacetic  acid  has  an  inter- 
mediate significance  between  acetone  and  beta-oxybutyric  acid. 

Of  the  other  secretions,  the  perspiration,  when  present,  frequently  con- 
tains sugar,  at  times  a  notable  amount,  as  much  as  6  1-2  grains  (0.42  gm.) 
having  been  extracted  by  Fletcher  from  a  piece  of  flannel,  three  inches 
square,  which  had  lain  upon  the  skin  of  a  diabetic  patient  for  forty-eight 
hours.  The  salizv  has  rarely  been  found  to  contain  sugar  independently  of 
that  which  it  acquires  from  the  food.     That  the  gastric  juice  ever  contains  it 


*  Gallois,  "  Comptes  Rendues,"  i,  p.  533;  also  "  De  I'Inosurie,"  Paris,  1864. 


8o6  COXSTITUTIOXAL  DISEASES. 

under  similar  conditions  is  disputed,  but  it  has  been  found  in  effusions  and 
exudations,  as  might  be  expected. 

Duration. — Though  the  course  of  a  few  cases  of  diabetes  is  so  rapid  as 
to  justify  the  name  acute,  the  number  of  these  cases  is  not  sufficient  to  justify 
a  classification  into  acute  and  chronic.  In  such  rapid  cases  death  has  taken 
place  at  periods  ranging  from  two  days  to  six  weeks,  yet  in  no  instance  can 
it  be  averred  that  the  disease  was  of  as  short  duration  as  it  seemed,  since  it 
may  have  existed  some  time  before  it  was  discovered,  while  in  several  it  was 
evidently  of  longer  duration.  It  is  true,  therefore,  that  diabetes  mellitus  is 
a  disease  almost  invariably  of  long  duration.  Cases  of  fifteen,  eighteen,  and 
twenty  years'  duration  are  reported.  I  have  had  a  number  of  cases  under 
my  care  for  more  than  ten  years.  The  younger  the  subject,  the  shorter  the 
duration  and  the  more  promptly  fatal  the  result,  while  after  middle  age,  under 
treatment,  the  duration  may  be  indefinite. 

Diabetes  mellitus  is  sometimes  distinctly  intermittent  for  a  time,  re- 
gardless of  treatment.  I  was  for  a  long  time  incredulous  on  this  subject, 
but  recent  experience  has  taught  me  that  such  a  form  of  diabetes  occurs,  in 
which  both  polyuria  and  glycosuria  may  disappear  without  treatment,  to 
recur  again.  Such  cases  are,  however,  easily  controlled  by  treatment  when 
discovered,  while  they  are  as  certain  to  pass  over -into  the  permanent  form 
if  neglected. 

Complications. — The  diabetic  is  characteristically  subject  to  compli- 
cations, which  may  be  accounted  for  in  a  word  by  his  diminished  power  of 
resistance  to  all  disease-causing  agencies  and  to  the  toxic  influences  inci- 
dent to  the  disease  itself.  ]\Iost  of  these  have  already  been  considered  among 
symptoms.  Such  are  the  num.erous  skin  aft'ections,  gastro-intestinal  dis- 
turbances, pancreatic  and  renal  affections,  functional  cardiac  and  nervous 
symptoms,  including  neuritis  and  diabetic  coma.  Tuberculosis  has  also  been 
mentioned.  It  is  especially  apt  to  attack  young  subjects  and  to  cause  their 
death.  Arteriosclerosis  is  prone  to  occur  in  diabetics,  with  its  full  train  of 
consequences,  and  to  appear  earlier  in  life  among  them.  Jaundice  sometimes 
occurs,  and  having  presented  itself  twice  in  the  history  of  a  case  under  my 
observation,  can  hardly  be  considered  accidental.  Senator  says  that,  when 
not  an  accidental  complication  due  to  a  catarrh  of  the  duodenum,  it  may  re- 
sult from  compression  of  the  biliary  capillaries  by  the  overloaded  blood- 
vessels or  enlarged  gland-cells  of  the  liver.* 

Gout  and  diabetes  are  sometimes  associated,  and  an  interesting  and  im- 
portant fact  has  been  learned  from  this  association,  viz. :  that  cases  of  diabetes 
complicated  with  gout  are  always  mild  cases  and  easily  controlled.  Some- 
times the  symptoms  of  gout  and  diabetes  alternate.  That  is,  when  the  gly- 
cosuria appears  the  gouty  symptoms  subside  and  vice  versa.  These  cases  are 
apt  to  be  associated  with  arteriosclerosis  and  death  from  apoplexy  may 
ensue. 

Diagnosis. — The  diagnosis  of  diabetes  mellitus  is  very  easy,  yet  I  have 
known  it  to  be  long  overlooked  by  the  practitionsr.  Unnatural  thirst  and 
copious  diuresis  should  always  suggest  a  chemical  examination  of  the  urine, 
and  although  there  are  sources  of  error  in  testing  for  small  quantities  of 
sugar,  the  quantities  thus  overlooked  are  not  usually  of  clinical  significance. 
In  fact,  in  my  observation,  glucose  is  more  frequently  declared  present  by 
inexpert  examiners  when  absent  than  the  reverse.     Almost  any  one  of  the 

*  Senator,  loc.  cit..  p.  912. 


DIABETES  MELLITUS.  807 

tests,  therefore,  which  are  found  in  the  various  manuals  for  the  examination 
of  urine,  apphed  with  ordinary  care,  will  respond  readily  to  quantities  which 
are  of  clinical  significance. 

Tests  for  Sugar. — For  provisional  purposes  Trommer's  method  of  using 
the  copper  test  answers  very  well.  Its  ingredients  are  easily  attainable,  and 
there  is  no  risk  of  error  from  changes  during  keeping,  to  which  Fehling's 
and  Pavy's  solutions  are  subject. 

( 1 )  Trommer's  test  is  used  as  follows : 

To  a  small  quantity  of  urine,  say  five  c.  c.  (80  minims),  add  half  as 
much  liquor  potassse  or  sodse,  then  drop  by  drop  a  5  or  10  per  cent,  solution 
of  cupric  sulphate.  On  first  adding  the  copper,  a  blue  precipitate  of  hydrated 
cupric  protoxid  takes  place,  which,  if  sugar  is  present,  is  redissolved  on 
shaking,  producing  a  clear  blue  liquid.  The  copper  solution  should  be  thus 
added  until  the  precipitate  is  no  longer  dissolved  on  shaking.  Then  heat 
the  mixture  to  boiling,  and  if  sugar  is  present,  a  copious  yellow  precipitate 
of  hydrated  cuprous  oxid  or  of  red  cuprous  oxid  occurs.  Either  is  con- 
clusive evidence.  Occasionally  the  precipitate  of  earthy  phosphates  is  so 
copious  as  decidedly  to  obscure  the  reaction,  and  by  beginners  is  sometimes 
mistaken  for  the  suboxid.  In  this  event  the  earthy  phosphates  may  be  re- 
moved by  filtration  after  slightly  warming"  the  mixture.  The  reaction  should 
take  place  as  soon  as  the  boiling-point  is  reached — indeed,  it  sometimes  occurs 
before  this  point  is  reached.     Prolonged  boiling  should  be  avoided. 

(2)  In  Fehling's  solution  *  the  constituents  of  Trommer's  test  are  united 
in  definite  proportions  in  order  that  a  quantitative  estimation  may  be  made. 
It  is  also  used  for  qualitative  testing,  while  a  rough  quantitative  estimation 
may  be  made  at  the  same  time  by  what  is  known  as  the  clinical  method  at  the 
University  of  Pennsylvania  Clinic. 

A  given  quantity,  say  one  c.  c,  of  Fehling's  solution  is  placed  in  a  test- 
tube,  diluted  with  about  four  times  its  bulk  of  water,  and  boiled  for  a  few 
seconds.  If  the  solution  remains  clear,  add  immediately  the  suspected  urine, 
drop  by  drop.  If  sugar  is  abundant,  the  first  few  drops  will  usually  cause 
the  red  or  yellow  precipitate,  but  if  the  reaction  does  not  occur,  the  dropping 
may  be  continued,  followed  each  time  by  heating  until  an  equal  volume  has 
been  added.  If  no  red  or  yellow  precipitate  occurs,  sugar  is  absent.  Now, 
Fehling's  solution  is  so  composed  that  if  an  equal  volume  is  exactly  reduced 
by  an  equal  volume  of  urine,  that  urine  contains  1-2  of  i  per  cent,  of  glu- 
cose; if  by  half  bulk,  i  per  cent. ;  if  twice  the  bulk,  1-4  per"  cent.,  and  so  on, 
whence  one  can  easily  estimate  roughly  the  percentage.  Should  the  urine 
contain  more  than  i  per  cent,  of  sugar,  it  should  be  diluted  one  to  ten  and 
the  result  multiplied  by  ten. 

If  a  reduction  takes  place  on  boiling  the  test  fluid  alone,  a  new  supply 
may  be  obtained,  or  a  little  more  soda  or  potash  may  be  added,  the  fluid 
filtered,  and  it  is  again  ready  for  use.  Such  spontaneous  reduction  of  the 
cuprous  oxid  often  occurs  when  Fehling's  solution  is  kept  for  some  time. 

In  judging  the  progress  of  a  case  of  diabetes  under  treatment  it  is  not 
sufficient  to  test  the  urine  qualitatively,  but  a  quantitative  determination  of 

*  Fehling's  solution. — Dissolve  34.652  %m.  of  pure  crystallized  sulphate  of  copper  in  200  gm.  of  dis- 
tilled water;  175  gm.  of  chemically  pure  crystallized  neutral  sodic  tartrate  in  480  gm.  solution  of 
caustic  soda  of  specific  gravity  1.14,  and  into  thisfbasic  solution  the  copper  solution  is  poured,  a  little 
at  a  time.     The  clear  mixed  fluid  is  diluted  to  one  liter,  or  1000  c.  c. 

Ten  c.  c.  of  this  solution  will  be  reduced  by  0.05  gm.,  or  50  milligrams,  of  diabetic  sugar.  If 
Fehling's  sohition  is  to  be  kept  some  time,  it  is  absolutely  essential  that  it  should  be  placed  in 
smaller  bottles  holding  from  40  to  80  gm.,  sealed,  and  kept  in  a  cellar. 

Still  greater  security  may  be  obtained  by  dissolving  the  cupric  sulphate  in  500  c.  c.  and  the  tartrate 
salt  and  potash  in  500  c.  c,  keeping  the  two  solutions  separate  in  rubber-stoppered  bottles.  Equal 
volumes  of  the  two  solutions  are  united  when  needed  for  use. 


8o8  CONSTITUTIONAL  DISEASES. 

sugar  must  be  made.  This  may  be  done  by  the  cHnical  method  just  de- 
scribed or  by  volumetric  processes  described  in  the  manuals  for  the  exami- 
nation of  urine,  but  the  simplest  process  is  the  (3)  fermentation  method  of 
Dr.  Roberts.  In  this  the  specific  gravity  of  the  urine  is  taken  before  and  after 
fermentation,  and  the  difference  in  the  two  results  indicates  the  number  of 
grains  of  sugar  in  each  fluid  ounce  of  urine.  Suppose,  then,  the  specific 
gravity  before  fermentation  to  be  1045,  S'^d  after  fermentation  1035 :  the 
quantity  of  sugar  is  ten  grains  to  the  fluid  ounce,  or  0.65  gm.  in  thirty  c  c. 
These  figures  can  be  reduced  to  percentage  by  multiplying  by  0.23. 

Mention  should  be  made  of  those  rare  instances  in  which  the  sugar  does 
not  reduce  cupric  oxid.  I  have  had  a  case  under  my  care.  The  urine 
had  a  specific  gravity  of  1050  when  the  patient  came  under  observation,  but 
there  was  no  response  whatever  to  the  copper  or  bismuth  test;  yet  by  the  fer- 
mentation test  a  large  amount  of  sugar  was  shown  to  be  present. 

(4)  Polarimetry  is  a  very  convenient  method  of  analysis  if  an  instru- 
ment is  at  hand,  though  the  costliness  of  a  good  instrument  will  probably 
always  be  in  the  way  of  its  general  use. 

Tests  for  Acetone,  Diacetic  Acid,  and  Oxybutyric  Acid. — Of  the 
numerous  tests  for  acetone,  most  of  which  require  the  distillate  for  their  suc- 
cessful application,  Legal's  nitroprussid  of  sodium  test  is  the  most  satis- 
factory for  the  practitioner,  because  it  does  not  require  the  distillate. 

LegaTs  Test  for  Acetone. — A  fresh,  rather  strong  solution  of  sodium 
nitroprussid  is  made  by  dissolving  a  few  fragments  in  a  little  water  in  a  test- 
tube.  To  three  or  four  c.  c.  of  the  suspected  urine  add  enough  liquor  sodas 
or  potassse  to  secure  a  distinct  alkaline  reaction.  To  the  mixture  then  add  a 
few  drops  of  the  nitroprussid  solution,  when  the  whole  quickly  assumes  a 
red  color,  whether  acetone  is  present  or  not,  said  to  be  produced  by  creatinin 
even  more  rapidly  than  by  acetone.  In  any  event  the  red  color  disappears ; 
but  if  acetone  is  present,  the  addition  of  a  few  drops  of  concentrated  acetic 
acid  causes  a  purple  or  violet- red  color.  If  there  is  no  acetone,  this  final 
change  does  not  occur,  while  the  purple  color  also  fades  in  a  little  while,  even 
if  caused  by  acetone. 

To  test  for  diacetic  acid  add  a  few  drops  of  a  solution  of  ferric  chlorid 
to  a  small  quantity  of  the  urine,  when  a  beautiful  Burgundy-red  reaction 
occurs.  A  precipitate  of  phosphates  succeeds  the  adding  of  the  first  few 
drops,  but  this  is  redissolved  by  a  further  addition  of  the  chlorid.  The  test 
is  confirmed  if,  after  heating  the  original  fluid,  there  is  no  response  on  appli- 
cation of  the  chlorid  of  iron — the  effect  of  heat  being  to  dissipate  the  diacetic 
acid.  A  more  brilliant  reaction  is  obtained  if  the  urine  be  first  treated  with 
a  solution  of  acetate  of  lead,  filtering  out  the  white  precipitate  and  testing  the 
filtrate.  Urine  passed  after  the  administration  of  salicylic  acid,  antipyrin, 
carbolic  acid,  salol,  phenocol,  kairin,  and  other  drugs  furnishes  a  similar 
reaction. 

The  reaction  for  diacetic  acid  being  obtained,  it  is  scarcely  necessary  ta 
test  for  beta-oxyhutyric  acid,  as  the  significance  is  the  same.  The  test  is  a 
complicated  one,  but  beta-oxybutyric  acid  is  presumably  present  when  a 
quantitative  estimation  indicates  a  larger  quantity  of  glucose  than  does 
polarization,  since  beta-oxybutyric  acid  rotates  polarized  light  to  the  left,  as 
contrasted  with  the  dextrorotatory  power  of  grape-sugar.  Again,  if  after 
complete  fermentation  with  yeast  or  precipitation  with  basic  acetate  of  lead 
and  ammonia  the  urine  is  found  Isevorotatory,  beta-oxybutyric  acid  is  pre- 
sumably present. 


DIABETES  MELLITUS.  809 

Prognosis. — The  prognosis  of  diabetes  varies  with  the  age  at  which  the 
disease  makes  its  appearance,  the  time  which  has  been  allowed  to  elapse  before 
treatment  is  instituted,  and  the  treatment  itself.  Once  thoroughly  established 
early  in  life,  or  before  twenty-five  years  of  age,  recovery  is  rarely  possible, 
but  even  at  this  age,  if  treatment  is  instituted  sufficiently  early,  much  may 
often  be  done  to  avert  the  end.  Diabetes  is  a  disease  in  which  the  expectant 
plan  of  treatment  is  disastrous.  It  is  a  disease  which  never  gets  well  of  itself, 
and  always  gets  worse  if  not  properly  treated.  At  the  same  time  the  mild 
cases  amenable  to  treatment  are  in  a  decided  majority.  When  the  disease 
appears  after  middle  life  in  fat  persons  or  those  disposed  to  gout,  and  is  early 
recognized  and  promptly  treated,  it  is  usually  easily  controlled ;  and  although 
it  is  almost  never  safe  to  declare  a  case  of  diabetes  absolutely  cured,  it  does 
occasionally  happen  that  recovery  is  so  complete  that  the  patient  may  be  left 
to  his  own  mode  of  living.  As  a  rule,  however,  even  those  who  have  appar- 
ently recovered  must  keep  a  watch  upon  their  diet,  and  should  at  intervals 
have  their  urine  examined  with  a  view  to  sounding,  as  it  were,  their  condi- 
tion. We  are  entirely  justified  in  saying  to  a  diabetic  patient,  "  As  long  as 
your  urine  remains  free  of  sugar  you  are  practically  as  well  as  if  you  had  no 
tendency  to  diabetes."  On  the  other  hand,  for  spare,  nervous,  and  hard- 
worked  persons,  especially  mentally  overworked,  under  forty,  there  is  a  much 
more  unfavorable  outlook.  Even  here,  if  the  co-operation  of  the  patient  can 
be  secured,  much  may  be  done.  Every  intermediate  degree  of  seriousness 
may  occur.  When  diabetes  depends  upon  recognized  nervous  lesions,  the 
prognosis  is  altogether  that  of  the  lesion  itself.  The  cause  of  death  is  very 
frequently  some  intercurrent  or  consequent  disease,  as  phthisis  or  diabetic 
coma.  The  syphilitic  origin  of  the  disease  and  obesity  are  favorable  prog- 
nostic factors ;  a  spare  habit  and  habitual  constipation  are  unfavorable. 

Treatment. — This  resolves  itself  easily  into  the  dietetic,  the  hygienic, 
and  the  medicinal. 

I.  Dietetic  Treatment. — This  is  by  far  the  most  efficient,  and  no  per- 
manent results  have  ever  been  obtained  without  it.  It  consists  essentially  in 
the  elimination  from  the  diet  of  such  articles  as  are  readily  convertible  into 
glucose — viz.,  the  carbohydrates.  It  is  acknowledged  that  in  the  early  stage 
of  the  disease  only  the  saccharine  and  amylaceous  foods  fail  to  be  consumed 
in  the  economy  in  the  usual  way  and  appear  in  the  urine  as  glucose.  Hence, 
if  these  be  excluded  from  the  diet  and  their  place  supplied  by  other  assimilable 
articles,  the  symptom  disappears,  and  the  disappearance  of  this  symptom 
seems  to  be,  for  the  time  being  at  least,  the  cure  of  the  disease. 

If  it  were  necessary  to  select  a  diet  absolutely  free  from  sugar  and  starch, 
it  would  indeed  be  restricted,  as  there  are  comparatively  few  articles  of  food 
thus  constituted.  Such  are,  however,  meats  of  every  kind,  fresh  or  salted, 
including  tripe,  tongue,  ham,  bacon,  and  sausage ;  soups  made  from  meat  and 
without  flour  ;  game,  poultry,  fish,  oysters,  lobsters,  crabs,  eggs  in  every  form  ; 
butter  and  new  cheese,  oils  and  fats.  Happily,  however,  it  is  not  necessary  to 
use  articles  absolutely  free  from  the  two  baneful  principles,  and  in  this  man- 
ner quite  a  variety  of  palatable  articles  may  be  added  to  the  dietary.  Among 
these  are  cream,  curds,  milk,  and  buttermilk,  and  all  green  vegetables,  includ- 
ing spinach,  endive,  lettuce,  dandelion,  cabbage  in  various  forms  including 
coleslaw,  Brussels  sprouts,  cauliflower,  broccoli,  string-beans,  tomato,  water- 
cress, celery  tops,  asparagus  tops,  turnip  tops,  young  onions,  cucumbers, 
pickles,  and  olives.  To  these  may  be  added  unsweetened  jellies  (prepara- 
tions of  gelatin)  and  especially  a  variety  of  nuts,  including  almonds,  walnuts. 


8 10  CONSTITUTIONAL  DISEASES. 

butternuts,  filberts,  pecan  nuts,  Brazil  nuts,  but  not  chestnuts ;  also,  all  acid 
fruits,  as  apples,  lemons,  strawberries,  etc.  Tea  and  coffee,  with  cream  and 
without  sugar,  cocoa-nibs,  but  not  chocolate,  are  permitted ;  also  all  wines 
which  contain  little  or  no  sugar,  including  claret.  Burgundy,  Rhine,  and  still 
Moselle  wines,  together  with  very  dry  sherry,  unsweetened  brandy, 
whisky,  and  gin  when  required.  The  carbonated  waters,  natural  or  artificial 
(the  so-called  soda-water  of  the  shops),  are  pre-eminently  suitable.  Water 
is  to  be  allowed  ad  libitum,  for  water  is  the  medium  by  which  the  sugar  is 
carried  out  of  the  blood  and  tissues.  Its  supply  should  therefore  be  liberal, 
and  with  the  diminished  sugar  formation  comes  diminished  thirst.  Better 
still  are  the  alkaline  mineral  waters,  especially  those  of  Vals,  Vichy,  Carlsbad, 
and  the  Saratoga  Vichy. 

Beer,  ale,  porter,  cider,  and  the  fermented  liquors  generally  are  not 
allowable  because  of  the  sugar  and  carbohydrates  they  contain.  They  are 
less  objectionable  when  fermentation  is  carried  to  a  high  degree,  resulting  in 
a  more  complete  destruction  of  the  sugar.  This  is  the  case  with  certain 
bottled  lager  beers  and  English  ales. 

It  is  not  simply  the  small  quantity  of  sugar  and  starch  contained  in  them 
which  renders  the  vegetable  substances  named  admissible,  for  many  of  them 
contain  a  great  deal  of  sugar ;  but  these  sugars,  unlike  grape-sugar,  are  more 
easily  assimilable.  Such  are  pre-eminently  mannite,  the  sugar  of  manna ; 
lactin,  or  sugar  of  milk ;  levulose,  or  fruit-sugar,  and  probably,  also,  inosit,  or 
the  sugar  of  muscle.  Such  is  also  inulin,  a  hydrocarbon  and  starchy  prin- 
ciple found  in  the  inula  hcleniuin,  or  elecampane,  but  especially  in  Iceland 
moss.  Hence,  too,  •  the  impunity  with  which  milk  can  often  be  taken  by 
diabetics,  although  it  contains  from  3  to  6  per  cent  of  lactin.  On  this  ac- 
count, too,  levulose  may  be  cautiously  used  for  sweetening  tea  and  coffee  in 
mild  cases.  Glycerin  is  also  sometimes  substituted  for  sugar,  but  though 
less  objectionable,  both  theory  and  experience  go  to  show  that  it  is  not  a 
safe  substitute.  Levulose  and  even  mannite  are  much  to  be  preferred  to 
glycerin,  both  for  sweetening  and  as  a  substitute  for  sugar  in  force  produc- 
tion. But  none  of  these  sugars  can  be  used  with  safety  for  sweetening  pur- 
poses, and  if  sweetening  is  indispensable  for  the  patient,  it  should  be  done 
with  saccharin. 

It  will  be  noticed  that  not  only  all  saccharine  substances  of  animal  or 
vegetable  origin  and  all  vegetables  largely  composed  of  starch,  as  potatoes, 
rice,  and  corn,  are  omitted  from  the  category  of  admissible  articles,  but  that 
bread,  and  all  preparations  made  of  wheat,  rye,  rice,  or  corn-flour,  are  con- 
spicuous by  their  absence.  This  is  found  to  be  a  very  important  omission 
from  the  dietary  of  most  persons,  and  numerous,  indeed,  have  been  the 
attempts  to  devise  substitutes  for  it,  with  varying  success.  The  best  known 
and  most  popular  of  these  is  gluten  bread,  made  of  the  so-called  gluten  flour, 
whence  the  starch  is  partially  removed  by  washing.  Unfortunately,  the 
gluten  flour  made  in  this  country  contains  nearly  as  much  starch  as  the  white 
flours,  with  perhaps  a  single  exception — a  meal  made  by  the  Battle  Creek 
Sanitarium  Co.,  of  Battle  Creek,  Mich.*  In  England  and  France  diabetic 
patients  are  much  more  fortunate,  gluten  flours  of  sufficient  purity  being 
there  obtainable.  Flour  of  the  soya  bean  [soya  hispida),  containing  only  4 
per  cent,  of  starch  and  a  large  amount  of  nitrogenous  matter  and  oil,  is  also 
used  for  making  griddle-cakes  and  biscuit.     These,  if  freshly  made,  are  very 

*  This  is  known  as  gluten  meal  No.    i.     A  biscuit   is  made  of  this  known  as  No.  i  gluten  biscuit. 
No.  2  meal  and  biscuit  contain  more  starch. 


DIABETES  MELLITUS.  Sii 

palatable ;  but  biscuits  made  for  some  time  become  rapidly  rancid  from 
decomposition  of  the  oil. 

Another  substitute  is  bran  flour  or  unbolted  wheat  flour,  which  contains 
relatively  less  starch.  The  pure  bran  itself  is  not  wholly  innutritions.  Dr. 
Prout  very  early  recommended,  as  a  substitute  for  bread,  a  compound  of 
bran,  milk,  and  eggs,  which  he  declared  not  unpalatable.* 

Still  another  substitute  for  wheaten  bread  is  the  almond  food  suggested 
by  Dr.  Pavy.  The  almond  is  composed  of  54  per  cent,  of  oil,  24  per  cent,  of 
nitrogenized  matter  known  as  emulsin.  6  per  cent,  of  sugar,  3  per  cent,  of 
gum,  and  no  starch.  Chemically  speaking,  it  is  therefore  admirably  adapted 
for  diabetic  food,  and  when  the  sugar  and  gum  have  been  extracted,  it  leaves 
nothing  to  be  desired.  The  sugar  and  gum  are  removed  by  treating  the 
powered  almonds  with  boiling  water  slightly  acidulated  with  tartaric  acid,  or 
by  soaking  the  almonds  in  a  boiling  acidulated  liquid,  which  may  form  part 
of  the  process  for  blanching.  The  boiling  and  the  acid  fluid  are  necessary  in 
order  to  precipitate  the  emulsin ,  which  would  otherwise  emulsify  the  oil  of 
the  almond.  Biscuits  made  of  almond-flour  f  and  eggs  are  palatable,  and 
may  be  eaten  with  a  little  dry  sherry  or  whisky  and  water. 

Biscuits  made  of  imiUn,  the  starchy  principle  already  referred  to  on  page 
810,  were  suggested  by  Kiilz.i  Lichenin,  or  moss-starch,  abundant  in  Ice- 
land moss,  is  a  variety  of  inulin,  and  would  be  the  material  used  for  the  pur- 
pose. Being  very  cheap,  it  is  suitable  on  this  account.  Though  a  starch,  it 
is,  according  to  Kiilz,  one  of  the  assimilable  starches  already  mentioned,  of 
which  small  quantities,  at  least,  do  not  increase  the  excretion  of  sugar.  The 
biscuits  are  mxade  with  the  addition  of  milk,  eggs,  and  salt. 

The  best  of  these  substitutes  is  unsatisfacton,-,  as  patients  soon  tire  of 
them  and  want  the  real  bread.  Aleuronat  §  bread  is  regarded  by  von  Noor- 
den  as  the  only  one  at  all  satisfacton,-,  since  it  retains  the  bread  taste. 
Although  containing  some  carbohydrate,  I  have  lately  commenced  to  use  it 
for  my  patients,  and  it  promises  to  be  fairly  satisfactory. 

The  following  classified  summary  of  articles  of  food  admissible  for 
diabetics  will  be  found  convenient  for  reference : 

Shell-fish. — Oysters,  mussels,  and  clams,  raw  or  cooked  in  any  way. 
without  the  addition  of  flour. 

Fish  of  all  kinds,  fresh  or  salted,  including  lobsters,  crabs,  sardines,  and 
other  fish  in  oil :  fish  roe,  caviare. 

*  The  folio-wing  are  Dr.  Catnplin's  directions  for  making  biscuit  of  the  bran  flour:  To  one- 
quarter  of  a  pound  of  flour  add  three  or  four  fresh  eggs,  one  and  a  half  ounces  of  butter,  and  half  a 
pint  of  milk;  mix  the  eggs  with  a  little  of  the  milk,  and  warm  the  butter  with  the  other  portion;  then 
stir  the  whole  ^vell  together;  add  a  little  nutmeg  or  ginger  or  other  agreeable  flavoring,  and  bake  in 
small  forms  or  patty-pans.  The  cake,  when  baked,  should  be  about  the  thickness  of  an  ordinary 
captain's  biscuit.     The  pans  must  be  well  buttered.     Bake  in  rather  a  quick  oven  for  half  an  hour. 

These  cakes  or  biscuits  may  be  eaten  by  the  diabetic  with  meat  or  cheese  for  breakfast,  dinner, 
or  supper;  at  tea  they  require  rather  a  free  allowance  of  butter,  or  they  ma3-  be  eaten  with  curd  or 
anyof  the  soft  cheeses. 

'  +  Seegen  recommends  an  almond  food  made  as  follows  :  Beat  a  quarter  of  a  pound  of  blanched 
s-weet  almonds  in  a  stone  mortar  for  about  three-quarters  of  an  hour,  as  fine  as  possible;  put  the 
flour  thus  produced  into  a  linen  bag,  which  is  then  immersed  for  an  hour  and  a  quarter  in  boiling 
water  acidulated  with  a  few  drops  of  vinegar.  The  mass  is  then  thoroughly  mixed  with  three 
ounces  of  butter  and  two  eggs;  the  j-olks  of  three  eggs  and  a  little  salt  are  added,  and  the  whole  is 
to  be  stirred  briskly  for  a  long  time'.  A  fine  froth  made  by  beating  the  whites  of  the  three  eggs  is 
then  added.  The  whole  paste  is  now  put  into  a  form,  smeared  with  melted  butter,  and  baked  by  a 
gentle  fire. 

t  Kiilz,  "  Beitrage  zur  Path,  und  Therapie  des  Diabetes  Mellitus,"  Marburg.  1874,  Bd.  i,  p.  i45- 

§  Aleuronat  bread  is  made  by  R.  Williamson  as  follows:  Mix  two  ounces  C62  gm.)  of  desiccated 
cocoanut  powder  with  a  little  w'ater  containing  a  small  quantity  of  German  \-east.  Make  the  mass 
into  a  sort  of  paste,  and  put  in  a  warm  place  fo5  half  an  hour  or  longer.  The  small  amount  of  sugar 
contained  in  the  cocoanut  is  almost  entirelv  decomposed  bv  the  fermentation  produced  by  the  yeast, 
and  the  cocoanut  paste  becomes  spongv.  Add  two  ounces'(62  gm.)  of  aleuronat.  one  beaten  egg,  and 
a  small  quantitv  of  water  in  which  a  little  saccharin  has  been  dissolved,  and  mix  well  until  a 
dough  is  formed'.     Divide  into  cakes  and  bake  in  a  moderate  oven  for  twenty  or  thirty  minutes. 

Aleuronat  is  a  vellowish  powder  containing  from  80  to  go  per  cent,  of  vegetable  albumin  and 
only  7  per  cent  of  carbohydrates.  I  have  found  much  difficulty  in  securing  properly  desiccated 
cocoanut  powder. 


8i2  CONSTITUTIONAL  DISEASES. 

Meats  of  every  variety  except  livers,  including  beef,  mutton,  chipped 
dried  beef,  tripe,  ham,  tongue,  bacon,  and  sausages.  Also  poultry  and  game 
of  all  kinds,  with  which,  however,  sweetened  jellies  and  sauces  should  not 
be  used. 

Soups. — Clear  bouillon  and  other  soups,  beef-tea  and  broth  made  with- 
out flour,  rice,  vermicelli,  or  other  starchy  substances ;  and  without  the  vege- 
tables named  below  as  inadmissible. 

Vegetables. — Cabbage,  cauliflower,  Brussels  sprouts,  broccoli,  green 
string-beans,  the  green  ends  of  asparagus,  spinach,  dandelion,  mushrooms, 
tomatoes,  lettuce,  endive,  coleslaw,  olives,  cucumber  (fresh  or  pickled), 
radishes,  sorrel,  young  onions,  watercresses,  mustard  and  cress,  turnip  tops, 
celery  tops,  artichokes,  gherkins,  okra,  parsley,  or  any  other  green  vegetables. 

Bread  and  \cakes  made  of  pure  gluten,  bran,  aleuronat,  soya,  peanut- 
or  almond  flour,  inulin,  with  or  without  eggs  and  butter.  Griddle-cakes, 
pan-cakes,  biscuit,  porridges,  etc.,  made  of  these  flours.  Oatmeal  porridge 
with  cream.  Where  especial  stringency  is  required,  the  last  should  be  alto- 
gether omitted. 

Eggs  in  any  quantity  and  prepared  in  all  possible  ways,  without  sugar 
or  ordinary  flours. 

Butter  and  Cheese. 

Nuts. — All  except  chestnuts,  including  almonds,  walnuts,  Brazil  nuts, 
hazelnuts,  filberts,  pecan  nuts,  butternuts,  cocoanuts. 

Condiments. — Salt,  vinegar,  and  pepper  in  moderate  quantities. 

Fruits. — Cranberries,  plums,  cherries,  gooseberries,  red  currants,  straw- 
berries, acid  apples,'  lemons,  oranges  sparingl}' — all  without  sugar.  Acid 
fruits  may  be  stewed,  with  the  addition  of  bicarbonate  of  sodium  instead  of 
sugar. 

Jellies. — None  except  those  not  sweetened  with  sugar.  Saccharin  may 
be  used  for  sweetening  instead  of  sugar.  Jellies  may  be  made  of  calf's  foot 
or  gelatin  and  flavored  with  wine. 

Drinks. — Coffee,  tea,  and  cocoa-nibs,  with  milk  or  cream,  but  without 
sugar.  Also,  milk,  cream,  soda-  (carbonated)  water,  and  all  mineral  w^aters 
freely;  lemonade  without  sugar,  acid  wines,  including  clarets,  Bordeaux, 
Rhine,  and  still  Moselle  wines,  and  very  dry  sherry.  Unsweetened  brandy, 
whisky,  and  gin.  No  malt  liquors  except  those  ales  and  beers  which  have 
been  long  bottled  and  in  which  the  sugar  has  all  been  converted  into  carbonic 
acid  and  alcohol.     Saccharin  may  be  used  for  sweetening  tea  and  coffee. 

To  be  Especially  Avoided. — Cantaloupes,  watermelons,  peaches,  grapes, 
and  all  other  sweet  melons  and  fruits ;  potatoes  (white  and  sweet),  rice," 
beets,  carrots,  turnips,  parsnips,  peas,  and  beans ;  all  vegetables  containing 
starch  or  sugar  in  any  quantity ;  sweet  wines,  including  sherry,  Madeira,  port, 
and  champagne. 

In  mild  cases  the  dietetic  measures  previously  indicated  are  usually  fol- 
lowed by  the  most  prompt  and  decided  results,  in  some  instances  by  the  per- 
manent removal  of  all  symptoms,  in  others  by  a  continued  absence  of  them 
so  long  as  a  watchfulness  over  diet  is  maintained.  In  a  more  advanced  stage 
of  the  disease,  in  which  more  rapid  emaciation  and  loss  of  strength  show 
themselves,  such  a  regimen  is  followed  by  a  decided  dimunition  in  the  amount 
of  sugar  excreted,  but  it  fails  to  disappear  altogether,  and  a  more  rigid  elimi- 
nation of  saccharin  and  amylaceous  articles  must  be  attempted.  Sooner  or 
later,  however,  a  stage  is  reached  when  not  only  albuminous  food  breaks  up 
into  urea  and  sugar  and  urea  and  water,  but  the  albumin  of  the  tissues  under- 


DIABETES  MEELITUS.  813 

goes  the  same  metabolism  and  excretion,  while  emaciation,  starting  first  with 
the  disappearance  of  fats,  invades  even  the  muscular  tissue.  Fatty  foods 
longest  resist  this  breaking  up,  but.  ultimately,  in  progressive  cases,  even 
they  increase  the  elimination  of  sugar. 

Each  case  should  be  thoroughly  studied  as  to  its  own  peculiarities  and 
demands.  I  do  not  pursue  the  same  plan  in  every  case.  Sometimes  I  place 
the  patient  at  the  onset  on  a  strict  nitrogenous  diet  of  broths,  meat,  and  eggs, 
Avith  a  view  to  determining  what  can  be  accomplished.  This  done,  successive 
articles  of  food  are  added  and  their  effect  upon  the  urine  is  watched.  In 
other  cases,  especially  when  the  quantity  of  sugar  is  not  large,  I  first  take 
away  from  the  diet  all  sweets,  and  the  purest  starch  foods,  including  bread. 
Too  great  stringency  must  not  be  insisted  upon,  and  the  presence  of  one 
per  cent,  or  a  maximum  of  two  per  cent,  of  glucose  in  urine  may  be  per- 
mitted for  a  time;  but  semi-occasionally,  say  once  a  month,  a  return  should 
be  made  to  the  strict  diet,  with  a  view  to  taking  soundings,  and  if  it  is  found 
that  all  the  glucose  disappears,  we  may  be  encouraged  to  permit  for  a  time 
a  more  liberal  diet. 

In  many  cases  of  diabetes  of  long  standing  there  comes  a  time  when  it 
becomes  necessary  for  the  welfare  of  the  patient  that  a  rigid  diet  must  be 
suspended  for  a  time.  So  settled  is  this  truth  that  some  physicians  erred 
on  the  other  side  and  have  been  led  to  decry  altogether  the  dietetic  treatment. 
A  question  of  great  practical  importance  asks  what  shall  guide  us  to  such  a 
change  of  diet?  It  has  occurred  to  me  that  it  is  the  continued  presence  of 
diacetic  acid  in  the  urine.  For  this  informs  us  that  not  only  the  proteid  ele- 
ments of  food,  but  even  the  fixed  proteids  of  the  body,  are  splitting  up  to 
supply  the  demand  for  glucose  which  is  still  wasted  because  it  cannot  be 
oxidized.  The  carbohydrate  at  least  meets  this  demand  and  thus  conserves 
the  fixed  proteids  for  other  uses. 

2.  Hygienic  Treatment. — Xext  in  importance  to  the  dietetic  is  the 
hygienic  treatment  of  diabetes.  This  consists  in  bathing,  and  attention  to 
the  skin,  together  with  outdoor  muscular  exercise  and  perfect  ventilation 
within  doors. 

The  diabetic  should  breathe  the  freshest  and  purest  air.  While  the  cases 
are  not  numerous  in  which  embarrassed  respiration  results  in  glycosuria. 
there  are  undoubted  instances  in  which  this  has  occurred,  as  in  croup  and 
whooping-cough ;  and  it  is  well  known  that  asphyxiated  lower  animals  are 
likely  to  have  glycosuria.  Although  the  glycosuria  thus  resulting  is  prob- 
ably reflex,  it  can  hardly  be  expected  that  the  diabetic  should  improve  under 
unfavorable  respiratory  conditions.  He  should  not,  therefore,  live,  work, 
or  sleep  in  a  confined  atmosphere,  but  secure  the  most  perfect  ventilation, 
spending  much  of  his  time  out  of  doors,  and  sleeping  in  large,  well-ventilated 
chambers,  with  windows  open,  etc.  Especially  should  he  avoid  inhalation 
of  irrespirable  gases.  Attention  to  the  skin,  or  skin  culture,  is  most  impor- 
tant to  the  diabetic.  He  should  bathe  at  least  twice  a  week  in  tepid  or  hot 
w^ater  on  going  to  bed  in  winter,  and  on  rising  take  a  cool  sponge-bath  daily. 
In  summer  he  may  take  a  cool  bath  on  rising  and  on  retiring.  He  should 
groom  his  skin  thoroughly  daily,  either  after  the  bath  or  independent  of  it 
on  the  days  on  which  he  does  not  bathe.  Two  tablespoonfuls  of  sodium  car- 
bonate to  an  ordinary  bath  is  a  suitat)le  addition  to  the  latter,  softening  the 
skin  and  facilitating  its  action  by  removing  the  effete  epithelium. 

^Muscular  exercise  should  be  taken  daily  by  the  diabetic,  both  by  walking 
and  ofvmnastics.     Glvcosren  is  undoubtedlv  consumed  in  the  muscles  during 


8 14  CONSTITUTIONAL  DISEASES. 

their  action,  and  it  is  quite  certain  that  in  diabetes  there  is  an  undue  accumu- 
lation of  sugar  in  the  muscles.  Exercise  should  be  sustained  regularly  day 
by  day,  even  in  wet  weather,  care  being  taken  to  keep  the  feet  dry,  while  it 
should  never  be  carried  to  the  point  of  fatigue. 

Attention  to  other  secretions,  particularly  to  that  of  the  bowels,  is  of  the 
greatest  importance.  Diabetics  who  are  constipated  are  always  more  difficult 
to  relieve.  It  is  probably  partly  on  account  of  their  action  in  this  respect  that 
the  alkaline  and  alkaline-saline  aperient  waters,  as  those  of  Vichy,  \'als.  and 
Carlsbad,  are  so  useful.  To  those  who  visit  these  springs,  a  part  of  the  benefit 
is  ascribable  to  the  other  favorable  hygienic  influences,  such  as  rest,  fresh 
air,  and  exercise,  by  which  they  are  surrounded.  Independently  of  these  in- 
fluences, however,  there  is  reason  to  believe  that  the  alkaline  waters  are  of 
service  to  diabetics,  and  when  their  cost  is  not  a  consideration,  a  quart  of 
Vichy  or  Vals  and  half  as  much  Carlsbad  may  be  taken  during  the  day,  begin- 
ning before  breakfast.  The  Vichy  is  a  more  alkaline  water,  containing  thirty- 
five  grains  (2.3  gm.)  of  carbonates  to  a  pint  (0.5  liter),  while  Carlsbad  con- 
tains but  eleven  grains  (0.51  gm.),  but  twice  the  proportion  of  chlorids,  eight 
grains  (0.7  gm.)  to  a  pint  (0.5  liter),  and  nearly  ten  times  as  much  sodium 
sulphate,  or  nineteen  grains  (1.25  gm.)  ;  hence  its  more  purgative  quality. 
Since  Carlsbad  has  the  highest  reputation,  it  is  more  likely  that  it  is  through 
the  action  of  the  sulphates  and  chlorids  on  the  liver  rather  than  that  of  the 
alkalines  they  contain  that  these  waters  are  efficient.  This  is  the  more  likely, 
as  other  alkaline  waters  nearly  as  rich  as  those  of  Vichy  and  richer  than  Carls- 
bad waters  in  sodium  carbonate,  but  without  sulphate  of  sodium,  are  without 
reputation.  The  alkalies  may,  however,  increase  the  effect,  and  are  especially 
of  service  when  there  is  acidity. 

The  waters  of  the  celebrated  Saratoga  Springs  in  this  country  have  an 
undoubted  action  on  the  liver,  probably  through  the  chlorids  they  contain, 
which  are  in  very  large  proportion,  reaching  in  the  Geyser  Spring  seventy 
grains  (4.6  gm.)  to  the  pint  (0.5  liter),  and  in  the  Empire  and  Hathorn, 
sixty-three  grains  (4.19  gm.)  to  the  pint  (0.5  liter).  They  contain  no  sul- 
phates, but  the  carbonates  are  present  in  considerable  proportion,  though 
much  less  than  in  the  Vichy  waters.  Saratoga  Vichy,  which,  of  the  Saratoga 
waters,  contains  most  sodium  carbonate,  has  ten  grains  (0.6  gm.)  to  the 
pint;  the  Geyser,  nine  grains  (0.58  gm.).  In  the  absence  of  the  Carlsbad 
and  Vichy  waters  I  would  use  the  purgative  Saratoga  waters,  especially  the 
Vichy  and  Geyser. 

3.  The  Medicinal  Treatment. — Like  all  diseases  in  which  treatment  by 
drugs  is  relatively  inefficient,  diabetes  has  its  full  share  of  reputed  remedies, 
most  of  which  are  useless.     This  dare  not,  however,  be  said  of  all. 

The  only  drug  that  can  be  relied  upon  to  produce  an  effect  in  diminish- 
ing glycosuria  is  opium.  It  seems  that  it  was  used  for  diabetes  as  early  as 
the  second  century  by  Archigenes.  It  was  also  used  by  ^^tius  the  physician, 
in  the  fourth  century,  and  in  the  latter  part  of  the  eighteenth  century  and 
beginning  of  the  nineteenth  by  Rollo,  Frank,  Tommasson,  and  especially  the 
English  physician,  Pelham  Warren,  in  1812.  It  is  certainly  a  useful  agent 
in  diabetes,  but  its  use  is  united  with  disadvantages  in  the  locking-up  of  the 
secretions  which  attends  it.  On  account  of  its  comparative  freedom  from 
these  effects,  codein  has  come  to  be  the  favorite  alkaloid  of  opium  in  dia- 
betes. It  may  be  given  in  1-4-grain  (0.016  gm.)  doses  three  times  a  day, 
or  1-2  grain  (0.032  gm.)  twice  a  day,  increasing  1-4  grain  (0.016  gm.)  daily 
until  the  desired  effect  is  produced  or  it  proves  useless.     If  the  sugar  dis- 


DIABETES  MELLITUS.  815 

appears,  the  drugs  should  be  gradually  withdrawn.  If  constipation  is  caused 
by  it,  aperient  remedies  should  be  associated,  and  very  suitable  are  the  natural 
aperient  waters,  including  the  bitter  waters,  Friedrichshalle,  Hunyadi  Janos, 
Racokzy,  Piillna,  etc.  I  have  seen  a  patient  entirely  relieved  under  its  use, 
and  it  alone,  with  no  return  of  the  sugar  after  its  omission.  I  rarely  give  as 
much  as  ten  grains  (0.65  gm.)  a  day,  and  usually  defer  its  use  until  I  find 
other  measures  insufficient. 

After  opium,  arsenic  has  longest  maintained  its  reputation  as  a  remedy 
in  diabetes,  and  I  use  it  in  all  mild  cases,  preferring  Fowler's  solution.  It 
seems  to  me  there  is  something  more  than  a  simple  tonic  action  in  it.  Pos- 
sibly it  acts  partly  on  the  gastro-intestinal  tract  and  partly  on  the  red  blood 
discs,  increasing  their  oxidizing  power  over  glucose.  The  plan  I  have 
adopted,  after  many  years'  experience,  is  to  give  small  doses  long  continued 
rather  than  to  attempt  to  bring  about  its  physiological  action.  Hence  three 
drops  twice  a  day,  continued  indefinitely,  is  now  my  favorite  method. 

The  bromid  of  potassium  is  sometimes  efficient  in  diabetes  accompanying 

functional  nervous  disorders  due  to  mental  overwork  or  psychic  disturbance. 

Bromin  and  arsenic  are  combined  in   the   shape   of   Clemens'   solution  of 

•bromid  of  arsenic,  of  which  the  dose  is  from  three  to  five  minims   (0.184 

to  0.3  c.  c). 

Substances  which  possess  the  power  of  oxidizing  sugar  in  the  blood  have 
long  been  sought.  The  alkalies,  and  especially  the  alkaline  carbonates,  at 
one  time  enjoyed  considerable  reputation  in  the  treatment  of  diabetes,  after 
Mialhe  claimed  for  them  the  power  of  destroying  the  sugar  in  the  blood,  and 
of  neutralizing  the  volatile  acids  retained  within  the  organism  in  consequence 
of  the  defective  action  of  the  skin.  Whatever  their  mode  of  action,  the  car- 
bonates continue  to  be  used  by  many  physicians,  both  in  Germany  and  in  Eng- 
land, with  results  which  justify  the  practice.  Potassium  or  sodium  bicar- 
bonate, in  ten-,  fifteen-,  or  twenty-grain  doses  (0.6,  i,  or  1.3  gm.),  may  be 
administered.  The  efficiency  of  the  alkaline  mineral  waters  is  thus  explained. 
Much  was  hoped  of  pancreas  preparations,  especially  since  the  brilliant 
results  that  followed  the  use  of  thyroid  extract  in  myxedema.  They  have 
proved  disappointing.  The  glycolytic  ferment  isolated  by  Lepine  from  the 
pancreas  and  from  malt  diastase  has  not  been  any  more  satisfactory.  Supra- 
renal extract  has  also  been  employed. 

The  coal-tar  derivatives,  antipyrin,  antifebrin,  and  phenacetin  have  been 
highly  recommended  by  the  French  physicians,  and  I  have  found  them  of 
service  in  mild  cases,  giving  from  ten  to  fifteen  grains  (0.6  to  i  gm.)  three 
times  a  day  on  an  empty  stomach,  beginning  with  the  smaller  dose  in  the  case 
of  the  first  two.  Their  efficacy  is  said  to  be  increased  when  combined  with 
an  equal  bulk  of  sodium  bicarbonate.  Salicylate  of  sodium  has  warm  advo- 
cates, and  in  gouty  cases  it  may  be  useful.  According  to  von  Noorden,  it  is 
especially  in  neurogenous  diabetes  that  the  last  of  the  remedies  just  named 
is  useful,  quieting  the  irritability  of  the  central  nervous  system. 

Jambul  is  a  remedy  with  some  reputation.  I  have  been  so  much  dis- 
appointed in  its  effects  that  I  rarely  use  it.  It  is  given  in  the  shape  of  powder 
or  fluid  extract,  in  doses  of  5  to  30  grains  (0.3  to  2  gm.)  of  the  former 
and  a  half  to  2  drams  ( 1.8  to  7  c.  c.)  of  the  latter. 

lodid  of  potassium  has  produce'd  some  striking  results  in  the  case  of 
diabetes  due  to  syphilitic  lesions  of  the  brain. 

Lactic  acid  was  strongly  advocated  by  the  Italian  physicians.  Cantani 
recommends  that  from  75  to  150  grains  (5  to  10  gm.)  of  the  acid  should  be 


8i6  CONSTITUTIONAL  DISEASES. 

taken  daily  in  from  eight  to  ten  fluid  ounces  (240  to  300  c.  c.)  of  water. 
Whence  buttermilk  or  Zoolak  (a  fermented  milk  in  which  the  sugar  of  milk 
is  converted  into  lactic  acid  by  a  ferment)  becomes  a  suitable  food  at  least. 
Cod-liver  oil  becomes  a  useful  remedy  in  cases  in  which  the  carbo- 
hydrates are  totally  converted  into  sugar  and  excreted,  the  albuminoids  for 
the  most  part,  while  the  body  albumin  is  being  encroached  upon  as  a  source 
of  energy.  Especially  useful  does  it  become  when  associated  with  alcohol 
in  the  shape  of  whisky  or  brandy,  which  always  helps  the  assimilation  of  fat. 
In  the  same  category  as  cod-liver  oil  must  be  placed  butter,  cream,  bacon,  and 
the  like  as  foods. 

Treatment  of  Complications. 

Eczema  and  Pruritus. — These  sometimes  intensely  annoying  symptoms 
commonly  abate  with  the  reduction  of  the  glycosuria,  but  require  also  other 
mieasures.  In  the  first  place  scrupulous  cleanliness  is  necessary,  accom- 
plished by  warm,  tepid  bathing.  In  addition,  we  may  use  solutions  of  boric 
acid  2  drams  (8  gms.)  to  the  quart  (i  liter)  or  sodium  hypophosphite,  one 
ounce  (30  gm.)  to  a  quart  (i  liter)  of  water;  also  zinc  ointment,  ointment  of 
acetate  of  lead ;  solutions  of  corrosive  sublimate,  very  weak, — i  to  3000, — 
and  tumenol-sulphonic  acid  in  10  per  cent,  alcohol  solutions.  Carbolic  acid  5 
to  10  minims  (.3  to  .6  gm.) glycerin  ^ss  (8  c.  c.)  and  water  an  ounce  (30  c. 
c.)  make  a  soothing  preparation.  As  a  last  resort  in  pruritis  nitrate  of  silver 
may  be  used  in  the  strength  of  twenty  grains  (1.3  gm.)  to  the  ounce  (30 
c.  c),  making  daily  applications,  which  though  sometimes  painful,  are  ulti- 
mately effectual. 

Diabetic  Coma. — Treatment  is  usually  futile  here.  The  alkalies  and' 
alkaline  mineral  waters  should  be  pushed.  Intravenous  injections  of  alka- 
line solutions  have  been  disappointing.  More  hopeful  is  the  intravenous 
injection  of  a  0.8  per  cent,  salt  solution,  as  recommended  by  von  Noorden, 
using  a  liter  in  four  doses  at  intervals  of  four  hours.  A  teaspoonful  of  com- 
mon salt  to  a  gallon  of  sterilized  water  aflfords  a  strength  sufficiently  near  the 
percentage  named.  Hypodermoclysis.  which  is  much  easier,  will  accomplish 
the  same  result,  as  I  can  attest  from  personal  experience.  Copious  diuresis 
follows,  and  may  be  expected  to  carry  out  noxious  substances. 

More  hopeful  is  a  prophylactic  treatment  of  diabetic  coma,  called  for 
when  diacetic  acid  or  oxybutyric  acid  and  large  amounts  of  acetone  are  found 
in  the  urine.  Under  these  circumstances  it  seems  certain  that  whatever  be 
the  form  of  diet  in  use  at  the  time,  it  must  be  changed,  and  if  it  be  remem- 
bered that  these  substances  are  now  conceded  to  arise  from  the  disintegration 
of  body  albumin  and  not  from  food,  as  formerly  supposed,  diet  would 
at  least  seem  a  matter  of  indifference  under  the  circumstances,  while 
a  change  alone  seems  desirable.  The  patient  should  be  immediately  placed 
upon  alkaline  treatment,  associated  with  the  free  use  of  alkaline  mineral 
waters.  Thus,  twenty  grains  (1.3  gm.)  of  sodium  bicarbonate  may  be  given 
every  three  hours,  dissolved  in  eight  ounces  (250  c.  c.)  of  Vals  or  Vichy 
water.  The  bowels  should  be  kept  open,  and  alcohol  in  the  shape  of  whisky 
or  brandy  freely  given. 


DIABETES  INSIPIDUS.  817 


DIABETES  INSIPIDUS. 

Definition. — Any  excessive  secretion  of  non-saccharine  and  non- 
albuminous  urine  which  has  continued  for  a  long  time. 

Etiology. — The  condition,  unlike  diabetes  mellitus,  affects  more  fre- 
quently younger  persons,  being  rare  in  those  over  fifty  years  of  age,  relatively 
frequent  in  infancy,  and  most  common  between  the  ages  of  twenty  and 
thirty. 

As  to  sex,  it  is  said  to  be  much  more  frequent  in  males  than  in  females, 
two  to  three  times  as  many  of  the  former  as  of  the  latter.  In  my  own  experi- 
ence I  have  found  the  disease  nearly  equally  frequent  in  both  sexes. 

As  to  causes,  the  same  uncertainty  prevails  as  with  diabetes  mellitus. 
An  examination  of  cases  shows  an  association  with  a  certain  number  of  con- 
ditions, such  as  cerebral  disease,  including  tumor  of  the  brain,  meningitis, 
paralysis  of  the  sixth  nerve,  sunstroke,  cerebrospinal  fever,  falls  and  blows 
on  the  head,  exposure  to  cold  and  the  drinking  of  cold  fluids,  drunkenness, 
pregnancy,  hysteria,  emotion,  especially  fright,  hereditary  influence,  syphilis, 
and  previous  disease,  etc.,  but  this  does  not  show  causation.  The  propor- 
tion, however,  of  cases  in  which  the  condition  is  associated  with  brain  diseases 
and  injuries  to  the  head,  taken  in  connection  with  the  fact  of  Bernard's  dis' 
covery  that  puncture  of  the  floor  of  the  fourth  ventricle  above  the  diabetic 
center  produces  polyuria  without  glycosuria,  makes  it  very  likely  that  central 
nervous  irritation,  however  induced,  is  at  the  bottom  of  the  symptom.  It  is 
reasonable  to  suppose,  too,  that  diabetes  insipidus  may  be  the  result  of  some 
irritation,  direct  or  reflex,  of  this  center  in  the  medulla  oblongata,  or  of  the 
sympathetic  ganglia  in  the  abdomen.  The  latter  explanation  also  applies  to 
cases  of  polyuria  attending  the  presence  of  abdominal  diseases,  such  as  tumor, 
aneurysm,  or  peritonitis,  though  it  is  doubtful  whether  these  should  be 
regarded  as  cases  of  diabetes  insipidus. 

Morbid  Anatomy, — The  essential  morbid  anatomy  of  diabetes  insipidus 
would  be  the  lesions  of  the  nerve  centers  or  sympathetic  ganglia  which  may 
underlie  the  symptoms.  But  as  these  are  often  undiscoverable,  or  at  least 
indefinite,  it  is  impossible  to  describe  them.  Notably  is  this  the  case  with 
lesions  of  the  third  and  sixth  nerves.  Associated  central  nervous  lesions, 
when  present,  are  found  more  frequently  in  the  vicinity  of  the  base  of  the 
"brain. 

Symptoms. — ^The  enornwus  secretion  of  urine  of  almost  spring- water- 
hke  clearness,  and  of  specific  gravity  often  as  low  as  1003.  is  the  most  con- 
spicuous symptom,  but  more  annoying,  probably,  is  the  extreme  thirst  which 
always  attends  it.  These  may  be  said  to  be  the  essential  symptoms,  others 
which  may  or  may  not  be  present  being  rather  their  consequence.  Very  con- 
stant among  the  latter  are  dryness  of  the  skin  and  absence  of  perspiration. 
The  health  may  be  otherwise  perfect,  though  emaciation  and  weakness 
are  often  present.  The  debility  is  sometimes  extreme.  Occasionally  there 
are  derangements  of  digestion,  and  sometimics  also  the  appetite  is  ravenous,  as 
in  diabetes  mellitus,  though  less  frequently  so. 

These  symptoms  may  occur  suddenly  in  the  midst  of  apparent  health, 
or  they  may  supervene  upon  others  or  be  substituted  for  them,  chiefly  those 
of  a  nervous  character,  which  may  be  the  result  of  the  nervous  lesion  caus- 
ing   the    polyuria.     Such    symptoms    are    headache,    restless,    irritability, 


8i8  CONSTITUTIONAL  DISEASES. 

sleeplessness,  what  is  commonly  called  nervousness,  more  rarely  convulsions,, 
delirium,  paralyses — indeed,  any  one  or  more  of  the  great  variety  of  symp- 
toms which  result  from  organic  or  functional  nervous  disease.  Sometimes 
these  symptoms  succeed  upon  the  polyuria  or  are  increased  by  it.  It  is  cer- 
tain that  the  milder  nervous  symptoms  are  sometimes  the  result  simply  of  the 
inconvenience  and  annoyance  caused  by  the  two  cardinal  symptoms,  polyuria 
and  thirst.  The  patient  is  kept  busy,  as  it  were,  night  and  day,  in  passing 
water.  It  is  not  surprising  that  such  a  patient  should  be  fretful  and  irritable,, 
and  that  sooner  or  later  his  health  should  be  broken  if  the  symptoms  are  not 
relieved. 

In  addition  to  the  symptoms  detailed,  there  are  said  to  occur  at  times 
dryness  of  the  tongue,  epigastric  and  lumbar  pains,  diarrhea,  and  impairment 
of  mental  faculties  and  of  the  sexual  function.  In  some  instances  there  is 
the  most  extraordinary  tolerance  of  alcoholic  drinks,  while  in  others  there  is 
an  exaggerated  susceptibility  to  their  influence.  A  very  slight  lowering  of 
the  ho&y-temperature  has  been  observed,  amounting,  however,  to  but  a  few 
tenths  of  a  degree,  and  it  is  never  below  97°  F.  (36.1°  C).  In  advanced 
stages  of  the  disease  edema  of  the  lower  extremities  sometimes  occurs. 

The  duration  of  the  condition  varies  greatly.  Sometimes  it  continues 
through  life  with  no  inconvenience  except  that  from  the  constant  diuresis 
and  thirst.  Dr.  Willis  records  a  case  lasting  fifty  years.  On  the  other  hand, 
it  is  seldom  of  brief  duration ;  indeed,  there  is  needed  a  certain  chronicity  in 
order  to  admit  it  in  the  category  of  diseases.  One  case  is  reported  as  termi- 
nating fatally  in  seven  weeks.  Under  prognosis  will  be  found  some  further 
information  as  to  duration,  but  it  may  be  said,  in  general,  that  most  cases 
which  terminate  unfavorably  and  most  which  recover  completely  do  so  within 
a  year.  I  have  now  under  my  care  a  lad  of  seventeen  who  has  been  under 
treatment  for  eleven  years.  He  is  able  to  work  quite  hard  much  of  the 
time. 

No  complications  arise  except  such  as  cause  the  disease  or  results  from 
it.  Among  the  latter  is  occasionally  dilatation  of  the  pelvis  of  the  kidney, 
and  atrophy  of  this  organ  is  mentioned,  due  to  pressure  of  the  accumulated 
urine  and  resulting  in  a  sacculated  condition.  The  symptoms  of  the 
malady  are  almost  always  influenced,  and  sometimes  even  cut  short,  by  inter- 
current disease,  especially  of  a  febrile  character,  or  even  by  a  profound 
physical  impression,  as  long-continued  suppuration  after  a  blister.  The  boy 
referred  to  was  an  aggravated  choreic  before  he  became  diabetic. 

Physical  and  Chemical  Characters  of  the  Urine. — As  to  the  quantity  of 
urine  passed,  it  is  enormous,  exceeding  often  the  amount  passed  in  saccha- 
rine diabetes.  As  many  as  forty-three  liters  (90  pints)  are  recorded  by 
Trousseau,  and  one-fourth  this  quantity  is  common.  It  has  been  said,  even, 
that  the  quantity  secreted  sometimes  exceeds  the  amount  of  fluid  ingested, 
but  this  is  impossible  for  any  length  of  time,  unless  water  is  absorbed  from 
the  atmosphere,  which  is  not  impossible.  In  point  of  fact,  the  water  excreted 
is  always  a  little  less  than  that  ingested,  either  as  drink  or  in  the  solid  food. 
As  the  quantity  of  urine  excreted  increases  or  its  normal  acidity  diminishes, 
its  color  disappears  and  its  specific  gravity  declines.  In  one  case  under  my 
care  the  specific  gravity  w^as  scarcely  looi,  while  the  urine  in  moderate  bulk 
was  absolutely  colorless.  Again,  a  faint  greenish  tinge  is  exhibited  b}'  the 
urine  in  bulk. 

As  to  the  other  constituents  of  the  urine,  it  may  be  said  in  general  that 
they  are  all  increased,  except  possibly  uric  acid.     Thus,  the  urea  is  increased 


DIABETES  INSIPIDUS.  819 

to  three  and  even  four  times  its  normal  amount.     In  a  case  reported  by  J.  AI. 
Da  Costa  *  the  urea  was  diminished. 

Sulphuric  and  phosphoric  acids  are  both  increased,  and  especially, 
according  to  Dickinson,  the  combination  of  phosphoric  acid  with  the  earths, 
lime,  and  magnesia.     The  same  is  true  of  the  chlorids. 

Of  abnormal  constituents,  inosit  has  been  found,  and  alhiiinin  very 
rarely,  but  care  should  be  taken  not  to  confound  the  polyuria  with  the  slight 
albuminuria  of  a  contracted  kidney  or  with  an  albuminous  polyuria  in  which 
there  is  no  organic  disease  of  the  kidney. 

Some  of  the  accounts  published  as  to  the  quantity  of  water  consumed 
and  excreted  are  almost  incredible,  yet  they  seem  well  authenticated.  In 
illustration  may  be  mentioned  the  following  instances  from  Dr.  Willis'  work 
on  "  Urinary  Diseases  " :  f  An  artisan,  fifty-five  years  old,  had  had  constant 
thirst  with  commensurate  diuresis  since  he  was  five  years  of  age.  From  the 
age  of  sixteen  he  had  drunk,  on  an  average,  no  less  than  two  pailfuls  daily. 
While  in  the  Hotel  Dieu,  to  which  he  was  admitted  for  an  injury  of  the  knee, 
he  drank  on  an  average  thirty-three  pints  of  water  every  day,  often  swallow- 
ing two  liters,  or  about  two  quarts,  at  a  draught.  He  passed  daily  about 
thirty-four  pounds  of  urine  and  one  pound  of  feces.  He  otherwise  enjoyed 
good  health,  and  was  the  father  of  several  children.  The  long  duration  of 
this  case  and  the  otherwise  excellent  health  enjoyed  by  him  are  by  no  means 
exceptional.  X&vy  little  serious  disturbance  seems  to  result  so  long  as  water 
is  supplied  to  quench  the  resulting  thirst.  In  extreme  cases  patients  have 
been  known  to  drink  their  own  urine. 

An  extraordinary  flow  of  saliva  was  observed  in  one  instance  by  Kiilz,:|: 
along  with  polyuria,  in  a  hysterical  girl  of  eighteen  years,  from  whom  as 
much  as  18.72  ounces  (525  c.  c.)  were  collected  in  twenty-four  hours,  while 
the  quantity  ranged  during  four  months  from  360  c  c  to  the  former  amount. 
The  quantity  of  urine  passed  during  this  time  ranged  from  200  to  260  ounces 
(6000  to  7800  c.  c).  The  increased  flow  of  saliva  may  be  explained  by  the 
fact  that  in  some  of  the  experiments  of  Eckhard,§  Loeb,||  and  Gruetzner  ^ 
puncture  of  the  medulla  oblongata  was  followed  by  ptyalism. 

Diagnosis. — The  diagnosis  of  diabetes  insipidus  is  very  easy.  The  per- 
sistent thirst,  polyuria,  and  absence  of  sugar  from  the  urine  are  pathog- 
nomonic. The  only  possible  error  is  mistaking  the  polyuria  of  chronically 
contracted  kidney  of  interstitial  nephritis  for  that  of  diabetes  insipidus.  In 
addition,  however,  to  the  fact  that  a  careful  examination  for  albumin  will  dis- 
close it  in  the  urine  of  contracted  kidney,  the  quantity  is  never  so  large,  nor 
is  the  thirst  so  extreme ;  so  that  it  would  seem  only  necessary  to  mention  the 
possibility  of  such  an  error  in  order  to  avoid  it. 

Prognosis. — It  is  extremely  unusual  for  a  case  of  diabetes  insipidus  to 
terminate  unfavorably  unless  there  have  been  also  present  symptoms  point- 
ing to  serious  nen^ous  lesion.  Recovery  is  not  infrequent.  According  to 
Roberts,  of  67  cases  collected,  16  are  reported  as  complete  recoveries  and  14 
ended  fatally,  nearly  an  equal  proportion.  The  remaining  ■^'j  were  still  in 
progress.  In  cases  of  recovery  or  death  the  duration  is  comparatively  short. 
Of  the  16  recoveries,  in  9  the  duration  was  less  than  a  year;  in  i,  four  years; 

in  2,  eighteen  and  nineteen  years,  and  in  the  remainder,  some  years.     Of  the 
' f 

*  "  Transactions  of  the  College  of  Physicians  of  Philadelphia,"  third  series,  vol.  i.,  1873,  p.  139. 

+  American  edition,  Philadelphia,  zB%q,  p.  2:;. 

X  "  Diabetes  Alellitus  and  Insipidus,"  Marburg:,  1873. 

§  Eckhard,  "  Beitrage  zur  Anat.  und  Phj'siol.,"  iv,  p.  iqi. 

P  Loeb,  Eckhard's  "  Beitrage,"  v.,  p.  i;  and  "  Dissertation,"  Giessen,  1869. 

IT  Gruetzner,  "  Pfliiger's  Archiv,"  vii.  p.  552. 


820  CONSTITUTIONAL  DISEASES. 

14  fatal  cases,  9  terminated  in  less  than  a  year,  i  in  seven  weeks,  and  2  in  two 
months ;  the  other  two  survived  eighteen  months  and  twenty  years 
respectively.  Of  the  ■t,?  cases  in  progress,  only  5  continued  for  a  year  or  less. 
The  remainder  had  continued  for  periods  ranging  from  something  over  a 
year  to  fifty-nine  years. 

These  results  seem  to  be  tolerably  independent  of  treatment.  It  may  be 
said,  therefore,  that,  as  a  rule,  cases  that  last  more  than  a  year  are  apt  to  con- 
tinue, but  ordinarily  only  require  to  be  furnished  with  an  abundance  of  water 
to  keep  them  tolerably  comfortable.  According  to  Dickinson,  cases  due  to 
drunkenness  are  more  likely  to  run  a  severe  and  rapid  course,  usually  termi- 
nating fatally  within  a  few  months,  and  one  terminated  thus  in  two  months. 

The  disease  appears  to  me  altogether  less  serious  than  diabetes  mellitus, 
and  I  quite  concur  with  Senator,  who  says  "  it  is  rather  a  troublesome  than 
a  dangerous  complaint."  But  Trousseau  and  Da  Costa  were  inclined  to  con- 
sider it  more  serious  than  diabetes  mellitus. 

Treatment. — ^The  treatment  of  diabetes  insipidus  would  naturally  resolve 
itself  into  the  treatment  for  the  disease  of  which  it  is  the  symptom  rather  than 
of  the  symptom  itself ;  but  as  the  former  is  very  frequently  undiscoverable,  it 
must  consist  mainly  of  efforts  to  diminish  the  secretion  of  urine,  and  with  it 
the  thirst. 

First,  it  is  generally  conceded  that  there  should  be  no  restriction  in  the 
drinking  of  water  or  other  harmless  fluids,  for  the  diuresis  is  not  so  much 
caused  by  the  great  ingestion  of  water  as  the  thirst  is  caused  by  the  diuresis. 
It  should  be  mentioned,  however,  that  one  or  two  instances  are  reported 
wherein  improvement  seems  to  have  resulted  from  such  restriction ;  and  if, 
as  in  some  cases,  a  habit  of  drinking  has  been  the  initial  event,  moderate 
restriction  may  be  reasonable.  Caution  should  be  used  in  the  administration 
of  drugs,  though  my  experience  is  not  that  of  Dickinson,  who  says  that 
"  remedies  designed  to  restrain  the  urinary  secretion  seldom  fail  to  do  harm." 
The  older  remedies  are  ergot,  opium,  gallic  acid,  and  valerian ;  of  all,  the 
doses  ultimately  used  are  usually  large.  In  one  of  my  patients  the  symptoms 
subsided  under  the  use  of  gallic  acid  after  I  had  failed  with  full  doses  of 
ergot.  In  another,  probably  due  to  syphilis,  the  effect  of  the  iodid  of  potas- 
sium was  shown  in  an  aggravation  of  the  symptom  whenever  it  was  discon- 
tinued and  an  amelioration  when  it  was  resumed.  Of  all  drugs,  I  have  found 
the  iodid  of  potassium  most  frequently  followed  by  improvement. 

Trousseau  and  Rayer  claimed  extraordinary  results  from  the  use  of 
valerian,  the  former  using  the  fluid  extract  in  enormous  doses — 2  1-2  drams 
(6  c.  c.)  a  day,  which  was  increased  to  one  ounce  (30  c.  c.)  daily  in  one 
instance.  Rayer  used  the  powdered  valerian  and  the  valerianate  of  zinc,  giv- 
ing the  latter  in  pills  in  gradually  increasing  doses  until  twenty  grains  (1.25 
gm.)  a  day  were  given.  At  the  present  day  the  more  palatable  elixir  of 
valerianate  of  ammonia,  combined  with  bromid  of  potassium,  is  to  be 
preferred. 

Reasoning  from  the  effect  of  intercurrent  disease  and  powerful  physical 
and  nervous  impressions,  Roberts  suggests  a  large  blister  at  the  nape  of  the 
neck  or  epigastrium,  according  as  the  associated  symptoms  and  the  anamnesis 
point  to  the  nervous  or  the  digestive  system,  a  suggestion  which  may  be  acted 
upon  with  advantage. 

The  constant  galvanic  current  has  been  recommended,  and  in  cases  of 
spinal  lesion  may  be  expected  to  be  of  advantage.  Both  Seidel  and  Kiilz 
have  used  it  with  good  results.     The  former  applied  one  pole  of  a  "  strong 


OBESITY.  821 

battery  "  over  the  loins  near  the  spine,  and  the  other  as  deeply  as  possible 
over  the  hypochondrium,  upon  each  side  daily  for  five  minutes.  In  eight 
days  the  urine  fell  from  195.9  ounces  (5957  c.  c.)  to  153.3  ounces  (4600  c.  c.) 
per  diem,  in  three  weeks  to  76.6  ounces  (2300  c  c),  and  the  next  month  63.5 
ounces  (1904  c.  c),  while  the  weight  of  the  body  increased  nine  pounds. 
Kiilz  applied  one  pole  of  a  battery  of  from  thirty  to  forty  cells  as  high  as  pos- 
sible in  the  nape  of  the  neck,  and  the  other  to  the  loins  or  epigastrium,  the 
best  results  being  apparently  obtained  with  the  positive  pole  to  the  nape  of 
the  neck,  and  the  negative  first  to  the  loins  for  four  minutes  and  then  to  the 
pit  of  the  stomach  for  four  minutes. 

Tonics  and  nervines,  such  as  strychnin,  iron,  arsenic,  salts  of  quinin, 
cod-liver  oil,  etc.,  are  appropriately  added  to  the  treatment  with  a  view  to  sus- 
taining the  strength  of  the  patient,  which  is  apt  to  fail.  To  these  are  to  be 
added  fresh  air,  sea  air,  exercise,  and  all  possible  favorable  hygienic 
influences. 

Hygiene  is  even  more  important  than  in  diabetes  mellitus,  and  should 
include  a  careful  attention  to  the  skin,  warm  clothing,  warm  baths,  frictions, 
etc.,  in  order  to  divert  a  portion  of  the  circulation  from  the  kidneys  to  the 
skin.  The  thirst  should  also  be  quenched  when  possible  by  bits  of  ice  and 
acidulous  fluids. 


OBESITY. 

Synonyms. — Adipositas  universalis;  Polysarcia  adiposa;  Corpulence. 

Definition. — Obesity  may  be  defined  as  an  inconvenient  accumulation  of 
adipose  tissue  in  the  body. 

Etiology. — The  most  usual  cause  of  an  excessive  accumulation  of  fat 
doubtless  is  overeating  associated  with  an  inactive  life ;  and  though  it  may  be 
true  of  some  fat  persons  that  they  are  really  moderate  eaters,  careful  exami- 
nation will  generally  prove  that  they  are  not.  Heredity  exerts  an  undoubted 
influence,  and  we  find  corpulence  running  in  families.  Commonly  it  does 
not  make  its  appearance  until  after  thirty-five  years  of  age,  but  in  this 
country  particularly  it  is  often  seen  earlier,  in  boys  and  girls  of  ten  years  and 
upward. 

Of  foods,  each  one  of  the  representative  varieties,  albuminoids,  carbo- 
hydrates, and  fats,  is  capable  of  contributing  fat,  deposited  in  fat  vesicles  in 
the  body,  and  it  has  even  been  said  that  albuminoids  furnish  more  of  the  fatty 
tissues  of  the  body  than  the  carbohydrates.  Certain  it  is  that  a  person  may 
become  corpulent  who  eats  very  little  fat.  In  most  cases,  however,  corpulent 
persons  are  found  to  be  liberal  consumers  of  all  three  of  the  food  elements. 
While  the  carbohydrates  are  direct  sources  of  fat  production,  it  is  generally 
conceded  that  they  act  largely  by  sparing  the  fats  derived  from  other  sources. 
They  decompose  and  oxidize  so  rapidly,  and  thus  give  themselves  up  so 
readily  to  force  production,  that  the  stored  fats  are  not  called  upon.  Thus  it 
is  that  sugars  and  starches  indirectly  favor  corpulence.  To  this  class  belong 
also  alcohol,  and  especially  beer,  which  contains  over  five  per  cent,  of  carbo- 
hydrates, in  addition  to  from  3  to  4  per  cent,  of  alcohol,  and  it  is  well  known 
that  liberal  beer-drinkers  furnish  a  large  quota  of  fat  men.  A  second  method 
in  which  large  quantities  of  alcohol  contribute  to  adiposis  is  by  hastening 
albuminous  metamorphosis,  setting  free  non-nitrogenous  substances  readily 


822  CONSTITUTIONAL  DISEASES. 

converted  into  fat,  which  are  deposited,  among  other  situations,  in  the  Uver, 
giving  rise  to  the  fatty  Hver  so  constantly  found  in  drunkards. 

Another  cause  of  corpulency  is  muscular  inactivity.  Fat  is  consumed 
by  muscular  contraction,  and  its  absence  must  contribute  to  fat  accumulation, 
and  one  need  not  go  far  to  see  its  evidence  in  many  who  lead  lives  of  idleness. 
Oertel  has  especially  called  attention  to  the  fact  that  a  simple  diminished  in- 
gestion of  fluids,  without  other  changes  in  the  diet,  will  reduce  the  amount  of 
fat.  The  effect  may  be  brought  about  in  two  ways ;  first,  by  diminishing  the 
work  of  the  heart  and  thereby  favoring  oxidation ;  second,  by  an  effect  which 
is  not  so  much  the  diminution  of  fat  as  a  withdrawal  of  water — a  sort  of 
"  desiccation,"  it  is  called  by  Striimpell. 

The  subjects  of  anemia  and  chlorosis  often  become  fat,  probably  because 
of  defective  oxidation,  growing  out  of  a  diminished  supply  of  oxygen,  which 
the  crippled  corpuscles  are  unable  to  carry  in  sufficient  quantity. 

Sexual  continence  probably  contributes  to  corpulence,  since  eunuchs  are 
well  known  to  grow  fat,  and  both  w'omen  and  men  are  disposed  to  grow  fat 
when  the  sexual  function  begins  to  abate.  Finally,  corpulence  itself  favors 
the  further  accumulation  of  fat,  first  by  interfering  with  the  muscular  activity 
of  its  subject,  and  therefore  with  the  oxidation  of  fat,  and,  again,  diminishing 
combustion  by  reason  of  a  reduced  demand  for  heat,  the  fat  itself  conserving 
heat  by  preventing  its  radiation. 

Symptoms. — A  description  is  scarcely  needed  of  the  anatomical  condi- 
tion which  constitutes  obesity.  The  round,  plump  face,  the  double  chin  and 
hanging  cheeks,  the  enormous  girth  of  body,  the  pendulous  belly  and  elephan- 
tine arms,  legs,  and  thighs  need  no  further  description.  The  labored,  wad- 
dling gait  is  often  conspicuous.  The  first  evident  indication  of  harmfulness 
due  to  corpulence  is  an  increased  frequency  in  the  breathing-rate,  at  first  on 
slight  exertion  and  later  independently  of  it.  This  is  in  part  a  true  cardiac 
asthma — due,  first,  to  the  fact  that  the  heart  cannot  push  the  blood  through 
the  lungs  rapidly  enough  to  permit  its  aeration  at  the  ordinary  breathing- 
rate  ;  and,  second,  to  the  fact  that  the  motion  of  the  lungs  is  also  restricted. 
The  latter  is  due  to  the  accumulation  of  fat  over  the  thorax  and  in  the  medias- 
tinum, and  to  the  accumulated  intra-abdominal  fat  and  probably  enlarged 
liver,  which  interfere  with  the  proper  descent  of  the  diaphragm.  This  leads 
at  first  to  cardiac  hypertrophy,  further  stimulated  by  the  extra  work  demanded 
of  the  heart  in  propelling  the  increased  bulk  of  the  blood ;  further  augmented 
by  resulting  arteriosclerosis,  and  impeded  venous  circulation.  Later  the 
fatty  infiltration  of  the  muscular  walls  of  the  heart  leads  to  further  embar- 
rassment in  its  action  and  to  impairment  of  its  nutrition,  whence  come 
cardiac  weakness  and  ultimate  failure,  with  edema,  pericardial  and  pleuritic 
effusion,  and  sometimes  sudden  death. 

The  pulse,  hard  to  find,  is  usually  frequent,  but  may  be  slow  and  irregu- 
lar. The  heart  can  be  examined  only  wdth  difficulty,  on  account  of  the  large 
accumulation  of  fat,  and  the  normal  sounds  are  feeble  and  distant.  The 
situation  of  the  apex  can  be  found  only  by  the  aid  of  the  stethoscope.  Inter- 
trigo is  often  an  annoying  symptom,  and  great  care  is  required  to  avert  it. 
Interstitial  nephritis  may  be  superadded.  By  no  means  all  corpulent  per- 
sons run  this  course.     Many  lead  lives  of  considerable  comfort. 

Treatment. — This  consists  in  acting  upon  two  principles :  first,  furnish- 
ing less  food  to  oxidize,  and,  second,  increasing  the  oxidation  of  the  fat  in 
the  body. 

The  first  is  accomplished  by  cutting  down  the  quantity  of  all  kinds  of 


OBESITY.  823 

food,  but  especially  carbohydrates.  Sugar  should  be  prohibited  altogether, 
and  saccharin  substituted,  if  sweetening  is  desired.  Bread  may  be  taken  in 
small  amounts,  say  two  ounces,  well  toasted  and  with  it  a  thin  layer  of  butter  ; 
or  hard  biscuit  may  be  substituted.  A  cup  of  tea  or  coffee  with  a  little  milk 
may  be  allowed ;  also  a  single  egg  at  breakfast  or  luncheon ;  meat  once  a  day. 
The  latter  may  be  of  any  kind,  and  with  it  may  be  taken  green  vegetables, 
such  as  peas,  string-beans,  tomatoes,  cabbage,  spinach,  Brussels  sprouts, 
lettuce,  celery,  and  the  like,  omitting  altogether  rice,  potatoes,  and  the  fari- 
nacea  in  general.     A  little  cheese  may  be  allowed. 

Only  small  quantities  of  fluid  should  be  permitted  at  meals — just  enough 
to  aid  in  the  solution  and  digestion  of  food.  This  may  be  tea,  coffee,  water, 
or  skimmed  milk,  the  first  two  without  sugar  or  cream.  Beer,  porter,  and 
sweet  wines  should  be  prohibited,  but  a  glass  or  two  of  hock  or  claret  with 
an  alkaline  mineral  water  may  be  allowed. 

A  diet  of  skimmed  milk  only  is  a  sure  way  of  reducing  fat,  and  a  start 
may  be  made  with  it,  commencing  with  two  ounces  every  two  hours  and 
increasing  until  from  six  to  eight  ounces  are  attained.  Unfortunately,  very- 
few  persons  will  bear  this  treament  for  any  length  of  time,  but,  as  stated,  a 
beginning  may  be  made  with  it,  and  when  the  patient  tires,  the  other  treat- 
ment just  described  may  be  instituted. 

The  second  indication  to  promote  oxidation  is  accomplished  by  exercise, 
gymnastics,  walking,  mountain-climbing,  or  cycling.  The  last  has  been 
effective  in  reducing  the  weight  of  the  corpulent,  and  if  combined  with  a 
proper  diet,  may  be  expected  to  do  more.  Massage  is  also  useful,  especially 
in  co-operation  with  the  Turkish  bath  and  steam  bath.  These  last  help  in  the 
"  desiccation  "  of  the  body,  which  in  turn  facilitates  oxidation.  Great  diffi- 
culty is  experienced  in  getting  the  patient  to  carry  out  the  dietary  and  to  exer- 
cise assiduously. 

Certain  health  resorts  have  much  reputation  for  their  efficiency  in  reduc- 
ing corpulence.  Homburg,  Marienbad,  and  Carlsbad  are  among  the  most 
celebrated  of  these,  and  I  have  seen  many  patients  return  thence  after  a  cure 
of  four  to  six  weeks  markedly  improved  in  all  the  symptoms  which  come 
from  obesity.  The  effect  is  probably  altogether  due  to  the  strict  diet,  the 
systematic  exercise,  and  the  bathing,  the  massage,  and  the  laxative  effect  of 
the  waters,  although  the  physicians  at  the  various  spas  which  have  a  repu- 
tation for  reducing  obesity  claim  also  that  the  effect  of  the  sulphate  of  soda, 
which  is  a  constituent  of  most  of  these  waters,  is  to  stimulate  oxidation  in  the 
direction  of  the  fatty  structures,  while  limiting  the  metamorphosis  of  the 
nitrogenous  substances.  This  intermittent  method  of  treating  obesity,  by 
recourse  to  baths  and  springs  once  a  year  while  the  intervening  period  is 
spent  in  free  eating,  is  not  to  be  recommended.  It  is  much  better  to  adopt 
a  continuous  method  which  may  not  be  as  rapid,  but  is  persistent. 

Thyroid  extract  has  been  administered  with  reputed  advantage  in  obesity 
in  doses  of  from  three  to  five  grains  (0.2  to  0.35  gm.)  three  times  daily,  which 
may  be  gradually  increased  to  twenty  grains  (1.3  gm.),  with  the  same  precau- 
tions as  advised  in  the  treatment  of  myxedema.  Under  this  treatment  the 
loss  of  weight  is  sometimes  quite  rapid,  going  to  show  that  defective  thyroid 
secretion  may  be  a  factor  in  causing  obesity. 

Mention  should  perhaps  be  made  of  the  so-called  systems  of  diet  for 
reducing  corpulency,  a  number  of  which  have  been  suggested.  Those  espe- 
cially deserving  of  notice  are  the  Banting  system,  Ebstein's  method,  the 
method  of  Dancel-Oertel,  in  addition  to  the  mineral  water  cures.     It  is,  of 


824  CONSTITUTIONAL  DISEASES. 

course,  impossible  in  the  limited  space  of  a  text-book  to  give  these  methods 
in  full.  The  principles  of  their  application  will  alone  be  considered  and  the 
student  is  referred  to  special  sources  for  their  detailed  description/'' 

( I )  The  Banting  system  consists  in  the  administration  of  a  large  amount 
of  albuminous  food,  especially  lean  meat  to  the  exclusion  of  fats  and  carbo- 
hydrates;  green  vegetables  being  allowed  ad  libitum;  (2)  Ebstein's  method 
demands  moderation  and  restriction  in  the  quantity  of  foods  generally,  and 
for  the  fat-forming  carbohydrates  substitutes  the  albumin-saving,  but  not  fat- 
forming  fats  1(3)  the  Dancel-Oertel  method  reduces  especially  the  quantity  of 
water  and  other  liquids,  only  a  minimum  of  800  grams  (about  i  1-2  pints) 
of  water  mixed  with  wine,  and  twice  a  day  a  cup  of  coffee  or  tea ;  of 
solid  foods,  nitrogenous  alimentary  substances  and  vegetables,  especially 
such  as  contain  little  water,  with  fat  only  in  such  quantity  as  to  render 
the  dishes  palatable.  Oertel  emphasizes  the  mechanical  advantages  of  restric- 
tion in  the  use  of  water  upon  derangements  of  the  vascular  system;  (4)  the 
mineral  water  cures,  as  might  be  expected,  are  based  chiefly  upon  the  use  of 
such  waters,  especially  those  containing  sulphate  of  sodium  and  chlorid  of 
sodium,  the  cold  springs  being  preferred.  The  springs  are  thus  classified: 
(a)  cold  waters  containing  sulphate  of  soda — Marienbad,  Tarasp,  Schulz, 
Frazensbad,  Elster,  Cudowa.  and  Rolitsch — carbonic  acid  waters;  (h)  hot 
springs  containing  sulphate  of  sodium — Carlsbad,  Bertrich ;  (c)  cold  waters 
containing  chlorid  of  sodium — Homburg,  Kissengen,  Nauheim,  Neuhaus  and 
Oeynhausen ;  in  America  the  Saratoga  springs;  (rf)  springs  containing  iodin 
— Hall,  Krankenheil,  Salzschlirf,  Kreuznach,  Miinster  am  Stein.  The  drink- 
ing of  waters  at  these  places  is  combined  with  the  use  of  saline,  carbonated, 
mud,  and  steam  baths. 

RICKETS. 

Synonym. — Rachitis. 

Definition. —  "There  is  a  disease  of  infants  called  the  rickets,  wherein 
the  head  waxeth  too  great,  while  the  legs  and  lower  parts  wane  too  little  " 
(Thomas  Fuller,  1608-61).  This  quaint  description  of  the  celebrated  Eng- 
lish chaplain,  written  over  two  hundred  and  fifty  years  ago,  remains  so  nearly 
correct  at  the  present  day  that  I  cannot  forbear  adopting  it.  It  is  further 
defined  as  a  constitutional  disease  characterized  by  deformity  in  bones,  due  to 
cell  overgrowth  and  deficiency  in  lime  salts. 

"  The  rickets  "  was  evidently  known  for  some  time  by  the  laity  before 
it  received  its  description  by  F.  Glisson  in  1650,  who  suggested  the  change  of 
name  to  rachitis  from  the  Greek  pocxi^,  the  spine.  The  term  rickets  is 
derived  from  the  old  English  word  wrickken,  to  twist. 

Etiology. — Rickets  rarely  begins  before  the  child  is  six  months  old  or 
after  it  has  attained  the  age  of  eighteen  months,  though  a  form  is  described 
by  Sir  William  Jenner  coming  on  as  late  as  the  ninth  or  even  the  twelfth  year ; 
on  the  other  hand,  it  may  begin  earlier,  and  the  child  may  even  be  rickety  in 
the  womb.  Yet  it  cannot  be  admitted  that  rickets  is  hereditary,  in  the  usual 
sense  of  the  term.  The  child  may  become  rickety  in  the  womb  if  the  mother 
is  feeble,  underfed,  and  overworked,  and  if  the  father  is  weak  at  its  concep- 
tion, but  not  because  the  father  and  mother  were  rickety  when  children. 

*  "  Dietetic  and  Therapeutic  Hints  to  the  Visitors  of  Bad  Homburg."    By  Heinrich  Will,  M.  D., 
1893. 


RICKETS. 


825 


Again,  certain  races  tend  to  be  rickety,  especially  the  negro  and  the  Italian- 
Foul  air  and  bad  food,  absence  of  sunlight  and  exposure  to  dampness  and 
cold,  are  more  potent  factors,  and  it  is  likely  that  a  defective  composition  of 
the  iDreast  milk,  including  a  deficiency  in  the  phosphates,  is  the  strongest. 
Prolonged  lactation  may  contribute  to  such  deficiency.  It  is  a  disease  of  the 
city  rather  than  of  the  country,  and  of  the  Continent  of  Europe  rather  than 
of  America.     Vienna,  London,  and   Paris  are  prolific  fields.     In  the  first- 


Fig.  81.— Deformed  Skeleton  from  a  Case  of  Rachitis— (/r^w  Atlas  du  Musee 

Dupnytren). 

named  cities  from  50  to  70  per  cent,  of  all  children  brought  to  the  clinics  are 
said  to  be  rickety.  Parrot  held  that  congenital  rickets  was  a  form  of  syphilis, 
basing  this  view  on  studies  in  the  French  capital.  On  the  other  hand,  there  is 
reason  to  believe  that  the  changes  in  prenatal  rickets  are  not  identical  with 
those  of  the  postnatal  form.  The  subjects  of  the  former  are  usually  still- 
born, are  short  of  limb,  and  though  the  curves  of  the  bones  are  exaggerated, 
there  is  no  proliferating  zone  of  cartilage  between  the  epiphysis  and  apophysis, 
v;hence  the  term  achondroplasy,  suggested  by  Parrot,  and  chondro dystrophia^ 


826  CONSTITUTIONAL  DISEASES. 

foetalis,  by  Kaufmann.  Boys  and  girls  are  equally  liable  to  rickets.  The 
syphilitic  origin  of  congenital  rickets  is  not,  however,  conceded  by  others. 

Minute  examination  recognizes  numerous  cells  in  the  spongy  spaces  in 
the  bone.  The  studies  of  Kassowitz  lead  him  to  believe  that  a  hyperemia  of 
the  periosteum,  the  marrow^,  the  cartilage,  and  the  bone  itself  is  the  funda- 
mental condition  responsible  for  the  abnormal  development.  His  views  may 
be  regarded  as  a  refinement  and  development  of  those  originally  suggested 
in  1650  by  F.  Glisson,  who  held  that  an  excessive  vascularity  was  at  the  bot- 
tom of  the  changes. 

Morbid  Anatomy. — This  shades  somewhat  into  symptomatology,  and 
the  two  can  scarcely  be  separated.  The  changes  are  mainly  in  the  bones  of 
the  skull,  the  long  bones,  and  the  ribs.  The  first  may  escape  if  the  disease 
sets  in  after  the  middle  or  end  of  the  second  year.  The  frontal  and  parietal 
eminences  are  exaggerated,  while  the  top  of  the  head  and  the  occiput  are 
flattened,  the  whole  effect  being  toward  making  the  head  square  or  "  box- 
shaped."  The  fontanels  remain  open  some  time, — until  the  second  or  third 
year  of  life, — while  the  edges  of  the  bones  where  they  come  together  to  form 
the  sutures  are  thickened,  though  soft  and  yielding.  In  addition  to  these 
changes,  or  instead  of  them,  there  may  be  large  areas  of  delayed  ossification 


Fio.  82. — Rickety  Chest— {after  Gee). 
Dotted  line  indicates  the  shape  of  the  chest  of  a  healthy  infant  about  the  same  age. 

in  the  parieto-occipital  regions,  producing  yielding  spots,  constituting  the 
so-called  craniotabes-  of  Elsasser ;  but  as  craniotabes  occurs  in  connection 
with  syphilis  and  other  wasting  diseases  of  young  infants  exhibiting  no  other 
sign  of  rickets,  and  even  in  new-born  infants,  it  cannot  be  regarded  as 
pathognomonic. 

In  the  long  bones,  such  as  the  radius  and  ulna,  swelling  of  the  cartilage 
between  the  epiphysis  and  shaft  is  apparent.  Owing  to  the  rapid  prolifera- 
tion of  cartilage  cells,  resultingSn  a  broad  band  of  jelly-like  material  between 
the  cartilage  and  the  bone,  a  spongy  structure  is  rapidly  built  up,  deficient  in 
strength  and  stiffness.  Beneath  the  periosteum  the  same  gelatinous  material 
is  deposited,  and  a  spongy  tissue  is  formed  instead  of  normal  bone.  The 
process  of  bone  formation  does  not  proceed  further.  There  is  no  deposit  of 
lime  salts.  The  periosteum  is  loosely  attached.  The  long  bones  bend  easily, 
especially  the  tibia,  producing  the  characteristic  bow-leg,  which  may  occur 
even  before  the  child  walks,  when  it  is  caused  by  sitting  cross-legged.  The 
thighs  may  also  become  bowed,  the  inner  ends  of  the  condyles  prolonged 
downward  and  the  tibia  set  outward,  producing  the  "  knock-knee."  This 
does  not,  however,  appear  until  the  child  begins  to  walk.  In  extreme  cases 
the  long  bones  may  fracture.  Sometimes  both  the  femora  and  tibiae  are 
bowed  forward. 


RICKETS.  827 

Quite  as  characteristic  are  the  changes  in  the  chondral  ends  of  the  ribs 
and  in  the  shape  of  the  chest.  The  former  are  enlarged  and  nodular  at  the 
junction  with  the  bone,  producing  the  well-known  beaded  appearance,  which 
may  often  be  recognized  at  a  glance.  The  altered  shape  of  the  chest-walls, 
most  marked  in  children  who  have  had  much  cough,  is  due  to  the  yielding  of 
the  soft  costal  ends  of  the  cartilages  and  to  a  falling-in  of  the  ribs  at 
these  points,  while  the  sternum  and  cartilages  are  pushed  forward,  as  seen  in 
Figure  82. 

This  is  especially  the  case  in  the  region  between  the  fourth  and  eighth 
ribs,  which  may  be  so  bent  in  as  to  form  a  vertical  groove,  increased  during 
inspiration.  Associated  with  this  is  sometimes  a  transverse  groove,  known 
as  Harrison's  groove,  starting  at  the  ensifomi  cartilage  and  passing  trans- 
versely outward  toward  the  axilla.  At  the  same  time  the  arch  of  the  ribs 
below  may  be  widened  and  the  belly  thrown  forward  by  the  arching  inward 
of  the  vertebrae.  Extreme  degrees  of  this  chest  deformity  produce  the  proi-jii- 
nent  sternum  constituting  the  "  chicken-breast  "  or  ''  keel-shaped  "  thorax. 
Other  changes  in  the  bones  are  an  exaggeration  of  the  normal  double  curve 
in  the  clavicle ;  a  bending  of  the  humerus,  usually  at  the  insertion  of  the 
deltoid,  sometimes  produced  by  lifting  the  child  by  the  arms ;  the  radius  and 
ulna  may  be  curved  and  twisted,  the  articulations  knotted  and  bulbous,  loose 
and  mobile,  because  of  relaxed  ligaments.  The  spine  is  also  often  altered, 
the  change  being  for  the  most  part  an  increase  in  the  normal  curve  outward 
in  the  cervico-thoracic  portion  and  inward  at  the  lumbo-sacral.  In  other 
cases  there  is  a  lateral  curvature.  The  scapula  is  often  thickened.  The 
pelvis  is  distorted  and  twisted,  and  the  antero-posterior  diameter  is  markedly 
lessened.  The  rickety  pelvis  is  one  of  the  well-recognized  causes  of  dys- 
tocia. These  changes  are  all  the  result  of  mechanical  causes,  such  as  the 
weight  of  the  body  or  muscular  traction. 

Chemical  analysis  of  rickety  bones  approximately  reverses  the  normal 
proportion  of  organic  and  mineral  constituents  (calcium  salts),  reducing  the 
latter  to  35  per  cent.,  while  the  gelatinous  or  organic  matters  amount  to  65 
per  cent. 

An  enlarged  liver  and  spleen  are  usually  present,  and  sometimes  also 
the  mesenteric  glands  are  enlarged. 

Symptoms. — (See  also  Morbid  Anatomy.)  The  earliest  symptoms 
noticed  are  not  invariably  the  same.  There  is  usually  profuse  szveating. 
especially  about  the  head  and  neck,  and  a  mild  degree  of  fever,  as  the  result 
of  which  the  child  is  inclined  to  throw  off  the  bed-clothing.  There  is  evi- 
dent discomfort  in  being  handled.  The  last  symptom  is  apparently  due  to  a 
tenderness  of  the  skeleton,  causing  pain  when  the  child  is  raised  or  danced  up 
and  down  after  the  manner  of  amusing  children.  Along  with  these  are  the 
less  distinctive  symptoms  of  indigestion,  indicated  by  nausea  and  vomiting, 
offensive  stools  containing  partly  digested  milk,  and  flatulent  distention, 
causing  the  belly  to  be  prominent.  Among  other  less  essential  symptoms 
may  be  mentioned  nervousness,  restlessness,  peevishness,  and  infantile  con- 
vulsions, the  relationship  of  which  to  rickets  is  not  accidental  and  was  pointed 
out  by  Jenner.     Tetany  and  laryngismus  stridulus  are  also  often  symptoms. 

Concurrently  it  is  noticed  that  teething  is  delayed,  and  we  have  the 
authority  of  Sir  William  Jenner  that  if  there  are  no  teeth  at  nine  months 
there  is  something  rickety  about  the  child.  But  I  am  confident  that  I  have 
seen  dentition  delayed  after  this  time  in  children  who  were  not  and  who  did 
not  become  ricketv-     In  ricketv  children  the  teeth  which  are  cut  soon  decay. 


828  CONSTITUTIOXAL  DISEASES. 

Muscular  n'cakiicss  is  characteristic,  so  that  the  child  cannot  sit  up  and 
makes  but  a  feeble  or  no  efifort  to  walk.  Such  muscular  weakness  has  been 
mistaken  for  paralysis,  whence  it  has  been  called  the  pseudoparesis  of  rickets. 
Close  upon  these  symptoms,  or  at  least  within  two  or  three  weeks  of  the  first 
symptom,  follow  the  skeletal  changes  described  under  morbid  anatomy,  page 
826.  The  head  is  large  in  comparison  with  the  face,  the  skin  is  pale  and 
thin,  and  the  child  has  often  an  old  and  a  wise  look  quite  beyond  its  years. 
The  appearance  of  the  beaded  ribs,  the  bowed  legs  or  "  knock-knees,"  promi- 
nent belly,  and  curved  spine  often  serve  to  make  the  diagnosis  easy  at  a  glance. 
The  prominent  belly  requires  some  further  description,  as  it  varies  somewhat 
at  different  periods.  Before  the  child  walks  the  normal  cervical  anterior 
curve  may  be  increased  and  a  posterior  curve  present  from  the  first  dorsal  to 
the  last  lumbar  vertebra,  which  may  be  recognized  by  holding  the  child  up. 
After  it  begins  to  walk,  however,  the  dorsal  spine  continues  curved  backward 
while  the  lumbar  projects  forward.  The  latter,  therefore,  contributes  also 
to  the  prominent  belly  produced  in  part  by  flatulent  distention,  and  partly  at 
times  by  an  enlarged  liver  and  spleen. 

Complications. — These  include  especially  bronchial  catarrh  and  broncho- 
pneumonia, the  eft'ects  of  which  are  aggravated  by  the  conformity  of  the 
chest,  the  weakness  of  the  ribs,  and  the  feebleness  of  the  respiratory  muscles. 
Collapse  of  the  lung  is  often  a  consequence  of  lung  affections.  Chronic 
hydrocephalus  is  a  complication,  while  many  of  the  conditions  mentioned 
under  symptomatology — viz.,  diarrhea,  convulsions,  laryngismus  stridulus, 
and  the  like — may  also  be  so  regarded.  The  rickety  child  is  weak  and  is  vul- 
nerable to  all  the  illnesses  of  childhood. 

Diagnosis, — This  is  usually  easy,  although,  of  course,  all  the  symptoms 
detailed  are  not  always  present  in  their  typical  expression.  The  various 
spinal  curvatures  may  be  somewhat  confusing.  Thus,  the  question  of  caries 
may  arise.  But  the  rickety  spine  differs  from  that  of  caries  by  the  wide 
curve,  the  absence  of  angularity,  the  flexibility  of  the  spine,  and  the  fact  that 
by  laying  the  child  flat  on  its  face  the  curs^e  disappears.  The  other  symptoms 
of  rickets  are  also  present.  The  lordosis  of  rickets  produces  a  deformity 
resembling  that  of  congenital  dislocation  of  the  hip  and  of  hip  disease,  but 
here  again  other  signs  of  rickets  are  present,  while  the  distinctive  signs  of  the 
disease  in  question  are  absent. 

Prognosis. — Rickets  is  never  in  itself  fatal,  and  the  course  is  toward 
recovery.  But  the  child  is  always  in  danger  from  the  complications.  Such 
are  bronchitis,  bronchopneumonia,  laryngeal  spasm,  and  convulsions.  Walk- 
ing is  always  delayed,  and  the  child  may  be  still  unable  to  walk  at  the  end  of 
the  second  or  third  year.  [Mention  has  been  made  of  the  fact  that  the  rickety 
pelvis  in  women  is  one  of  the  most  frequent  causes  of  difficult  labor. 

Treatment. — We  should  seek  to  avert  rickets  by  a  judicious  prophylaxis, 
which  consists  in  keeping  the  health  of  the  mother  at  the  highest  point  at  all 
times ;  this,  not  by  organic  food  only,  but  by  a  judicious  admixture  of  salts 
such  as  are  contained  in  the  whole  cereal  grain,  especially  in  wheat  and  barley. 
Frequent  pregnancies  and  prolonged  nursing,  being  acknowledged  causes, 
should  be  interdicted. 

The  treatment  of  the  child  should  be  dietetic,  medicinal,  hvgienic,  and 
operative  or  mechanical.  As  the  condition  depends  often  upon  the  lack  of 
ordinary  good  food,  the  simple  addition  of  such  food  in  lieu  of  the  mother's 
milk,  if  this  be  found  defective,  may  be  all  that  is  required,  especially  if  it  be 
possible  to  secure  that  rarely  attainable  article,  a  healthy  wet-nurse.     In  the 


OSTEOMALACIA.  829 

absence  of  this  beef- juice,  the  yolk  of  eggs,  peptonized  milk,  and  beef  pep- 
tonoids  may  be  substituted.  Due  consideration  must,  however,  be  paid  to 
digestion  in  the  selection  of  food,  the  stools  should  be  examined  daily,  and  if 
undigested  residue  is  found,  the  food  should  be  changed.  Pepsin  and  hydro- 
chloric acid  in  doses  adapted  to  the  age  of  the  child  should  be  given,  while  the 
predigested  foods  are  often  highly  useful.  Cod-liver  oil  inunctions  are 
invaluable,  and  though  in  some  respects  unpleasant,  I  have  seen  so  many  chil- 
dren seemingly  wrested  from  death  by  their  use  that  I  value  nothing  more 
highly.  Saccharine  and  starchy  foods  should  not  be  allowed,  except  in  very 
moderate  quantities.  The  flours  of  the  whole  cereals,  well  baked  and  cooked 
as  thin  gruels  and  strained,  make  a  suitable  addition  to  the  food,  while  the 
fruit-juices  of  orange  and  lemon  may  be  given  in  small  quantities.  Medi- 
cines should  bC'  cautiously  given.  Among  them  are  lime  salts,  as  the  hypo- 
phosphite  of  calcium  or  lactophosphate  of  calcium,  ten  grains  (0.65  gm.)  of 
either  three  times  a  day,  or  lime-water,  or  the  official  syrups  containing  the 
salts  mentioned.  Doses  should  be  carefully  regulated,  as  digestion  is  feeble. 
Minute  doses  of  iron,  preferably  the  citrate  or  malate,  may  be  given.  Phos- 
phorus was  recommended  by  Kassowitz,  and  is  indorsed  by  Wegener,  Jacobi, 
and  Striimpell,  in  doses  of  from  1-200  to  i-ioo  grain  (0.00033  to  0.00066 
gm.)  two  or  three  times  a  day  dissolved  in  olive  oil  or  cod-liver  oil.  The 
principle  of  the  administration  of  these  two  drugs  is  different.  The  salts 
previously  mentioned  are  convenient  modes  of  administering  calcium,  while 
phosphorus  is  supposed  to  stimulate  bone  grozvth. 

The  hygienic  treatment  is  more  important  than  the  medicinal.  Fresh 
air  and  outdoor  life  are  indispensable.  If  the  child  is  warmly  clothed  and 
well  protected,  it  may  be  taken  out  even  in  cold  weather.  If  should  not  he 
aUoived  to  zvalk  or  even  tx)  sit  up  unless  properly  supported — in  fact,  should 
be  handled  as  little  as  possible. 

Mechanical  appliances  ma}'  be  employed  with  advantage,  especially  in 
lateral  bowing,  before  the  bone  is  hardened.  Forcible  manual  straightening 
may  also  be  employed  in  moderate  grades  of  deformity,  but  should  be  rele- 
gated to  the  experienced  orthopedic  surgeon.  After  ossification  is  complete, 
deformities  may  be  corrected  by  the  orthopedic  surgeon,  by  osteotomy,  chiefly 
of  the  bones  of  the  lower  extremities,  though  the  radius  and  ulna  are  some- 
times operated  on.  Osteotomy  of  the  pelvis  has  been  suggested  by  Macewen 
in  parturient  women  in  whom  delivery  is  impossible,  but  a  recently  revived 
operation,  symphysiotomy,  has  made  it  unnecessary. 


OSTEO^IALACIA. 

Definition. — A  softening  which  takes  place  in  the  bones  by  a  solution 
of  lime  salts  subsequent  to  their  complete  development. 

Etiology. — The  precise  cause  is  unknown.  A  geographical  distribu- 
tion, however,  exists,  in  accordance  with  which  it  is  common  on  the  Rhine, 
in  Westphalia,  in  Eastern  Belgium,  and  in  Xorthern  Italy.  In  this  respect 
it  is  similar  to  goiter,  which  prevails  in  special  localities,  and  it  has  been  sug- 
gested on  this  account  that  it  may  be  due  to  some  local  cause.  It  is  for  the 
most  part  a  disease  of  adults  between  thirty  and  forty  years  old,  and  of 
women  more  than  of  men.  It  is  favored  by  unhygienic  surroundings,  such 
as  damp  and  badly  ventilated  dwellings.  Frequent  pregnancy  is  supposed  to 
be  an  exciting  cause. 


830  CONSTITUTIONAL  DISEASES. 

Pathogeny. — There  is,  primarily,  increased  vascularity.  To  this  suc- 
ceed a  solution  and  disappearance  of  the  lime  salts  of  the  bone.  These  take 
place  from  within  outward,  from  the  marrow  cavity,  dissolving  out  first  the 
lime  salts  and  then  melting  away  the  matrix,  enlarging  the  central  cavity  until 
the  cortical  portion  acquires  a  paper-like  thinness.  The  whole  bone  has  been 
compared  to  an  "  inflated  and  dried  intestine."  The  product  of  the  solution 
at  first  is  a  mucoid  matter  that  mixes  with  the  marrow.  The  latter  soon 
loses  its  vascularity  and  gradually  acquires  a  thinner  but  still  viscid  character 
and  a  yellow  color.  The  periosteum  is  likewise  hyperemic  and  at  first  thick- 
ened. The  process  is  compared  to  the  artificial  solution  of  the  earthy  salts 
from  bone  by  hydrochloric  acid,  and  it  is  supposed  that  the  solvent  agent 
exerts  its  effect  from  the  medullary  spaces  and  Haversian  canals.  It  has 
been  suggested  that  lactic  acid  is  the  solvent,  as  it  has  been  found  in  the  medul- 
lary canal  and  in  the  urine  of  subjects  of  osteomalacia.  The  process  extends 
unevenly.  It  differs  from  rickets  in  being  a  degeneration  of  fully  formed 
hone,  while  the  latter  is  a  degeneration  of  developing  bone. 

Morbid  Anatomy. — The  favorite  seats  of  the  process  are  the  vertebrae 
and  the  bones  of  the  pelvis  and  thorax.  The  result  in  the  former  is  an  S-like 
curve  of  the  spinal  column,  due  to  a  kyphosocoliosis  or  backward  curvature 
of  the  dorsal  and  a  lordoscoliosis  or  forward  curvature  of  the  lumbar 
part,  while  the  cervical  portion  in  connection  with  the  upper  dorsal  portion 
protrudes  anteriorly.  The  thorax  is  distorted  and  compressed  laterally, 
while  the  sternum  is  prominent  and  bent.  The  pelvis  is  also  compressed 
laterally,  the  symphysis  projects  like  the  prow  of  a  ship,  and  the  sacrum  pro- 
jects forward  producing  a  deformity  of  the  pelvis  often  discoverable  only 
by  internal  examination. 

Symptoms. — The  first  symptom  is  usually  pain,  deep  seated  and  severe, 
oftenest  in  the  sacral  region,  nape  of  the  neck,  back,  and  thighs,  and  this  pain 
is  persistent  and  increased  by  motion,  giving  rise  to  a  hobbling  gait.  There 
is  also  tenderness.  Walking,  therefore,  becomes  more  and  more  difficult 
and  finally  impossible,  and  the  patient  takes  to  bed.  But  this  affords  no 
relief,  the  pain  being  kept  up  by  the  pressure  of  the  bed-clothing  and  the 
weight  of  the  body.  In  the  meantime  the  deformities  described  under 
morbid  anatomy  take  place,  though  those  of  the  pelvis  are  less  obvious  exter- 
nally. Diificiilt  labor  is  an  inevitable  consequence  should  the  patient  conceive, 
just  as  it  is  in  rickets.  Dyspnea  is  a  frequent  consequence  of  compression  of 
the  lung  by  the  distorted  thorax.  Fractures,  complete  and  incomplete,  are 
frequent  events,  even  of  the  ribs  as  well  as  of  the  extremities.  In  this  respect 
osteomalacia  differs  from  rickets,  in  which  the  bones  bend  but  do  not  break. 
Such  fractures  repair  imperfectly.  Sometimes,  on  the  other  hand,  the  limbs 
are  soft  and  yielding,  and  may  be  bent  like  lead  pipe.  The  bones  of  the  head 
and  face  are  for  the  most  part  exempt,  though  the  head  is  much  bent  toward 
the  chest,  making  the  stature  lower. 

The  general  condition  of  the  patient  often  remains  for  a  long  time  unal- 
tered. There  is  little  or  n6  fever.  The  organic  functions  are  normally  main- 
tained. The  presence  of  lactic  acid  in  the  urine  has  been  mentioned.  It  is 
said  that  phosphoric  acid  is  diminished.  Albumin  is  also  sometimes  present. 
Calcareous  concretions  have  been  found  in  the  kidneys  and  bladder. 

Diagnosis. — At  first  there  may  be  doubt  as  to  the  nature  of  the  disease, 
but  as  the  characteristic  symptoms  present  themselves,  its  real  nature  becomes 
evident.  Disease  of  the  vertebrce  and  cord  has  been  confounded  with  it,  but 
the  hobbling  gait  peculiar  to  it  does  not  usually  resemble  any  of  the  gaits  of 


PURPURA.  831 

spinal  disease.  Being  a  disease  of  adults,  it  is  not  likely  to  be  mistaken  for 
rickets.  Moreover,  it  is  a  disease  which  afifects  the  shafts  of  bones  rather 
than  the  epiphyses. 

Prognosis. — The  disease  is  usually  ultimately  fatal,  although  death  is 
often  long  deferred  and  the  course  is  chronic — from  two  to  ten  years.  Arrest 
sometimes  occurs,  but  is  only  temporary.  The  disease  again  starts,  and  its 
course  is  generally  irresistible.  Death  commonly  takes  place  from  exhaus- 
tion or  from  some  compHcation  like  pneumonia.  Recovery  is  not  impossible. 
The  so-called  cystic  degeneration  of  bone  is  said  to  be  a  consequence. 

Treatment. — Theoretically,  the  indications  are  the  same  as  for  rickets 
— viz.,  to  supply  the  blood  with  lime  salts.  Practically,  they  have  not  proved 
of  much  value.  They  may,  however, 'be  prescribed  in  the  shape  of  the  syrup 
of  the  lactophosphate  of  lime  in  the  dose  of  from  one  to  two  fluid  drams  (4 
to  8  c.  c.)  or  the  syrup  of  the  hypophosphites  in  the  same  dose  or  the  latter 
in  combination  with  iron  or  with  cod-liver  oil.  Proper  hygiene  and  good 
food  are  of  the  utmost  importance.  Phosphorus  itself  is  a  drug  highly  com- 
mended.     (See  Rickets.)      Striimpell  gives  the  following  prescription  for  it: 

i^     Phosphori,  o.oi  gm    (     3-20  grain 

Olei  amyg.  express,    ......     10.00  (150  grains) 

Misce,  deinde  adde, 

Pulv.  acaciffi     .     I  aa         .        .        .        .  5.00  gm.  (     75      " 

Syrupi,  simplicis,  f                              .  3       &       v     /j 

Aqusedest. , 80.00  gm.  (1200      " 

M.  Sig. — Two  to  four  teaspoonfuls  a  day. 

Women  who  are  subjects  of  osteomalacia  should  be  warned  against 
marriage. 

PURPURA. 

Synonyms. — Morbus  macitlosus ;  Peliosis. 

Definition. — A  name  given  to  several  dyscrasic  states,  all  attended  by 
subcutaneous  or  submucous  extravasations  of  blood.  Such  extravasations 
do  not  disappear  on  pressure,  and  vary  in  size  from  that  of  a  pin-point  to 
areas  a  centimeter  or  more  in  extent.  When  minute  or  punctiform,  they  are 
called  petechiae ;  when  larger  than  this,  ecchymoses.  An  indisposition  on  the 
part  of  the  blood  to  coagulate  is  commensurate  with  the  tendency  to  extrava- 
sation. Purpura  is  always  a  symptom  rather  than  a  disease,  but  in  certain 
conditions  it  forms  the  most  conspicuous  symptom  of  a  group  which  scarcely 
admits  of  any  other  classification.  In  this  event  an  adjective  term  derived 
from  some  more  conspicuous  one  of  these  symptoms,  or  from  the  name  of 
some  investigator  who  has  described  the  condition,  is  added  to  give  precision. 
In  other  instances  it  is  so  purely  a  symptom  and  plays  so  minor  a  role  in  the 
disease  that  it  is  called  symptomatic.  Under  any  circumstances  it  is  not 
always  easy  to  keep  the  varieties  distinct. 

Symptomatic  Purpura. 

This  includes  the  forms  of  purpi5ra  in  which  the  petechise  and  ecchy- 
moses are  usually  of  minor  importance.  In  a  few  instances  in  which  the 
dyscrasia  is  very  great  they  become  by  their  number  and  extent  indices  of 
the  degree  of  such  dyscrasia.     Such  are: 


§32  CONSTITUTIONAL  DISEASES. 

1.  The  purpura  which  often  invades  the  extremities  of  the  old  (senile 
purpura). 

2.  The  purpura  of  the  infectious  diseases  (infectious  symptomatic  pur- 
pura), especially  typhus  fever,  smallpox,  scarlet  fever,  measles,  pyemia, 
mycotic  endocarditis. 

3.  The  purpura  of  poisons  (toxic  symptomatic  purpura) — as,  for 
example,  that  which  occurs  in  connection  with  venomous  snake-bites,  or  with 
overdoses  of' certain  medicines,  such  as  ergot,  mercury,  copaiba,  quinin,  iodid 
of  potassium,  and  others.  Certain  persons  possessed  of  idiosyncrasies  acquire 
purpura  on  the  administration  of  much  smaller  doses.  In  these  the  extrava- 
sations may  occur  anywhere  on  the  body. 

4.  The  purpura  attending  certain  diseases  which,  though  not  infectious, 
induce  cachectic  states — viz.  (cachectic  symptomatic  purpura),  cancer,  tuber- 
culosis, Bright's  disease. 

5.  Certain  nervous  diseases  (neurotic  symptomatic  purpura),  including 
locomotor  ataxia,  myelitis,  rarely  neuralgia,  and  hysterical  states  associated 
with  the  bleeding  points  known  as  stigmata. 

6.  Mechanical  symptomatic  purpura,  when  induced  by  some  cause  resist- 
ing the  onward  movement  of  the  blood,  as  a  paroxysm  of  whooping-cough, 
croup,  or  an  epileptoid  fit. 

The  diagnosis  of  these  conditions  is  a  purely  etiological  one,  and  the 
prognosis  and  treatment  are  those  of  the  diseases  causing  them. 


SCURVY. 
Synonym. — Scorbutic  Purpura. 

Definition. —  A  disease  characterized  by  a  dyscrasic  state  of  the  blood, 
which  favors  subcutaneous  or  submucous  hemorrhage,  by  a  peculiar  spongy 
state  of  the  gums,  and  extreme  general  weakness. 

Etiology. — Less  than  half  a  century  ago  the  idea  of  scurvy  was  always 
associated  with  the  seafaring  life,  since  sailors  were  its  chief  victims,  though 
almshouses  and  prisons  also  held  their  complement.  In  the  food  of  these 
persons  fresh  vegetables  and  vegetable  juices  and  organic  salts  were  want- 
ing. So  it  came  to  be  acknowledged  that  such  privation  was  responsible  for 
scurvy,  and  proof  of  this  belief  was  thought  to  exist  in  the  fact  that  with  the 
quicker  voyages  of  ships  and  a  supply  of  suitable  food,  scurvy  had  almost 
vanished  from  the  nosology.  It  appears,  however,  that,  after  all,  the  effect  of 
such  causes  is  predisposing  and  the  disease  may  be  really  infectious,  being 
due  to  some  as  yet  undetected^^organism.  Especially  firm  in  this  belief  are 
those  who'  have,  by  reason  of  its  distribution,  had  the  best  opportunities  for 
its  study — as,  for  example,  in  Russia,  where  the  disease  is  endemic,  some- 
times epidemic.  Finally,  it  turns  out  that  not  only  sporadic  cases,  but  even 
epidemics,  occur  quite  independently  of  the  dietetic  causes  named. 

At  the  present  day  scurvy  has  become  a  rare  disease,  but  is  still  met  in 
camps,  prisons,  almshouses,  and  situations  where  the  food  causes  named  exist 
along  with  dampness,  foul  air,  and  depressing  influences  generally,  among 
which  nostalgia  is  supposed  to  be  especially  potent.  The  efifect  of  the  food 
causes  has  been  held  by  Garrod  and  by  Ralfe  to  be  the  deficiency  of  the  potas- 
sium salts,  more  especially  of  the  alkaline  carbonates  derived  from  the  con- 
version of  the  organic  salts  of  the  vegetable  and  fruit  juices — viz.,  the  malates, 
tartrates,  citrates,  and  lactates.     Experimental  proof  of  the  latter  is  adduced 


PURPURA.  833 

by  feeding  animals  upon  acid  salts,  the  effect  of  which  is  to  impair  their  nutri- 
tion and  to  produce  dyscrasic  states  of  the  blood  similar  to  those  of  scurvy 
and  followed  by  like  extravasations. 

The  disease  attacks  the  old  and  young  of  either  sex,  though  the  old  are 
more  susceptible,  and  it  happens,  probably  from  accidental  circumstances,  that 
more  males  are  affected  than  females. 

Reference  should  be  made  to  the  observations  of  my  colleague  J.  P.  C. 
Griffith,*  who  has  shown  that  scurvy  has  appeared  in  children  who  have  been 
too  long  fed  on  certain  artificial  infant  foods. 

Morbid  Anatomy. — This  consists  in  (i)  alterations  of  the  blood;  (2) 
the  extravasations  of  blood,  which  may  be  anywhere, — subcutaneous,  sub- 
mucous, intermuscular,  and  interstitial.  The  blood  changes  are  not  dis- 
tinctive. The  blood  is  dark  and  fluid,  the  blood-corpuscles  and  hemoglobin 
are  concurrently  reduced,  and  there  is  no  leukocytosis.  Rarely  there  is  even 
sloughing  of  the  skin  and  mucous  membrane,  leaving  ulcerated  patches  in 
the  skin  and  bowels.  The  spleen  is  soft  and  enlarged,  and  there  may  be 
degenerative  changes  as  well  as  hemorrhages  in  the  kidneys,  liver,  and 
muscles. 

Symptoms. — The  more  evident  symptoms  are  the  changes  in  the  gums, 
and  the  deep-seated  and  superficial  hemorrhages. 

The  gums  are  swollen,  soft,  and  spongy,  with  disposition  to  bleed  easily. 
In  the  more  severe  cases  there  is  ulceration,  with  loosening  and  falling  out 
of  the  teeth,  the  tongue  is  swollen,  and  the  breath  excessively  foul.  The 
gums  of  young  children  and  of  the  aged  are  more  often  uninvaded.  In  rare 
cases  only  is  there  necrosis  of  the  jaw\ 

The  hemorrhages,  always  petechial,  appear  usually  first  in  the  lower 
extremities,  then  on  the  arms  and  trunk,  but  they  occur  anywhere  as  roundish, 
dark-red  spots  which  may  assume  larger  size.  They  are  rare  in  the  face  and 
scalp,  and  are  less  common  under  the  mucous  membranes  and  in  deep-seated 
tissues.  Subperiosteal  hemorrhages  may  occur.  Nasal  hemorrhages  may 
be  frequent,  melena  and  hematuria  rare,  hematemesis  and  hemoptysis  still 
rarer.  The  extravasations  are  slow  to  disappear,  even  when  recovery  takes 
place.  The  occasional  sloughing  has  been  referred  to.  A  residual,  slowly 
healing  ulcer  results. 

Other  symptoms  are  debility,  extreme  in  severe  cases,  and  anemia.  The 
pulse  is  small,  feeble,  and  frequent,  and  corresponds  to  the  heart's  action, 
which  is  sometimes  irregular;  more  rarely  is  it  slower  than  in  health.  The 
temperature  is  normal,  rarely  somewhat  elevated.  Sore  throat  is  mentioned 
as  a  premonitory  symptom.  In  bad  cases  nephritis  and  endocarditis  occur. 
Articular  swelling  is  an  occasional  symptom ;  it  is  one  of  the  results  of  the 
dyscrasia ;  so  are  wheals  and  vesicles. 

Diagnosis. — This  depends,  as  stated,  on  the  etiology,  the  gingival 
changes,  and  the  hemorrhages.  It  is  these  which  chiefly  distinguish  it  from 
the  other  forms  of  purpura. 

Prognosis. — Sporadic  cases  always  get  well,  and  epidemic  cases  usually, 
unless  too  far  advanced  before  coming  under  treatment. 

Treatment. — This  is  usually  most  satisfactory  when  the  necessary  con- 
ditions are  fulfilled — a  restored  wholesome  hygiene  and  suitable  food.  Good 
ventilation  and  outdoor  life  in  health <-  localities,  with  plentv  of  fresh  vege- 
tables, fruits,  and  fresh  meats,  ordinarily  suffice  to  accomplish  a  prompt 
cure.  It  is  usual  to  give  lemon  and  orange- juice  as  the  types  of  the  fruit- 
juices.     Tonics  and  roborants,  of  which  iron,  quinin,  and  strychnin  are  the 

*  "  The  Relation  of  Scurvy  to  Recent  Methods  of  Artificial  Feeding,"  "  N.  Y.  Med.  Jour.,"  Feb. 
23,  igoi;  Scurvy,  Not  Rheumatism."  "Phila.  Med.  Jour.,"  Feb.  2,  iqoi;  "American  Pediatric  Society's 
Collective  Investigation  on  Infantile  Scurvy,"  "  Arch,  of  Fed.,"  July,  iSg8. 
53 


834  CONSTITUTIONAL  DISEASES. 

type,  are  the  medicines  needed.  Calcium  chlorid  may  be  used  in  doses  of 
from  5  to  15  grains  (0.3  to  i  gm.).  Antiseptic  and  astringent  mouth- 
washes should  be  used,  and  ulcers  should  be  stimulated  by  local  applications,, 
of  which  nitrate  of  silver  in  solution  is  the  best. 


Infantile  Scurvy. 

Synonyms. — Barloiv's  Disease;  Periosteal  Cachexia. 

Definition. —  A  cachectic  condition  of  infants,  associated  with  sub- 
periosteal hemorrhagic  extravasations. 

Historical. — In  1878  and  again  in  1S82  Cheadle  published  in  the  "  Lancet,"  and 
about  the  same  time  Gee  published  as  occurring  in  England,  cases  of  a  cachexia  in 
very  young  children,  associated  with  hemorrhage,  and  due  to  imperfect  food-supply. 
About  the  same  time  Barlow  made  an  exhaustive  study  of  the  subject  and  gave  his 
results  in  the  "  Medico-Chirurgical  Transactions,"  volume  xlvi.,  1883,  and  in  the  Brad- 
shaw  Lecture  for  1894.  W.  P.  Northrup  published  a  paper  on  "  Scorbutus  in  Infants," 
describing  cases  in  this  country,  in  the  "  New  York  Medical  Journal,"  December  12, 
1891,  and  another  with  Crandall  in  the  same  journal,  volume  i.,  1894. 

Symptoms. — Barlow's  account  is  graphic,  almost  sensational,  but  I 
gather  that  the  condition  exists  essentially  in  a  hemorrhagic  subperiosteal 
extravasation,  causing  thickening  and  tenderness  in  the  shafts  of  the  bones 
beginning  in  the  lower  extremities,  but  invading  also  the  forearm  and  arm, 
more  rarely  the  scapula,  vault  of  the  cranium,  and  face.  Rarely  there  is 
intermuscular  extravasation.  The  resulting  tenderness  and  pain  on  motion 
cause  the  child  to  keep  quiet,  with  the  legs  drawn  up,  and  to  cry  out  when 
handled.  The  lesions  are  symmetrical.  The  joints  remain  free.  The 
sternum  and  adjacent  cartilages  and  a  small  portion  of  the  contiguous  ribs 
may  be  sunk  bodily  back  as  though  subjected  to  violence.  There  may  be  a 
sudden  prolapse  of  an  eyeball.  Along  with  these  symptoms  are  profound 
am,emia  and  erratic  teuiperature,  which  may  be  subnormal,  normal,  or  as  high 
as  102°  F.  (38.9°  C). 

The  disease  occurs  at  any  period  after  four  months,  but  it  is  most  com- 
mon from  the  ninth  to  the  eighteenth  month,  and  is  of  rapid  development. 

Treatment. — It  has  been  ascribed  to  the  use  of  the  proprietary  forms  of 
condensed  milk  and  preserved  foods  for  infants.  These  should  therefore  be 
omitted,  and  fresh  cow's  milk  substituted,  with  beef -juice  and  strained  gruel 
made  from  whole-grain  cereals  only.  Orange- juice  or  lemon- juice  in  water 
may  also  be  given  in  moderate  doses.  Under  this  treatment  the  prognosis  is 
favorable  and  recovery  prompt^^ 

Arthritic   Purpura. 
Synonym. — Rheumatic  Purpura. 

Definition. — The  characteristic  feature  of  arthritic  purpura  is  a  joint 
involvement.  Hence  it  is  also  called  rheumatic  purpura,  though  its  rheu- 
matic nature  cannot  be  said  to  be  absolutelv  settled. 

Symptoms. — Three  varieties  are  distinguished  : 

I.  Simple  Arthritic  Purpura. — This  is  a  mild  form,  most  frequent  in 
children.  The  articular  pain  is  very  mild  and  attended  with  but  slight  fever. 
The  spots  are  found  for  the  most  part  on  the  legs,  more  rarely  on  the  trunk 
and  arms.     There  may  be  digestive  derangement,  manifested  by  loss  of  appe- 


PURPURA.  835 

tite  and  diarrhea.     The  condition  terminates  favorably  in  a  week  or  ten  days. 
It  may  be  associated  with  a  mild  degree  of  anemia. 

2.  Peliosis  Rheuinatica. — Schonlein's  disease.  This  is  a  much  more 
serious  affection  from  every  standpoint,  occurring  usually  in  young  persons 
from  fourteen  to  thirty.  The  joint  symptoms  are  pronounced  and  multiple, 
and  there  are  decided  swelling,  pain,  and  fever,  with  a  temperature  of  101" 
to  103°  F.  (38.3°  to  39.4"  C).  The  eruption  first  appears  on  the  legs  near 
the  affected  joint,  but  I  have  seen  it  present  extensively  on  the  arm,  distant 
from  the  joint,  followed  by  sloughing;  in  the  same  case  were  retinal  hemor- 
rhages. Sloughing  and  necrosis  of  the  skin  even  have  occurred.  It  may  be 
simply  purpuric,  or  may  be  associated  with  urticarial  wheals — exudative — or 
vesicles  (pemphigoid  purpura).  When  severe,  it  is  often  associated  with 
hematuria  and  hemorrhagic  nephritis  with  edema.  I  saw,  with  Agnew  and 
Osier,  a  remarkable  case  in  which  the  latter  condition  hastened  a  fatal  termi- 
nation by  uremia.     Endocarditis  is  also  a  complication. 

3.  Henoch's  Purpura. — This  is  a  variety  occurring  most  often  in  chil- 
dren, but  also  in  adults,  characterized  by  severe  gastro-intestinal  disturbance 
in  addition  to  the  previously  named  symptoms.  There  are  pain,  vomiting, 
and  diarrhea,  rarely  intestinal  ulceration,  and  perforation  with  fatal  peri- 
tonitis.    Acute  enlargement  of  the  spleen  has  been  observed. 

Here,  also,  recovery  is  the  rule. 

Diagnosis. — The  diagnosis  is  easy  by  reason  of  the  associated  joint 
symptoms,  but  the  same  doubt  exists  as  to  a  true  rheumatic  nature  in  all 
forms. 

Prognosis. — This  is  regarded  as  favorable,  but  fatal  terminations  do 
occur,  especially  in  peliosis  rheumatica  in  which  there  is  nephritis.  Relapses 
in  this  form  may  occur  at  the  same  time  of  year  for  several  years  in  succession. 

Purpura    Hemorrhagica. 
Synonym. — Morbus  maculosus  WerlhoH. 

Symptoms. — This  form  of  purpura  is  characterized  by  hemorrhage  from 
the  mucous  membranes,  including  nose,  mouth,  palate,  stomach,  and  intes- 
tinal canal,  in  addition  to  extensive  subcutaneous  ecchymosis.  The  brain 
and  kidneys  and  serous  membranes  may  also  be  seats  of  hemorrhage — 
apoplectic  symptoms  indicating  the  first.  A  prodrome  of  languor  and  weak- 
ness may  precede  for  a  couple  of  days,  to  be  succeeded  by  a  rapid  succession 
of  ecchymoses  and  hemorrhages.  More  decided  constitutional  disturbances 
follow,  including  typhoid  symptoms  and  fever,  though  the  latter  is  mild  and 
may  be  altogether  absent,  even  in  severe  cases. 

In  the  purpura  fuhninans  the  hemorrhages  are  mainly  confined  to  the 
skin,  producing  confluent  ecchymoses  and  dense  infiltrations  covering  large 
areas,  with  sanguineous  blisters.  The  internal  organs,  on  the  other  hand, 
remain  free,  while  the  urine  and  the  bowel  evacuations  are  natural.  At  times 
there  is  fever ;  at  others,  not.  Hemorrhagic  purpura  has  occurred  after  pneu- 
monia and  scarlet  fever,  and  again  in  children  apparently  healthy. 

Diagnosis. — As  to  diagnosis,  sc^irvy  is  almost  the  only  condition  liable 
to  be  mistaken  for  purpura  hsemorrhagica.  In  the  latter  the  gums  are  intact, 
and  there  is  an  absence  of  the  conditions  favoring  scurvy. 

Prognosis. — The  termination  is  usually  favorable  in  from  ten  days  to 
two  weeks,  although  there  may  be  fulminating  cases,  usually  in  children,  ter- 
minating fatally  in  twenty-four  hours.     Severe  cases  recover  more  slowly. 


836  CONSTITUTIONAL  DISEASES. 

Treatment   of   Arthritic    Purpura    and    Purpura    Haemorrhagica.— 

Treatment  is  best  directed  to  improving  the  quaHty  of  the  blood  and  to  build- 
ing up  the  general  tone  rather  than  to  the  control  of  the  hemorrhage,  though 
the  latter  must  not  be  entirely  ignored.  Almost  all  that  has  been  said  of  the 
treatment  of  scurvy  is  applicable  to  these  forms  of  purpura.  Iron  and  arsenic 
are  the  typical  roborants  and  blood-builders,  to  which  nutritious  food,  includ- 
ing vegetable  juices,  is  to  be  added.  Arsenic  should  be  given  in  full  doses, 
beginning  with  small  ones  and  ascending  rapidly. 

In  the  articular  forms  the  salicylates  and  salicin  should  be  used  in  such 
doses  as  the  stomach  will  tolerate. 

Of  the  astringent  remedies  found  serviceable  may  be  mentioned  ergot, 
in  doses  of  from  five  to  thirty  minims  (0.3  to  2  c  c.)  of  the  fluid  extract ;  per- 
sulphate of  iron,  in  doses  of  from  1-4  to  1-2  grain  (0.016  to  0.032  gm.)  ; 
acetate  of  lead,  one  to  three  grains  (0.0648  to  0.2  gm.)  ;  dilute  or  aromatic 
sulphuric  acid,  five  to  fifteen  minims  (0.33  to  i  c.  c). 

Hemorrhagic  Diseases  of  the  New-born. 

Hemorrhagic  Syphilis  of  the  New-born. — Usually  about  from  the  third 
to  the  fifth  day  after  birth  hemorrhage  is  observed  at  the  navel  of  the  child, 
or  it  may  occur  earlier.  Blood  also  flows  from  the  mucous  membranes  of 
the  mouth,  the  bowels,  and  the  kidneys.  The  skin  becomes  jaundiced.  The 
stomach  rejects  food,  and  though  it  may  appear  well  nourished  at  birth,  the 
child  rapidly  wastes,  and  dies  at  the  end  of  a  zveek  or  ten  days.  The  autopsy 
discloses  syphilitic  lesions  in  the  liver,  lungs,  nasal  passages,  and  elsewhere. 

Epidemic  Hemoglobinuria  of  Infants,  or  Winckel's  Disease. — As  de- 
scribed by  Winckel  in  1879,  in  an  epidemic  at  the  Foundlings'  Hospital,  at 
Dresden,  the  first  symptoms,  noticed  usually  on  the  fourth  day  after  birth, 
are  a  bluish  tinge  on  the  skin  of  the  face,  trunk,  and  limbs,  with  a  more  or 
less  icteroid  hue.  There  are  fever,  rapid  breathing,  and  sometimes  cyanosis. 
Occasionally  there  are  vomiting  and  diarrhea.  The  nrine  is  light  brown, 
albuminous,  contains  methemoglobin,  and  deposits  a  sediment  consisting  of 
epithelium  and  tube-casts.  The  blood  contains  an  excess  of  leukocytes  and 
numerous  granular  bodies.  The  child  lives,  on  an  average,  two  days,  though 
in  one  case  death  supervened  in  nine  hours.  The  autopsy  in  this  case  dis- 
closed yellow  staining  of  the  skin  and  internal  organs ;  the  spleen  was  large, 
hard,  and  darkened  ;  the  kidneys  were  dark  brown  in  color,  their  tubules  being 
filled  with  granular  pigment ;  the  liver  and  heart  were  fatty.  There  may  be 
punctiform  hemorrhages  on  the  surface  of  the  internal  organs.  There  is  no 
septic  condition  of  the  umbilicarvessels.     An  infectious  origin  is  not  unlikely. 

Acute  Degeneration  of  the  Internal  Organs  of  the  Nezv-born,  or  Buhl's 
Disease. — How  far  this  disease,  described  by  Buhl  in  1861,  differs  from 
Winckel's  disease,  or  the  latter  from  the  former,  remains  to  be  settled,  for, 
in  the  first  place,  fatty  degeneration  of  the  heart  and  liver  is  found  in  many 
cases  of  Winckel's  disease,  while  in  others  there  is  found  the  general  fatty 
degeneration  of  kidneys,  liver,  heart,  etc.,  described  by  Buhl.  In  the  second 
place,  infants  surviving  the  first  few  hours  after  birth  in  Buhl's  disease 
have  the  "same  symptoms  as  those  described  under  Winckel's  disease,  while 
the  other  symptoms,  such  as  minute  hemorrhages  and  bile  staining  of 
various  internal  organs,  are  not  essentially  different. 

Morbus  Macidosus  Neonatoriun. — Still  another  form  of  hemorrhage 
froiTi  one  or  more  of  the  surfaces,  and  especially  of  the  alimentary  canal,  in 


HEMOPHILIA.  837 

the  new-born  is  described  under  this  title.  The  bleeding  generally  beghis 
within  the  first  u'eek,  but  may  be  as  late  as  the  second  or  third  week. 
Hemorrhage  from  the  bowels  (melsena  neonatorum)  is  the  most  frequent 
form,  but  it  may  be  from  the  stomach,  mouth,  nose  and  navel,  or  from  the 
navel  alone.  It  may  be  accompanied  by  hematogenous  jaundice, — indeed, 
by  any  or  all  the  symptoms  described  under  Winckel's  disease, — ^but  differs 
in  the  occasional  presence  of  fever  and  apparent  absence  of  postmortem 
lesions,  though  ulcers  of  the  esophagus,  stomach,  and  duodenum  have  been 
found.  It  is  generally  fatal  in  from  one  to  seven  days.  All  these  con- 
ditions can  be  appropriatel}^  considered  as  forms  of  purpura. 

Treatment. — The  treatment  of  hemorrhagic  affections  of  the  new-born 
often  avails  little,  though  recoveries  sometimes  take  place,  especially  in  the 
last-described  form,  in  which  C.  W.  Townsend  reports  nineteen  recoveries 
out  of  fifty  cases  collected. 

The  treatment  demands  absolute  rest  with  the  head  low.  Even  the 
exertion  necessary  in  nursing  at  the  breast  should  be  interdicted,  and  the 
infant  should  be  fed,  vvhile  recumbent,  with  a  teaspoon,  using  also  the 
mother's  milk  if  this  be  not  condemned  as  worthless.  The  utmost  care 
in  providing  uniform  warmth  should  be  taken.  This  can  best  be  accom- 
plished by  means  of  an  incubator.  One  may  be  improvised,  as  suggested 
by  F.  A.  Hoffman,  out  of  a  box  in  the  bottom  of  which  hot  bricks  are 
placed.  Over  them  is  swung  the  infant's  bed.  A  thermometer  is  so 
inserted  as  to  be  readily  observable,  and  the  temperature  is  kept  at  90°  F. 
(32°  C).  To  control  the  hemorrhage  ergotin  may  be  used  hypodermically, 
one  grain  or  minim  (0.06  gm.)  every  six  hours.  Gallic  acid  may  be  given  by 
the  mouth  in  one  grain  (0.06  gm.)  doses,  but  extreme  care  should  be  taken 
in  using  remedies  by  the  mouth. 


HEMOPHILIA. 

Definition. —  A  hereditary  vice  of  constitution,  manifested  by  a  tend- 
ency to  uncontrollable  hemorrhage,  occurring  either  spontaneously  or  as 
the  result  of  trifling  injury. 

Etiology. — No  explanation  has  as  yet  been  offered  of  hemophilia 
other  than  that  it  is  usually  hereditary,  though  rarely  also  sometimes 
acquired.  While  individual  instances  of  fatal  hemorrhage  were  observed 
centuries  ago,  "  families  of  bleeders  "  were  first  described  in  this  country. 
Of  great  importance  because  of  its  bearing  on  the  marriage  of  these  hemo- 
philic subjects  is  the  fact  that  the  tendency  is  transmitted  through  the 
female  line  rather  than  through  the  male.  Thus,  if  a  man  belonging  to  a 
bleeding  family  who  is  himself  not  a  bleeder  marries  a  woman  who  is 
healthy  and  not  a  bleeder,  his  offspring  are  usually  exempt  from  the  afflic- 
tion. On  the  other  hand,  a  woman  a  member  of  a  bleeding  family  marries, 
and  even  if  she  be  exempt  herself,  she  m^ay  have  offspring  who  are  bleeders. 
These  facts  were  pointed  out  by  Grandidier.  Not  all  the  children  of  such 
persons  are  afflicted,  while  the  male  members  are  more  frequently  sub- 
ject than  females.  The  families  of  bleeders  are  apt  to  be  large,  and  their 
appearance  is  that  of  health,  as  a  rule.  It  is  said  that  blondes  predominate, 
with  delicate,  soft  skin  and  distinct,  distended  veins. 

Morbid  Anatomy. — Two  facts  of  importance  have  been  recognized 
■ — viz.,   that  in   some   instances   the   walls   of   the   blood-vessels   have   been 


838  COXSTITUTIONAL  DISEASES. 

found  thin  with  a  fatty  degeneration  of  the  intima,  and  in  many  there  is 
deficient  coagulabihty  of  the  blood.  A  third  fact,  which  adds  nothing  in 
explanation  of  the  hemorrhagic  tendency,  is  a  superficial  situation  of  the 
arteries.  A  striking  case  of  this  kind  in  a  blonde  woman,  formerly  a 
bleeder,  was  for  a  time  under  my  observation.  Beyond  this  w^e  know 
nothing,  notwithstanding  the  exhaustive  studies  of  Wickham  Legg,  Gran- 
didier,  and  Hossli. 

Symptoms. — Attention  is  commonly  called  to  a  bleeder  by  the  occur- 
rence of  a  hemorrhage  difficult  to  control,  though  induced  by  some  trifling 
cause.  The  extraction  of  a  tooth  is  one  of  the  most  frequent  of  these  events. 
It  may  be  the  prick  of  a  pin,  or  a  scratch,  or  a  slight  cut,  as  in  vaccination, 
or  no  cause  may  be  discoverable.  The  tendency  may  manifest  itself  at  the 
cutting  of  the  umbilical  cord  at  birth,  or  in  Jewish  children  at  the  circum- 
cision. On  the  other  hand,  the  same  accidents  which  are  without  result  early 
in  life  may  induce  the  hemorrhage  later.  Uncontrollable  epistaxis  is  one  of 
the  most  frequent  manifestations,  occurring  in  169  out  of  334  cases  collected 
by  Grandidier.  It  may  be  induced  by  simply  blowing  the  nose.  Other 
situations  are  the  mouth,  stomach,  ear,  and  eyelids.  On  the  other  hand, 
hemorrhages  rarely  occur  in  the  interstices  of  organs,  and  though  inter- 
stitial hemorrhages  do  occur,  they  are  usually  the  result  of  trifling  blows, 
when  the  well-known  "  black-and-blue "  appearance  is  produced.  The 
absence  of  interstitial  hemorrhages,  except  as  the  result  of  some  cause, 
however  trifling,  may  be  said  to  distinguish  hemophilia  from  the  acquired 
hemorrhagic  tendency. 

Menstruation  may  be  very  copious  in  w'omen,  but  not  fatal,  while  the 
natural  loss  of  blood  in  child-bearing  is  rarely  augmented.  In  the  case  re- 
ferred to  on  page  837  the  hemophilia  disappeared  with  the  appearance  of  the 
menopause,  soon  after  which  it  w^as  substituted  by  a  chronic  nephritis. 

The  external  hemorrhages,  including  those  of  the  mouth  and  nose, 
may  be  profuse  and  even  fatal.  They  often  last  twenty-four  hours  or 
longer.  When  checked,  reaction  from  them  is  rapid,  and  the  victims 
quickly  resume  their  natural  appearance,  though  repeated  hemorrhages  may 
engender  a  permanent  anemia. 

Joint  affections  may  be  associated  w^ith  this  as  with  the  acquired  hem- 
orrhagic tendency.  They  involve  usually  the  larger  joints,  and  may  include 
swelling  and  pain,  with  fever,  producing  a  close  resemblance  to  rheumatism, 
or  there  may  only  be  pain. 

Diagnosis. — This  is  apparent  if  the  family  tendency  is  known,  and  any 
alarming  hemorrhage  without  sufficient  cause  should  excite  inquiry. 

Prognosis. — Sooner  or  later  hemophilia  is  apt  to  be  fatal,  though 
there  may  be  many  severe  hemorrhages  before  the  last  one  comes.  The 
younger  the  subject,  the  more  serious  the  outlook.  It  does,  however,  happen 
that  the  tendency  is  outgrown,  subsequent  attacks  becoming  milder  and 
milder.  In  the  majority  of  cases  death  takes  place  between  the  first  and 
the  eighth  year,  and  adolescence  once  survived,  the  chances  of  outgrowing 
it  are  greatly  increased. 

Treatment. — ^This  may  be  prophylatic.  The  children  of  bleeding 
families  should  be  carefully  guarded  against  traumatic  causes,  however 
slight,  while  they  should  be  carefully  looked  after  from  the  hygienic  and 
nutritive  standpoints.  Fresh  air,  daily  bathing,  outdoor  exercise,  and  judi- 
cious measures  intended  to  harden  the  threatened  subject  should  be  prac- 
ticed.    Plain,  wholesome,  and  nourishing  food  should  be  given,  and  due 


HEMOPHILIA.  839 

attention  should  be  paid  to  digestion.  As  a  part  of  the  prophylatic  treat- 
ment, too,  is  discouragement  from  marriage,  especially  in  the  case  of  women. 

During  an  attack  absolute  quiet  must  be  enjoined.  Styptics  are  to  be 
•employed  locally,  rather  than  internal  medicines.  Of  styptics,  the  solution 
of  the  perchlorid  or  persulphate  of  iron  is  the  best,  beginning  at  first  with 
dilute  solutions  and  increasing  to  the  full  strength  of  the  official  solution  if 
necessary.  Tannic  acid  is  another  good  styptic,  and  if  at  hand,  may  be 
dusted  well  upon  the  part  or  applied  on  cotton  to  cavities.  In  epistaxis 
the  nose  must  'be  plugged  if  the  ordinary  methods  of  applying  these 
agents  fail. 

Though  little  is  to  be  expected  from  internal  remedies,  they  may  be 
tried.  Wickham  Legg  recommends  the  tincture  of  the  perchloiid  of  iron 
in  half-dram  (2  c.  c.)  doses  every  two  hours.  Ergotin  and  acetate  of  lead 
may  also  be  used.  Suprarenal  extract  and  its  active  principle,  adrenalin 
chlorid,  have  also  been  employed  for  hemophilia,  the  former  in  doses  of 
five  grains  every  three  hours.  Adrenalin  chlorid  is  used  in  the  shape  of 
a  one  per  cent,  solution,  of  which  a  fluid  dram  (4  c.  c.)  may  be  added  to 
a  half-pint  or  pint  (250  to  500  c.  c.)  of  normal  salt  solution  by  hypo- 
dermoclysis,  or  intravenous  injection.  If  urgent  15  minims  (i  c.  c.)  may 
be  used  undiluted  and  the  remainder  in  the  diluted  form. 

The  usual  treatment  for  consequent  anemia  should  be  employed. 


SECTION  IX. 

DISEASES  OF  THE  NERVOUS  SYSTEM.      ' 

GENERAL    INTRODUCTION. 

HISTOLOGY  OF  THE  NERVOUS  SYSTEM. 

The  difficulties  in  the  diagnosis  of  diseases  of  the  nervous  system  are 
gradually  diminishing  as  the  thread  of  its  histology  is  being  unraveled. 
The  studies  of  Golgi,  His,  Forel,  "VValdeyer,  Ramo  y  Cajal,  Dejerine, 
Lenhosse,  van  Gehuchten,  and  others  have  considerably  altered  previously 
accepted  views.  A  brief  statement  of  the  fundamental  features  of  the 
newer  histology  seems,  therefore,  necessary. 

The  studies  of  these  and  other  observers  resolve  the  nervous  system  into 
an  immense  number  of  units,  to  which  Waldeyer  has  given  the  name  neurons 
— whence  the  name  neuron  theory.  It  is  necessary  to  state  that  the  neuron 
theory  is  now  being  vigorously  attacked,  but  as  it  is  of  service  in  explain- 
ing nervous  diseases,  it  may  be  employed  until  the  evidence  against  it  be- 
comes so  convincing  that  we  are  free  to  abandon  it.  Each  neuron  is  made 
up  of: 

1.  A  nerve  cell. 

2.  Protoplasmic  processes,  or  dendrites. 

3.  An  axis-cylinder  or  axon  continuous  with  the  nerve-fiber. 

4.  Terminal  ramifications  of  the  axis-cylinder. 

The  axis-cylinder  of  a  motor  spinal  cell  gives  off  at  different  intervals 
lateral  branches  known  as  collaterals.  These  collaterals  or  paragons,  and 
finally  the  axis-cylinder  itself,  break  up  intO'  many  fine  fibers,  known  as  ter- 
minal ramifications,  or  end  brushes,  or  branch  tufts.  Each  neuron  has  been 
believed  to  be  independent  of  every  other — that  is,  no  protoplasmic  process  of 
one  neuron  is  continuous  with  that  of  another,  nervous  communication  being 
through  simple  contact  or  proximity.  More  recent  investigations,  however, 
throw  some  doubt  on  this.  The  protoplasmic  processes  conduct  impulses  to 
the  cell,  are  cellulipetal,  as  named  by  Cajal ;  the  axis-cylinders  conduct  im- 
pulses away  from  it  and  are  cellulifugal.  The  nutrition  of  the  neuron 
depends  largely  on  the  cell  body.  If  the  latter  is  intact,  the  processes  are 
preserved.  If  it  is  injured  they  waste,  or  if  they  are  cut  off  they  degenerate; 
on  the  other  hand,  the  cell  body  suffers  when  its  processes  become  diseased. 

The  motor  neurons,  having  their  cell  bodies  in  the  gray  matter  of  the 
brain,  are  called  central  neurons ;  those  neurons  having  their  cell  bodies  in 
the  spinal  cord  and  in  the  ganglia  on  the  peripheral  nerves,  are  called  peri- 
pheral neurons.  The  end  brushes  or  terminal  ramifications  of  a  central 
motor  neuron  surround  the  body  and  protoplasmic  processes  of  a  peripheral 
motor  neuron,  while  those  of  the  peripheral  neuron  are  in  connection  with  a 
motor  plate.  The  axis-cylinders  of  the  central  and  peripheral  neurons 
traverse  chiefly  the  white  tracts  of  the  brain  and  spinal  cord  and  the  per- 

840 


HISTOLOGY  OF  THE  NERVOUS  SYSTEM. 


841 


ipheral  nerves.  The  cells  of  the  anterior  roots  of  the  spinal  nerves  lie  in 
the  anterior  cornua  of  the  gray  matter,  and  have  the  protoplasmic  processes 
short  and  the  axis-cylinders  long.      (See  Fig.  83.) 

The  cells  of  the  posterior  roots  are  situated  in  the  ganglia  on  those 
roots ;  the  axis-cylinders  of  these  cell  bodies  divide  soon  after  leaving  the 
cell  body,  one  process  passing  to  the  periphery,  the  other  to  the  spinal  cord. 
Communication  between  different  parts  of  the  nervous  system  and  with  the 
rest  of  the  body  is  thus  rendered  possible.  The  processes  extending  to  the 
periphery  receive  impressions  from  the  exterior  and  carry  them  cellulipetal 
to  the  ganglion  cells  on  the  posterior  root  of  the  spinal  nerves,  whence  they 
are  conveyed  by  the  axis-cylinders  cellulifugal  to  the  cord.     This  impres-^ 


|1    Skin 


Fig.  83. — Diagram  of  an  Element  of  the  Motor  Path — {after  Strumpell,  modified). 

C.  Motor  ganglion  cell  in  the  cerebral  cortex.  Py  S.  Lateral  pyramidal  tract, 
central  or  upper  motor  neuron.  V.  Ganglion  cell  of  anterior  horn.  in.  Motor- 
nerve,  peripheral  neuron.     M.    Muscular  fiber. 


sion  may  result  in  a  reflex  act  without  the  co-operation  or  knowledge  of  the 
brain,  or  it  may  proceed  to  the  brain  and  give  rise  to  a  volitional  act  through 
the  motor  tract. 

A  motor  impulse  starting  from  the  brain  cortex  must  pass  through  at 
least  two  sets  of  neurons  before  it  can  reach  the  muscles.  In  this  course 
it  is  cellulifugal  from  the  cell  in  the  cortex,  cellulipetal  to  the  cells  in  the  gray 
matter  at  different  levels  in  the  anterior  coruna,  and  thence  cellulifugal  from 
the  latter  cells  to  the  various  muscles  of  the  body,  ending  in  the  end-plates. 
Hence  we  speak  of  the  motor  tract  as  being  composed  of  two  segments,  an 
upper  end  and  a  lower.  The  neurons  of  the  upper  motor  segment  have  their 
cell  bodies  and  protoplasmic  processes  in  the  cortex  about  the  fissure  of  Ro- 


842  DISEASES  OF  THE  NERVOUS  SYSTEM. 

lando.  The  axis-c}"linder  processes  run  through  the  internal  capsule  and 
the  cerebral  peduncles,  through  the  pons,  medulla  oblongata,  and  cord,  ending 
in  terminal  ramifications  around  the  protoplasmic  processes  and  cell  bodies 
of  the  lower  segment.  The  neurons  of  the  lower  segment  are  those  having 
their  cell  bodies  and  protoplasmic  processes  in  the  anterior  cornua  of  the 
gray  matter,  while  their  axis-cylinders  leave  the  spinal  cord  by  the  anterior 
roots  of  the  spinal  nerves,  to  be  distributed  as  described.  The  upper  seg- 
ment, in  large  at  least,  is  a  crossed  tract — that  is,  the  neurons  com- 
posing it  have  their  cell  bodies  and  protoplasmic  processes  in  the  cortex, 
while  their  axis-cylinders  cross  the  middle  line  to  end  about  the  cell  bodies 
in  the  opposite  half  of  the  spinal  cord ;  so  that  motor  impulses  starting  in 
the  left  half  of  the  brain  produce  contraction  in  the  muscles  of  the  right 
half  of  the  body,  and  vice  versa,  although  both  sides  of  the  brain  probably 
innervate  unequally  each  side  of  the  body.  (See  Fig.  83.)  The  lozver  motor 
segment  is  a  direct  tract — that  is,  its  neurons,  and  the  muscles  to  which  they 
are  distributed,  are  all  on  the  same  side  of  the  body. 

The  path  for  sensory  conduction  is  also  composed  of  segments,  but  the 
direct  route  of  sensory  conduction  is  more  complicated  and  our  knowledge 
is  much  less  exact.  The  cell  bodies  of  the  lower  neurons  are  in  the  gan- 
glia of  the  posterior  roots  of  the  spinal  nerves  and  in^the  ganglia  of  the  sen- 
sory cranial  nerves.  These  ganglion  cells  have  a  single  process,  which,  after 
leaving  the  cell,  divides  in  a  T-shaped  manner,  one  branch  running  into  the 
central  nervous  system  and  the  other  toward  the  periphery.  The  process 
which  connects  with  the  periphery  is  regarded  by  some  as  a  protoplasmic 
process,  while  that  which  passes  to  the  center  is  known  as  the  axis-cylinder. 
The  former  runs  in  the  sensory  nerves,  starting  from  the  various  specialized 
sensory  apparatus  of  the  periphery.  The  axis-cylinder  enters  the  cord  by 
the  posterior  roots.  After  entering  the  cord  it  divides  into  an  ascending 
and  a  descending  limb,  which  traverse  the  posterior  columns.  The  descend- 
ing branch  runs  a  short  distance  and  ends  in  the  gray  matter  of  the  same 
side  of  the  cord,  giving  off  a  number  of  collaterals,  which  also  end  in  the 
gray  matter.  The  ascending  branch  may  end  in  the  gray  matter  soon  after 
entering  the  cord,  or  it  may  run  in  the  posterior  columns  as  high  as  the 
medulla  oblongata,  ending  in  the  nuclei  of  the  posterior  columns.  Thus  the 
Iciver  segment  is  also  a  direct  tract  terminating  in  the  gray  matter  of  the  pos- 
terior cornua  at  different  levels,  and  in  the  gray  matter  of  the  medulla  oblon- 
gata. (See  also  section  on  Spinal  Cord.)  The  upper  segment  starting  from 
these  is  a  crossed  tract,  crossing  at  different  levels,  so  that  sensory  impressions 
are  ultimately  lodged  in  the  brain  on  the  side  opposite  that  whence  they 
start  in  the  periphery.  The  so-called  muscular  sense,  perhaps  better  called 
the  sense  of  position,  is  probably  conducted  upward  on  the  same  side  in  the 
columns  of  Burdach  and  Goll  on  each  side  of  the  posterior  median  fissure. 
The  exact  termination  of  the  sensory  processes  in  the  cerebral  hemisphere  is 
not  known,  but  they  pass  up  in  the  tegmentum  of  the  pons  and  possibly  in 
the  internal  capsule.  It  is  believed  by  many  that  these  processes  terminate 
in  the  optic  thalamus,  and  that  from  here  the  impulses  are  conducted  to  the 
cortex  by  means  of  another  set  of  neurons.  The  motor  cortex  is  probably 
also  sensory,  although  the  sensory  area  may  be  more  extensive  than  the  motor. 

Both  motor  and  sensory  spinal  nerve  roots  come  from  definite  segments 
of  the  spinal  cord.  They  descend  a  short  distance  within  the  spinal  canal, 
unite  within  the  intervertebral  foramen,  but  external  to  the  point  where  the 
roots  perforate  the  dura  mater  and  pass   through  the  foramina  as  spinal 


GENERAL  SYMPTOMATOLOGY.  843 

nerves.  But  in  their  distribution  they  do  not  retain  the  same  definiteness,  the 
same  sensory  and  motor  areas  being  suppHed  with  nerve  fibers  from  different 
segments  of  the  cord,  and  there  is  an  overlapping,  as  it  v^ere,  of  parts  supplied 
by  different  nerve  fibers.  At  the  same  time,  by  the  combined  aid  of  experi- 
ment and  morbid  physiology,  we  have  learned  that  movements  in  certain 
muscles  are  accomplished  by  motor  nerves  which  emanate  from  corresponding 
segments  of  the  spinal  cord,  and  that  from  certain  sensitive  areas  are  gath- 
ered up  impressions  which  are  carried  to  corresponding  sections  of  the  spinal 
cord.  Nay,  more.  By  the  same  means  we  have  learned  that  there  are  areas 
in  the  cortex  of  the  brain  that  preside  over  certain  motions,  and  areas  which 
have  to  do  with  sensation ;  though  with  respect  to  the  latter  our  knowledge 
is  much  less  definite.  We  know  more  of  the  cortical  localization  of  the  special 
senses  than  of  general  sensibility  and  pain.  These  facts  are  the  foundation  of 
what  is  known  as  topical  diagnosis,  in  the  case  of  the  brain  as  cerebral  lo'cali- 
sation,  by  which  is  meant  the  inference,  from  the  study  of  local  derange- 
ments of  sensation  and  motion,  of  the  more  or  less  exact  site  of  lesions  in 
the  nervous  centers.  These  will  be  considered  with  appropriate  detail  in 
our  study  of  the  diseases  of  different  parts  of  the  nervous  system. 


GENERAL  SYMPTOMATOLOGY. 
(Investigation  of  a  Case  of  Nervous  Disease.) 

The  advantages  of  a  careful  method  in  the  study  of  disease  are  per- 
haps more  apparent  in  the  case  of  the  nervous  system  than  in  that  of  any 
other  of  the  anatomical  divisions  of  the  human  body.  This  is  partly 
because  of  the  number  and  variety  of  the  affections  to  which  the  nervous 
system  is  subject,  and  partly  because  of  the  association  of  certain  identical 
symptoms  with  widely  different  lesions. 

The  primary  steps  of  family  and  personal  history  are  the  same  as  for 
other  diseases,  including  age,  sex,  occupation,  and  whether  married  or 
single.  We  may  therefore  pass  at  once  to  the  study  of  such  symptoms  as 
are  special. 

L  Phenomena  of  Motion. — It  is  immaterial  whether  we  set  out  with 
sensory  or  motor  phenomena,  but  it  appears  somewhat  easier  to  begin 
with  derangements  of  motion,  and  of  these  ( i )  voluntary  motion  is  natu- 
rally first  investigated.  To  this  end,  the  patient  is  asked  to  move  his 
iimbs,  while  the  strength  of  whatever  motion  he  is  capable  is  easiest 
measured  by  resisting  it,  and  by  testing  the  power  of  his  hand-grasp. 
For  more  accurate  measurement  the  dynamometer  is  used,  an  instrument 
devised  to  measure  both  compression  and  traction,  although  it  is  more  com- 
monly restricted  to  the  former.  Advantage  may  be  taken  of  the  fact,  too, 
that  the  same  motion  requires  different  degrees  of  strength  in  different  posi- 
tions of  the  body.  Thus  it  is  easier  to  draw  up  the  thigh  when  lying  on 
the  back  than  when  on  the  side,  and  it  may  be  possible  in  the  former  posi- 
tion when  it  is  not  in  the  latter.  Both  extensor  and  flexor  muscles  must 
be  thus  tested.  By  such  an  investigation  we  discover  the  presence  of  a 
complete  paralysis  or  total  loss  of  Voluntary  motion,  and  paresis  or  simple 
weakening  of  such  power. 

By  a  monoplegia  is  meant  an  isolated  paralysis  of  one  part  of  the  body, 
as  of  an  arm  or  a  leg.     By  a  lieniiplegia  is  meant  a  paralysis  of  the  entire 


544 


DISEASES  OE  THE  NERVOUS  SYSTEM. 


half  of  the  body,  inchiding  half  of  the  face,  one  arm,  and  one  leg,  also 
known  as  unilateral  paralysis.  By  a  paraplegia  is  meant  a  simultaneous 
paralysis  of  corresponding  halves  of  the  body.  Paralysis  of  the  two  arms 
is  known  as  a  superior,  or  hrachial,  paraplegia,  of  the  two  legs  as  an  inferior, 
or  crural  paraplegia,  while  the  word  paraplegia  alone  is  often  used  for  the 
latter  condition.  A  diplegia  is  a  paralysis  in  which  upper  and  lower  limbs 
are  affected  on  both  sides  of  the  body,  usually  attended  with  spasm  of  all  the 
extremities,  although  the  term  is  also  employed  for  bilateral  facial  paralysis. 
Though  commonly  congenital,  diplegia  may  also  be  acquired. 

Impairment  of  voluntary  muscular  power,  as  thus  tested,  must  be  the 
result  of  structural  change  in  the  motor  area  of  the  cortex,  in  the  great  motor 
tract  of  the  brain  or  cord,  or  impairment  in  the  integrity  of  the  efferent 
nerves,  or  it  may  be  more  rarely  in  the  muscle  itself,  "  myopathic  palsy  " ;  or 
the  power  of  the  will  may  be  abrogated.  In  diseases  of  the  peripheral  nerves, 
when  the  paralysis  is  called  peripheral,  it  is  limited  to  the  region  of  distribu- 


JixiTi 


pxce 


-pyjc. 


"iExrireTm^i^ 


Fig.  84. — Illustrating  Crossed  Paralysis— (rt//^r  Hirf). 


O.  Medulla  oblongata,    pyx.  Decussation  of  anterior  pyramids, 
going  to  extremities.     F.  Nerve-fiber  to  face. 


E.  Nerve-fiber 


tion  of  the  affected  nerves,  whether  one  or  many.  It  may  be  said  in  general 
that  hemiplegia  is  the  usual  form  of  cerebral  paralysis,  while  paraplegia  is 
the  expression  of  spinal  paralvsis.  Monoplegias  are  usually  either  due  to 
lesions  of  the  cortex,  or  are  peripheral  palsies ;  cortical  monoplegia,  however, 
is  rare. 

In  all  hemiplegias  caused  by  lesions  above  the  pons  the  palsy,  including 
that  of  the  face  and  extremities,  is  on  the  side  opposite  the  lesion,  but  in  most 
lesions  in  the  middle  or  lower  part  of  the  pons  there  is  crossed  paralysis — that 
is,  there  is  paralysis  of  the  extremities  on  one  side,  and  of  the  face  on  the 
other  side,  provided  the  central  fibers  of  the  extremities  and  the  facial  nerve 
are  involved  in  the  lesion.  The  reason  of  this  is  that  the  central  fibers  of  the 
facial  nerve  cross  much  higher  than  do  the  fibers  to  the  extremities,  and  in 
such  a  lesion  the  intra-medullary  portion  of  the  facial  nerve,  and  not  the  cen- 
tral fibers  connecting  its  nucleus  with  the  brain  cortex,  are  injured.  The 
result  is  a  paralysis  of  the  face  on  the  same  side  as  the  lesion  and  of  the 
extremities  on  the  other.     This  would  be  the  case  with  a  lesion  at  h,  Figure 


GENERAL  SYMPTOMATOLOGY. 


845 


84.  If,  on  the  other  hand,  the  lesion  is  higher  up,  above  the  decussation  of 
both  the  facial  and  pyramidal  tracts,  as  at  a,  the  paralysis  is  on  the  side  oppo- 
site the  lesion  in  both  face  and  extremities.  Other  nerves  may  substitute  the 
facial  in  this  crossed  paralysis  as  the  oculomotorius  (third  nerve)  or 
hvpoglossal  (twelfth  nerve)  or  abducens  (sixth  nerve).  In  rarer  instances 
it  is  possible  that  a  lesion  at  the  very  decussation  of  the  pyramids,  by  cutting 
the  motor  fibers  of  one  extremity  before  they  cross,  and  those  of  another  after 
crossing,  may  produce  the  very  rare  event  of  paralysis  of  an  arm  on  one  side 
and  of  a  leg  on  the  other.  That  this  is  theoretically  possible  may  be  seen  from 
Fig.  85,  in  which  the  black  lines  represent  fibers  to  the  upper  extremities  and 
red  lines  fibers  to  the  lower,  and  the  red  circle  the  seat  of  a  small  hemorrhage. 
(2)  Having  determined  this  question  of  muscular  strength,  and  the 
corollaries  which  grow  out  of  it,  we  have  next  to  ascertain  to  what  extent 
the  power  of  co-ordination  is  influenced.  Every  muscular  act  requires  the 
duly  proportioned  co-operation  of  a  number  of  muscles ;  and  as  the  com- 
plexity of  the  act  increases,  the  number  of  muscles  required  to  co-operate 
also  increases.  Such  co-operation  is  termed  co-ordination,  and  its  absence 
is  recognized  in  the  staggering  gait  of  the  drunkard,  and  the  condition  is 
known  as  ataxia.     There  are  certain  parts  of  the  nervous  system  which 


Fig.  85. — Illustrating  the  possibility  of  paralysis  of  arm  on  one  side  and 
of  leg  on  the  other. 


preside  over  co-ordination — such  as  the  cerebellum,  and  the  posterior 
columns,  and  probably  the  direct  cerebellar  tract,  of  the  spinal  cord.  Disease 
of  any  of  these  may,  therefore,  produce  ataxia.  The  ataxia  or  tabetic  gait 
is  described  under  tabes  dorsalis,  p.  926. 

A  corollary,  growing  out  of  the  investigation  of  the  co-ordinating 
power,  is  the  study  of  station,  or  the  steadiness  with  which  one  stands  with 
the  eyes  closed  or  open,  and  it  is  measured  by  sway  of  the  head  and  body, 
laterally  and  anteroposteriorly.  In  health  a  lateral  sway  of  the  head  exists 
to  the  extent  of  half  an  inch  (1.25  cm.),  and  an  anteroposterior  sway  of 
an  inch  (2.5  cm.).     A  sway  much  beyond  these  limits  is  abnormal. 

(3)  After  ascertaining  the  condition  of  voluntary  motion,  co-ordination, 
and  station,  we  must  inquire  into  the  question  of  possible  motor  irritation 
or  excessive  muscular  action  or  spasm.  Spasm  may  be  continuous, — i.  e. 
lasting  for  minutes,  hours,  or  days, — when  it  is  known  as  tonic  or  tetanic;  it 
may  be  intermittent  or  clonic;  or  it  may  be  an  admixture  of  both,  when  it 
is  termed  tonic-clonic.  Tonic  spasm  is  well  illustrated  by  trismus  or  lock- 
jaw, while  tetanic  contraction  of'  the  muscles  of  the  back  produces 
opisthotonos,  in  which  the  vertebral  column  is  arched  and  the  body 
rests  uoon  the  back  of  the  head  and  upon  the  heels.  Tonic  spasms  are  often 
attended    with    pain,    probably    due    to   pressure   on   intramuscular   nerves, 


846  DISEASES  OF  THE  NERVOUS  SYSTEM. 

when  they  are  called  "  cramps."  Spasm  occurs  also  in  uivoluntary  non- 
striated  muscular  tissue.  The  presence  of  spasm  implies  irritation  of 
motor  centers,  motor  tract,  or  motor  nerves,  but  motor  irritation  may  also  be 
excited  secondarily  by  some  reflex  route,  the  result  being  a  reflex  spasm. 

Spasm  and  paralysis  are  often  associated.  Thus,  a  limb  may  be  par- 
alyzed in  a  state  of  contraction,  exhibiting  a  peculiar  rigidity,  and  to  such  a 
condition  the  name  spastic  paralysis  is  applied.  This  condition  may  also 
exist  as  a  state  of  persistent  contraction  of  the  antagonists  of  the  paralyzed 
muscles,  constituting  the  so-called  contractures.  Paralyses  in  which  there 
is  no  such  resistance  to  passive  motion  are  known  as  Uaccid  paralyses. 

Through  the  combination  of  tonic  and  clonic  spasm  result  different 
varieties  of  morbid  involuntary  movements  more  or  less  complex.  Some 
of  these  are  the  following : 

1.  The  Epileptiform  Convulsion. — This  consists  in  a  succession  of  clonic 
and  tonic-clonic  spasms  extending  over  the  whole  or  a  part  of  the  body, 
throwing  the  part  involved  into  violent  motion.  The  masseter  and  the 
temporal  muscles  share  in  the  contraction,  whence  the  tongue  is  often 
bitten.  The  convulsion  of  epilepsy  is  the  type  of  this  form,  but  the  con- 
vulsions of  uremia,  or  hysteria,  and  of  organic  disease  of  the  brain  may 
be  epileptoid. 

2.  Rhythmical  Contractions. — These  occur  in  single  groups  of  muscles, 
and  are  sometimes  seen  in  apoplexy  and  cerebral  sclerosis.  They  may 
usher  in  the  epileptiform  convulsion,  or  the  convulsion  may  terminate  by  a 
gradual  substitution  of  the  rhythmical  contractions  for  the  more  violent 
spasms. 

3.  Tremors  or  Trembling  Motions. — These  are  limited  movements — /.  e., 
movements  of  short  excursion  which  rapidly  succeed  each  other.  "  Shak- 
ing "  is  a  more  pronounced  degree  of  tremor.  Tremor  is  characteristic  of 
paralysis  agitans  and  of  some  other  nervous  affections.  It  occurs  in  old 
persons  as  senile  tremor,  and  in  abusers  of  alchohol  and  tobacco.  When  it 
occurs  or  increases  during  voluntary  motion,  it  is  known  as  intention 
tremor,  and  is  characteristic  of  multiple  sclerosis.  The  immediate  ana- 
tomical changes  on  which  tremors  depend  are  not  known. 

4.  Single  Contractions. — These  are  either  sudden  twitchings  or  slow 
contractions  of  muscles,  seen  especially  in  diseases  of  the  nerves, — as,  for 
example,  in  old  facial  palsy.  They  may  be  single  or  multiple  and  persistent. 
They  may  be  the  result  of  direct  motor  irritation  or  reflex  in  origin. 

5.  Fibrillary  Contractions. — These  are  contractions  of  separate  small 
bundles  of  muscular  fibrillae,  comparable  to  the  "  quivering  "  of  raw  flesh. 
They  are  independent  of  voluntary  or  passive  motion.  They  may  be  pro- 
nounced and  wave-like  over  the  muscular  substance.  They  are  seen  espe- 
cially when  the  motor  nerve  cells  are  degenerating,  as  in  progressive  spinal 
muscular  atrophy  or  bulbar  paralysis.  The  "  quivering  "of  the  eyelid  and 
of  the  orbicularis  muscle  below  the  eye,  the  so-called  "  jumper,"  often  an 
annoying  symptom,  is  an  instance  of  this  condition. 

6.  Choreic  Movements. — These  are  inco-ordinated  movements,  usually 
separated  by  short  intervals  of  time,  often  first  seen  in  the  face,  later  in  one 
limb  or  over  the  whole  body.  They  may  be  very  complex  and  general. 
They  are  characteristic  of  chorea,  but  also  accompany  other  nervous  affec- 
tions, such  as  posthemiplegic  chorea.  Under  the  term  posthemiplegic  chorea, 
however,  a  variety  of  movements  are  included. 

7.  Athetosis. — This   is  a  peculiar  slow,  involuntary   rhythmical   move- 


GEXERAL  SYMPTOMATOLOGY.  847 

ment,  usually  of  the  fingers  and  hands,  but  also  of  the  head  and  trunk,  or 
of  the  toes.  The  fingers  make  slow  movements  of  the  nature  of  extension, 
and  flexion,  spreading  and  approximating  each  other  in  a  striking  way. 
Thev  are  a  symptom  of  certain  central  nervous  diseases,  especially  of  the 
cerebral  palsies  of  children. 

8.  Constant  or  Co-ordinate  Spasms. — These  consist  in  irresistible  com- 
plicated movements,  like  moving  forward  or  moving  in  a  circle  or  rotating 
on  the  axis  of  the  body;  also  complicated  forms  of  spasm  resembling 
jumping,  laughing,  screaming,  all  involuntary  and  forced.  The  first  group 
of  these  is  especially  seen  in  disease  of  the  cerebellum  and  cerebellar  pe- 
duncles, the  latter  in  severe  forms  of  hysteria. 

9.  Xystaguius  is  a  clonic  rhythmical  oscillatory  and  involuntary  move- 
ment of  the  eyeball,  usually  horizontal,  sometimes  rotatory,  more  rarely 
vertical,  the  result  of  spasm  of  muscles  supplied  by  the  third  nerve,  espe- 
cially the  internal  rectus  and  levator  palpebrcc.  It  is  noticed  in  congenital 
and  acquired  afifections  of  the  brain,  including  Friedreich's  ataxia  and  insu- 
lar sclerosis ;  also  in  albinism  and  in  miners  who  work  in  dimly  lighted  mines, 
using  the  pick  while  reclining  and  directing  the  eyes  laterally. 

10.  Cataleptic  Rigidity. — In  this  there  is  also  a  tonic  contraction  of 
muscles  whereby  a  limb  remains  for  a  considerable  time  in  any  position  in 
which  it  may  be  passively  placed,  the  will  being  abrogated.  If  the  position 
of  the  limb  be  changed,  it  remains  again  in  this  situation,  and  from  a 
resemblance  to  the  behavior  of  wax  under  like  circumstances  it  has 
received  the  name  of  "  waxy  flexibility."'  It  is  characteristic  of  certain 
forms  of  hyst-eria,  and  may  be  produced  at  times  in  hypnotism.  In  hysteria 
it  is  commonly  associated  with  anesthesia  and  loss  of  consciousness.  It  is 
also  associated  with  psychoses,  especiallv  grave  forms  of  melancholia  known 
as  melancholia  attonita  and  w4th  katatonia. 

11.  Associated  Movements. — These  are  unintentional  and  uncontrollable 
movements  which  take  place  in  muscles  coincident  with  other  motions 
actually  intended — as,  for  instance,  a  motion  in  the  arm  when  the  patient 
wills  to  move  only  the  leg. 

(4)  Bladder  control  and  rectum  control  are  next  to  be  looked  into.  Full 
control  over  the  acts  of  these  organs  im.piies,  first,  an  integrity  of  the  sacral 
portion  of  the  cord,  in  which  reside  the  reflex  centers  regulating  these  acts; 
second,  the  integrity  of  volition,  which,  to  a  certain  extent,  fortifies  such  reg- 
ulation ;  and  thirdly,  integrity  of  the  afferent  and  efferent  nerv^e  fibers  con- 
stituting the  reflex  arcs.  Through  the  operation  of  the  reflex  center,  bladder 
and  rectum  both  empty  themselves  when  a  certain  degree  of  distention  is  at- 
tained. Through  the  operation  of  the  will  such  evacuation  is  put  off  to 
a  convenient  time.  Through  an  undue  irritability  of  the  reflex  center  such 
evacuation  is  imperative,  and  does  not  bide  the  will,  or  it  may  take  place 
while  the  will  is  in  abeyance,  as  in  sleep.  Thus  may  be  explained  some  of 
the  cases  of  incontinence  of  urine  in  children.  Again,  if  will-power  is  lost 
from  disease  of  the  cerebral  cortex,  evacuations  of  the  bowels  and  bladder 
take  place  involuntarily  so  long  as  the  sacral  cord  is  intact,  but  not  in  a  nor- 
mal manner. 

On  the  other  hand,  if  the  integrity  of  the  sacral  cord  is  lost,  there  will 
be  no  response  to  the  sensory  impressions  conveyed  from  a  full  bladder  or 
rectum,  because  the  reflex  arc  is  interrupted,  and  the  organ  remains  un- 
emptied;  whence  torpor  or  complete  paralysis  of  the  bowels  and  bladder 
are  common  sym.ptoms   of  spinal  disease ;  and  while  the   repletion  of  the 


848  DISEASES  OF  THE  XERJ'OUS  SYSTEM. 

latter  may  finally  overcome  the  resistance  of  its  sphincter  and  lead  to  drib- 
bling, the  rectum  may  go  on  filling  up  until  it  is  emptied  by  the  finger  or 
the  handle  of  a  spoon.  A  lesion  situated  higher  in  the  central  nervous  system 
than  the  sacral  portion  of  the  cord  may  also  cause  similar  disturbance  of  de- 
fecation and  urination,  probably  because  of  a  spastic  condition  of  the  sphinc- 
ters, so  that  the  laiter  do  not  relax  until  the  bladder  or  rectum  becomes  dis- 
tended, and  finally  they  lose  all  function. 

Again,  if  it  should  happen  that  the  sphincter  center  is  destroyed  while 
the  detrusor  center  is  intact,  there  would  be  dribbling  of  urine  from  the 
outset,  but  this  is  not  likely  to  occur. 

(5)  The  state  of  the  reflexes,  as  they  are  called,  is  next  ascertained.  As 
here  used,  the  term  "  reflex "  is  applied  to  a  muscular  contraction  stimu- 


Fig.  86.— Diagram  Showing  Probable  Plan  of  tne  Center  for  'Slictmition—[Gou'£rs). 

MT.  Motor  tract.  ST.  Sensory  tract  in  the  spinal  cord.  MS.  Center,  and  ms 
motor  nerve  for  sphincter.  MD.  Center,  and  w^  motor  nerve  for  detrusor,  s 
Afferent  nerve  from  mucous  membrane  to  S,  sensory  portion  of  center.  B.  Blad- 
der. At  r  the  position  during  rest  is  indicated,  the  sphincter  center  in  action,  the 
detrusor  center  not  acting.  At  a  the  condition  during  action  is  indicated,  the 
sphincter  center  inhibited,  the  detrusor  center  acting. 

lated  by  a  sensory  impression,  the  simplest  illustration  of  which  is  the  re- 
traction of  the  leg  of  the  sleeper  when  the  sole  of  the  foot  is  tickled.  For 
diagnostic  purposes  the  reflexes  are  divided  into  the  "  cutaneous  reflexes  " 
and  the  "  tendon  reflexes." 

The  cutaneous  or  superficial  reflexes  are  muscular  contractions  which 
take  place  in  different  parts  of  the  body  in  response  to  irritation  of  sensory 
nerves  of  the  skin,  as  by  tapping  the  skin  lightly  or  drawing  the  finger  or 
a  pointed  instrument  lightly  over  it.  The  sudden  application  of  heat  or  cold 
or  the  prick  of  a  pin  or  pinching  are  modes  of  excitation.  The  contractions 
are  generally  confirmed  to  the  neighborhood  of  the  locality  irritated.  The 
skin  reflexes  are  much  more  easily  excited  in  children  than  in  adults, 
and  in  the  lower  extremities  rather  than  in  the  upper;  also  with  varying 
facility  in  different  persons.  They  receive  various  names,  according  to 
the  situations  where  they  are  readily  excited.  Thus  we  have  the  "  plantar 
reflex,"  where  contraction  is  excited  by  tickling  the  sole  of  the  feet, 
resulting  in  a  movement  of  the  toes  or  foot,  or  even  in  a  drawing  up  of 


GENERAL  SYMPTOMATOLOGY.  849 

the  leg;  the  "  cremaster  reflex,"  contraction  of  the  cremaster  muscle  and 
consequent  drawing  up  of  the  scrotum  on  stroking  or  scratching  the  inside 
•of  the  thigh.  The  retraction  may  take  place  on  the  one  side  of  the  scrotum 
only  or  on  both.  Then  thrre  is  the  "abdominal  reflex,"  or  a  contraction 
of  the  abdominal  muscles  when  the  skin  of  the  abdomen  is  stroked  or 
scratched.  A  subdivision  of  the  latter  is  the  "  epigastric  reflex,"  produced 
iDy  an  irritation  on  the  side  of  the  thorax  in  the  fourth,  fifth,  and  sixth  inter- 
spaces. The  result  is  a  dimplmg  of  the  epigastrium  on  the  side  stimulated. 
Cutaneous  reflexes  may  be  brought  out  in  other  portions  of  the  body,  as  in 
the  gluteal  region  by  irritating  the  skin  of  the  buttock.  A  contraction  of 
the  muscles  about  the  scapula,  the  "  scapular  reflex,"  is  produced  by  an  irri- 
tation between  the  scapulae.  To  test  for  the  cutaneous  reflexes  is  more 
important  in  the  lower  extremity  than  in  the  upper. 

The  tendon  reflexes,  or  deep  reflexes,  are  so  called  because  they  are 
-generally  elicited  by  striking  upon  tendons,  while  the  corresponding  muscles 
are  placed  slightly  on  the  stretch,  care  being  taken,  however,  to  avoid  all 
active  tension  in  the  muscle  by  the  person  examined.  The  blow  is  made 
either  with  the  edge  of  the  hand  or  with  a  hammer  adapted  to  the  purpose, 
commonly  made  of  rubber.  A  sharp,  sudden  contraction  of  the  muscle  usu- 
ally takes  place.  A  similar,  though  less  decided,  contraction  may  be 
elicited  by  the  mechanical  irritation  of  parts  analogous  to  tendons,  as  peri- 
osteum and  fasciae,  and  by  striking  the  muscle  itself.  When  the  reflexes 
are  in  excess,  sudden  tension  alone  will  excite  them. 

The  most  commonly  tried  of  the  tendon  reflexes  is  the  knee-jerk,  or 
patellar  tendon  reflex,  produced  by  striking  the  tendon  of  the  quadriceps 
femoris  between  its  insertion  and  the  patella,  while  the  leg  is  crossed  upon 
its  neighbor.  The  weight  of  the  pendent  leg  gives  a  sufficient  degree  of 
tenseness.  When  the  knee-jerk  is  normal,  there  is  a  decided  rise  of  the  foot 
with  each  blow  of  the  hand  hammer.  This  motion  may  become  abnor- 
mally increased  or  diminished.  A  more  limited  movement  may  also  be 
produced  by  striking  the  patella  itself  or  the  quadriceps  tendon  above  the 
patella,  and,  when  the  reflex  is  exaggerated,  by  a  very  light  tap  in  these 
situations  or  even  on  the  tibia.  When  thus  exaggerated,  the  reflex  may 
also  be  brought  out  in  bed,  as  follows :  the  quadriceps  tendon  being  put  on 
the  stretch  by  pressing  the  patella  downward  in  the  direction  of  the  leg  with 
the  finger,  the  patella  is  percussed  in  the  same  direction.  With  each  stroke 
there  is  a  contraction,  and  the  finger  and  patella  are  drawn  upward.  A 
■"  clonus,"  or  repeated  contraction,  may  even  be  produced  thus. 

Similar  is  the  ankle  reflex,  produced  by  tapping  I'-e  tendo  Achillis  when 
the  calf  muscles  are  placed  slightly  on  the  stretch  by  a  slight  dorsal 
flexion  of  the  foot.  In  health  the  ankle  reflex  is  not  always  producible, 
but  in  disease  in  connection  with  this  contraction  is  shown  the  most  remark- 
able of  the  exaggerated  reflexes,  the  "ankle  clonus  "  or  "  foot  clonus."  It 
consists  in  contractions  rapidly  repeated  so  long  as  the  tension  of  the  calf 
muscle  is  kept  up  by  pressing  the  foot  toward  dorsal  flexion.  From  six  to 
nine  such  contractions  ma}-  occur  in  a  second,  and  sometimes  the  whole  leg 
is  thrown  into  vigorous  contractions.  One  of  the  best  ways  to  obtain  the 
tendo  Achillis  jerk  is  to  have  the  patient  kneel  on  a  chair  with  the  feet 
projecting  over  the  edge  of  the  chair ;  the  muscles  are  thus  relaxed,  and  a 
tap  over  the  tendo  xA.chillis  produces  a  movement  of  the  foot. 

The  Babinski  reflex  or  phenomenon  is  the  extension  or  turning  up- 
ward of  the  toes,   and   especially   of  the  great   toe,   obtained  by   stroking 


850  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  sole  of  the  foot.  In  the  normal  individual,  stroking  the  sole,  if  it  pro- 
duces any  response,  causes  plantar  flexion  or  turning  downward  of  the 
toes,  especially  of  the  four  outer  toes.  The  reflex  usually  indicates  a  lesion, 
or  compression  of  the  motor  tracts  in  the  cord  and  brain,  and  probably  also 
of  the  motor  centers  in  the  brain.  The  response  is  usually  best  brought  out 
by  stroking  the  inner  surface  of  the  sole  from  the  heel  toward  the  toe,  al- 
though in  marked  cases  it  may  be  elicited  by  applying  the  stimulus  to  the 
sole  in  various  positions  and  directions.  In  infancy  some  observations  have 
shown  that  the  toes  tend  to  turn  upward  normally  when  the  sole  is  stimu- 
lated. 

The  reflex  is  obtainable  in  about  70  per  cent,  of  cases  of  hemiplegia  and 
diplegia,  and  ni  about  the  same  proportion  of  diseases  involving  the  motor 
tract  in  the  spinal  cord.  It  is  found  only  exceptionally  in  cases  of  another 
class,  viz.,  meningitis,  hydrocephalus,  poisoning,  as  for  example  alcohol  or 
uremia. 

Reflexes  are  also  elicited  in  the  upper  extremities,  but  they  are  much 
less  striking,  and  often  cannot  be  shown  in  health.  The  most  important 
of  these  are  the  arm-jerks^  produced  by  striking  the  biceps  tendon  at  the 
elbow- joint  in  front,  or  by  striking  the  triceps  tendon  above  the  olecranon. 
So-called  periosteal  reflexes — reflexes  excited  by  striking  the  periosteum — 
may  in  exaggerated  states  be  produced  in  the  supinator  longus  and  biceps  of 
the  upper  extremity  by  striking  the  lower  end  of  the  radius  and  ulna ;  also 
in  the  adductors  of  the  thigh  by  striking  the  internal  condyle  of  the  femur. 

A  w^ist  clonus,  resembling  the  ankle  clonus  of  the  lower  limbs,  may 
sometimes  be  obtained  when  the  tendon  reflexes  of  the  upper  limbs  are  much 
exaggerated.  It  is  produced  by  pushing  the  hand  of  the  patient  forcibly  back- 
ward and  holding  it  dorsally  flexed ;  involuntary  antero-posterior  move- 
ments of  the  hand  may  then  occur.  The  jaw-jerk  is  produced  by  tapping  on 
the  front  of  the  jaw,  while  the  closing  muscles  of  the  jaw — viz.,  the  ptery- 
goids, masseters,  and  temporals — are  placed  on  the  stretch  by  partially  open- 
ing the  mouth. 

The  ophthalnik  (supraorbital)  reflex  is  a  pure  sensori-motor  reflex, 
elicited  by  mechanical  irritation  (tapping  lightly  with  the  percussion  ham- 
mer), or  by  the  application  of  heat,  cold,  or  pain-stimuli  over  the  distribu- 
tion of  the  ophthalmic  nerve,  especially  in  the  distribution  of  the  supraorbital 
branch  on  the  forehead.  It  is  manifested  by  a  fibrillary  contraction  of  the 
individual  fibers  in  the  inferior  half  of  the  orbicularis  palpebrarum.  The 
sensory  impulse  travels  through  the  supraorbital  nerv^e  (purely  sensory)  to 
the  pons  and  thence  through  the  facial  fibers  (purely  motor)  to  the  orbicu- 
laris palpebrarum. 

The  value  of  the  reflex  depends  upon  the  loss  of  the  contractions  from  a 
lesion  cutting  the  arc  either  in  the  ophthalmic  branch  of  the  trifacial,  in  the 
nucleus  of  the  trifacial  or  facial  in  the  pons,  or  in  the  fibers  of  the  facial  going 
to  the  orbicularis  palpebrarum..  It  is  therefore  of  value  in  localizing  lesions  of 
the  pons  in  which  it  may  be  lost,  and  differentiating  a  facial  paralysis  due  to 
a  lesion  of  the  nucleus  or  its  peripheral  fibers,  where  it  is  likewise  lost,  from 
a  supranuclear  or  cortical  lesion  in  which  case  the  reflex  is  present  and 
increased.  It  has  the  same  significance  as  the  reflex  closure  of  the  eyelids 
from  irritation  of  the  conjunctiva,  as  this  also  is  a  reflex  in  the  distribution 
of  the  facial  and  trigeminal  nerves. 

Physiology  of  Tendon  Reflexes. — The  tendon  reflexes  were  first  studied 
by  Erb  and  Westphal,  and  later  by  Tschirjew,  Gowers,  Jendrassik,  Weir 


GENERAL  SYMPTOMATOLOGY.  851 

Mitchell,  Lombard,  and  others.  Erb  explained  the  phenomena  as  purely 
reflex  in  their  character,  requiring  the  offices  of  a  centripetal  and  a  centri- 
fugal nerve,  an  intermediate  center,  and  an  excitant.  Westphal,  on  the  other 
hand,  regarded  them  as  simple  muscular  contractions,  stimulated  as  are  the 
bared,  quivering  muscles  of  the  recently  killed  animal,  the  tendon  being 
simplv  the  intermediary  substance  through  which  the  irritation  is  conveyed. 
It  was  early  objected  to  the  purely  reflex  nature  of  these  phenomena  that  a 
shorter  time  is  usually  required  to  produce  them  than  to  produce  an  ordinary 
reflex  action,  being  but  from  1-40  to  1-30  of  a  second,  as  compared  with  1-15 
of  a  second.  But  the  strongest  objection  is  found  in  the  results  of  the  experi- 
ment of  Tschirjew,  who  cut  all  the  nerves  to  the  patellar  tendon  and  found 
that  the  reflex  still  remained  excitable. 

Nevertheless,  the  tendon  reflexes  are  arrested  by  any  lesion  which 
arrests  reflex  action.  Hence  reflex  action  must  somewhere  come  into  play. 
Accordingly,  Gowers  suggests  that  "  the  irritability  is  developed  by  the 
passive  tension.  If  the  muscle  is  relaxed,  the  fibers  may  contract,  if  they 
are  struck  directly,  as  do  the  fibers  of  a  separated  frog's  muscle,  but  no  con- 
traction ensues  on  striking  the  tendon.  Hence  we  must  assume  that  the 
tension  excites,  by  a  reflex  influence,  a  state  of  irritability  to  local  mechanical 
stimulation,  such  as  a  tap  on  the  muscle,  its  tendon,  or  even  the  vibration 
from  a  tap  on  adjacent  parts.  But  only  that  form  of  mechanical  stimulation 
is  effective  which  suddenly  increases  the  previous  tension.  It  is  only  because 
the  tap  on  the  tendon  does  this  so  readily  that  the  tendon  is  the  means  by 
which  the  contractions  are  most  easily  produced,  and  through  which  they 
have  been  chiefly  studied  and  prematurely  named.  If  the  tension  put  on  a 
muscle  is  gentle  and  gradual,  it  may  only  develop  the  irritability,  and  an, 
additional  local  stimulation  is  necessary  to  produce  a  visible  contraction. 
If,  however,  the  tension  is  sudden  and  forcible,  it  not  only  develops  the 
irritability,  but  produces  visible  contraction  in  the  muscle  thus  rendered 
irritable,  as  in  setting  up  foot-clonus."  Hence,  too,  according  to  Gowers, 
the  term  "  tendon  reflex  "  is  altogether  too  inaccurate,  and  he  suggests  the 
word  myotatic,  from  /xvgjv,  muscle,  and  ratiHO?,  extended,  because  tension 
is  necessary  for  the  production  of  the  contractions.  Weir  Mitchell  describes 
it  well  in  these  words :  "  A  muscle  moves  when  struck  because  of  its  innate 
capacity  to  twitch  when  irritated,  but  it  does  not  move  when  excited  by  a 
blow  on  its  tendon  unless  it  has,  besides  its  own  excitability,  a  constant 
influx  of  tone-weaves  from  spinal  centers."  * 

Hence  in  a  com.plete  examination  the  "  muscle  jerk,"  or  idiomuscular 
contraction,  also  known  as  mechanical  muscular  irritability,  should  be  tested 
as  well.  It  is  done  by  a  sharp,  sudden  tap  on  the  muscle  with  the  hammer. 
The  response  is  of  two  kinds,  first  as  a  sudden  contraction,  and  second  as  a 
hump-like  rise  which  subsides  slowly.  The  pectoral  muscles  are  favorite 
sites  for  eliciting  the  pure  muscle  reflexes.  It  is,  of  course,  impossible  to 
deny  that  there  is  nerve  as  well  as  muscle  irritation  in  such  a  blow. 

Both  the  tendon  jerk  and  muscle  jerk  are  capable  of  re-enforcement 
by  coincident  muscular  exertion,  as  in  lifting  weights  or  clinching  fists, 
originally  discovered  by  Jendrassik  y  m  1883  in  the  case  of  the  tendon  jerk. 
Mitchell  and  Lewis  |  also  discovered  in  the  course  of  their  study  of  ataxic 
cases  that  the  pure  muscle  jerk  or  hump  could  be  produced  after  the  tendon 


*  Mitchell  and  Lewis, "  Tendon  and  :Muscle  Jerk,"  "  Trans.  Assoc,  of  Amer.  Physicians,"  vol.  i.  p. 
1886. 

t "  Beitra 
xxxiii.  p.  175. 


13,  1886.  ,   J.   ■ 

f'Beitrage  zur  Lehre  von  den  Sehnenflechsen,"  "  Deutsches  Archiv   f.  khn.  Medicm,     i88^,  vol. 

t  Loc.  at. 


852  DISEASES  OF  THE  NERVOUS  SYSTEM. 

reflex  could  no  longer  be  elicited,  and  that  both  could  be  produced  by  the 
re-enforcement  referred  to  after  the}'  had  disappeared  to  ordinary  conditions. 

Significance  of  Abnormal  Reflexes. — What  are  the  conclusions  to  be 
drawn  from  modifications  in  the  reflexes?  In  the  first  place,  it  is  to  be  re- 
membered that  they  vary  somewhat  within  the  limits  of  health.  Especially  is 
this  true  of  the  cutaneous  reflexes,  which  are  also  less  easily  elicited  than 
those  of  the  tendons.  In  general  terms,  diniinution  or  absence  of  a  reflex 
norinally  present  in  health  implies  either,  first,  a  breach  of  integrity  somewhere 
in  the  reflex  arc  as  formed  by  the  centripetal  nerve,  the  motor  nerve  cells  in 
the  spinal  cord  situated  in  the  anterior  cornua  of  the  gray  matter,  and  the 
motor  nerve ;  or,  second,  an  increase  in  the  reflex  cerebral  inhibitory  influence. 
The  latter  would  be  irritative.  Thus,  it  is  well  known  that  disease  of  one 
cerebral  hemisphere  may  lessen  or  abolish  the  superficial  reflexes  on  the  oppo- 
site or  paralyzed  side  of  the  body  soon  after  the  onset  of  a  hemiplegia.  Breach 
of  integrity  may  lie  in  the  spinal  cord  or  in  the  centrifugal  or  the  centripetal 
nerve;  more  commonly,  of  course,  in  the  former.  If  it  is  in  the  centripetal 
nerve,  it  may  be  accompanied  by  impaired  sensation ;  if  in  the  centrifugal, 
there  will  be  defective  motion.  Disease  of  the  centrifugal  nerve  and  of  the 
motor  center  in  the  cord  may  also  cause  degeneration  and  wasting  of  muscle 
with  loss  of  its  irritability. 

Increase  of  the  reflexes,  on  the  other  hand,  implies  increased  irritability 
of  the  motor  areas  of  the  cord — when  the  reflexes  are  spinal  (anterior  cornua 
and  possibly  of  the  pyramidal  fibers)  or  a  withdrawal  of  cerebral  inhibition, 
as  in  certain  cases  of  destructive  brain  disease  or  disease  of  the  cord  high  up. 
In  the  case  of  a  cortical  lesion  the  increase  in  the  reflexes  is  greater  on  the 
side  opposite  that  of  the  brain  lesion,  but  the  reflexes  on  the  same  side  as  the 
lesion  may  also  be  somewhat  increased.  In  certain  diseases  of  the  cord  there 
is  a  delay  in  the  manifestation  of  the  cutaneous  reflexes  after  the  irritation 
has  been  applied  to  the  skin,  an  interval  of  from  ten  to  fifteen  seconds  being 
often  recorded  before  the  response  ensues.  Increase  of  cutaneous  reflexes 
is  manifested  by  an  unusual  readiness  of  response  in  the  normal  areas,  or  an 
extension  of  these  areas  beyond  their  normal  boundaries. 

In  general  it  may  be  said  that  absence  of  the  tendon  reflexes  is  espe- 
cially characteristic  of  poliomyelitis  and  tabes  dorsalis,  and  of  all  peripheral 
paralyses  and  neuritis ;  also  of  advanced  diabetes  melHtus.  Abnormal 
increase  is  present  in  spastic  spinal  paralysis  and  in  cerebral  paralyses,  being 
due  in  the  latter  instance  to  withdrawal  of  the  normal  inhibitory  influences. 

Appended  is  a  table  showing  the  conditions  under  which  the  tendon 
reflexes  as  represented  by  the  knee-jerk  are  increased  or  diminished: 

TENDON  REFLEXES. 

Increased.  Decreased. 

Spastic  spinal  paralysis.  Poliomyelitis,  acute  and  chronic. 

Amyotrophic  lateral  sclerosis.  Tabes  dorsalis. 

Cerebral  paralysis  in  which  the  inhibitory  Progressive  spinal  muscular  atrophy. 

center  is  impaired.  Muscular  dystrophy. 

Lesions  of  the  cord  above  the  reflex  arcs.  Peripheral  paralysis. 

Disseminated  cerebrospinal  sclerosis.  Neuritis. 

Irritability  of  cord,  as  in   maniacal   hys-  Degenerated  muscle. 

teria.  Exhausted  spinal  centers. 

Strychnin  poisoning.  Poisoning  from  drugs  (?) 

Cerebral  palsies  of  children.  Advanced  diabetes  mellitus. 

Increased  or  Diminished. 

Paretic  dementia:    Diminished   as  a   tabetic  symptom;  increased   in   beginning 
spastic  paralysis  of  the  leg. 

Cerebellar  tumor,  not  infrequently  diminished. 


GENERAL  SYMPTOMATOLOGY. 


853 


Se<rments  of  the  Cord  Presiding  over  Certain  Reflexes. — Further  accu- 
racy in  the  application  of  a  knowledge  of  the  reflexes  and  of  their  modifica- 
tions is  secured  by  a  knowledge  of  the  exact  portion  of  the  gray  matter 
presiding  over  the  most  important  of  them.  Premising  that  some  of  these 
centers  are  of  considerable  extent  vertically,  the  following  from  Gowers  may 
be  regarded  as  approximate  for  each  of  the  reflexes  named : 

Superficial  Reflexes. — Plantar,  opposite  second  sacral  nerve;  gluteal, 
fourth  lumbar;  cremaster,  second  lumbar;  abdominal,  sixth  to  seventh 
dorsal ;  epigastric,  sixth  dorsal ;  scapular,  fifth  cervical  to  first  dorsal. 

Tendon  or  Deep  Reflexes — Calf  muscles  (foot  clonus),  fifth  lumbar  and 


Frontalis 
Facial  {upper). 

Corrugator    super- 
cilii. 

Orbic.      palpe- 
brarum. 

Nasal    muscles.  - 

Zygomatic!. 

Orbic.   oris.  ^ 

Facial  (middle) 

Masseter, 

Levator  menti 

Quadratus 

Triangularis, 

Hypogtossits 

Facial  (lower). 

Platysma  myoides 

Hyoid  muscles 


Omohyoid 


Ext.  anterior. 
thoracic  (pectoralis 
major). 


Ascending  frontal  and 
parietal  convolutions 
(motor  area). 


Third  frontal  convolu- 
tion and  insula  (cen- 
ter of  speech). 

Temporalis. 
Facial  {upper  branch). 
Facial  {trunk). 
Posterior  auricular. 
Facial  {middle  branch). 
Facial  {lower  branch). 
Splenius. 

Sternomastoideus. 

Spinal  accessory. 
Levator    anguli 

scapulae. 
Trapezius. 

Dorsalis   scapulce 
(rhomboidei). 


Circumflex. 


Long    thoracic     (ser- 
ratus  magnus). 


Phrenic.        Fifth  and  sixth  cervical 
(deltoid,  biceps,  bra- 
chialis  anticus,  supi- 
nator longus). 


Brachial  plexus. 


Fig.  87. — Motor  Points  on  Face  and  Neck — {after  Erb  and  de  Wattevtlle.) 


first  sacral ;  knee-jerk,  third  and  fourth  lumbar ;  flexor  digitorum  and  tri- 
ceps, seventh  cervical ;  biceps  and  supinator  longus,  sixth  cervical. 

(6)  Paradoxical  contraction  is  a  symptom  allied  to  the  reflexes  for 
which  no  satisfactory  explanation  has  been  afforded.  It  was  first  studied 
by  Westphal,  and  is  only  occasionally  observed.  In  the  tibialis  anticus  mus- 
cle it  is  induced  by  forcibly  flexing  the  foot  on  the  leg.  As  a  result,  the 
foot  remains  thus  flexed  for  a  considerable  time,  after  which  it  slowty  re- 
laxes. In  one  case  the  flexion  continued  for  twenty-seven  minutes.  On 
repeating  the  flexion,  the  phenomenon  recurs,  but  the  response  gradually 
diminishes  in  intensity.  Contract'ofis  induced  by  faradism  may  similarly 
persist.  It  has  been  noticed  in  both  spinal  and  cerebral  disease,  including 
the  early  stage  of  tabes  dorsalis,  multiple  sclerosis,  and  paralysis  agitans. 
More  rarely  it  may  be  induced  in  the  flexors  of  the  leg  and  forearms. 


854 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


(7)  Elcctrkal  excitation  of  motion  is  an  important  means  of  investiga- 
tion m  nervous  diseases.  In  health  nerves  and  muscles  are  excitable  by  elec- 
tricitv,  and  in  diseased  conditions  these  reactions  are  liable  to  change. 
Motion  may  be  excited  by  electrical  stimulus  applied  to  the  muscle  through 
its  nerve  or  directly  to  the  muscle  itself.     The  latter  is  called  direct,  the 


Triceps  (long  head). 

Triceps  (inner  head). 
Ulnar. 


Flexor  carpi  ulnaris. 

Flexor  profundus 
digitorum. 


Flexor  sublimis  digitor 
um  (II  and  III). 


Flexor  sublimis  digitor- 
um (index  and  little 
fingers). 

Ulnar. 


Palmaris  brevis 

Abductor  min.  digit.  ' 

Flexor  min.  digit. 
Opponens  min.  digit. 


Lumbricales. 


Deltoid     ("anterior 
portion). 


Musculocutaneous. 
Biceps. 
Brachialis  anticus. 

Median. 
Supinator  longus. 

Pronator  teres. 
Flexor  carpi  radialis. 

Flexor  sublimis  digitorum. 
Flexor  longus  pollicis. 
Mediant. 

Abductor  pollicis. 
Opponens  pollicis. 
Flexor  brevis  pollicis. 


Adductor  pollicis. 


Pig.  88.— Motor  Points  on  Upper  Limb,  Flexor  Surface— (a//^r  Erb  and  de  Watteville). 


former  indirect.  This  is  equally  true  of  the  constant  or  galvanic  current, 
and  of  faradism  or  the  induced  current.*  Hence  every  complete  investiga- 
tion should  include  the  use  of  both  currents. 


be  shown   through 

muscle  protoplasm  to  remain 


GENERAL  SYMPTOMATOLOGY. 


855 


In  order  to  test  the  electrical  condition  of  muscles  and  nerves,  one 
electrode,  the  indifferent  pole,  may  be  held  in  the  hand  of  the  patient  or 
placed  over  the  sternum  or  at  the  back  of  the  neck,  while  the  other  or  test- 
ing pole  is  applied  to  the  nerve  or  muscle,  selected  in  accordance  with  the 
Avell-known  nerve  points  of  Erb  in  Ziemssen's  plates ;  or  the  indifferent  pole 
may  be  placed  on  the  nerve  point  of  a  given  muscle  or  set  of  muscles,  and  the 


Deltoid  (poste- 
rior part). 


Musculospiral. 
Brachialis  anticus. 

Supinator  longus. 
Bxt.  carpi  radial,  longiof. 
Ext.  carpi  radial,  brevior. 


Extensor  communis 
digitorum. 


Extensor  indicis 


Ext.  ossis  metacarpi  pollicis. 
Ext.  primi  internodii  pollicis. 


Dorsal  interossei.  - 


Triceps  (long  head). 


Triceps  (outer  head). 


Extensor  carpi  ulnaris. 
Stipinator  brevis. 

Extensor  minimi  digiti. 
Extensor  indicis. 

Extensor  secundi    internodii 
pollicis. 


Abductor  minimi  digiti. 
Dorsal  interossei  (III  and IV). 


Fig.   89. — Motor  Points  on  Upper  Limb,  Extensor  ^nvisice— {after  Erb  and  de 

Watteville.) 

testing  pole  applied  to  the  belly  of  the  same  muscle.  The  testing  electrode 
should  be  small  enough  to  permit  the  isolation  of  a  single  nerve  or  muscle. 
With  the  faradic  or  galvanic  battery  contractions  may  generally  be  pro- 
duced in  health  with  great  facihty,  either  directly  or  indirectly,  although 
stronger  currents  are  required  for  direct  stimulation.  Contractions  take 
place  with  the  galvanic  battery  only  at  the  making  and  breaking  of  the  cur- 
rent by  the  "  commutator  "  or  "  reverser."  A  definite  law  of  response  exists 
with  galvanism.  Thus,  beginning  with  very  weak  currents,  it  is  observed 
that  contraction  first  takes  place  at  the  moment  of  that  closure  which  makes 


856 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


the  testing  pole  the  kathode  or  negative  pole — kathodal  closure  (KaCl).  As. 
the  strength  of  the  current  is  increased  the  kathodal  closure  contractions 
become  stronger,  and  anodal  closure  (AnCl)  contractions  make  their  appear- 
ance. With  still  stronger  currents  the  anodal  opening  (AnO)  contraction 
occurs,  and,  last  of  all,  when  the  kathodal  closure  contractions  become  tetanic 
(Te),  slight  kathodal  opening  (KaO)  contractions  appear.  These  facts  are 
equally  true  of  normal  muscle  and  nerve,  and  may  he  formulated.  Represent- 
ing slight  contraction  by  a  small  "  c,"  decided  contraction  by  a  large  "  C," 
and  the  absence  of  contraction  by  a  minus  sign  ( — )  : 

With  weak  currents,  KaClc,  AnCl — ,  AnO — ,  KaO — ;  with  stronger 
currents,  KaClC,  AnClc,  AnO — ,  KaO — ;  with  still  stronger  currents,  Ka- 


Anterior  crural. 

Obturator. 
Pectineus. 

Adductor  magnus. 
Adductor  longus. 


Cruretis. 


Vastus  intern 


US-( 


>  Tensor  fasciae  femoris. 

Sartorius. 

Quadriceps  femoris. 
Rectus  femoris. 

\  Vastus  externus. 


Fig.  go.— Motor  Points  on  Thigh,  Anterior  Surface— (a//^r  Erb  and  de  Wattevilley 


CIC,  AnClC,  AnOc,  KaO—;  with  strongest  currents,  KaClTe,  AnClC, 
AnOC,  KaOc. 

In  pathological  states  two  sets  of  deviations  from  the  normal  reaction 
to  electrical  stimulus  are  observed — viz.,  quantitatwe  and  qualitative. 

In  the  quantitative  deviations  there  is  simply  an  increase  or  a  diminution 
of  the  normal  irritability  of  both  nerve  and  muscle  to  either  faradism  or  gal- 
vanism. These  differences  are,  of  course,  most  easily  measured  when  the 
alteration  exists  only  on  one  side  of  the  body,  which  may  then  be  compared 
with  the  other.  When  both  sides  are  affected,  estimates  can  be  made  only 
by  comparison  with  a  healthy  body  or  by  the  galvanometer.  For  this  purpose 
superficial  nerves,  such  as  the  frontal,  ulnar,  and  peroneal,  are  usually 
selected.  Instances:  Increased  quantitative  changes  are  found  in  tetanus  and 
in  the  early  stage  of  certain  peripheral  palsies,  while  diminished  electrical. 


GEXERAL  SYMPTOMATOLOGY.  857 

excitability  is  found  when  the  lower  motor  segments  (  motor  spinal  cells, 
motor  nerA^es,  including  the  muscles  )  are  involved — as,  for  example,  in  pro- 
gressive spinal  muscular  atrophy,  bulbar  paralysis,  and  muscular  dystrophy. 
]\Iore  important  from,  a  diagnostic  point  of  view,  at  least,  are  the 
so-called  qualitatiz-e  deviations  from  the  normal  law  of  contraction  knoivn  as 
the  reaction  of  degeneration.  These  are  produced  by  the  gahanic  current 
only,  and  may.  in  general  terms,  be  regarded  as  a  reversal  of  the  usual  order 
of  response  to  interruption  of  currents  and  in  the  substitution  of  a  slow  and 
vermicular  contraction  for  the  usual  sudden  and  jerking  contraction.  The 
entire  group  of  events  is  best  illustrated  by  describing  the  electrical  phe- 
nomena which  present  themselves  in  an  ordinary  case  of  peripheral  paralysis. 
In  two  or  three  days  to  a  week  after  its  appearance  there  begins  a  gradually 
diminishing  response  in  the  nerve  to  both  faradic  and  galvanic  currents. 
This  goes  on  for  one  or  two  weeks,  at  the  end  of  which  time  it  disappears  to 
both  currents,  even  the  strongest.  The  nerve  is  now  dead.  During  this 
same  time  the  muscle  is  also  losing  its  responsiveness  to  the  faradic  current, 
but  not  to  the  galvanic.  There  may  be  also  at  first  a  slight  diminution  to  the 
galvanic  current,  lasting,  say.  one  week,  and  constituting  the  "  first  degree  " 
or  "  first  stage  "  of  degeneration.  But  during  the  second  week  this  is  substi- 
tuted by  an  increased  excitability,  so  that  there  is  now  marked  response  to 
weak  currents — increased  quantitative  deviation.  But  there  is  also  qualita- 
tive change.  The  anodic  closure  contractions  become  now  as  strong  as  or 
stronger  than  the  cathodic  closure  contractions.  Xay,  more:  the  cathodal 
opening  contractions,  which  in  health  were  exceedingly  weak  and  could  be 
brought  about  onlv  by  the  strongest  currents,  are  now  often  stronger  than 
the  cathodal  closure.  This  state  of  affairs  for  muscle  may  be  represented 
thus : 

(  Diminished  quantitative  response  to  gal- 
First  stage  of  reaction  of  degenera-       -      vanism. 
tion — one  week  :  (  No  qualitative  deviation. 

f  Increased  quantitative  response  to  gal- 
j      vanism. 
Second  stage  of  reaction  of  degen-       J  Qualitative  deviation  as  follows: 
eration — four  to  eight  weeks:  1  AnCl=or  >  KaClc. 

^  I  KaOC  >  KaClc. 

1^  Contraction  prolonged  and  A-ermicular. 

The  phenomena  of  qualitative  change  are  purely  muscular,  and  it  should 
be  mentioned  that  they  are  not  always  typically  present.  Even  more  con- 
stant and  equally  distinctive  and  more  reliable  as  a  sign  of  reaction  of  degen- 
eration is  the  second  qualitative  change  in  the  muscular  contractions  excited 
by  galvanism  in  this  stage.  Instead  of  being  quick  or  sudden,  they  become 
slow,  prolonged,  and  vermicular. 

The  second  stage  lasts  from  four  to  eight  weeks,  increasing  during  the 
third  and  fourth.  In  cases  of  recover}-  the  abnormal  muscle  irritability  to 
galvanism  often  persists  after  return  of  voluntary  power,  but  it  diminishes 
as  the  faradic  irritability  returns.  In  severe  cases,  when  recovery  does  not 
take  place  and  the  nerve  is  not  restored  to  its  natural  state,  all  nerve  irrita- 
bility and  faradic  muscular  irritability  remaining  permanently  absent,  the 
increased  galvanic  muscular  irritability  mav  continue  for  months,  but  ulti- 
mately also  decreases,  disappearing  finally  with  the  muscular  substance. 

Certain  exceptions  to  these  laws  must  be  mentioned.  Thus,  when  the 
nerve  lesion  is  slight,  the  fall  in  quantitative  nerve  irritability  is  sometimes 
preceded  by  a  corresponding  rise,  or  the  rise  may  persist  throughout,  and 


858 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


such  rise  may  be  considered  as  evidence  of  a  slight  lesion.  Further,  the 
change  is  not  always  the  same  to  faradism  and  galvanism,  and  is  often 
brought  out  much  better  by  the  slow  interruptions  in  the  faradic  battery  than 
by  the  rapid  interruptions  in  the  same  or  by  the  galvanic  current.  Gowers 
noticed  in  one  instance  moderate  but  prolonged  diminution  of  faradic  irrita- 
bility when  no  change  could  be  found  with  galvanism,  and  Bernhardt  has 
noticed  lessened  irritability  to  faradism  with  distinct  increase  to  galvanism  in 
an  ulnar  nerve  the  seat  of  traumatic  paralysis.  Again,  faradic  irritability 
may  not  diminish  to  the  same  degree  in  the  muscle  as  in  the  nerve  in  mild 


Sciatic. 

Biceps  (long  head). 
Biceps  (short  head). 


Peroneal. 


Gastrocnemius 
(outer  head). 


Soleus. 


Plexor  longus  hallucis. 


Gluteus  maximus. 


Adductor  magnus. 

Semitendinosus. 

Semimembranosus. 


-   Posterior  tibial. 


Gastrocnemius 
(inner  head). 


Soleus. 


Flexor  longus  digitorum. 
Posterior  tibial. 


Fig.  91. — Motor  Points  on  Lower  Limb,  Posterior  ^uxid^QQ— {after  Erb  and  de 

Watteville^. 


cases,  and  conduction  of  voluntary  impulses  from  the  brain  may  be  possible 
when  there  is  no  response  to  electrical  currents,  and  there  may  be  response  to 
electrical  currents  when  there  is  no  conduction  of  voluntary  impulses  from 
the  brain.  In  still  milder  peripheral  paralyses  there  is  no  reaction  of 
degeneration  at  all,  whence  a  favorable  prognosis  may  always  be  made.  It 
is  to  be  especially  observed  in  recovery  from  nerve  lesions  that  voluntary 
motion  often  returns  decidedly  earlier  than  the  electrical  excitabilitv  of  peri- 
pheral nerv'es. 

What  do  reactions  of  degeneration  teach  usf     Simply  that  the  disease 


GENERAL  SYMPTOMATOLOGY. 


859 


is  seated  in  the  anterior  cornua  of  the  gray  matter  of  the  cord,  or  in  the 
peripheral  nerves.  They  teach  us  nothing  as  to  the  nature  of  the  lesion. 
Upon  the  integrity  of  the  cells  in  the  anterior  cornua  and  their  "  trophic 
influence  "  depends  the  nutrition  of  the  nerve  and  the  muscle  over  v^hich  the 
cells  preside.  Hence  with  disease  of  the  cornua  result  degeneration  of  the 
nerve  and  wasting  of  the  muscle.  The  muscular  fasciculi  become  reduced 
in  size  and  ultimately  totally  disappear.  This  is  associated  with  a  certain 
amount  of  interstitial  overgrowth.  In  the  transition  referred  to,  certain  fas- 
ciculi assume  the  yellow,  glassy  appearance  known  as  waxy  degeneration. 
The  sensibility  of  the  muscle,  if  the  sensory  nerve  is  intact,  becomes  increased, 
and  there  may  be  pain,  partly  due  to  compression  of  the  nerves  by  morbid 
contraction,  and  partly  to  a  morbid  sensitiveness  of  the  nerve-endings  and  to 


Tibialis  anticus.  _, 
Extensor  longus  digitorum 


Peroneus  brevis. 


Extensor  longus  hallucis. 


Interossei.  \ 


Peroneal. 


Gastrocnemius. 
Peroneus  longus. 


-Soleus. 


Flexor  longus  hallucis. 


Extensor  brevis  digitorum. 
Abductor  minimi  digiti. 


Fig.  92. — Motor  Points  on  Leg,  External  Surface— («//i?r  Erb  and  de  Watteville). 

the  interstitial  inflammation.  The  recovery  of  the  nerve  is  followed  not  only 
by  gradual  restoration  of  its  power  over  the  muscle,  but  also  by  restoration 
of  the  nutrition  and  redevelopment  of  the  muscle.  For  this,  however,  much 
time  is  required,  and  it  often  remains  permanently  smaller  than  normal.  The 
atrophy  of  muscle  can  be  prevented  to  some  extent  by  massage. 

Lesions  of  motor  nerves,  whether  inflammatory  or  traumatic,  are  fol- 
lowed by  similar  results — degenerative  atrophy  of  nerve  and  muscle  because 
of  interference  with  the  conduction  of  the  atrophic  influence.  Occasionally 
in  cerebral  palsies  and  in  spinal  paralyses  in  which  the  lesion  is  above  these 
ganglion  cells  there  is  some  wasting,  but  no  reaction  of  degeneration  is  devel- 
oped, because  the  nutrition  is  maintained  by  the  intact  cell  body  of  the  lower 
neuron. 


86o  DISEASES  OF  THE  NERVOUS  SYSTEM. 

From  the  foregoing  the  diagnostic  and  prognostic  value  of  the  reaction 
of  degeneration  is  at  once  apparent.  The  seat  of  the  lesion,  whatever  its 
nature,  is  easily  determined,  in  so  far  as  it  is  within  the  cerebral  or  peripheral 
motor  segments,  but  we  may  not  be  able  to  say  whether  the  nerve-cells  or 
their  peripheral  processes  (the  peripheral  nerves)  are  diseased.  We  are  also 
informed  that  recovery,  though  not  impossible,  must  be  delayed  in  proportion 
to  the  degree  of  degenerative  reaction,  because  of  the  extensive  repair  necessi- 
tated in  muscle  and  nerve.  Much  experience  with  the  use  of  electricity 
should,  however,  be  had  before  the  physician  permits  himself  to  draw 
conclusions. 

II.  Sensory  Phenomena. — Under  this  head  naturally  fall  first  the  sub- 
jective sensations  of  the  patient.  They  include,  strictly  speaking,  only  the 
various  modifications  of  sensibility  appreciable  to  him  alone  and  independent 
of  external  impression, — pre-eminently,  pain.  They  also  include  those 
peculiar  modifications  due  to  internal  irritation  as  contrasted  with  external 
impression,  and  known  as  paresthesias — viz.,  numbness,  tingling,  prickling^ 
formication,  or  a  feeling  as  of  ants  crawling  over  the  skin ;  also  a  sensation 
like  that  of  the  contact  of  wool  or  fur, — a  furry  feeling, — vertigo,  tinnitus 
aurium,  or  ringing  in  the  ears,  and  a  sense  of  unpleasant  odors  or  tastes. 

After  these  come  modifications  of  the  different  varieties  of  cutaneous 
sensibility  as  excited  by  external  impressions — objective  sensations.  They 
are  of  the  nature  of  increase  or  decrease,  the  former  being  known  as  hyper- 
esthesias and  the  latter  as  anesthesias,  the  latter  "being  further  characterized 
as  partial  or  complete.  To  the  latter  the  term  paralysis  of  sensation,  partial 
or  complete,  is  also  applied. 

I.  Tactile  sensibility,  the  sense  of  touch  or  pure  contact,  is  usually  first 
investigated.  The  simplest  method  is  by  the  touch  of  a  finger  or  other  blunt 
object  of  about  the  same  temperature  as  the  body,  for  both  heat  and  cold 
must  be  eliminated  in  this  test.  The  patient  should  be  directed  to  close  his 
eyes  or  avert  his  head.  More  refined  measures  are  the  application  of  rough, 
smooth,  or  coarsely  uneven  surfaces.  More  delicate  still  is  the  esthesiometer, 
essentially  a  pair  of  compasses  with  blunt  and  sharp  points  and  graduated 
quadrant  attached,  by  which  the  distance  between  the  two  points  is  accu- 
rately measured.  By  this  instrument,  in  connection  with  a  normal  standard 
of  relative  sensibility  worked  out  by  E.  H.  Weber,  the  degree  of  impairment 
in  delicacy  of  touch  may  be  measured.  Closer  approximation  may  be  recog- 
nized if  the  two  points  of  the  compasses  are  put  down  one  after  the  other  and 
varying  the  test  by  touching  th^  same  place  twice  or  a  different  place  each 
time.     Weber's  table  is  as  follows  : 

Minimum  distance  at  zvhich  the  two  points  of  a  pair  of  compasses  in  con- 
tact with  the  skin  may  be  recognized  as  two  points: 

Cheek,  ii  to  15  millimeters.  Backs  of  the  hands,  31  millimeters. 

Tip  of  the  nose.  6  millimeters.  Backs  of  the  finishers,  11  to  16  millimeters. 

Forehead,  22  millimeters.  Tips  of  the  fingers,  2  or  3  millimeters. 

Tip  of  the  tongue,  1.2  millimeter.  Back,  55  to  77  millimeters. 

Back  of  tongue  and  on  the  lips,  4  or  Chest,  45  millimeters. 

5  millimeters.  Thigh,  77  millimeters. 

Neck,  34  millimeters.  '  Leg,  40  millimeters. 

Upper  arm,  77  millimeters.  Instep,  40  millimeters. 
Forearm,  40  millimeters. 

These  figures  can,  however,  only  be  used  within  limits,  as  they  are  by 
no  means  constant  for  ditTerent  individuals,  or,  indeed,   for  the   same  indi- 


GEXERAL  SYMPTOMATOLOGY.  86i 

vidual  at  different  times.     ^Marked  deviations  from  them  may,  however,  be 
accepted  as  indicating  derangements  of  tactile  sense. 

2.  The  sense  of  pain  is  of  equal  importance  to  that  of  pure  touch, 
because  these  two  not  infrequently  fail  to  diminish  or  increase  pari  passu  in 
morbid  states.  Parts  insensible  to  touch  may  respond  decidedly  to  painful 
impressions.  Pain  is  most  easily  investigated  by  pricking  with  a  pin  or 
pinching  a  fold  of  skin,  by  painful  electrical  currents  or  painfully  hot  metals. 
The  special  term  analgesia  is  applied  to  loss  of  sense  of  pain  while  the  tactile 
sense  is  preserved.  Analgesia  exists  in  peripheral  and  central  nervous  disease 
and  may  be  observed  especially  in  syringomyelia. 

Tenderness  or  pain  on  pressure  in  the  course  of  nerves  should  be  studied 
in  connection  with  the  sense  of  pain.  It  is  found  in  nerves  which  are  the 
seat  of  inflammation,  especially  in  sciatic  neuritis  and  multiple  neuritis. 

3.  The  sense  of  temperature  may  be  roughly  tested  by  ascertaining  the 
power  of  the  patient  to  discriminate  between  the  warm  breath  close  to  the 
skin  and  the  cooler  current  produced  by  blowing  from  a  distance.  More 
precisely,  the  sense  of  temperature  is  studied  by  testing  the  ability  to  recog- 
nize dift'erences  in  the  temperature  of  flat-bottomed  test-tubes  filled  with 
water  of  different  temperatures  and  brought  into  contact  with  the  skin.  The 
therm-esthesiometer  has  been  devised  by  Eulenburg  for  the  same  purpose, 
but  the  student  is  referred  to  works  on  nervous  diseases  for  its  descrip- 
tion. 

In  health  dift'erences  of  1-2''  to  i""  F.  (0.27'  to  0.55^  C.)  may  be  recog- 
nized on  the  fingers  and  face  at  temperatures  from  80"  to  100''  F.  (26°  to 
37°  C).  while  on  the  back  differences  to  be  recognized  must  amount  to  2" 
F.  (1°  C.J. 

In  disease  we  sometimes  notice  complete  loss  of  sense  of  temperature, 
while  the  skin  appreciates  other  forms  of  irritation,  and,  again,  this  state  of 
affairs  is  precisely  reversed;  or  the  temperature  and  pain  sense  may  be  lost 
or  impaired,  while  tactile  sense  is  preserved,  as  in  syringomyelia.  This  is 
known  as  dissociation  of  sensation.  It  occurs  most  commonly  in  syrin- 
gomyelia, but  has  been  seen  in  other  diseases.  Striimpell  has  called  atten- 
tion to  a  peculiar  reversal  of  the  sense  of  temperature,  as  the  result  of  which 
cold  objects  appear  warm.     This  has  been  noticed  in  various  diseases. 

4.  Sense  of  Locality. — By  this  sense  we  know,  without  looking,  w^hat 
part  of  the  body  is  being  touched.  \\'hile  cutaneous  sensibility  may  remain 
intact,  the  sense  of  locality  may  be  seriously  deranged.  Thus,  a  patient  may 
think  he  is  being  touched  on  the  leg  when  the  contact  is  with  the  foot. 

5.  Delayed  conduction  of  sensory  impressions  represents  a  form  of 
modified  sensibility  of  which  after-sensations  are  a  further  subdivision.  In 
delayed  conduction  an  irritation,  more  particularly  a  painful  one,  like  the 
prick  of  a  pin,  is  noticed  by  a  patient  after  an  appreciable  interval,  whereas 
in  health  the  recognition  is  instantaneous  so  far  as  the  unaided  perception  is 
able  to  judge.  Touch  and  pain  may  even  be  thus  separated,  the  immediate 
contact  of  the  pin  being  promptly  recognized,  while  the  sense  of  pain  presents 
itself  a  few  seconds  later.  It  is  likely,  also,  that  the  sense  of  touch  ma}-  be 
delayed. 

6.  An  after-sensation  is  a  prolonged  sense  of  pain  which  succeeds  a 
momentary  impression.  Such  is  the  prolonged  burning  on  the  sole  of  the 
foot  which  sometimes  succeeds  the  prick  of  a  pin.  or  which  may  occur  once  or 
oftener  after  a  short  interval,  as  if  additional  pricks  had  been  made.  Occa- 
sionally an  isolated  prick  of  a  pin  is  not  perceived,  and  repeated  pricks  are 


862  DISEASES  OF  THE  NERVOUS  SYSTEM. 

necessary,  the  whole  producing  a  painful  sensation ;  this  is  known  as  summa- 
tion of  sensation. 

These  abnormal  sensations  occur  particularly  in  diseases  of  the  spinal 
cord  or  of  the  nerves,  and  especially  in  tabes  dorsalis. 

7.  TJie  muscular  sense,  it  were  better  named  the  sense  of  position,  is 
that  sense  by  which  we  become  aware  of  the  position  of  any  of  our  limbs 
without  the  aid  of  vision,  as  well  as  of  any  degree  of  motion  by  them.  It  is 
probable,  however,  that  the  sensibility  of  the  articular  surfaces,  ligaments, 
tendons,  and  skin  aids  the  sensibility  of  the  muscles  in  furnishing  this  infor- 
mation, and  it  is  better  to  call  this  sense  the  seiise  of  position  when  we  speak 
of  it  in  reference  to  the  position  of  the  limbs,  or  deep  sensation.  This  power 
is  diminished  in  nervous  diseases,  and  may  be  tested  by  having  the  patient 
first  touch  a  certain  object  with  his  eyes  open  and  asking  him  to  repeat  the  act 
with  the  eyes  closed ;  or  by  moving  the  fingers  or  toes  of  a  patient  and  request- 
ing him  to  give  their  positions  when  his  eyes  are  closed  and  voluntary  move- 
ments of  the  parts  are  restrained. 

The  "  muscular  sense  "  is  not  only  thus  estimated,  but  the  strength 
required  to  lift  a  leg  or  an  arm,  more  plainly  evident  when  one  is  tired,  is  also 
measured  through  it.  It  is  the  muscular  sense  which  causes  the  paretic  to 
say  that  his  leg  feels  heavy.  By  the  m.uscular  sense,  too,  or  by  the  "  sense 
of  power,"  we  estimate  the  amount  of  strength  demanded  by  any  muscular 
contraction,  and  thus  measure  the  difference  in  weight  of  objects,  eliminat- 
ing, however,  the  sense  of  pressure,  which  may  be  done  by  suspending  the 
object  in  a  towel. 

In  tabes  dorsalis,  as  well  as  in  paralysis  of  cerebral  origin  and  in  cortical 
lesions,  the  muscular  sense  may  be  defective ;  also  in  hysterical  affections. 
It  is  also  found  defective  in  diseases  of  the  peripheral  nerves  and  in  diseases 
of  the  lemniscus,  or  of  the  internal  capsule,  or  of  the  nerve  fibers  passing  to 
the  cortex  around  the  fissure  of  Rolando. 

It  is  disputed  whether  the  muscular  sense  has  a  center  separate  from 
that  of  motion  in  the  cortex  or  from  the  pain  or  tactile  or  temperature  senses, 
but  a  recent  observation  by  Allen  Starr  *  would  go  to  show  that  it  has  a  sepa- 
rate center  two  inches  behind  the  fissure  of  Rolando  and  about  an  inch  and  a 
half  to  the  left  of  the  median  line.  It  seems  probable  that  the  posterior 
columns  of  the  spinal  cord  and  the  parietal  lobes  are  especially  concerned 
with  the  muscular  sense. 

The  muscular  sense  is  estimated  by  the  amount  required  to  be  added  to 
an  existing  weight  on  the  skin  before  the  addition  is  appreciated.  Thus  it 
has  been  ascertained  that  in  health  an  addition  of  1-20  or  1-30  to  an  existing 
weight  can  be  appreciated.  Thus,  if  a  weight  of  ninety-five  gm.  be  placed 
on  the  skin,  an  addition  of  a  single  gram  will  not  be  recognized,  but  nearly 
five  gm.  must  be  added  before  the  increase  is  appreciated,  while  if  consider- 
ably more  than  this  is  necessary,  it  means  that  the  sense  of  pressure  is  less 
delicate.  Sufficiently  accurate  measures  are  coins  of  different  weights. 
Temperature  must  be  eliminated  by  placing  non-conducting  substances  be- 
tween the  weight  and  the  skin,  while  the  part  to  be  tested  must  also  be  sup- 
ported. 

It  is  not  unusual  to  find,  in  paralysis  of  the  muscular  sense,  failure  to 
recognize  a  doubling  and  even  tripling  of  weights.  It  is  more  especially  in. 
tabes  dorsalis  that  such  paralyses  are  found  while  the  tactile  sense  proper  is 

*  "  Psychological  Review,"  January,  1895. 


GENERAL  SYMPTOMATOLOGY.  863, 

intact,  a  light  touch  of  the  skin  being  felt,  while  a  considerable  pressure  is 
not  appreciated. 

Stereo  gnosis — the  faculty  of  recognizing  the  nature  and  uses  of  objects 
by  contact  in  handling  them.  Astereognosis,  or,  as  some  prefer  to  call  it, 
stereoagnosis,  is  the  inability  to  so  recognize  objects. 

The  ability  to  recognize  objects  by  handling  them  depends  upon  the 
integrity  of  the  afferent  nerves,  the  cortical  sensory  area,  and  the  cortical 
perceptive  area.  Disease  of  either  of  these  will  make  it  impossible  for  the 
patient  to  recognize  objects  by  handling  them.* 

,  8.  Anesthesia  is  said  to  be  peripheral,  spinal,  or  cerebral,  in  accordance 
with  the  seat  of  the  broken  conduction  between  the  terminal  apparatus  and 
the  cerebral  cortex.  Peripheral  anesthesia  occurs  after  chilling  of  the  skin 
through  the  action  of  ether,  from  cocain,  aconite,  veratrum,  as  w^ell  as  cor- 
rosive agents  like  acids,  alkalies,  and  carbolic  acid.  Spasm  of  the  small  ves- 
sels, forming  the  so-called  spastic  anemias,  is  also  attended  by  anesthesia. 
The  anesthesias  of  washerwomen,  who  have  their  hands  in  water  all  day 
long,  may  belong  to  this  class.  Lesions  of  nerve  trunks  by  pressure,  inflam- 
mation, and  degeneration  may  cause  anesthesia.  The  paresthesias  referred  to 
— numbness,  formication,  and  tingling — are  among  the  eft'ects  of  such  lesions. 
Spinal  anesthesias  are  found,  especially  in  connection  with  disease  of  the 
posterior  roots,  posterior  columns,  and  posterior  cornua  of  the  cord.  Such 
a  disease  is  tabes  dorsalis  especially.  Anesthesia  is  found,  however,  also  in 
myelitis,  acute  and  chronic,  and  when  there  is  pressure  on  the  cord  from 
hemorrhage  into  the  spinal  canal  or  pressure  by  diseased  or  broken  vertebrae 
or  from  tumors.  Such  anesthesia  is  usually  bilateral  and  is  known  as  para- 
anesthesia.  Cerebral  anesthesia  occurs  as  the  result  of  hemorrhages,  soften- 
ing, or  tumors,  whicli  impinge  on  the  posterior  limb  of  the  internal  capsule^ 
through  which  the  sensory  fibers,  probably  after  interruption  in  the  thalamus, 
pass  upward  to  the  cerebral  cortex.  If  the  cerebral  anesthesia  affects  half 
of  the  body,  it  is  known  as  hemianesthesia,  and  the  half  of  the  body  affected 
is  opposite  the  hemisphere  of  the  brain  in  which  the  lesion  lies,  since  the  sen- 
sory libers  also  decussate  in  their  course  from  the  periphery,  and  most  of 
them  throughout  the  cord  very  soon  after  their  entrance  into  the  posterior 
roots. 

The  hysterical  anesthesias,  and  anesthesias  due  to  the  action  of  narcotics 
and  anesthetics,  are  regarded  as  cerebral  in  their  origin.  Those  succeeding 
such  acute  infectious  diseases  as  typhoid  fever  have  been  ascribed  to  both 
peripheral  and  spinal  origin.  The  hysterical  hemianesthesia  is  much  com- 
moner than  the  organic  cerebral  hemianesthesia. 

III.  Sensory  ]\Iotor  Phexomexa. — These  words  explain  themselves,- 
but  in  addition  to  the  general  application  they  include  such  special  conditions 
as  akinesia  algera  in  which  all  sorts  of  muscular  action  are  attended  with 
pain  in  the  active  muscles — even  the  act  of  speaking  is  attended  with  pain. 
It  is  a  symptom  of  several  neuroses,  among  which  hysteria  and  neurasthenia 
are  conspicuous.  Atreniia.  which  resembles  akinesia,  differs  from  it  in  the 
absence  of  tenderness  of  the  muscles  affected. 

IV.  Vasomotor  and  Trophic  Phexomexa. — We  pass  next  to  the 
study  of  vasomotor  and  trophic  alterations.     Two  sets  of  vasomotor  nerves 

*  See  Burr,  "  American  Journal  of  the  IMedical  Sciences,"  March,  igoi. 


864  DISEASES  OF  THE  NERVOUS  SYSTEM. 

have  been  demonstrated  by  physiologists, — the  vasoconstrictors  and  vaso- 
dilators— the  former  contracting  the  arteries  when  stimulated  and  permitting 
their  dilatation  when  paralyzed.  The  vasodilators  are  influenced  in  an  oppo- 
site manner  by  the  same  agencies,  but  their  number,  so  far  as  proved,  is  not 
great,  as  thev  include  up  to  the  present  time  only  fibers  in  the  chorda  tympani, 
nervi  erigentes,  and  sciatic  nerve.  Blushing  may  be  the  result  of  stimula- 
tion of  vasodilators.  Moreover,  pathology  has  as  yet  failed  to  separate 
lesions  of  the  two  sets  of  ner\^es  and  their  consequences,  and  the  latter  are 
generally  looked  upon  as  results  of  paralysis  or  of  irritation  of  vasocon- 
strictors. Instances  of  the  former  are  redness,  a  feeling  of  warmth,  and 
sometimes  an  actual  elevation  of  temperature,  sweating,  all  in  circumscribed 
areas  or  half  the  body.  They  may  persist  or  intermit.  Instances  of  vaso- 
motor irritation  are  pallor,  coldness,  accompanied  by  stiffness,  formication, 
and  even  pain.  These  are  the  phenomena  of  vasomotor  spasm.  A  more  or 
less  permanent  condition  of  the  hands  sometimes  results,  characterized  by  a 
blueness  or  mottled  appearance  accompanied  by  a  lowered  temperature  fur- 
ther augmented  by  external  cold.  Still  higher  degrees  are  said  to  have  pro- 
duced circumscribed  gangrene  (Raynaud's  disease). 

Symptoms  of  vasomotor  paralysis  occur  in  connection  with  cerebral  and 
:spinal  lesions  and  with  injuries  of  the  sympathetic  system  and  nerve  trunks 
which  include  vasomotor  fibers.  The  essential  causes  of  vasomotor  spasm 
are  less  easy  to  locate.  It  is  found  associated  with  prolonged  convulsive 
seizures,  and  in  angina  pectoris  at  the  beginning  of  the  attack,  as  if  caused 
by  irritation  of  the  sympathetic  ganglia  in  the  heart. 

That  trophic  or  nutritive  phenomena  are  closely  allied  to  vasomotor  phe- 
nomena is  commonly  admitted.  That  they  are  under  the  control  of  the  same 
nerves  is  doubtful,  although  the  proof  of  the  existence  of  separate  trophic 
nerves  is  still  wanting.  \'esicular  eruptions  in  the  area  of  distribution  of 
nerves,  such  as  herpes  zoster,  certain  atrophic  skin  diseases,  pigmentations 
and  depigmentations,  such  as  morphea,  Addison's  disease  and  vitiligo,  sclero- 
derma, and  the  glassy  skin  which  succeeds  certain  injuries  to  nerve  trunks 
are  illustrations  of  trophic  influences.  Similar  are  the  changes  in  the  skin, 
hair,  and  nails,  as  the  result  of  which  the  first  becomes  dry,  the  second  is  lost 
or  becomes  rapidly  gray,  and  the  last  grow  brittle,  thicken,  or  drop  off.  The 
latter  events  are  the  result  of  spinal  and  even  cerebral  lesions.  The  circum- 
scribed edema  known  as  acute  angioneurotic  edema  and  the  more  permanent 
condition  of  myxedema  are  also  probably  trophic.  So,  also,  are  the  atrophies 
which  result  from  disease  of  the  cells  of  the  anterior  horns  of  the  gray  matter 
of  the  cord,  or  from  injuries  to  nerves  by  which  they  are  essentially  cut  ofif 
from  the  trophic  cells ;  also  unilateral  facial  atrophy,  including  even  atrophy 
of  bone,  and  the  still  more  remarkable  spinal  arthropathies  of  Charcot,  as  the 
result  of  which  the  joints  enlarge  or  become  the  seat  of  efifusions. 

Finally,  there  is  the  acute  bed-sore  or  eschar,  so  well  described  by 
Charcot,*  beginning  in  an  erythematous  patch  on  which  bullae  and  blebs  are 
rapidly  developed,  quickly  succeeded  by  gangrene.  While  pressure  or  irrita- 
tion may  be  necessar>^  to  the  production  of  these  sores  as  exciting  causes, 
they  are  more  easily  invited  in  spinal  paralyses  than  in  non-paralytic  condi- 
tions. Such  results  follow  cerebral  lesions  and  lesions  in  the  medulla 
oblongata,  spinal  cord,  and  sympathetic  nerve. 

It  is  well  known  that  the  vasomotor  nerves  surrounding  the  various 

*  "  Lectures  on  Diseases  of  the  Nervous  System,"  Philadelphia.  1879. 


GENERAL  SYMPTOMATOLOGY.  865 

blood-vessels  are  derived  from  the  sympathetic  trunks,  which,  in  turn,  receive 
their  vasomotor  filaments  from  the  roots  of  the  spinal  nerves. 

V.  Mental  Phenomena. — Under  this  head  come  the  phenomena  of 
consciousness  or  unconsciousness,  coma,  the  state  of  the  will,  the  various  per- 
versions of  mental  process,  including  delirium,  hallucinations,  delusions, 
illusions,  and  insane  acts.  Hallucinations  are  states  of  the  mind  in  which  the 
subject  conceives  that  he  perceives  external  objects  which  do  not  exist.  The 
victim  of  delirium  tremens  who  conceives  that  he  is  pursued  by  monsters  of 
various  sorts  is  the  subject  of  hallucinations.  Hallucinations  may  exist 
through  any  of  the  special  senses.  A  delusion  is  a  false  idea  unassociated 
with  sensory  conceptions.  The  deluded  person  imagines  that  he  is  the  happy 
possessor  of  millions  when  he  is  actually  a  pauper,  or  complains  of  poverty 
although  affluent.  An  illusion  is  based  upon  an  actual  perception,  but  an 
erroneous  impression  arises  therefrom.  In  a  hallucination  no  object  is 
actually  seen;  there  is  no  sensory  impression.  The  idea  of  relief  obtained 
on  looking  at  a  picture  in  the  stereoscope  is  an  illusion  ;  and  Gowers  adds  that 
if  used  in  connection  with  morbid  mental  states,  the  term  illusion  should  be 
confined  to  false  ideas  and  images  the  erroneousness  of  which  the  patient 
recognizes. 

Delirium  is  the  more  or  less  acute  manifestation  of  one  or  all  these  per- 
versions of  mental  process,  associated  with  muttering  or  active  speech  sug- 
gested by  them  or  with  action  growing  out  of  them.  Thus  constituted, 
delirium  may  be  the  result  of  toxic  states  or  acute  disease  other  than  of  the 
brain. 

The  same  perversions  of  mental  process  continued  and  unaccompanied 
by  fever  constitute  insanity,  which  is  probably  always  associated  with  struc- 
tural change  in  the  brain  or  its  membranes,  although  such  may  not  always  be 
demonstrable.  Other  symptoms  are  added,  however,  in  iwsanity,  such  as 
extreme  depression  of  spirits,  while  hallucination,  delusion,  and  illusion  may 
l>e  present  in  various  degrees.  Special  insane  acts  should  be  specified  and 
modifications  of  normal  sleep  noticed. 

VI.  Alterations  in  Vision  and  Hearing. — In  addition  to  the  ordi- 
nary defects  of  vision,  the  response  of  the  pupil  to  light  should  be  noticed ; 
also  its  accommodating  power.  The  former  is  absent  in  three-fourths  of  all 
cases  of  locomotor  ataxia,  while  the  latter  remains.  The  pupil  thus  failing 
to  respond  to  light,  but  retaining  its  accommodation  to  change  of  distance,  is 
known  as  the  Argyll  Robertson  pupil.  Each  eye  should  be  tested  separately, 
the  other  being  covered.  Finally,  the  eye-ground  should  be  examined  in 
every  exhaustive  study  of  a  nervous  case. 

Modifications  in  hearing  are  of  the  nature  of  increased  and  diminished 
intensity,  and  there  is  that  very  common  symptom  known  as  tinnitus  aurium, 
or  ringing  in  the  ears,  already  alluded  to  as  a  good  instance  of  a  subjective 
symptom.  Hyperacusis  occurs  in  association  with  augmented  acuteness  of 
the  other  senses  in  acute  affections  of  the  brain  or  when  there  is  hyperemia  of 
the  brain  from  any  cause.  It  is  also  often  complained  of  in  hysteria.  Deaf- 
ness, on  the  other  hand,  is  more  frequently  the  consequence  of  diseases  of  the 
ear  itself.  Ringing  in  the  ears  occurs  in  many  conditions,  known  and 
unknown.  While  some  more  than  usual  impression  on  the  nerve  is  a  condi- 
tion of  tinnitus,  it  by  no  means  follows  that  the  cause  resides  in  the  nervous 
system.     In  addition  to  the  numerous  forms  of  irritation  due  to  ear  disease, 

55 


866  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  blood  in  an  adjacent  vessel  may  be  thrown  into  vibration  and  produce  an 
audible  murmur.  On  the  other  hand,  tinnitus  is  sometimes  due  to  intra- 
cranial irritation  either  of  the  nerve  or  of  the  auditory  centers. 

VII.  Alterations  in  Breathing  and  Pulse. — Alterations  of  breath- 
ing are  very  common  in  nervous  diseases.  Respiration  may  be  rapid  or  slow, 
and  labored  and  sighing',  or  irregular,  but  especially  peculiar  is  the  Cheyiie- 
Stokes  breathing,  in  which,  succeeding  a  long  pause,  so  long  sometimes  that 
it  seems  as  though  the  patient  would  never  breathe  again,  follows  gentle  and 
shallow  respiration,  which  gradually  grows  deeper  and  more  frequent  until 
an  acme  of  dyspnea  breathing  is  reached,  when  it  again  gradually  diminishes 
in  depth  and  frequency  until  the  pause  again  occurs.  It  is  an  arrythmical 
breathing  of  a  periodic  type.  During  the  pause  the  pupil  often  contracts  and 
the  heart's  action  becomes  less  frequent.  Cheyne-Stokes  breathing  may 
occur  in  tubercular  meningitis,  cerebral  hemorrhage,  embolism,  thrombosis,. 
and  aneurysms  of  the  basilar  artery ;  also  in  uremia,  heart  disease,  and  more 
rarely  in  other  conditions,  including  the  infectious  fevers,  in  which  the  respi- 
ratory center  is  influenced.  The  period  of  arrest  varies  from  five  to  forty 
seconds,  and  the  duration  of  each  cycle  may  be  from  fifteen  to  seventy-five 
seconds,  and  may  vary. 

A  modification  of  Cheyne-Stokes  breathing  is  a  form  in  which  there  are 
periods  of  deep  and  energetic  breathing  which  begin  suddenly,  and  in  which 
the  respirations  gradually  become  shallower  until  they  cease,  and  after  a  pause 
energetically  recommence. 

Cheyne-Stokes  "breathing  was  ascribed  by  Walsh  and  later  by  Traube 
and  Rosenbach  to  lessened  excitability  of  the  respiratory  center  in  the  medulla 
oblongata.  Filehne  suggested  that  the  rhythmogenic  purpose  of  the  respira- 
tory center  is  modified  by  a  periodical  vasomotor  spasm  caused  by  stimula- 
tion of  the  I'asomotor  center  by  the  asphyxiated  blood.  The  arterial  spasm  in 
the  medulla  oblongata  thus  caused  prolongs  the  stimulation  of  the  respira- 
tory center  as  well  as  that  of  the  vasomotor  center  by  hindering  the  access  of 
oxygenated  blood.  The  respiratory  center  being  less  excitable,  the  re- 
spiratory movements,  therefore,  continue  energetic — run  riot  as  it  were — 
after  the  blood  has  become  oxygenated.  The  gradual  onset  of  the  breathing 
may  be  due  to  the  fact  that  the  reactive  vasomotor  dilatation  exceeds  the  nor- 
mal, and  thus  the  quantity  of  blood  reaching  the  respiratory  center  lessens 
the  stimulating  influence  of  its  quality ;  but  these  are  merely  theories. 

The  pulse  is  influenced  chiefly  by  diseases  of  the  cranial  contents,  espe- 
cially of  the  medulla  oblongata^,  the  cerebrum,  and  the  meninges.  It  is  at 
times  very  slow,  as  in  meningitis  and  apoplexy,  or  when  there  is  intracranial 
pressure  from  any  cause  or  when  there  is  pneumogastric  irritation.  It  may 
be  accelerated  when  there  is  inflammatory  pyrexia  or  irritation  of  the  cardiac 
center.  Again,  it  may  be  irregular,  acting  through  the  nervous  system,  of 
which  opium  poisoning  is  among  the  familiar  causes  ;  uremia  is  another  cause, 
rarelv  also  is  influenza. 

Changes  in  the  order  of  investigation  proposed  in  this  section  will,  of 
course,  be  demanded  by  circumstances,  while  at  times  certain  steps  may  be 
omitted  altogether. 


NEURITIS.  867 

AFFECTIONS  OF  THE  PERIPHERAL   NERVES. 

NEURITIS. 

Definition. — Neuritis,  or  inflammation  of  a  nerve,  may  be  confined  to  a 
single  trunk,  whence  it  is  called  localised;  or  it  may  involve  a  large  number 
of  nerves,  when  it  is  known  as  nuiltiple  neuritis  or  polyneiiritis.  In  peri- 
neuritis the  connective  tissue  surrounding  a  nerve  is  the  seat  of  the  inflamma- 
tion; in  interstitial  neuritis  the  tissue  between  the  bundles  of  nerve-fibers  is 
involved,  and  in  parenchymatous  or  degenerative  neuritis  the  substance  of 
the  nerve-fibers  themselves  is  affected. 

Localized  Neuritis. 

Etiology. — Exposure  to  cold  is  the  most  frequent  cause  of  neuritis,  and 
the  nerve  most  frequently  thus  afifected  is  the  facial.  Trauma  is  another 
cause,  including  compression,  contusions,  or  cuts,  as  with  glass,  or  stretching 
and  laceration  such  as  occur  when  there  are  dislocation,  fracture,  and  other 
violent  injuries.  Neuritis  may  also  occur  as  the  result  of  extension  of  inflam- 
mation from  contiguous  parts,  as  from  caries  in  a  bone  through  which  the 
nerve  passes,  adjacent  joint  inflammation,  pleurisy,  and  meningitis.  Finally, 
neuritis  may  be  caused  by  toxins  and  morbid  states  of  the  blood,  such  as  pro- 
duce the  infectious  and  constitutional  diseases,  as  diphtheria,  syphilis,  and 
gout.  The  mineral  poisons,  especially  lead  and  arsenic,  are  frequent  causes. 
Alcohol  is  also  a  cause  of  this  kind  of  neuritis,  although  it  more  frequently 
produces  multiple  neuritis. 

Morbid  Anatomy. — An  inflamed  nerve  is  reddish,  from  hyperemia  of 
the  vasa  nervorum,  though  the  stage  of  demonstrable  hyperemia  may  have 
passed  away  when  the  nerve  comes  under  observation.  In  perineuritis  and 
interstitial  neuritis  the  primary  change  is  in  the  connective  tissue — in  the 
former,  an  infiltration  of  the  nerve  sheath  with  leukocytes,  and  in  the  latter, 
of  the  interstitial  tissue  with  the  same  cells.  There  may  even  be  minute 
extravasations  of  blood.  These  changes  are  more  apt  to  occur  in  places 
along  the  course  of  the  nerve  where  it  is  exposed  to  special  irritation,  as  in 
passing  through  foramina  or  over  bone.  The  lymphoid  cells  gradually 
become  fusiform  cells,  resulting  in  the  formation  of  true  connective  tissue. 
The  pressure  of  this  new  tissue  gradually  destroys  the  nerve  itself,  the 
medullary  sheath  being  gradually  broken  up  into  drops,  which  subsequently 
disappear,  while  the  nuclei  of  the  sheath  of  Schwann  increase;  finally,  the 
axis-cylinder  also  becomes  granular  and  disappears — all  this  in  varying  de- 
grees. The  nerve-fiber  may  be  substituted  by  a  fiber  of  connective  tissue, 
in  which  there  may  be  a  deposit  of  fat,  a  condition  seen  in  the  lipomatous 
neuritis  of  Leyden. 

In  parenchymatous  neuritis  the  primary  change  is  in  the  nerve-fiber 
itself.  Here  the  medullary  sheath  and  the  axis-cylinder  are  the  first  involved, 
the  former  breaking  up  into  drops,  as  flescribed,  and  the  latter  into  granules, 
both  ultimately  disappearing,  while  the  interstitial  connective  tissue  remains 
comparatively  unchanged  ;  but  the  nuclei  of  the  sheath  of  Schwann  proliferate 
and  become  a  part  of  the  interstitial  connective  tissue.  The  muscles  con- 
nected with  the   inflamed   nerve  also  atrophy, — in  the   case   of   the   motor 


868  DISEASES  OF  THE  NERVOUS  SYSTEM. 

nerves,  at  least, — being  practically  cut  off  from  their  center  of  nutrition. 
The  change  in  the  nerve  is  essentially  the  W'allerian  change  noticed  in  the 
nerve-fiber  of  a  cut  nerve.  In  some  instances  the  changes  noticed  in  the 
sheath  of  Schwann  extend  over  into  the  interstitial  tissue  of  the  muscle. 

Symptoms, — There  is  not  much  constitutional  disturbance  in  localized 
neuritis,  though  the  thermometer  may  show  some  rise  of  temperature. 
Pai)i,  especially  pain  on  motion,  and  tenderness,  are  the  salient  symptoms. 
The  pain  may  be  confined  to  the  seat  of  the  inflammation  or  may  involve 
the  distribution  of  the  nerve,  or  the  whole  limb  may  be  involved.  It  varies 
in  degree  and  also  in  character,  being  sometimes  burning  and  at  other 
times  aching,  boring,  or  shooting.  It  is  apt  to  be  worse  at  night,  and  when 
in  situations  involving  pressure  on  the  nerve  itself.  The  nerve  may  be 
swollen  appreciably,  and  rarely  the  skin  over  it  is  reddened. 

The  pain  in  the  trunk  of  an  inflamed  nerve  is  probably  due  to  pressure 
on  the  }ierf-i  nervornin.  Weir  ^Mitchell  has  especially  called  attention  to 
this.  An  interesting  fact  is  that  the  nerves  composed  almost  purely  of  motor 
fibers  are  less  tender  than  sensory  nerves.  This  would  imply  that  fewer 
sensory  nerves  are  distributed  to  the  motor  nerve  trunks  than  to  sensory 
nerves.  Mitchell  also  describes  elevation  of  surface  temperature  and 
trophic  disturbances,  such  as  sweating,  herpes,  and  eft'usion  into  neighboring 
joints.  Other  motor  disturbances,  including  twitchings  and  contractions,  are 
noticed.  Trophic  derangements,  including  muscle  wasting,  associated  with 
peculiar  "  glossy  skin  ''  or  slight  edema,  may  be  present.  Vesicles,  bullae, 
and  herpetic  eruptions  may  occur.  The  nails  become  brittle,  rough,  and 
marked  with  transverse  ridges.  The  bones  in  the  fingers  may  even  become 
atrophied.  There  may  be  thickening  of  the  skin  and  a  condition  resembling 
ichthyosis  may  be  present.  Ultimately  the  hyperesthesia  and  paresthesia 
may  become  anesthesia,  though  usually  limited  to  small  areas. 

The  electrical  condition  of  the  nen^es  and  muscles  must  be  studied. 
It  may  be  normal  in  slight  cases.  In  more  severe  cases  there  may  be  the 
reaction  of  degeneration,  with  the  slow,  lazy  contraction  of  the  muscles, 
and  the  reversed  reaction  to  opening  and  closing  currents,  described  on 
page  856. 

The  course  of  the  disease  is  variously  prolonged.  Alany  acute  cases 
terminate  favorably  in  a  few  weeks.  More  cases  become  chronic,  extending 
over  months  and  even  years,  after  which  they  may  gradually  subside. 

A  rare  variety  is  "  ascending  neuritis,"  in  which  the  inflammation 
extends  from  smaller  to  larger  branches,  until  finally  most  of  the  nerves  of 
a  limb  may  be  involved,  01^  possibly  even  the  spinal  cord,  producing 
myelitis,  with  or  without  spinal  meningitis.  Paralysis  may  result  from  such  a 
condition.  This  is  possibly  the  rare  form  of  paralysis  that  succeeds  visceral 
disease,  as  that  of  the  bladder.  Even  the  corresponding  ner^^es  of  the  other 
side  ma)^  be  involved.  It  is  the  opinion  of  some  of  the  best  neuropatholo- 
gists that  this  ascending  neuritis  occurs  only  from  a  suppurating  wound. 
The  theory  of  an  ascending  neuritis  is  not  universally  accepted. 

Additional  Sympto:sis  Due  to  Nerves  Involved. — In  inflammation 
of  the  facial  nerve  there  is  complete  paralysis  of  all  the  muscles  supplied  by 
the  nerve.  In  inflammation  of  the  niedhini  nerve  there  is  disturbance  on  the 
palmar  surface  of  the  thumb,  forefinger,  and  middle  finger  on  its  radial  side, 
and  there  is  often  intense  pain  in  these  same  situations.  In  inflammation  of 
the  ulnar  nerve,  there  are  pain  and  loss  of  sensation  in  the  outer  half  of  the 
fhird  finger  and  in  the  fourth  finger,  with  wasting  of  the  flexor  carpi  radialis, 


NEURITIS.  869 

the  intrinsic  muscles  of  the  Httle  finger,  the  interossei,  lumbricales,  and  the 
adductor  of  the  thumb.  Here,  in  case  of  long  standing,  we  have  the  "  claw 
hand,"  the  result  of  overextension  of  the  first  phalanges  and  flexion  of  the 
last  two. 

In  inflammation  of  the  ninsculospiral  there  are  great  pain  and  tenderness 
of  the  upper  arm  and  forearm,  the  region  of  the  brachial  anticus  and  triceps 
extensor,  the  extensors  of  the  wrist  and  fingers,  the  two  supinators — the 
back  of  the  hand,  thumb,  and  index  finger.  In  extreme  degrees  we  have  the 
characteristic  wrist  drop  and  inability  to  extend  the  first  phalanges  of  the 
fingers  and  thumb,  with  partial  anesthesia  of  the  base  of  the  thumb  and 
forefinger. 

The  circumflex  nerve  supplies  the  deltoid  and  teres  minor.  There  may 
be  pain  or  impaired  sensation  in  the  muscles  and  the  skin  over  them,  to  which 
may  succeed  loss  of  power  and  atrophy  of  the  deltoid  and  the  arm  cannot  be 
raised. 

In  inflammation  of  the  brachial  plexus,  which  is  prone  to  occur  in  gouty 
subjects  over  fifty  years  old,  there  may  be  a  combination  of  the  symptoms 
belonging  to  the  last-named  four  nerves.  A  subvariety  of  brachial  neuritis 
is  radicular  neuritis,  in  which  the  pain  suggests  the  involvement  of  the  roots 
of  the  nerves. 

Diagnosis. — The  disease  is  chiefly  to  be  differentiated  from  neuralgia. 
This  depends  upon  pain  and  tenderness  in  the  course  of  the  nerve  and  upon 
the  limitation  of  the  symptoms  to  its  distribution.  Neuralgia  is  more  inter- 
mittent, and  is  relieved  rather  than  aggravated  by  pressure.  The  presence 
of  the  paresthesia  points  to  neuritis  and  the  diagnosis  is  confirmed  if  there 
is  ultimately  lessened  sensibility.  In  neuralgia,  nerve  and  muscle  reactions 
remain  normal.  It  is  possible,  however,  that  neuralgia  may  result  in  neuritis. 
The  distal  pain  of  central  spinal  disease  must  be  separated.  In  brachial 
neuritis  the  pain  may  radiate  to  the  left  side,  suggesting  angina  pectoris,  and 
there  may  even  be  a  tendency  to  cardiac  distress,  but  there  is  no  tenderness 
in  the  course  of  the  nerve  in  angina. 

Prognosis. — The  prognosis  varies  greatly,  being  favorable  in  mild  and 
in  most  traumatic  cases.  Those  consequent  upon  local  suppuration  are  the 
gravest.  In  ordinary  cases  from  cold  or  contusion  recovery  ensues  sooner 
or  later,  although  some  last  a  long  time  and  recurrences  are  not  unusual,  espe- 
cially in  neuropathic  dispositions,  in  which,  too,  recovery  is  slower. 

Treatment. — Here,  as  elsewhere,  if  a  cause  is  discoverable,  it  should 
be  removed.  Exposure  to  cold  and  dampness  should  be  avoided,  pressure 
by  cicatricial  tissue  or  dislocated  bones  should  be  relieved,  and  constitutional 
states  favoring  neuritis,  such  as  gout  and  syphilis,  should  be  corrected. 

Of  curative  measures,  rest  is  the  most  important.  When  a  limb  can  be 
splinted,  this  should  be  done,  pressure  by  muscular  contraction  being  thus 
prevented.  Cold  may  be  a  useful  application,  as  by  an  ice-bag.  In  other 
instances  heat,  now  dry  and  again  moist,  subserves  a  useful  purpose.  A 
blister  or  blisters  may  be  applied  over  the  tender  nerve.  Especially  con- 
venient is  the  Paquelin  cautery,  which  should  be  used  earlier  than  it  com- 
monly is;  its  application  takes  but  a  second,  and  may  be  rendered  painless 
bv  previously  applying,  for  a  few  minutes,  a  mixture  of  ice  and  salt  to  the 
spot  to  be  burned,  although  this  has'been  largely  superseded  of  late  by  the 
more  convenient  ethyl  chlorid.  Morphin  is  sometimes  indispensable,  and  the 
hypodermic  method  of  application  is  best — 1-6  to  1-4  grain  (o.oii  to  0.0165 
gm.)  for  an  adult.     But  the  m_orphin  habit  is  easily  acquired,  and  the  patient 


3;o  DISEASES  OF  THE  XERVOUS  SYSTEM. 

should  not  be  allowed  to  use  the  syringe  himself.  Cocain  may  be  similarly- 
used — i-io  to  1-3  grain  (0.0066  to  0.022  gm.) — and  Gowers  recommends  it 
highly,  more  particularly  for  its  power  in  arresting  local  transmission  of  the 
impulses  that  cause  pain.  Eucain  is  even  better.  Here,  too,  the  injection 
should  be  made  at  the  seat  of  the  pain  by  the  physician  or  a  trusted  attendant. 
Gowers,  whose  large  experience  always  bespeaks  respect,  considers  mercury 
also  a  most  efficient  agent,  in  the  shape  of  a  blue  pill,  one  grain  (0.066  gm.) 
once  or  twice  a  day,  associated,  if  necessary,  with  morphin,  the  constipating 
effect  of  which  it  counteracts.  Salicylate  of  sodium  is  undoubtedly  some- 
times viseful,  as  is  also  more  rarely  iodid  of  potassium.  Strychnin  is  also  of 
service. 

In  the  chronic  form  also  Paquelin's  cautery  should  be  repeatedly  used, 
or  if  not  at  hand,  blistering  may  be  substituted.  Electricity  here  comes  into 
play,  and  galvanism  is  the  form  to  be  used,  the  positive  electrode  being  placed 
over  the  nerve  or  seat  of  pain,  and  the  negative  indififerentiy  placed.  A  weak 
current  should  be  used,  but  its  strength  may  be  increased  if  such  current  be 
inefficient.  The  application  should  continue  for  about  ten  minutes.  The 
wasted  muscles  usually  recover  as  the  inflammation  subsides,  but  massage 
and  galvanic  electricity  help  them.  Faradism  is  less  favorably  regarded, 
especially  in  the  active  stage. 

Special  Variety  of  Localized  Neuritis — Sciatica. 

Definition. —  This  term  is  applied  to  all  painful  affections  in  the  dis- 
tribution of  the  sciatic  nerve,  some  of  which  may  be  neuralgic,  but  the  vast 
majority  are  inflammatory  and  perineuritic,  as  it  is  the  sheath  of  the  nerve 
that  is  usually  involved. 

Etiology. — Sciatica  is  far  more  common  in  men  than  in  women,  in  the 
ratio  of  about  four  to  one.  Brachial  neuritis  affects  both  sexes  about  equally. 
It  is  also  a  disease  of  adults,  being  unknowm  in  children  and  very  rare  in  the 
second  decade.  It  is  most  frequent  between  forty  and  fifty,  next  between 
fifty  and  sixty,  and  next  between  thirty  and  forty. 

Gout  and  rheumatism  are  favoring  causes,  especially  fibrous  rheuma- 
tism. Very  rarely  syphilis  may  be  a  predisposing  cause.  Exposure  to  cold 
is  the  most  frequent  exciting  cause,  especially  after  severe  muscular  exertion, 
while  standing  in  water,  sitting  or  lying  on  the  cold  ground,  and  the  like  are 
frequent  causes.  Exposure  to  drafts,  though  less  frequently  so  than  in  neuritis 
of  the  upper  extremity,  is  still  a  cause.  A  sciatica  may  also  arise  by  exten- 
sion from  a  rheumatic  focus,  especially  that  form  of  lumbago  involving  the 
fibrous  attachments  of  muscles  at  the  back  of  the  sacrum,  whence  the  inflam- 
mation extends  to  the  sheath  of  the  sciatic  nerve.  Pressure  by  mechanical 
agents  and  possibly  muscular  contraction  may  be  a  cause ;  also  pressure  by 
tumors  and  other  new^  formations  within  the  pelvis.  Even  fecal  accumula- 
tions may  cause  it  by  pressure.  In  bilateral  sciatica  the  possibility  of  intra- 
pelvic  tumor  should  be  carefully  considered.  In  addition  to  the  intrapelvic 
causes  referred  to,  secondary  sciaticas  may  be  caused  by  bone  disease  and 
other  foci  of  suppuration  external  to  the  pelvis. 

Morbid  Anatomy. — The  morbid  changes  are  those  already  described 
under  neuritis. 

Symptoms. — The  leading  symptom,  is,  of  course,  pain  in  the  course  of 
the  nerve.  Felt  first  in  the  back  of  the  thigh,  it  also  travels  above  the  hip- 
joint,  into  the  sciatic  notch,  behind  the  knee,  below  the  head  of  the  fibula. 


NEURITIS.  871 

behind  the  internal  malleolus,  and  on  the  dorsum  of  the  foot.  It  may  be 
more  diffuse,  but  the  course  of  the  main  trunk  of  the  nerve  is  often  indicated 
bv  it.  and  the  points  previously  named,  especially  the  back  of  the  middle  of 
the  thigh  and  the  sciatic  notch,  will  often  be  pointed  out  h\  the  patient  as 
seats  of  special  tenderness.  It  usually  begins  gradually,  but  it  may  start 
suddenly,  especially  in  cases  of  rheumatic  origin.  ^Motion,  particularly  in 
walking,  and  positions  in  which  the  nerve  is  put  in  a  state  of  tension  or  is 
compressed,  aggravate  it.  A  valuable  sign  of  sciatica  is  pain  produced  by 
passive  flexion  of  the  thigh  upon  the  pelvis  with  the  knee  extended 
(Lasegues  sign)  ;  by  this  means  the  sciatic  nerv^e  is  stretched,  and  pain  is 
readily  produced  if  the  nerve  is  inflamed.  The  characteristics  of  the  pain 
are  those  already  described  under  neuritis.  The  other  more  unusual  symp- 
toms of  neuritis  may  also  be  present,  as  herpes,  edema,  and  wasting,  but  the 
reaction  of  degeneration  is  almost  never  present.  The  loss  of  the  tendo 
Achillis  jerk  is  an  important  sign. 

Diagnosis. — This  is  not  difficult,  although  a  careful  study  should  be 
made  of  each  case  with  a  view  to  determining  its  primary  or  secondary 
origin.  Pekic  tumors,  especially  in  women,  and  rectal  accumulations  should 
be  sought  for.  Lumbago,  hip  disease,  and  sacro-iliac  diseases  are  all  to  be 
recalled,  but  in  none  of  these  is  there  pain  on  pressure  in  the  course  of  the 
nerv^e.  In  the  last  only  is  there  sometimes  pain  in  the  posterior  part  of  the 
thigh.  Pain  felt  only  in  the  outer  side  of  the  thigh  is  not  sciatica.  The  rare 
cases  of  sciatic  neuralgia  are  not  characterized  by  tenderness.  They  occur 
in  persons  subject  to  neuralgia,  and  the  pain  is  not  influenced  by  position  and 
motion.  It  is  purely  spontaneous.  Disease  of  the  vertebra:,  of  the  cauda 
equina,  and  even  of  the  spinal  cord  may  produce  sciatic  pain ;  but  here,  again, 
there  is  no  tenderness  in  the  course  of  the  nerve,  the  pain  is  peripheral  and 
is  more  apt  to  be  bilateral.  Inflammation  of  the  roots  of  the  sciatic  nerve, 
however,  may  extend  downward.  Bilateral  pain  is  indicative  of  disease  of 
the  nerve -roots,  although  bilateral  sciatica  does  occasionally  occur.  The 
shooting  pains  of  tabes  dorsalis  are  like  those  of  sciatica,  but  the  other  symp- 
toms of  the  former  disease  are  present. 

Prognosis. — Cases  of  sciatica,  however  obstinate,  usually  sooner  or 
later  get  well,  although  they  may  persist  for  months.  A  case  came  under 
my  observation  which  lasted  seven  years. 

Treatment. — Every  case  of  sciatica  should  be  at  once  ordered  to  rest, 
and  the  more  complete  the  rest,  the  sooner  the  recovery.  Splinting  of  the 
limb  as  recommended  by  \\q\t  ^^litchell,  is  necessary  in  some  cases,  and 
would  probably  hasten  cure  if  used  earlier,  but  it  is  so  inconvenient  that  the 
temptation  to  temporize  is  very  strong.  Rest  being  secured,  I  am  confident 
that  recoveries  would  be  prompter  if  Paquelin's  cautery  were  oftener  used  at 
the  onset.  Counterirritation  by  blisters,  mustard,  and  iodin  is  relatively 
inefficient.  Treatment  by  cold  along  the  course  of  the  nerve  certainly  relieves 
the  pain  for  a  time,  but  in  my  experience  the  relief  thus  obtained  is  not 
permanent. 

First,  attention  should  be  paid  to  the  local  causes,  if  these  are  discov- 
erable, and  to  constitutional  causes  as  well.  If  of  rheumatic  or  gouty  origin, 
the  salicylates  will  be  found  useful :  in  other  cases  they  are  useless.  Here, 
as  in  neuritis  from  other  causes.  Cowers  commends  the  pill  of  blue  mass,  one 
grain  (0.06  gm.)  twice  daily,  when  there  is  active  inflammation. 

For  the  relief  of  mild  degrees  of  pain  phenacetin  and  antifebrin,  and 
especially  a  combination  of  phenacetin  and  caft'ein  citrate,  say  ten  grains 


8/2  DISEASES  OE  THE  NERVOUS  SYSTEM. 

(0.66  gm.)  of  the  former  and  three  grains  (0.2  gm.)  of  the  latter  every  two 
hours  are  often  efficient.  For  severe  degrees  morphin  is  necessary,  and  is 
best  given  hypodermically  in  doses  of  from  1-8  to  1-4  grain  (0.008  to  0.0165 
gm.).  The  danger  of  establishing  the  morphin  habit  must  always  be  kept 
in  mind,  and  cocain  should  be  tried  first  as  a  deep-seated  injection  in  doses  of 
from  1-8  to  1-4  grain  (0.008  to  0.0165  gm.).  Acupuncture  over  the  course 
of  the  nerve  is  of  service  for  the  same  purpose — relief  of  pain  rather  than 
cure.  Anodyne  liniments  may  be  used,  and  although  not  curative,  do  give 
some  comfort  and  meet  the  wishes  of  the  patient  that  something  should  be 
done.  Recently  the  internal  administration  of  ichthyol  in  small  doses  has 
been  highly  recommended  by  Grocq.  Ichthyol  locally  is  sometimes 
serviceable. 

In  chronic  cases  change  of  scene  is  often  of  advantage,  and  if  associated 
with  thermal  bath  treatment  may  accomplish  a  cure  in  otherwise  obstinate 
cases.  The  mud-bath  is  a  measure  of  treatment  applied  in  Europe  with 
some  success.  In  the  chronic  stage  electricity  also  meets  the  demands  of 
patients  and  friends  and  may  do  some  good.  The  galvanic  current  should 
be  employed.  Massage  is  less  efficient  than  in  muscular  rheumatism,  though 
it  should  be  tried.  Nerve-stretching  may  be  resorted  to.  I  have  had  it  done 
in  cases  with  uncertain  result. 


Multiple  Neuritis. 

Synonyms. — Polyneuritis;  Peripheral  Neuritis. 

Definition. — An  inflammatory  condition  involving  many  peripheral 
nerves,  either  simultaneously  or  in  rapid  succession. 

Historical. — Multiple  neuritis  is  a  disease  of  modern  recognition.  The  symptoms 
peculiar  to  the  condition  were  described  first,  probably,  by  James  Jackson,  Sr, ,of 
Boston,  Mass.,  as  early  as  1S22.  In  1854  Robert  Bentley  Todd,  of  London,  wrote  of  lead 
palsy  ;  "  The  nervous  system  is  thus  first  affected  at  its  periphery,  in  the  nerves,  and, 
the  poisoning  influence  continuing,  the  contamination  gradually  advances  toward  the 
center."  Duchenne  described  the  symptoms  fully  in  1858.  Samuel  Wilks  described 
alcoholic  paraplegia,  but  the  existence  of  multiple  neuritis  as  an  actual  disease  was 
first  demonstrated  by  Dumenil,  at  Rouen,  in  1864,  and  the  literature  was  further  con- 
tributed to  by  Joffroy  in  1879,  Leyden  in  1880,  Grainger  Stewart  in  1881,  Buzzard  in 
1886,  James  Ross,  Henry  Hun,  and  Charles  K.  Mills  in  1892.  W.  R.  Gowers'  article 
in  the  second  edition  of  ''  Diseases  of  the  Nervous  System,"  1891,  is  a  ver}^  complete 
one. 

Etiology. — The  causes  of  multiple  neuritis  are  numerous,  and  by  no 
means  easy  of  classification.     They  include : 

1.  The  commonly  acknowledged  poisons  introduced  from  without:  (a) 
Organic,  including  alcohol,  by  far  the  most  frequent  cause,  ergot,  morphin, 
ether,  carbon  monoxid,  carbon  bisulphid,  benzine  and  its  products,  and 
anilin ;  (b)  inorganic,  including  lead,  arsenic,  phosphorus,  and  mercury. 

2.  Endogenous  toxins  generated  in  the  organism  by  chemical  changes. 
Such  is  the  cause  of  the  neuritis  of  diabetes  mellitus,  whether  oxybutyric 
acid,  diacetic  acid,  or  acetone,  all  of  which  are  found  in  the  blood  in  that 
disease. 

3.  Toxins  inherent  to  the  infectious  diseases,  whether  an  organism  or 
its  product.  Instances  of  the  former  are  malarial  neuritis,  leprous  neuritis, 
beri-beri  or  so-called  endemic  neuritis,  also,  probably,  the  neuritis  of  acute 
infectious  jaundice  (Weil's  disease).  In  these  instances  the  cause  is  an 
organism.      Of    the    latter,    diphtheritic    neuritis,    septicemic    neuritis,    the 


.  MULTIPLE  NEURITIS.  873 

neuritis  of  smallpox,  typhoid  fever,  tuberculosis,  and  possibly  syphilis  are 
instances.     The  cause  is  here  a  toxin  generated  by  an  organism. 

4.  Intrinsic  states  of  the  blood  of  undetermined  nature,  with  which  cold 
may  or  may  not  co-operate  as  an  exciting  cause — viz.,  rheuiTiatism,  gout; 
also  the  puerperal  state,  and  chorea.  Advanced  microbic  doctrines  would 
place  rheumatic  neuritis  in  3,  while  a  greater  conservatism  might  place  septi- 
cemic neuritis  in  4.  Malnutrition  such  as  characterizes  cachectic  and  senile 
states,  cancer,  tuberculosis,  and  wasting  diseases  generally  are  also  causes. 
It  is  not  impossible  that  cold  alone  may,  by  its  operation,  generate  a  poison 
capable  of  producing  a  polyneuritis,  but  more  probably  it  acts  by  lowering 
the  vitality  of  the  nerves  and  rendering  them  liable  to  attacks  from  other 
agents. 

Age  and  Sex. — Multiple  neuritis  is  a  disease  of  adults.  Aside  from 
rare  cases  of  diphtheritic  neuritis,  the  most  common  form  met  in  children  is 
a  compHcation  of  acute  poliomyehtis.  Gowers  says  "  it  may,  perhaps,  now 
and  then  be  met  with  apart  from  the  spinal  malady  as  an  infantile  variety  of 
multiple  adventitial  neuritis  irregular  in  distribution."  It  is  not  improb- 
able that  in  some  of  the  cases  of  poliomyelitis  the  changes  in  the  ner^^es  are 
secondary  to  alterations  of  the  nerve  cells  in  the  anterior  horns  of  the  spinal 
cord. 

The  remaining  chief  forms  occur  usually  between  the  ages  of  tw,enty 
and  fifty,  the  alcoholic  between  thirty  and  forty  or  later,  and  senile  neuritis 
at  a  still  later  age.  The  alcoholic  form  is  more  frequent  than  all  others  put 
together,  and  of  this  form  70  per  cent,  occur  among  women.  This  pre- 
ponderance of  the  disease  in  women  has  been  especially  noticed  in  England, 
where  alcoholism  among  females  is  more  common  than  in  this  country. 
More  than  one  cause  may  co-operate,  when  one  may  be  the  predisposing  and 
the  other  the  exciting.  Cold  probably  most  frequently  plays  the  latter  role, 
but  there  may  be  others,  such  as  depressing  emotions,  anemia,  and  the  like. 

Morbid  Anatomy. — The  special  characteristic  of  multiple  neuritis  is 
that  it  is  parenchymatous,  as  contrasted  with  interstitial  and  perineural — that 
is,  the  changes  begin  in  the  nerv^e-fibers  themselves,  as  described  on  page 
867,  rather  than  in  the  connective  tissue  between  and  around  them.  Yet  this 
is  not  invariable.  Indeed,  it  is  improbable  that  either  form  of  neuritis  exists 
without  the  other  for  any  length  of  time.  It  is  further  characteristic  of 
multiple  neuritis  that  the  involvement  is  symmetrical — that  is,  the  cor- 
responding nerves  on  the  opposite  side  of  the  body  are  affected.  The  more 
this  is  the  case,  the  more  likely  is  it  that  the  change  is  parenchymatous.  The 
changes  are  also  more  marked  in  the  peripheral  distribution  of  the  nerve  than 
in  the  trunk  of  nerves.  Macroscopic  changes  are  very  rarely  appreciable. 
In  acute  changes  the  nerve  may  be  swollen,  reddened,  hemorrhagic,  or  in 
old  cases  hardened  from  overgrowth  of  connective  tissue. 

Symptoms, — The  symptoms  vary  greatly  in  different  varieties  of  neu- 
ritis, but  there  are  some  more  or  less  common  to  all  varieties,  particularly 
illustrated  by  the  alcoholic  and  rheumatic.  These  common  symptoms  will 
be  considered  first,  and  aftervvard  some  special  features  of  varieties  due  to 
specific  causes,  particularly  the  metallic  poisons,  the  acute  infectious  diseases. 
and  the  poison  of  beri-beri. 

The  symptoms  are  easily  dividend  into  three  classes:  Motor  weakness, 
sensory  derangement,  and  inco-ordination.  The  first  is  the  result  of  the  in- 
volvement of  motor  nerves,  and  manifests  itself  usually  first  in  the  extensors 
of  the  wrist  and  fingers,  flexors  of  the  ankle,  and  extensors  of  the  toes.     The 


874  DISEASES  OF  THE  NERVOUS  SYSTEM. 

sensor}'  disturbances  are  tingling,  numbness,  and  pain,  while  the  inco-ordina- 
tion  resembles  that  of  the  mildest  degree  of  tabes.  According  as  one  or  the 
other  of  these  sets  of  symptoms  predominates  we  have  a  motor  form,  a  sen- 
sory form,  and  an  ataxic  form. 

The  onset  may  be  rapid  or  slozi.'.  In  the  rheumatic  form,  or  that  due 
to  cold,  it  is  usually  sudden,  with  chill  and  fever  and  a  temperature  of  103° 
or  104°  F.  (39.5°  to  40°  C),  headache,  and  backache.  The  slow  onset  is 
characteristic  of  alcoholic  neuritis,  though  it  may  be  precipitated  by  some 
exciting  cause,  as  cold,  exposure,  fatigue,  or  some  toxic  state.  It  is  rarely 
febrile.  In  the  initial  stage  sensory  symptoms  are  numbness  and  tingling 
of  the  fingers  and  toes,  palms  of  the  hands  and  soles  of  the  feet,  and  other 
parts  of  the  lower  arms  and  legs ;  then  hyperesthesia,  tenderness,  and  pain, 
more  marked  in  the  legs,  including  cramps  in  the  calves.  These  may  in  mild 
degree  precede  the  onset  as  premonitory  symptoms  for  weeks  and  for  months, 
especially  in  the  alcoholic  form. 

The  motor  symptoms,  seldom  absent,  soon  follow  the  sensory  phenomena 
previously  mentioned.  They  include  palsy  or  inco-ordination  or  both  in  upper 
and  lower  limbs,  but  with  this  characteristic — that  the  involvement  of  the 
limbs  is  symmetrical  and  the  distal  extremities,  as  the  feet  and  hands  are 
affected,  the  former  more  frequently.  Motor  symptoms  may  exist  in  the  feet 
and  sensory  symptoms  in  the  hands,  the  latter  commonly  preceding. 

The  muscles  commonly  involved  are  those  supplied  by  the  peroneal  nerve 
in  the  lower,  and  by  the  posterior  interosseous  branch  of  the  musculospiral 
in  the  upper  extremity.  With  weakness  in  the  legs  comes  loss  of  knee-jerk 
and  ankle-jerk,  quite  constant,  but  not  invariable,  depending,  of  course,  on 
the  involvement  of  the  nerves  forming  these  reflex  arcs.  The  muscles  above 
the  knee  are  less  frequently  affected,  and  still  less  frequently  those  which 
move  the  hip-joint. 

The  paralysis  of  the  muscles  innervated  by  the  peroneal  nerve  gives  rise 
to  a  peculiar  and  distinctive  walk  known  as  the  steppage  gait,  and  occasion- 
ally it  is  unilateral,  when  only  one  peroneal  nerve  is  affected.  It  is  the  gait 
of  polyneuritis  in  which  the  foot  drops,  and  in  order  to  raise  it  from  the 
ground  and  thereby  to  "  shorten  "  the  limb,  the  thigh  is  drawn  up  unneces- 
sarily high  and  the  knee  is  flexed  excessively  so  that  the  gait  resembles  that 
of  the  "  high-stepping  "  horse.  The  extremity  of  the  foot  strikes  the  ground 
first,  followed  by  the  heel,  so  that  there  is  often  a  recognized  interval  of  time 
between  the  two  events.     Closing  of  the  eyes  does  not  affect  this  gait. 

As  contrasted  with  the  diminished  tendon  reilexes,  the  reflex  action  from 
the  skin  may  be  increased,  especially  when  there  is  hyperesthesia,  even  when 
there  is  considerable  motor  paralysis,  the  movement  being  caused  by  the 
muscles  which  escape  involvement.  In  severe  cases,  on  the  other  hand, 
when  there  is  much  loss  of  sensation  and  motion,  the  skin  reflex  is  absent; 
exceptionally,  it  may  be  absent  when  sensation  is  perfect.  Myotatic  irrita- 
bility is  almost  always  lost,  although  some  rare  cases  are  reported  in  which 
it  was  said  to  be  present. 

Very  characteristic  is  the  tenderness  qf  the  muscles  themselves,  devel- 
oped as  they  become  weaker,  and  elicited  by  grasping  them,  the  slightest 
pressure  often  causing  the  patient  to  cry  out  with  pain.  This  is  regarded  as 
evidence, that  all  the  nerves  of  the  muscles  are  involved,  the  sensory  as  well 
as  the  motor.  The  nerve-trunks  are  also  tender,  although  this  tenderness  is 
less  marked  than  in  simple  neuritis,  because  the  contrast  with  the  hyper- 
esthesia of  the  surrounding  skin  is  less  conspicuous. 


MULTIPLE  NEURITIS.  875 

In  the  arms  it  is  the  extensors  of  the  wrist  and  fingers  which  are  first 
affected,  and  these  symmetrically,  illustrated  by  one  of  the  best  recognized 
toxic  forms  of  neuritis,  lead  palsy.  In  the  latter  there  is  paralysis  of  the 
extensors,  though  the  extensor  of  the  metacarpal  bone  of  the  thumb  and  the 
supinator  longus  usually  escape,  although  in  some  cases  of  lead  palsy  these 
muscles  are  affected.  After  the  extensors,  the  flexors  of  the  wrists  and 
fingers  are  involved,  then  the  interosseous  muscles,  and,  finally,  the  thenar 
and  hypothenar  muscles  are  attacked,  always  to  a  less  degree  than  the  exten- 
sors.    The  muscles  above  the  elbow  suffer  less. 

Occasionally  the  fibers  of  the  pneumo gastric  are  involved,  causing  fre- 
quent pulse-rate  and  paralysis  of  the  vocal  cords,  cardiac  failure,  and  death. 
Still  more  rarely  the  diaphragm  and  muscles  of  the  thorax  and  abdomen  are 
involved.  The  facial  and  motor  oculi  nerves  are  possible  seats.  Neuritis 
confined  to  the  cranial  nerves  has  been  described.  The  sphincters  are  also 
rarely  affected. 

The  muscles  exhibit  the  reaction  of  degeneration,  faradic  irritability 
being  lost,  while  galvanic  irritability  is  increased,  but  not  always  altered  in 
quality.  In  the  nerves,  irritability  to  both  currents  diminishes  and  ultimately 
disappears,  although  in  the  very  first  stage  there  may  be  increased  galvanic 
irritability,  as  described  under  the  reaction  of  degeneration.  In  severe  cases 
total  loss  of  excitability  may  occur  at  once  because  of  a  corresponding  de- 
struction of  muscular  substance,  instead  of  being  preceded  by  an  intermediate 
state  of  increased  excitability. 

Wasting  of  the  muscles  is  sooner  or  later  inevitable,  unless  the  dis- 
ease is  of  short  duration,  although  it  may  be  obscured  by  a  temporary  edema 
or  a  condition  of  fatty  infiltration,  in  which  the  fat  accumulates  between  the 
wasting  fasciculi,  keeping  up  for  a  time  the  bulk  of  the  muscle.  The  less 
affected  muscles  are  apt  to  undergo  shortening  and  contracture  because  of 
maintaining  so'  long  a  fixed  position,  either  from  being  given  over  to  gravi- 
tation or  as  a  result  of  an  effort  to  relieve  pain.  This  alteration  occurs  most 
frequently  in  the  lower  extremity,  contributing  to  intensify  the  "  foot-drop  " 
at  the  ankle,  and  more  rarely  to  produce  flexure  at  the  knee-joint  and  to  a 
less  degree  even  at  the  hip,  both  of  the  latter  being  the  result  of  posture. 
The  foot-drop  may  possibly  be  increased  by  the  pressure  of  the  bedclothes 
upon  the  foot. 

The  sensory  and  motor  phenomena  are  commonly  associated  pari  passu, 
the  latter  extending  from  the  hands  and  feet  up  the  outside  of  the  arm  and 
leg.     Very  rarely  either  set  of  symptoms  may  occur  alone. 

Tremor  is  a  marked  symptom  in  some  alcoholic  cases  and  may  precede 
loss  of  power. 

Ataxic  phenomena  are  usually  associated  with  the  sensory  and  motor 
symptoms.  They  are  manifested  by  difficulty  in  balancing  while  standing, 
or  by  inability  to  execute  finer  movements  with  the  fingers.  Indeed  these  may 
be  the  first  symptoms,  and  may  lead  when  studied  to  the  knowledge  of  some 
defect  in  extending  the  wrist  and  fingers,  or  in  raising  the  toes,  or  foot,  from 
the  ground  while  walking.  The  ataxia  is  more  marked  in  the  lower  extremi- 
ties, and  is  believed  to  depend  chiefly  upon  the  afferent  nerve  involvement, 
since  these  are  supposed  to  have  most  to  do  with  co-ordination.  Involve- 
ment of  the  motor  nerves  may  possibly  also  cause  ataxia.  Because  of  the 
associated  absence  of  the  knee-jerk,  the  term  peripheral  pseudotabes  has  been 
applied  to  the  ataxic  stage.  The  neuritis  may  in  some  cases  not  progress 
beycnd  this  stage.     The  symptoms  may  closely  resemble  those  of  tabes,  but 


8/6  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  phenomena  always  fall  short  of  those  of  true  tabes.  It  may  be  said,  too, 
of  the  ataxic  form  that  the  sensory  disturbances  are  sometimes  less  severe 
than  in  other  typical  cases.  Absence  of  the  Argyll  Robertson  pupil  and  of 
vesical  disturbance,  rapid  development  of  the  disease,  a  history  of  the  case 
suggesting  a  cause  for  neuritis,  and,  finally,  recovery,  are  diagnostic  points 
in  favor  of  the  ataxic  form  of  neuritis. 

Trophic  changes  may  occur  in  prolonged  cases,  including  mainly  glossy 
skin,  arthritic  adhesions,  and  thickening ;  also  vasomotor  derangement,  shown 
by  edema,  especially  about  the  ankles  and  the  dorsum  of  the  foot ;  also  pallor 
of  the  fingers,  and  changes  in  the  nails  and  hair. 

Mental  symptoms  are  found  more  particularly  in  connection  with  the 
alcoholic  form  of  neuritis.  Besides  irritability  and  general  ill  temper,  more 
active  symptoms  are  at  times  present.  A  childish  jocularity  in  women, 
hysteria,  and  skillful  duplicity  in  obtaining  alcohol  are  characteristic.  The 
phenomena  may  be  those  of  delirium  tremens  or  simple  hallucination  with 
extravagant  ideas.  Especially  peculiar  is  the  condition  described  by  Wilks, 
in  which  there  is  a  loss  of  appreciation  of  time  and  place,  the  patient  describ- 
ing with  minute  detail  impossible  journeys  recently  taken  and  persons  whom 
he  imagines  he  has  seen.  Convulsions  and  optic  neuritis  are  rarely  present; 
if  present,  they  are  probably  due  to  meningeal  inflammation.  A  simple  mild 
delirium  ma}^  occur  in  toxemic  cases  from  the  actioii  of  the  poisons  on  the 
brain-cells.  Mental  symptoms  are  not  usually  present  in  multiple  neuritis 
from  other  causes. 

The  number  and  variety  of  the  symptoms  vary  greatly  in  different  forms, 
being  most  widespread  in  those  cases  due  to  alcoholism,  to  cold,  or  to  com- 
bined causes,  and  limited  in  the  cases  due  to  metallic  poisons,  as  lead.  The 
more  acute  the  case,  the  more  widespread  are  the  symptoms. 

Complications. — These  are  the  other  diseases  to  which  alcoholics  are 
subject — cirrhotic  and  fatty  livers,  gastric  catarrh,  and  diseased  kidneys  and 
their  consequences.  The  chief  one  in  the  toxic  form  is  gout  the  result  of 
mineral  poisons,  almost  exclusively  of  lead.  Pulmonary  tuberculosis  is  com- 
mon, and  pneumonia,  invading  especially  the  middle  portion  of  the  lung,  and 
sometimes  bilateral,  is  a  frequent  cause  of  death. 

Diagnosis. — The  diagnosis  of  alcoholic  cases  is  usually  easy  from  the 
history,  although  sometimes  skillful  deception,  especially  in  women,  deprives 
the  physician  of  this  assistance.  The  distinctive  features  of  the  disease  are 
the  symmetrical  localization  of  the  sensory  and  motor  symptoms,  first  and 
mainly  in  the  extremities,  and  the  tenderness  of  the  skin,  nerve  trunks  and 
muscles.  There  are,  however,  great  variations  in  different  cases,  even  in 
those  dependent  on  the  same  cause,  some  being  very  acute  and  general  and 
even  rapidly  fatal,  others  slow  and  limited  to  groups  of  muscles ;  some  mainly 
motor,  others  sensory  and  ataxic  (pseudotabes). 

The  possible  sources  of  confusion  are  rheumatism,  acute  and  chronic; 
neuralgia,  tabes  dorsalis,  poliomyelitis,  acute  and  subacute ;  pachymeningitis, 
damaging  the  nerve-roots,  aaite  ascending  paralysis,  and  hysterical  palsy. 

In  rheumatism  the  tingling  characteristic  of  neuritis  is  not  present,  and 
although  the  tenderness  of  a  nerve  passing  in  the  neighborhood  of  a  joint, 
especially  apt  to  be  aggravated  in  motion,  may  be  mistaken  for  joint  pain, 
careful  examination  will  elicit  its  true  nature.  Neuritis  differs  from  neu- 
ralgia in  the  bilateral  symmetry  of  the  pain,  and  in  the  persiitence  of  tender- 
ness and  hyperesthesia  as  contrasted  with  the  spontaneous  pain  of  neuralgia. 

The  ataxic  form  of  the  disease,  especially  the  form  called  neurotabes 


MULTIPLE  NEURITIS.  877 

(peripheral  pseudotabes),  sometimes  resembles  tabes  dorsalis  very  closely. 
In  neurotabes  the  lesion  consists  only  in  the  nerve  degeneration,  while  the 
spinal  cord  is  free,  its  claim  to  the  title  being  the  fact  that  the  loss  of  motor 
power  may  be  slight  in  neurotabes,  as  in  most  cases  of  true  tabes.  The  diag- 
nosis from  tabes  may  generally  be  easily  made.  The  association  of  absolute 
paralysis  or  distinct  weakness  of  extensors  with  inco-ordination  would  in- 
dicate neuritis.  The  "  lightning  pains  "  of  tabes  are  seldom  found  in  neu- 
ritis, nor  are  waist  constriction  nor  pupillary  symptoms,  while  the  muscular 
tenderness  is  not  found  in  tabes.  Rapid  onset  of  the  disease  and  ultimate 
recovery  occur  in  pseudotabes.  The  extreme  hyperesthesia,  so  distinctive  a 
symptom  of  neuritis,  is  less  valuable  in  diagnosis,  because  it  is  often  absent  in 
the  ataxic  form.  Girdle  pains,  paralysis  of  the  sphincters  of  bladder  and 
rectum,  all  point  to  cord  involvement,  even  in  alcoholic  cases. 

Poliomyelitis — inflammation,  acute  or  subacute,  of  the  gray  matter  of 
the  cord — resembles  the  rheumatic  and  toxemic  forms  of  neuritis,  which  have, 
like  it,  a  febrile  onset,  initial  rheumatic  pains,  and  muscular  wasting  with 
the  reaction  of  degeneration.  But,  again,  we  contrast  the  symmetrical  dis- 
tribution of  the  palsy  of  neuritis  and  its  limitation  to  nerve  distribution  with 
the  random  distribution  of  poliomyelitis.  Pain  on  pressure  and  subjective 
sensory  disturbances  are  not  prominent  in  poliomyelitis. 

In  pachymeningitis  which  involves  the  nerve-roots,  producing  paralysis, 
wasting,  and  anesthesia,  the  legs  do  not  suffer  early  in  the  disease,  as  a  rule ; 
and  while  the  upper  parts  of  the  arms  and  trunk  may  be  anesthetic,  there  is 
no  tenderness  of  the  nerve  trunks,  unless  these  are  also  inflamed. 

Acute  ascending  paralysis  (Landry's)  resembles  the  most  rapid  form  of 
multiple  neuritis  in  some  of  its  symptoms,  but  the  paralysis  usually  ascends 
the  trunk  from  the  legs  to  the  arms,  and  does  not  begin  in  the  hands  and  feet 
at  the  same  time,  nor  does  it  affect  the  trunk  last,  as  in  neuritis.  There  is, 
moreover,  no  anesthesia  in  typical  ascending  paralysis.  There  are,  however, 
transitional  cases  between  multiple  neuritis  and  Landry's  paralysis,  and  the 
term  Landy's  paralysis  is  somewhat  in  disfavor. 

Some  assistance  m  diagnosis  may  be  had  from  the  etiological  standpoint ; 
the  history  of  metallic  poisoning,  of  alcoholic  excesses,  or  of  exposure  to 
infectious  diseases,  or  the  presence  of  diabetes  being  suggestive. 

Prognosis. — A  very  large  number  of  cases  of  multiple  neuritis  get  well, 
though  slowly,  especially  if  the  cause  be  discovered  and  removed.  Especially 
is  this  true  of  the  alcoholic  cases,  although  improvement  does  not  always 
begin  immediately  on  withdrawing  the  cause — indeed,  the  disease  may  even 
progress  for  a  time,  and  improvement  may  not  be  observed  for  several 
months.  Hence  the  prognosis  should  be  guarded.  The  acute  and  wide- 
spread cases  are  the  most  dangerous  to  life,  and  in  such  the  prognosis  should 
always  be  guarded.  The  involvement  of  the  muscles  of  respiration,  includ- 
ing the  diaphragm,  is  most  to  be  feared.  Pain  in  the  tnmk  muscles  is  a 
grave  symptom  if  the  motor  power  of  the  limbs  has  diminished  much. 
Paralysis  of  the  diaphragm  may  be  insidious  and  unnoticed  until  that  of  the 
intercostals  is  added,  when  there  may  be  accumulation  of  mucus,  bronchitis, 
and  death  by  suffocation.  Involvement  of  the  cardiac  nerves  is  also  serious, 
and  is  manifested  by  frequency  of  pulse.  Superadded  involvement  of  the 
spinal  cord  increases  the  danger.  At  best,  months  are  required  for  recovery, 
and  even  years  may  be  necessan'.  Involvement  of  the  spinal  cord  precludes 
total  recovery.  The  return  of  faradic  irritability  in  nerve  and  muscle  is  fav- 
orable.    To  sum  up  with  Gowers :  "  The  prognosis  is  better  in  the  sensory 


8/8  DISEASES  OE  THE  NERVOUS  SYSTEM. 

than  in  the  motor  form,  better  when  the  arm  escapes  than  when  all  the  limbs 
are  involved,  better  in  cases  of  chronic  than  acute  onset,  and  better  if  a  case 
of  apparently  acute  onset  is  really  such  than  if  it  succeeds  slight  symptoms 
of  longer  duration." 

Treatment. — The  removal  of  the  cause,  if  possible,  is  a  primary  step 
in  treatment.  Along  with  this,  rest  is  most  important,  and  the  rest  should 
be  complete — in  bed,  and  this  should  be  enforced  in  the  earlier  stages ;  later 
the  pain  and  loss  of  motor  power  make  rest  obligatory.  Care  should  be 
taken  to  avoid  any  pressure  of  the  bed-clothes  upon  the  feet,  which  might  aid. 
in  the  contracture  of  the  muscles  in  the  position  of  foot-drop.  There  should 
be  no  compromise  with  alcohol,  although  in  some  cases  of  great  debility,  when 
the  cardiac  action  is  feeble,  gradual  withdrawal  may  be  justifiable.  The 
patient  should,  on  the  other  hand,  be  fed  on  the  most  nutritious  food.  Local 
anodyne  applications  may  be  resorted  to  to  relieve  the  pain,  and  may  be  varied 
according  to  effect.  Dry  heat,  moist  heat,  applications  of  lead-water  and 
laudanum,  and  ointments  of  aconite  and  veratrum  are  some  of  those  which 
may  be  employed.  Wrapping  in  cotton  or  wool  is  sometimes  beneficial. 
Warm  baths  are  soothing ;  sometimes  very  hot  ones  give  relief. 

Postures  assumed  because  of  the  relief  they  give  to  pain  should  not  be 
too  long  permitted  lest  deformity  result  by  contraction  and  adhesion,  difficult 
or  impossible  to  overcome.  Dropping  of  the  feet  should  be  prevented  by 
splints  or  by  support  with  sand-bags.  The  same  is  true  of  flexion  at  the  knee 
and  hip. 

As  to  drugs,  they  are  of  little  use ;  the  salicylates,  phenacetin,  antifebrin, 
and  antipyrin  may  be  useful  in  mild  cases,  and  should  be  tried  in  doses  of 
from  five  to  fifteen  grains  (0.3  to  i  gm.).  They  are  more  particularly  use- 
ful in  cases  due  to  cold.  Extreme  pain  may  demand  the  cautious  use  of 
morphin  hypodermically  in  doses  of  from  1-6  to  1-3  grain  (o.oii  to  0.022 
gm.)  combined  with  1-150  grain  (0.00044  gm.)  of  atropin,  which  modifies 
and  improves  the  action  of  morphin  most  happily.  For  the  mental  symp- 
toms the  hydrobromate  of  hyoscin  in  doses  of  from  1-200  to  i-ioo  grain 
(0.00033  to  0.00066  gm.)  hypodermically,  or  hyoscin  in  doses  of  from  1-400 
to  1-150  grain  (0.00016  to  0.00044  gii^-)  may  be  tried.  Mercurials,  so 
highly  approved  by  Cowers  in  simple  neuritis,  are  useless  here.  The 
iodids  are  sometimes  beneficial  in  chronic  cases  and  in  cases  due  to  lead 
absorption. 

Roborant  medicines,  such  as  iron  and  cod-liver  oil,  are  indicated  to  build 
up  the  patient,  who  is  generally  broken  down.  Electricity  and  massage  are 
very  useful  after  convalescence  has  set  in. 

Endemic   Neuritis. 

Definition. —  This  term  is  applied  to  certain  forms  of  multiple  neuritis, 
supposed  to  be  due  to  vegetable  organisms,  limited,  or  endemic  to  certain 
localities.  Three  separate  varieties  have  been  recognized,  but  others  prob- 
ably exist.  The  three  referred  to  are  malarial  neuritis,  beri-beri,  and  leprous 
neuritis. 

I.  Malarial  Neuritis. — This  corresponds  in  its  clinical  features  to 
the  simpler  forms  of  multiple  neuritis,  and  requires  no  detailed  description. 
Its  malarial  nature  is  based  on  its  prevalence  in  malarial  districts  and  its 
curability  by  quinin.     A\'hile  it  is  believed  to  be  caused  by  the  plasmodium  of 


MULTIPLE  NEURITIS.  879 

malaria,  I  am  not  aware  that  this  organism  has  as  yet  been  discovered  in  the 
blood  of  patients  suffering  from  it ;  the  plasmodium,  however,  has  been  found 
in  the  central  nervous  system  of  persons  who  have  manifested  various  symp- 
toms of  nen/ous  disease. 

2.  Beri-beri,  the  Kakke  of  Japan. — Beri-beri  is  a  disease  prevalent 
in  Japan,  the  Eastern  Archipelago,  India,  New  Zealand,  Ceylon,  the  South 
Pacific  Islands,  and  the  coast  of  Brazil.  It  is  especially  prevalent  in  the 
Dutch  East  Indies  among  soldiers  and  in  prisons,  and  has  been  thoroughly 
investigated  under  the  Xetherlands  Government.  In  this  countr}^  J.  J.  Put- 
man  has  described  a  similar  disorder  among  New  England  fishermen  who 
frequent  the  Grand  Banks  of  Newfoundland,  and  Bondurant  has  observed  it 
among  sailors  in  the  Gulf  ports  of  Alabama.  It  is  also  not  uncommon 
among  Norwegian  sailors.  Seguin,  of  New  York,  has  described  cases  origi- 
nating in  the  West  Indies  and  coming  to  this  country. 

Etiology. — Sheube  and  Baelz  first  determined  its  true  nature,  but  our 
knowledge  has  been  greatly  increased  of  late  by  the  studies  of  Pekelharing 
and  Winkler.*  It  is  believed  to  be  due  to  a  special  organism,  of  which  rods 
and  cocci  have  been  described,  and  of  which  cultures  have  been  made. 
These,  when  inoculated,  produced  peripheral  neuritis  of  the  same  distribu- 
tion as  beri-beri.  Repeated  inoculations  having,  however,  been  required  to 
produce  the  disease,  it  has  been  reasonably  concluded  that  repeated  exposures 
are  necessary  before  infection  results.  It  is  transmissible  from  individual  to 
individual.  The  disease  is  also  acquired  by  residence  in  certain  houses,  and 
patients  recover  after  removal  to  a  district  which  is  free,  relapsing  on  return- 
ing. It  has  been  thought  that  a  nitrogenous  and  especially  an  exclusive  fish 
diet  predisposes  to  the  disease,  and,  again,  a  rice  diet.  Roll  "j"  has  shown  that 
in  all  probability  the  disease  is  transmitted  through  drinking-water,  since  he 
traced  two  epidemics  on  board  ship  to  this  cause.  In  both  cases  the  sailors 
were  free  so  long  as  they  had  a  supply  of  European  water;  but  in  one 
instance,  after  laying  in  fresh  water  at  Batavia,  and  again  in  Alauritius, 
where  the  disease  prevailed  endemically,  it  appeared  among  the  crew  at  the 
end  of  five  wrecks. 

Symptoms. — There  are  several  types  of  cases.  Among  the  earliest 
symptoms  is  a  change  in  the  electrical  excitability  of  the  peroneal  nerves  and 
the  flexors  of  the  ankles,  consisting  in  a  slight  degree  of  reaction  of  degenera- 
tion, quantitative  and  often  qualitative,  this  even  before  there  are  any  sub- 
jective symptoms.  Sometimes,  indeed,  the  disease  goes  no  further.  Gener- 
ally, however,  the  subjective  symptoms  begin  as  a  sense  of  heaviness  of  the 
legs,  a  tendency  to  tire  easily,  perverted  sensation,  diminished  tactile  sense 
in  the  lozver  part  of  the  legs,  and  irritability  of  the  heart.  ■  In  an  acute  per- 
nicious formi  the  nervous  phenomena  are  less  marked.  There  are  fever, 
cmemia,  and  general  anasarca.  The  edema  is  quite  constant,  beginning  in  the 
legs.  The  urine  is  scanty,  but  not  otherwise  altered,  and  contains  no  albumin. 
A  critical  increase  in  the  quantity  of  urine  indicates  an  improvement.  In 
the  second  group  the  neuritic  symptoms  are  more  marked,  there  being  numb- 
ness, anesthesia,  loss  of  tendon  reflexes,  nnisciilar  atrophy,  and  anasarca.  In 
the  third  group,  the  atrophy  and  paralysis  are  most  conspicuous,  and  the 
clinical  picture  is  that  of  a  rapidly  progressing  multiple  neuritis  with  sen- 
sory and  motor  symptoms.     The  mortality  varies  from  3  to  60  and  even  to 


*  Pekelharing  and  Winkler,  "  Centralblatt  f.   Xervenkrankheiten."    iSoq,    and  "  Deutsche   med. 
Wochenschr.,''  1888  No.  30. 

+  "  Norsk  Magazin  for  Laegevidenskaben,"  November,  1895,  and  May;  1896. 


88o  DISEASES  OF  THE  NERVOUS  SYSTEM. 

70  per  cent.  The  diaphragm  and  larynx  may  become  paralyzed,  and  the 
cardiac  branches  of  the  vagus  involved,  producing  cardiac  failure  and  death. 

Treatment. — The  treatment  calls  for  the  removal  of  the  cause  by  dis- 
infection or  removal  of  the  patient  from  the  infected  house  or  district  and 
by  the  withdrawal  of  suspected  food  or  drinking-water. 

The  symptoms  are  treated  as  in  other  forms  of  neuritis.  In  conse- 
quence of  the  tendency  to  cardiac  weakness  heart  tonics  may  be  needed, 
such  as  digitalis,  strychnin,  strophanthus,  and  caffein. 

3.  Leprous  Neuritis. — Similar  to  beri-beri  is  leprous  neuritis,  already 
considered  as  to  its  etiology,  symptomatology,  and  treatment.  (See 
Infectious  Diseases.)  It  differs  from  beri-beri  in  being  transmitted  from 
parent  to  offspring  and  in  its  extreme  slowness  of  development  after  ex- 
posure, as  much  as  ten  years  intervening.  It  differs  also  from  beri-beri  in 
that  the  neuritis  is  not  an  essential  part  of  the  disease.  The  neuritis  is  a 
symptom  of  the  so-called  "  anesthetic  leprosy."  Leprous  neuritis  differs, 
further,  from  the  usual  forms  of  multiple  neuritis  in  not  being  perfectly  sym- 
metrical and  in  being  a  perineuritis  and  an  interstitial  neuritis  instead  of 
parenchymatous.  The  bacillus  is  also  found  in  the  tissue,  by  its  presence 
causing  the  inflammation,  while  in  beri-beri  the  virus  circulates  in  the  blood. 
Hence  the  irregular  distribution  of  the  neuritis  in  tlie  leprous  form,  resem- 
bling in  this  respect  the  more  isolated  neuritis  of  syphilis. 

Symptoms. — ^The  special  symptoms  are  muscular  wasting  and  anes- 
thesia, more  marked  toward  the  extremities  of  the  limbs,  but  not  confined  to 
them,  being  found  elsewhere,  as  in  the  face,  involving  the  fifth  and  seventh 
pairs  of  nerves.  Sometimes  tenderness  and  pain  are  present ;  the  latter  is, 
however,  not  severe.  There  may  be  tingling,  also  anesthesia,  and  dimin- 
ished electrical  excitability,  with  reaction  of  degeneration.  The  irregular 
areas  of  anesthesia  are  generally  associated  with  irregular  patches  of  pig- 
mentation and  pallor. 

The  diagnosis,  prognosis,  and  treatment  are  the  same  as  those  of 
leprosy. 

NEURALGIA. 

Definition. —  Strictly  speaking,  the  term  neuralgia  should  be  restricted 
to  such  varieties  of  nerve  pain  as  are  unattended  with  structural  changes  in 
the  nerve.  Formerly,  many  cases  now  regarded  as  cases  of  neuritis  were 
called  neuralgias,  and  it  is  probable  that,  as  our  knowledge  grows,  other 
so-called  neuralgias  will  be  eHminated.  Finally,  the  border-line  existing 
between  neuralgia  and  neuritis  cannot  be  drawn  sharply,  but  as  far  as  pos- 
sible, the  term  neuralgia  should  be  restricted  to  nerve  pain  without  organic 
change. 

Etiology. — Neuralgia  is  a  disease  of  adults.  It  rarely  occurs  before 
puberty,  and  is  relatively  rare  in  old  age.  It  is  more  common  in  women 
than  in  men,  although  not  so  very  rare  in  old  men.  Heredity  is  responsible 
for  a  tendency  to  neuralgia.  It  is  frequent  in  so-called  neurotic  families. 
According  to  Anstie,  fully  one-fourth  of  all  cases  are  the  result  of  heredity. 
Neuralgia  is  prone  to  occur  in  the  so-called  "  nervous  "  person — i.  e.,  one 
who  is  excitable,  anxious,  and  worrisome  in  disposition.  In  this  category, 
too,  come  the  hysterical  neuralgias.  The  debilitated,  anemic,  and  poorly  fed 
are  liable  to  it.     So  are  they  who  are  overworked  and  Avorried. 

The  most  frequent  exciting  cause  is  cold.     Malaria  is  one  of  the  most 


NEURALGIA.  88 1 

common  causes,  producing,  especially,  hemicrania,  while  the  malarial 
cachexia  also  predisposes  to  neuralgia.  The  pain  of  carious  teeth  is  not  re- 
garded as  neuralgic,  but  when  such  pain  causes  irritation  of  the  peripheral 
branches  of  the  fifth  nerve,  a  neuralgia  may  be  produced  in  the  distal  dis- 
tribution. 

Symptoms. — Pain  is,  of  course,  the  leading  symptom.  "  Spontaneous 
pain,"  by  which  is  meant  pain  independent  of  neuritis  or  irritation  of  the 
nerve,  and  the  modifications  to  which  it  is  subject  in  severity  and  distribution, 
constitute,  in  fact,  the  disease.  This  pain  is  irregularly  paroxysmal,  shoot- 
ing, darting,  or  burning  in  character,  not  usually  increased  by  motion,  and  if 
not  relieved  by  pressure,  may  be  by  gentle  friction.  The  more  the  pain  is 
increased  by  motion  and  the  more  there  is  pain  over  the  nerve-trunks  on 
pressure,  the  more  is  it  a  neuritis  and  the  less  a  neuralgia.  Yet  we  cannot 
literally  adhere  to  this,  as  evidenced  by  the  "  tender  points  "  of  Valleix, 
which  will  be  further  referred  to  under  the  different  varieties  of  neuralgia. 
Multiple  dartings  and  shootings,  separated  by  seconds  or  minutes  of  free- 
dom from  pain,  are  characteristic. 

The  absence  of  primary  tenderness  is  also  characteristic;  but  after  the 
pain  has  continued  for  some  time  there  often  succeed  tenderness  of  the  skin 
and  even  a  redness  and  swelling,  the  absence  of  any  unnatural  degree  of 
which  at  the  beginning  is  considered  distinctive.  These  phenomena,  includ- 
ing edematous  swellings,  are  regarded  as  vasomotor  in  origin.  Other  vaso- 
motor symptoms  are  hyperidrosis,  increased  secretion  of  saliva  and  tears, 
and  elevation  of  temperature.  Trophic  effects  are  seen  in  shedding  of  the 
hair  and  its  rapid  blanching,  and  other  symptoms  to  be  referred  to.  Muscu- 
lar twitchings  are  also  not  uncommon  at  the  seat  of  the  pain,  and  sometimes 
even  muscular  spasm. 

The  duration  of  an  attack  of  neuralgia  varies  from  an  hour  or  even 
less  to  many  hours.  Sooner  or  later,  if  not  relieved,  it  subsides  spontane- 
ously, though  with  a  greater  tendency  to  recur  than  when  relieved  by 
treatment. 

Varieties  Depending  upon  Nerves  Involved. 

Neuralgias  are  variously  named  in  accordance  with  the  nerves  affected, 
whence  we  have  the  following  varieties : 

I.  Trifacial  Neuralgia  (Neuralgia  of  the  Fifth  Pair;  Tic  douloureux ; 
Prosopalgia). — This  form  involves  one  or  more  of  the  branches  of  the  fifth 
pair,  rarely  all.  It  is  more  common  than  all  other  varieties  of  neuralgia  com- 
bined. Here,  doubtless,  we  have  sometimes  to  do  wdth  a  neuritis  not  always 
easily  separable.  One  or  more  numerous  tender  points  are  usually  demon- 
strable, of  which  those  at  the  supra-orbital  and  infra-orbital  foramen  are  the 
most  conspicuous. 

Of  the  branches  of  the  fifth,  the  ophthalmic,  or  the  first  division,  is  that 
most  frequently  affected,  giving  rise  to  the  well-known  supra-orbital  neu- 
ralgia. The  pain  radiates  from  the  "  tender  point "  at  the  supra-orbital 
notch  over  the  anterior  half  of  the  head  sometimes  to  the  eye  itself,  the  eye- 
lid, and  half  of  the  nose.  There  may  be  injection  of  the  eye  and  suffusion. 
There  is  sometimes  pain  in  the  occipital  protuberance  and  cervical  spines. 
This  supra-orbital  form  must  most  frequently  be  distinguished  from  catarrh 
of  the  frontal  sinuses,  but  the  latter  is  more  likely  to  be  symmetrical,  and 
while  the  pain  is  severe,  it  is  duller,  less  shooting,  and  is  accompanied  by 

56 


882  DISEASES  OF  THE  NERVOUS  SYSTEM. 

coryza;  it  terminates  suddenly  with  a  free  discharge  of  purulent  matter, 
sometimes  offensive. 

When  the  distribution  of  the  infra-orbital,  or  second  branch  is  involved, 
the  pain  occupies  the  area  between  the  orbit  and  the  mouth,  over  the  cheek 
to  the  ala  of  the  nose.  The  "  tender  points  "  are  at  the  emergence  of  the 
nerve  below  the  orbit,  at  the  side  of  the  nose,  over  the  most  prominent  part 
of  the  malar  bone,  and  along  the  gingival  line  in  the  upper  jaw,  rarely  in 
the  upper  lip. 

When  there  is  involvement  of  the  third,  or  inferior  maxillary,  division, 
less  common  as  an  isolated  form, — except  as  to  its  inferior  dental  branch, — 
there  is  a  much  more  extensive  area  of  pain,  including  the  parietal  eminence, 
the  temple,  the  ear,  the  lower  jaw,  and  the  tongue.  The  "  tender  point "  is 
in  front  of  the  ear  where  the  auriculotemporal  crosses  the  zygomatic  arch, 
where  there  is  often  burning  pain.  The  movements  of  mastication  and 
speaking  may  be  painful,  and  there  may  be  salivation.  A  herpetic  eruption 
about  the  eyes  or  lips  is  occasionally  present  and  is  then  distinctive. 
Atrophy  and  induration  of  the  skin  have  been  included  in  the  symptoms,  but 
these  are  ascribable  only  to  a  neuritis. 

There  is  a  pure  ocular  neuralgia  involving  the  eyeball  only.  It  may 
or  may  not  be  due  to  errors  of  refraction.  Of  these,  hypermetropia,  or  far- 
sightedness, is  the  most  common  cause.  Either  one  or  both  eyes  may  be 
affected.     It  may  be  accompanied  by  dimness  of  vision. 

A  form  of  trigeminal  neuralgia,  called  by  Trousseau  "  epileptiform," 
consists  in  sudden,  severe,  and  frequent  attacks  of  pain,  lasting  from  a  few 
seconds  to  a  few  minutes,  many  times  repeated  during  the  .day. 

2.  Cervico-occipital  Neuralgia. — This  affects  the  area  of  the  neck  sup- 
plied by  the  posterior  branches  of  the  first  four  cervical  nerves,  and  the  pos- 
terior part  of  the  head  supplied  by  the  great  occipital  branch  of  the  posterior 
division  of  the  second  cervical  nerve,  at  the  exit  of  which  there  is  a  tender 
point  about  half  way  between  the  mastoid  process  and  the  first  cervical  ver- 
tebra. Two  other  tender  points  are  just  above  the  parietal  eminence,  and 
between  the  sternomastoid  and  trapezius  muscles.  The  pain  may  extend 
over  the  greater  part  of  the  neck  and  head,  as  far  forward  as  the  parietal 
eminence  and  the  ear. 

Exposure  to  cold  or  a  draft  of  air  is  the  most  common  cause  of  this 
form.     Nephritis  has  been  believed  to  be  a  cause. 

3.  Cervico-brachial  and  Brachial  Neuralgia. — This  involves  the  area 
supplied  by  the  four  lower  cervical  and  the  first  thoracic  nerves,  the  area  of 
sensory  distribution  of  the  brachial  plexus. 

The  tender  points  are  the  axillary,  the  circumflex  at  the  posterior  part 
of  the  deltoid,  the  superior  ulnar  behind  the  elbow,  and  the  inferior  ulnar  in 
front  of  the  wrist.  This  form  is  often  confounded  with  neuritis  due  to  rheu- 
matic affections  of  the  joints  or  injury. 

4.  Neuralgia  of  the  Phrenic  Nerve. — This  is  rare,  the  pain  in  its  area 
during  pleurisy  and  pericarditis  being  rather  a  neuritis.  The  pain  is  at  the 
lower  part  of  the  thorax,  at  the  attachment  of  the  diaphragm.  Breathing  is 
shallow,  because  pain  is  caused  by  the  breathing  movements.  Coughing 
and  even  deglutition  cause  pain. 

5.  Trunk  Neuralgia. — This  naturally  divides  itself  into  two  subvarie- 
ties:  dorso-intercostal  and  lumbo-abdominal. 

(a)  Dorso-intercostal  neuralgia  covers  the  area  supplied  by  the  inter- 
costal nerves  from  the  third  to  the  ninth,  and  is  characterized  by  pain  along 


NEURALGIA.  883 

the  intercostal  spaces  or  in  parts  of  them.  It  is  sometimes  bilateral.  There 
is  usually  a  constant  dull  pain  with  or  without  acute  stabbing  exacerbations, 
or  the  latter  may  be  excited  by  deep  breathing  or  motion.  There  may  be 
special  tenderness  at  the  points  of  emergence  of  the  three  branches  of  the 
intercostal  nen,'e — viz.,  near  the  vertebrae,  anteriorly  near  the  median  line, 
and  midway  between  these  two  points  in  the  midaxillary  line. 

The  term  pleurodynia  has  been  used  with  a  good  deal  of  vagueness. 
Strictly  speaking,  it  should  be  limited,  as  it  is  by  Gowers,  to  neuralgia  of  the 
pleural  nerves.  Consistently  with  this  it  should  not  be  applied  to  pain  local- 
ized in  the  course  or  point  of  exit  of  an  intercostal  nerve.  It  is  very  acute 
in  character  and  excited  by  expansion  of  the  thorax  rather  than  by  lateral 
movements  of  the  trunk.  The  pain  of  herpes  zoster  is  not  a  neuralgia,  but 
a  neuritis. 

Another  variety  in  this  locality  is  the  inframammary  neuralgia  of  anemic 
women. 

(b)  Lumho-ahdominal  neuralgia  involves  the  posterior  branches  of 
the  lumbar  nerves,  especially  the  ilioscrotal  branch.  The  area  of  the  pain  is 
the  region  of  the  iliac  crest,  along  the  inguinal  canal  and  the  spermatic  cord 
in  the  scrotum,  or  round  ligament  in  the  labium  majus.  The  pain  is  often 
bilateral,  sometimes  resembling  the  constricting  girdle  pains  of  spinal  cord 
disease,  from  which  it  differs,  however,  by  its  changing  place.  It  is  espe- 
cially frequent  in  connection  with  diseases  of  the  pelvic  organs,  particularly 
in  women.     The  testes  and  penis  are  the  seat  of  neuralgic  pains. 

6.  Neuralgia  of  the  spinal  column  is  the  more  modern  term  for  the 
"  spinal  tenderness  "  of  the  older  authors.  It  is  common  in  feeble  and  hys- 
terical women,  and  a  sequel  of  the  modern  railway  accident  under  the  name 
of  "  spinal  congestion."  The  pain  in  most  cases  is  felt  along  a  considerable 
vertical  extent  of  the  spine,  but  is  more  intense  in  certain  spots.  The 
thoracic  region  is  the  most  common  seat,  next  the  lower  cervical,  and  least 
frequently  the  lumbar  region. 

7.  Sacral  neuralgia  and  coccygodynia  are  defined  by  their  names. 
These  affections  reside  in  the  nerves  between  the  bone  and  the  skin,  and  are 
often  exceedingly  difficult  to  cure.  The  pain  really  may  be  due  to  organic 
lesions  in  the  part. 

8.  Neuralgia  of  the  feet  includes  painful  heel,  plantar  neuralgia,  and 
erythromelalgia.  In  the  latter,  first  described  by  Weir  Mitchell,  vascular 
changes,  including  either  acute  hyperemia  or  cyanosis, — probably  of  vaso- 
motor origin, — are  associated  with  severe  pain  in  the  heel  or  sole  of  the  foot. 
It  is  probably  a  neuritis  in  some  cases. 

9.  Visceral  neuralgia  means  neuralgia  affecting  the  gastro-intestinal 
tract,  the  kidneys,  ovaries,  and  other  pelvic  organs.  Idiopathic  nephralgia, 
or  neuralgia  of  the  kidney,  I  regard  as  a  rare  event.  It  and  testicular  neu- 
ralgia are  more  frequently  secondarv-  to  inflammation  of  adjacent  urinary 
passages,  but  idiopathic  testicular  neuralgia  is  less  rare  than  nephralgia. 

Neuralgias  are  further  classified  according  to  character  and  cause. 
Thus,  in  addition  to  the  epileptiform  variety  alluded  to.  there  are  reflex  or 
symptomatic  neuralgias,  traumatic  neuralgias,  herpetic  neuralgias  accom- 
panying herpes,  hysterical,  rheumatic^,  gouty,  diabetic,  anemic,  malarial,  syph- 
ilitic, and  degenerative  neuralgias.  i\Iany  of  these  terms  are  loosely  applied. 
The  term  rheumatic  neuralgia  is  often  erroneously  applied  to  muscular  rheu- 
matism.    It  should  not  be  used. 

Very  interesting  and  important  is  the  subject  of  reflex  neuralgias  and 


884  DISEASES  OF  THE  NERVOUS  SYSTEM. 

referred  pains  which  have  been  especially  studied  by  the  late  Dr.  Anstie  in 
England  and  Charles  L.  Dana  in  this  country.  Reflex  neuralgias  are  due 
to  disease  in  organs  distant  from  the  actual  seat  of  the  neuralgia.  The  fifth 
nerve  is  a  favorite  seat  of  such  neuralgias.  Thus,  an  iritation  of  the  distri- 
bution of  one  branch  of  this  nerve  by  a  carious  tooth  may  excite  a  neuralgia 
in  another  distribution  of  the  same  nerve.  Illustrations  of  referred  pain 
are  the  "  pain  in  the  back  "  or  spinal  pain  in  ulcer  of  the  stomach,  the  left 
scapular  pain  in  diseases  of  the  liver,  the  sacral  pain  in  uterine  disease,  and 
the  testicular  pain  in  renal  colic. 

Diagnosis. — Neuralgia  is  chiefly  to  be  distinguished  from  neuritis  and 
the  effects  of  pressure  on  nerves;  and  also  rheumatism.  From  neuritis  it  is 
separated  by  its  unilateral  distribution  as  contrasted  with  the  more  frequent 
symmetrical  distribution  of  neuritis,  although  neuritis  is  not  infrequently 
unilateral ;  also  by  its  numerous  remissions  and  intermissions,  and  the  shift- 
ing of  the  pain  from  one  spot  to  another.  The  fixed  neuralgias  are  more 
difficult  of  separation  from  neuritis,  especially  mild  cases.  The  severe  forms 
of  neuritis  are  soon  recognized  by  the  anesthesia  which  succeeds  upon  the 
hyperesthesia  in  the  case  of  sensory  nerves,  and  muscular  wasting  with 
changes  in  the  electrical  irritability  in  mixed  nerves.  In  the  case  of  com- 
pression of  nerves  the  pain  is  continuous,  while  the  symptoms  and  conse- 
quences of  neuritis  will,  sooner  or  later,  show  themselves.  Nevertheless, 
doubt  and  error  must  not  infrequently  occur. 

Muscular  rheumatism  differs  in  its  localization  in  muscles  or  groups  of 
muscles  such  as  the  lumbar  or  shoulder  muscles,  its  continuousness  and  pain 
increased  by  motion. 

Prognosis. — The  prognosis  in  neuralgia  is  usually  ultimately  favorable, 
although  some  forms  and  cases  are  very  stubborn.  Especially  true  is  this  of 
neuralgia  of  the  fifth  pair.  The  more  frequent  the  recurrence  and  the  wider 
the  distribution,  the  more  difficult  is  the  cure.  On  the  other  hand,  the 
severity  of  the  pain  is  not,  in  my  experience,  a  measure  of  obstinacy  to  cure, 
some  of  the  severest  cases  being  easiest  relieved.  Hereditary  cases  are  the 
most  obstinate.  The  same  is  true  of  cases  occurring  in  the  decline  of  life. 
Epileptiform  neuralgia  is  said  to  be  incurable. 

Treatment. — The  treatment  of  neuralgia  is  divided  into  that  of  the 
condition  predisposing  to  it  and  of  the  paroxysm.  The  anemias, — especially 
chlorosis, — malaria,  and  other  predisposing  causes  should  be  corrected  by 
quinin,  iron,  and  arsenic.  Good  nourishing  food  is  important.  Change  of 
scene  and  residence  is  often  necessary.  Reflex  causes  should  be  carefully 
sought  for  and  removed.  Until  4hese  predisposing  causes  are  removed,  the 
treatment  of  the  paroxysm  affords  but  temporary  relief. 

For  the  paroxysm  quinin  is  by  far  the  most  efficient  remedy,  and  will 
cure  many  cases.  Two  or  three  grains  (0.12  to  0.194  gm.)  should  be  given 
hourly  until  the  paroxysm  is  relieved  or  decided  cinchonism  is  produced. 
The  salicylate  of  cinchonidia  is  a  valuable  preparation.  Some  cases  are 
relieved  by  phenacetin  or  antifebrin  (acetanilid)  in  from  ten  to  fifteen- 
grain  (0.66  to  I  gm.)  doses.  A  combination  of  phenacetin  and  caffein,  three 
grains  (0.33  gm.)  of  the  former  and  one  (o.ii  gm.)  of  the  latter  each,  in 
hourly  doses,  is  often  efficient.  Some  cases  can  only  be  relieved  by  sulphate 
of  morphin.  The  hypodermic  injection  is  the  promptest  and  surest  remedy, 
in  doses  of  from  1-8  to  1-4  grain  (0.008  to  0.016  gm.),  but  morphin  is  a  drug 
to  be  avoided  in  neuralgia,  if  possible,  as  the  danger  of  acquiring  the  mor- 
phin habit  is  extremely  great.     The  patient  should  never  be  allowed  to  use 


NEURALGIA.  885 

the  hypodermic  syringe  himself.  The  use  of  anodynes  is  sometimes  more 
than  palliative,  the  repeated  removal  of  the  pain  tending  to  prevent  its  recur- 
lence.  The  combination  of  atropin  with  morphin  undoubtedly  modifies  the 
unpleasant  effect  of  the  latter  drug  and  increases  its  efficiency. 

Belladonna,  and  its  active  principle,  atropin,  are  remedies  vv^hich  have 
long  enjoyed  reputation  in  the  treatment  of  neuralgia,  when  uncombined 
with  other  drugs,  but  in  my  hands  they  have  been  feeble  remedies.  The 
doses  recommended  are  from  1-6  to  1-2  grain  (o.oii  to  0.03  gm.)  of  the 
extract  and  from  1-120  to  1-60  grain  (0.0005  to  o.ooii  gm.)  of  atropin. 
Aconite  and  gelsemium  have  also  some  reputation,  especially  in  neuralgia  of 
the  fifth  nerve.  Gelsemium  may  be  given  in  doses  of  fifteen  minims  (0.92 
c.  c.)  of  the  tincture,  frequently  repeated.  Gelsemia  may  be  given  hypoder- 
mically  in  doses  of  from  1-60  to  1-30  grain  (o.ooii  to  0.0022  gm.),  and 
aconitin  in  doses  of  from  1-250  to  i-ioo  grain  (0.00027  to  0.00066  gm.), 
but  the  latter  is  a  remedy  so  dangerous  that  I  rarely  employ  it.  Cannabis 
indica  is  also  sometimes  useful  in  doses  of  1-4  grain  (0.016  gm.)  three  times 
a  day,  but  the  drug  varies  so  much  in  strength  that  it  cannot  be  relied  upon. 

Local  applications  are  sometimes  very  useful.  Pressure  relieves  many 
mild  cases,  especially  when  associated  with  gentle  friction.  Local  anes- 
thetics, such  as  menthol,  the  ointments  of  veratria  and  aconitia,  are  similarly 
useful ;  so  is  the  tincture  of  aconite  painted  over  the  involved  area.  The 
local  use  of  opiates,  at  least  without  first  removing  the  epidermis,  and  of 
atropin  (5  per  cent,  strength),  is,  however,  commended.  The  extract  of 
belladonna,  diluted  with  glycerin  so  as  to  admit  its  being  smeared  on,  is 
sometimes  useful.  Frequent  renewals  of  all  these  local  applications  should 
be  made  in  the  course  of  the  day.  Counterirritation  by  blisters  or  sinapisms, 
by  chloroform  either  pure  or  variously  diluted,  and  by  camphor  may  be  used. 
The  last  two  may  be  applied  on  lint  and  covered  with  oiled  silk.  Both  will 
blister  if  left  on  too  long. 

Cocain  might  be  reasonably  expected  to  be  useful,  but  to  act  through 
the  skin  the  ointments  and  solutions  containing  it  should  be  strong — from 
10  to  15  per  cent.  For  mucous  surfaces  this  strength  should  be  used  with 
caution.  A  cocain  habit  is  as  easily  established  as  morphinism,  and  is  about 
as  unpleasant  in  its  results.  The  hypodermic  injection  of  cocain  is  much 
more  efficient.  The  usual  dose  is  1-4  grain  (0.016  gm.),  but  smaller  doses 
may  be  commenced  with.  The  Paquelin  cautery  is  often  a  prompt  and  effi- 
cient agent. 

Acupuncture  and  aquapuncture  are  employed,  the  latter  consisting  of 
injecting  water  under  the  skin.  For  their  local  effect,  also,  chloroform,  car- 
hoik  acid,  and  osmic  acid  have  been  injected  hypodcrmicaUy.  From  fifteen 
to  twenty  minims  (0.92  c.  c.  to  1.23  c.  c.)  of  the  first  may  be  used,  from  five 
to  ten  minims  (0.31  c.  c.  to  0.62  c.  c.)  of  the  second,  and  one  or  two  drops  of 
a  I  per  cent  solution  of  osmic  acid  in  water  and  glycerin.  Chloroform 
should  be  cautiously  used  in  this  manner,  as  it  may  occasion  ugly  sloughing. 
It  is  more  especially  in  sciatica  that  these  measures  have  been  employed. 
Local  applications  of  heat  and  cold  have  been  found  useful — cold  by  freezing 
or  by  the  ether  spray ;  heat  by  the  hot-water  bag,  or  in  the  case  of  a  supra- 
. orbital  neuralgia,  by  the  nasal  douche.  Heat  is  usually  more  efficient  than 
cold;  indeed,  the  latter  sometimes  aggravates  neuralgia. 

Electricity  is  of  uncertain  value  in  neuralgia,  but  is  sometimes  very  use- 
ful. The  constant  current  is  the  form  most  frequently  used,  but  faradism 
may  also  be  employed.     It  is  used  in  two  ways :  a  strong  current  is  applied  at 


886  DISEASES  OF  THE  NERVOUS  SYSTEM. 

once  with  a  view  to  removing  the  neuralgia  promptly  (this  is  scarcely  to  be 
recommended)  ;  in  the  second  method  a  sedative  effect  is  sought  by  a  weak 
current,  preferably  of  galvanism,  just  sufficient  to  produce  a  tingling  or 
burning  sensation.  Experience  goes  to  show  that  the  direction  of  the  cur- 
rent may  be  ignored,  but  it  is  commonly  recommended  to  apply  the  positive 
pole  to  the  painful  part,  the  sponge  being  well  wet  with  warm  water,  and  if 
faradism  is  used,  it  should  be  with  rapid  interruptions. 

The  surgical  treatment  of  neuralgia  has  been  followed  by  brilliant 
results,  and  has  met  signal  failures.  The  most  common  procedure  is  divi- 
sion of  a  nerve,  or,  better,  the  exsection  of  a  portion  of  the  nerve.  It  has 
been  most  frequently  done  in  the  case  of  the  fifth  nerve,  and  is  almost  always 
followed  by  temporary  relief,  but,  sooner  or  later,  an  operation  on  the  Gas- 
serian  ganglion  usually  becomes  necessary.  Operation  is  to  be  recom- 
mended in  intractable  cases,  and  should  be  done  at  a  point  as  near  the  origin 
of  the  nerve  as  possible,  as  second  operations  are  not  infrequently  necessary 
on  account  of  the  recurrence  of  the  pain. 

Nerve  stretching  is  also  performed  with  a  measure  of  relief  less  thor- 
ough than  exsection,  but  in  view  of  the  fact  that  its  disadvantages  are  less 
lasting,  it  is  the  better  operation  to  do  first  in  the  case  of  certain  nerves.  It 
IS  important  to  remember  that  relief  does  not  always  immediately  follow  the 
operation.  The  sciatic  is  the  nerve  most  frequently  stretched,  but  the  inter- 
costals  and  branches  of  the  fifth,  including  the  lingual,  have  been  similarly 
treated  with  satisfactory  results.  The  removal  of  the  Gasserian  ganglion 
affords  relief  in  tic  douloureux,  but  is  a  serious  operation. 


TUMORS    OF   NERVES. 

Definitions    and    Morbid    Anatomy. — Strictly    speaking,    the    term 

neuroma  should  be  restricted  to  tumors  composed  purely  of  nervous  tissue, 
which  are  to  be  distinguished  from  flhroiis  tumors  or  fibromata,  often  seated 
on  nerves  and  known  as  false  neuromata.  Some,  however,  dispute  the 
existence  of  true  neuromata,  and  they  are  certainly  very  uncommon. 
Another  form  of  false  neuroma  is  a  variety  of  the  small,  subcutaneous,  pain- 
ful tumor — tubercula  dolorosa — occurring  in  nerves  of  the  skin  in  the 
neighborhood  of  the  joints  on  the  face,  and  on  the  breast.  Myxomata, 
sarcomata,  and  even  carcinomata  are  found  in  connection  with  nerves. 
The  latter  are  commonly  the  result  of  extension  by  contiguity,  infiltrating 
the  connective  tissue  between  the  fibers.  The  nervous  tissue  represented 
in  the  true  neuroma  is  usually  fibrous,  but  very  rarely  ganglionic  nerve- 
cells  are  found,  and  in  such  event  the  tumor  may  be  regarded  either  as  dislo- 
cated nerve  tissue  or  as  a  glioma  the  cells  of  which  closely  resemble  true 
nerve-cells.  The  nervous  tissue  may  be  of  the  medullated  or  non-medullated 
variety — i  e.,  myelinic  or  non-myelinic.  Connective  tissue  varying  in  quan- 
tity is  associated  with  both,  producing  various  degrees  of  hardness,  which 
is  most  striking  in  the  multiple  fibroneuroma. 

An  interesting  variety  is  the  plexiform  neuroma,  nodular  and  tortuous 
in  appearance  to  the  naked  eye,  tha  internal  structure  of  which  is  composed 
also  of  interlacing  nodular  and  tortuous  nervous  cords  made  up  of  con- 
nective tissue  and  nerve-fibers.  It  is  most  frequently  found  in  connection 
with  the  fifth  pair  of  nerves  in  the  orbit,  on  the  upper  eyelid,  or  on  the 


TUMORS  OF  NERVES.  887 

temporal  bone,  but  is  seen  also  in  connection  with  any  of  the  spinal  and  even 
sympathetic  nerves.     It  grows  slowly,  and  probably  begins  in  fetal  life. 

True  neuromata  are  usually  small,  but  may  be  three  or  four  inches 
(7.5  to  10  cm.)  in  diameter  and  even  larger.  They  are  usually  found  seated 
in  nerve-trunks,  or  at  their  ends,  are  often  multiple,  and  their  number  is 
sometimes  large. 

Etiology. — Nerve  tumors  which  are  not  congenital  may  be  traumatic. 
More  than  one  member  of  a  family  has  been  found  affected.  Their  growth 
seems  stimulated  by  perversion  in  the  healing  process,  since  they  are  found 
on  the  ends  of  nerves  in  cicatrices  after  amputation. 

Symptoms. — Neuromata  may  be  totally  without  symptoms.  At  other 
times  they  are  very  painful,  the  pain  being  aggravated  by  pressure.  There 
may  be  nu-mbness  and  formication  and  even  loss  of  sensation  on  the  one 
hand,  muscular  ttvitching  and  paralysis  on  the  other,  the  latter  especially 
when  the  tumor  is  in  the  course  of  the  nerve. 

Neuromata  of  the  cauda  equina  may  cause  paraplegia.  Reflex  spasm 
in  adjacent  or  distant  muscles,  and  even  epileptiform  convulsions,  are  occa- 
sionally present.  A  neuroma  may  give  rise  to  visible  swelling,  or  it  may  be 
beneath  the  surface  out  of  sight  and  touch. 

Diagnosis. — Except  in  the  case  of  plexiform  neuroma,  which  has  a 
characteristic  form  described,  the  exact  diagnosis  of  the  variety  of  nerve 
tumor  can  for  the  most  part  be  made  only  by  microscopic  examination 
after  removal,  since  all  the  symptoms  occasioned  by  true  neuroma  may  be 
caused  by  pressure  on  nerves  by  any  form  of  morbid  growth.  Multiple 
neuromata  are  usually  false  neuromata. 

Prognosis. — Nerve  tumors  rarely  cause  death,  though  they  sometimes 
undergo  malignant  change,  and  in  this  way  cause  a  fatal  termination. 
The  extreme  pain  which  is  so  characteristic  may  in  time  exhaust  a  patient, 
but  the  course  of  the  disease  is  always  prolonged. 

Treatment. — Excision  is  the  proper  treatment  for  neuromata  and  all 
other  forms  of  tumors  connected  with  nerves,  if  they  can  be  reached,  and  if 
the  symptoms  demand  active  treatment.  Often  such  treatment  is  not  de- 
manded. If  syphilitic  origin  be  suspected,  syphilitic  treatment  should  be 
adopted.  In  operations  involving  section  of  a  nerve  trunk  the  possibility  of 
loss  of  function  is  to  be  remembered. 

Local  anodyne  applications  may  be  used  to  palliate  in  mild  cases,  but 
they  are  useless  in  severe  ones.  Cocain  in  doses  of  from  1-6  to  1-2  grain 
(o.oii  to  0.033  grn-)  "^3-y  be  injected  hypodermically,  but  morphin  should 
not  be  used,  as  the  conditions  are  especially  favorable  to  the  production  of 
morphinism. 


888  DISEASES  OF  THE  NERVOUS  SYSTEM. 


AFFECTIONS  OF  THE  SPINAL    CORD. 

Anatomical. — The  spinal  cord,  covered  by  its  membranes,  the  dura 
and  pia  arachnoid,  hangs  loosely  in  the  spinal  canal  from  the  atlas  to  the 
second  lumbar  vertebra.  It  is,  therefore,  much  shorter  than  the  spinal  canal 
itself.  The  remainder  of  the  canal  is  occupied  by  the  cauda  equina.  Each 
pair  of  spinal  nerve-roots  arises  above  the  foramen  of  exit,  and  descends  to 
the  latter  within  the  canal.  The  part  of  the  cord  whence  each  pair  arises  is 
known  as  the  segment  of  that  particular  pair  of  nerves.  The  following  from 
Deaver's  "  Surgical  Anatomy  "  locates  with  sufficient  accuracy  the  origin  of 
these  nerves :  "  The  eight  cervical  nerves  arise  above  the  sixth  cervical  spine, 
the  upper  six  thoracic  nerves  between  the  sixth  cervical  and  fourth  thoracic 
spines,  the  lower  six  thoracic  nerves  between  the  fourth  and  eleventh  thoracic 
spines,  the  five  lumbar  nerves  between  the  eleventh  and  twelfth  thoracic 
spines,  and  the  five  sacral  nerves  between  the  last  thoracic  and  first  lumbar 
spines."     See  Fig.  93. 

In  transverse  section  the  cord  is  easily  seen  by  the  naked  eye  to  be 
made  up  of  central  gray  matter  and  external  white  substance.  The  former 
is  composed  largely  of  cells,  the  latter  of  fibers.  The  gray  matter,  roughly 
comparable  to  two  crescents  placed  back  to  back,  reaches  the  surface  only 
b}'  its  posterior  horns  at  the  two  points,  whence  enter  the  posterior  roots  of 
the  spinal  nerves.  The  broad,  blunt  anterior  cornua  do  not  reach  the  surface,, 
but  the  white  fibers  ,  of  the  anterior  roots  are  seen  perforating  the  white 
matter  to  enter  the  gray.  The  cord  is  separated  into  halves  by  the  anterior 
median  fissure,  and  by  the  posterior  median  septum,  which  is  not  a  fissure. 

At  the  bottom  of  the  anterior  median  fissure  is  the  transverse  commis- 
sure of  white  matter,  in  front  of  the  central  spinal  canal.  A  short  distance 
to  the  outside  of  the  posterior  median  septum  is  another  less  distinct  sep- 
tum, the  posterior  intermediate  septum,  which  bounds  the  posterior  median 
column  or  column  of  Goll,  which  does  not  extend  as  a  distinct  column  below 
the  cervical  and  thoracic  portions  of  the  cord.  Outside  of  this,  bounded  by 
the  posterior  horn,  is  the  posterior  external  column,  or  column  of  Burdach, 
limited  in  like  manner  to  the  cervical  and  thoracic  parts  of  the  cord.  The 
antero-lateral  column  is  divided  artificially  by  a  line  coinciding  with  the 
outermost  of  the  anterior  nerve  roots,  and  thus  is  made  an  anterior  and 
lateral  column,  which,  with  the  posterior  column,  makes  three  columns  for 
each  half  cord.  The  white  matter  is  composed  of  the  usual  medullated  nerve- 
fibers  unprovided  with  neurilemma  and  of  neuroglia  supporting  the  nerve 
fibers.  The  further  divisions  of  the  cord  in  transverse  section  are  clearly 
indicated  in  Fig.  95,  representing  a  transverse  section  of  the  cord  in  the 
cervical  region,  with  description. 

Of  these  parts,  the  anterior  (or  direct)  pyramidal  tract,  the  lateral  (or 
crossed)  pyramidal  tract  (adjacent  to  the  posterior  cornua),  and  anterior 
cornua  may  be  characterized,  generally  speaking,  as  motor,  while  the  pos- 
terior columns,  the  direct  cerebellar  tract,  the  antero-lateral  ascending  tract 
of  Gowers,  part  of  the  antero-lateral  ground  bundles,  and  the  posterior 
cornua,  may  be  described  as  sensory. 

The  white  matter  gradually  diminishes  as  the  cord  is  descended.  The 
gray  matter  also  varies  in  extent  and  shape  at  different  levels,  which,  will  be 
appreciated  by  the  examination  of  Fig.  94,  which  explains  itself.     It  should 


AFFECTIGXS  OF  THE  SPIXAL  CORD. 


8S9 


F^g-  93- — Diagram  from  an  Ori- 
iginal  Investigation  by  "W.  R. 
GoAvers,  Showing  Relation  of 
Vertebral  Spines  to  their 
Bodies  and  to  the  Xerve-roots. 

Only  in  the  lumbar  region  are  the 
ends  of  the  vertebral  spines 
opposite  the  middle  of  their 
bodies.  They  correspond  to 
the  lower  edge  of  their  bodies 
in  the  cervical  and  at  the  last 
two  dorsal;  and  to  the  upper 
part  of  the  body  below  them 
in  the  rest  of  the  dorsal  region. 
(See  also  text.) 


Fig.  94- — Diagram  Showing  Re- 
lative Size  and  Shape  of  the 
Cord  and  Gray  matter  at  Dif- 
ferent Levels— ( o.fterGo'wei-s). 


890 


DISEASES  OE  THE  NERVOUS  SVSTEAL 


be  added  that  certain  tracts  recently  described,  and  at  present  chiefly  of 
interest  to  the  anatomist,  are  not  included  in  this  diagram.  Mention  should 
be  made  of  Clarke's  column,  a  group  of  nerve-cells  in  the  inner  part  of  the 
neck  of  the  posterior  horn,  from  the  upper  dorsal  to  the  second  lumbar,  also 
known  as  the  lateral  fascicular  column.  Above  this,  in  the  upper  dorsal  and 
lower  cervical  regions,  a  group  of  cells  projects  outward  from  the  gray 
matter  into  the  lateral  column,  called  by  Lockhart  Clarke  the  intennedio- 
lateral  process,  but  well  named  also  the  lateral  horn.  The  lateral  or  crossed 
pyramidal  tracts,  representing  about  three-fourths  of  the  motor  fibers,  pass- 
ing down  from  the  cortex  decussate  at  the  lower  part  of  the  anterior 
pyramids,  and  pass  over  into  the  lateral  columns.  The  remaining  fibers, 
which  do  not  decussate,  pass  down  the  same  side  of  the  cord  in  the  inner  part 
of  the  antero-lateral  column,  constituting  the  anterior  or  direct  pyramidal 
tract,  also  known  as  Tiirck's  column.     At  every  level  of  the  spinal  cord  axis- 


Fig.  95- — Section  of  Spinal  Cord  in  the  Cervical  Region — [after  Cowers). 

c.  Anterior  commissure,  p.  c.  Posterior  commissure,  i.  g.  s.  Intermediary  gray- 
substance,  the  gray  matter  between  the  two  horn.  p.  cor.  Posterior  cornu.  c.  c. 
p.  Caput  cornu  posterioris.  l.  l.  l.  Lateral  limiting  layer,  a.  l.  a.  t.  Antero- 
lateral ascending  tract  of  Gowers, which  extends  along  the  periphery  of  the  cord. 


cylinders  leave  the  crossed  pyramidal  tract  to  enter  the  anterior  horns  and 
end  about  the  cell  bodies  of  the  lower  motor  neurons.  This  tract  extends 
down  to  the  end  of  the  cord,  but  becomes  smaller  and  smaller.  The  fibers 
of  the  direct  anterior  or  pyramidal  tract  possibly  cross  at  different  levels  in 
the  anterior  white  commissure,  to  end  about  the  nerve-cells  in  the  anterior 
horn  on  the  opposite  side  of  the  cord.  If  primarily  small,  this  tract  may  not 
extend  beyond  the  middle  of  the  cervical  enlargement.  If  originally  large,  it 
may  be  traced  as  far  as  the  lumbar  enlargement,  or  even  into  the  sacral  part 
of  the  cord.  Throughout  the  greater  part  of  the  cervical  and  dorsal  regions 
the  lateral  pyramidal  tract  is  separated  from  the  surface  by  a  narrow  layer 
of  fibers,  the  direct  cerebellar  tract,  which  in  the  upper  cervical  region  lies 
further  forward,  so  that  the  pyramidal  tract  comes  up  to  the  surface  close  to 
the  posterior  horn. 


AFFECTIONS  OF  THE  SPINAL  CORD. 


891 


The  axis-cylinder  processes  forming  the  anterior  roots  of  the  spinal 
nerves  start  from  the  nerve-cells  in  the  segments  where  these  roots  arise,  and 
pass  out  as  a  part  of  the  anterior  roots  to  be  distributed  to  the  muscles  they 
supply. 

The  relation  of  the  axis-cylinders  of  the  posterior  roots  after  they  enter 
the  cord  is  not,  however,  so  simple.     It  has  already  been  said  (p.  841)  that 


^■"'"-  ■P^''4-iiVu' 


Med. oblong 


Muscle 


Fig.  96.— Sensory  and  Motor  Paths  in  the  Spinal  Cord— {a/Ur  Barker). 


the  single  process  which  leaves  the  cell'in  the  ganglion  on  the  posterior  roots 
of  the  spinal  nerves  divides  in  a  T-shaped  manner,  one  limb  traversing  the 
spinal  nerve  to  the  periphery  of  the  body,  the  other  passing  toward  the  spinal 
cord  as  an  axis-cylinder.     After  entering  the  cord  each  axis-cylinder  process 


892  DISEASES  OF  THE  NERVOUS  SYSTEM. 

again  divides  into  an  ascending  and  a  descending  limb,  which  run  in  the  pos- 
terior cohnnns.  The  descending  branch  runs  a  short  distance  and  ends  in 
the  gray  matter  of  the  same  side  of  the  cord.  The  ascending  branch  may  end 
in  the  gray  matter  soon  after  entering  it  or  may  run  upward  in  the  posterior 
cokimns  to  the  medulla  oblongata,  ending  probably  in  the  nuclei  situated  in 
the  posterior  columns  of  the  medulla  oblongata  (nucleus  gracilis  and  nucleus 
cuneatus),  remaining  up  to  this  point  on  the  same  side  of  the  middle  line. 
From  the  nuclei  of  the  posterior  columns  of  the  medulla  oblongata  the  axis- 
cylinder  processes,  after  crossing,  run  toward  the  brain,  form  the  fillet,  into 
which  possibly  enter  also  the  ascending  fibers  of  the  lateral  column  contain- 
ing the  crossed  fibers  of  the  upper  sensory  neurons.  The  exact  termina- 
tion of  sensory  processes  in  the  cerebral  hemispheres  is  not  known.  The 
position  of  the  tract  in  the  crus  is  posterior.  The  lower  sensory  neurons 
also  have  endings  in  the  cells  or  about  the  cells  in  Clarke's  column,  from 
which  cells  the  axis-cylinders  run  in  the  direct  cerebellar  tract  of  the  same 
side ;  also  about  cells  the  axis-cylinder  processes  of  which  run  but  a  short 
distance  in  the  cord  to  end  in  the  gray  matter  on  a  different  level.  Thus 
the  possible  paths  of  sensory  conduction,  probably  many,  are  not  definitely 
determined,  whence  disturbances  of  sensation  do  not  give  us  so  much  help 
in  topical  diagnosis  as  those  of  motion.  It  may,  however,  be  said  in  sum- 
mary that  cutaneous  sensory  impulses  in  man  are  conducted  toward  the  brain 
chiefly  on  the  opposite  side  of  the  cord.  The  crossing  of  sensory  impulses 
takes  place  partly  in  the  central  gray  matter  soon  after  the  path  enters  the 
cord,  and  partly  after  the  fibers  leave  the  higher  nuclei  in  the  posterior 
columns  of  the  medulla  oblongata.  The  muscular  sense  "  or  sense  of  posi- 
tion "  is  probably  conducted  on  the  same  side  of  the  cord  in  the  posterior 
columns,  to  cross  in  the  medulla  oblongata,  and  we  have  some  evidence  that 
the  tactile  fibers  ascend  in  the  posterior  columns.  Thermal  and  pain 
impulses  probably  cross  to  the  antero-lateral  columns  of  the  other  side  very 
soon   after  entering  the  cord. 

Spinal  Cord  Localization. — It  has  already  been  said  that  the  areas  of 
distribution  of  spinal  nerves,  sensory  and  motor,  are  not  sharply  defined  for 
each  nerve  as  it  emanates  from  the  spinal  cord,  and  that  the  regions  thus  sup- 
plied overlap.  At  the  same  time  physiologists  and  clinicians  have  been  able 
to  map  out  with  approximate  accuracy  the  motor  and  sensory  areas  corre- 
sponding to  the  distribution  of  each  pair  of  nerves  emanating  from  different 
segments  of  the  cord.  Among  those  who  have  especially  devoted  themselves 
to  this  subject  are  M.  Allen  Starr,  Charles  K.  Mills,  and  Charles  L.  Dana  in 
America,  and  William  Thorburn  and  Henry  Head  in  England. 

The  results  of  various  observers  differ  in  detail,  but  agree  in  essentials. 
The  appended  table  is  that  originally  devised  by  Starr,  further  modified  by 
C.  L.  Dana  and  C.  K.  Mills. 

It  must  not  be  forgotten  that  these  areas  of  distribution  correspond  to 
a  nerve  constituted  as  it  is  when  it  emanates  from  a  corresponding  segment 
of  the  cord,  and  not  to  a  nerve  as  it  is  constituted  immediately  before  it  begins 
to  spread. 


AFFECTIONS  OF  THE  SPINAL  CORD. 


893 


LOCALIZATION    OF    THE 


FUNCTIONS    OF 
SPINAL   CORD. 


THE    SEGMENTS    OF  THE 


Segment. 

Muscles. 

Reflex  and  Centers. 

Sensation. 

IC. 

S.ectus  lateralis, 
tiectus  capitis. 
Anticus  and  posticus, 
sterno-hyoid. 
Sterno-thyroid; 

II    and    III 

Sterno-mastoid. 

Hypochondriiim    {?').      Sud- 

Back of  head  to  vertex  and 

C. 

Trapezius. 

den   inspiration    produced 

neck.      (Occipitalis  major, 

Scaleni  and  neck. 

by    sudden     pressure    be- 

occipitalis   minor,    auricu- 

3mo-hyoid. 

neath  the  lower  border  of 

laris  magnus,  superficialis 

Diaphragm. 

ribs. 

colli,  and  supraclavicular.) 

IV  c. 

Diaphragm. 

Pupillary    C4th    cervical     to 

Neck. 

Deltoid. 

2d   dorsal).      Dilatation   of 

Shoulder,  anterior  surface. 

Biceps. 

the  pupil  produced  by  ir- 

Outer  arm.     (Supraclavicu- 

Coraco-brachialis. 

ritation  of  neck. 

lar,     circumflex,     external 

Supinator  longus. 

musculo-cutaneous,    cuta- 

Rhomboid. 

neous.) 

Supra-  and  infra-spinatus. 

vc. 

Deltoid. 

Scapular    (5th     cervical     to 

Back  of  shoulder  and  arm. 

Biceps. 

ist   dorsal).      Irritation    of 

Outer  side  of  arm  and  fore- 

Coraco-brachialis. 

skin     over     the      scapular 

arm     to     the    wrist.      (Su- 

Brachialis anticus. 

produces     contraction     of 

praclavicular,    circumflex. 

Supinator  longus. 

scapular  muscles. 

external  cutaneous,    inter- 

Supinator brevis. 

Supi7iator  longus.      Tapping 

nal    cutaneous,     posterior 

Deep  muscles  of    shoulder- 

the   tendon  of  the    supina- 

spinal branches.) 

blade. 

tor  longus  produces  flexion 

Rhomboid. 

of  forearm. 

Teres  minor. 

Pectoralis   (clavicular    part) 

Serratus  magnus. 

VIC. 

Deltoid. 

Triceps  (5th  to  6th  cervical). 

Outer  side  and  front  of  fore- 

Biceps. 

Tapping    elbo-w   tendon 

arm. 

Brachialis  anticus. 

produces      extension       of 

Back  of    hand,    radial    dis- 

Subscapular. 

forearm. 

tribution. 

Pectoralis       (clavicular 

Posterior  ivrist  (6th   to    8th 

(Chiefly    external     cuta- 

part). 

cervical).      Tapping     ten- 

neous, internal  cutaneous, 

Serratus  magnus. 

dons    causes    extension  of 

radial.) 

Triceps. 

hand. 

Pronators. 

Rhomboid. 

Latissimus  dorsi. 

VII  c. 

Triceps  (long  head). 

Anterior    wrist    (7th    to  8th 

Radial    distribution    in    the 

Extensors     of      wrist      and 

cervical).        Tapping     an- 

hand. 

fingers. 

terior    tendons     causes 

Median   distribution    in    the 

Pronators  of  wrist. 

flexion  of  wrist. 

palm,   thumb,   index,    and 

Flexors  of  wrist. 

Palmar  (7th   cervical   to   ist 

one-half  middle  finger. 

Subscapular. 

dorsal)^       Stroking     palm 

(External   cutaneous,  in- 

Pectoralis (costal  part). 

causes  closure  of  fingers. 

ternal     cutaneous,     radial, 

Serratus  magnus. 

median,    posterior,    spinal 

Latissimus  dorsi. 

branches.) 

Teres  major. 

Till  C. 

Triceps  (long  head). 

Ulnar  area  of   hand,    back. 

Flexors    of  wrist    and    fin- 

and palm,  inner  border   of 

gers. 

forearm.      (Internal    cuta- 

Intrinsic hand  muscles. 

neous,  ulnar.) 

I  D. 

Extensors  of  thumb. 

Chiefly   inner  side  of    fore- 

Intrinsic hand  muscles. 

arm   and  arm  to  near  the 

Thenar       and      hypothenar 

axilla. 

muscles. 

(Chiefly     internal     cuta- 
ueous  and   nerve  of  Wris- 
berg  or  lesser  internal  cu- 
taneous.) 

II  D. 

Inner  side  of  arm  near  and 

in  axilla.     (Inter  costo- 

humeral.) 

II   to    XII 

Muscles    of    back    and    ab- 

Epigastric C4th  to   7th    dor- 

Skin of  chest  and  abdomen. 

D. 

domen. 

sal).       Tickling   mammary 

in   bands   running  around 

Erectores  spins. 

region  f  causes     retraction 

and      downward,      corre- 

of the  epigastrium. 

sponding  to  spinal  nerves. 

Abdominal  (7th    to  nth  dor- 

Upper  gluteal   region.     (In- 

sal).      Stroking      side    _  of 

tercostals  and   dorsal  pos- 

abdomen causes  retraction 

terior  nerves.) 

of  belly. 

Vasomotor  centers.    Second 

dorsal  to  2d  lumbar. 

894 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


LOCALIZATION    OF    THE    FUNCTIONS    OF    THE    SEGMENTS    OF    THE 
SPINAL    CORD— {ConitMued). 


Segment. 


I  L. 


II  L. 


Ill  L. 


IV  L. 


V  L. 


I    and    II 

S. 


Ill   to   V  S 


Muscles. 


None. 


Vastus  internus. 


adductors      of 


Sartorius  ; 

thigh. 
Flexors  of  thigh. 

Extensors  of  knee. 
Abductors  of  thigh. 


Outward  rotators. 
Flexors  of  knee. 
Flexors  of  ankle. 
Peronei. 
Extensors  of  toes. 


Calf  muscles. 
Glutei. 
Peronei. 

Extensors  of  ankle. 
Small  muscles  of  foot. 

Perineal. 

Muscles  of  bladder,  rec- 
tum, and  external  geni- 
tals. 


Reflex  and  Centers. 


Cremasteric  (ist  to  3d  lum- 
bar). Stroking  inner 
thigh  causes  retraction  of 
scrotum. 

Patellar,  .Striking  patellar 
tendon  causes  extension 
of  leg. 


Gluteal  (4th  to  5th  lumbar). 
Stroking  buttock  causes 
dimpling  in  fold  of  but- 
tock. 

Achilles    iettdon.      Over-ex 
tension   causes  rapid  flex- 
ion of  ankle,  called    ankle 
clonus. 


Plantar  (5th  lumbar  to  2d 
sacral).  Tickling  sole  of 
foot  causes  flexion  of  "toes 
and  retraction  of  leg. 


Genital  center. 
Vesical  centre. 
Anal  centre. 


Sensation. 


Skin  over  groin  and  front 
of  scrotum.  (Ilio-hypo- 
gastric,  ilio-inguinal.) 


Outer  side  and  upper  front 
of  thigh.  Lumbar  region. 
(Genito-cr  ur  a  1 ,  external 
cutaneous.) 

Front  and  outer  side  of 
thigh.  Inner  side  of  leg 
and  foot. 

Inner  side  of  thigh,  leg,  and 
'^oot.  (Internal  cutaneous, 
long  saphenous,  obtura- 
tor.) 

Back  of  thigh  and  outer 
side  of  leg  and  ankle ; 
sole ;  dorsum  of  foot. 
(External  popliteal,  ex- 
ternal saphenous,  muscu- 
lo-cutaneous,  plantar.) 

Back  of  buttock  and  thigh, 
side  of  leg  and  ankle ; 
sole  ;  dorsum  of  foot. 


Circum-anal  region,  anus> 
rectum,  penis,  urethra, 
vagina,  perineum. 

(Small  sciatic,  pudic, 
inferior  hemorrhoidal,  in- 
ferior pudendal.) 


The  preceding  table  includes  only  the  distribution  of  spinal  nerves. 

The  following  table  includes  the  distribution  of  nerves  starting  from 
the  nuclei  in  the  pons  and  medulla  oblongata,  so  far  as  these  are  concerned 
with  motion : 


Nuclei. 


Muscles. 


{.   Sphincter  iris.     Ciliary  muscles. 
Ill  Cranial.  \   Levator  palpebrae  superioris.   Rectus  internus  in  convergence. 


IV 


VI 

V 

VII 

XII 

IX 
X 

XI 


Superior  rectus.     Inferior  rectus. 
Obliquus  inferioris. 
Obliquus  superioris. 

(Upper  facial  group  .^ 
Rectus  externus.     Rectus  internus  of  opposite  side  in  lateral 

movements. 
Associate(J  movement  of  levator  palpebrae. 
Muscles  of  the  lower  jaw. 

Facial  muscles. 

Lower  facial  group. 
Muscles  of  tongue. 
Muscles  of  pharynx. 
Muscles  of  esophagus. 
Muscles  of  larynx. 


The  study  of  the  sensory  areas  is  facilitated  by  the  use  of  diagrams  in 
which  the  areas  are  mapped  out  and  indicated  by  color  or  a  shading  which 
will  permit  one  to  separate  them  easily  one  from  another,  like  those  annexed, 
in  which,  too,  the  areas  corresponding  to  each  spinal  segment  are  indicated 
by  suitable  lettering. 

Interpreting  by  the  data  contained  in  tables  and  diagrams  such  motor 


AFFECTIONS  OF  THE  SPINAL  CORD. 


895 


or  sensory  derangements  as  may  be  present,  one  may  deduce  with  more  or 
less  accuracy  the  seat  of  the  lesions  in  the  cord  producing  them.  It  has 
been  mentioned  that  motor  localization,  being  more  definite,  its  arrangement 
permits  more  exact  inference  than  sensory  derangements. 

The  union  of  both  adds  further  facility.  Results  vary  also  according 
as  a  lesion  involves  only  one  half  or  a  complete  section  of  the  cord. 
Recalling  the  distribution  of  the  two  tracts,  as  given  on  page  890,  it  is 
evident  that  an  injury  involving  the  entire  transverse  section  of  the 
cord    must    produce,    first,    motor    paralysis    in    all    parts    supplied    with 


^1 


^1 
1^ 


XIID 


Fig.  97. — Diagram  of  Lesion  Showing  Brown- 
Sequard's  Paralysis — {after  Starr). 

L.  Lesion  in  left  half  of  cord  cuts  off  motor 
impulses  to  left  leg,  sensory  impulses  from 
right  leg,  and  sensory  impulses  from  elev- 
enth dorsal  nerve. 


Fig.  98.— Schema  Sho^  Chief 

Symptoms  in  Left  unilateral 
Lesion  of  the  Dorsal  Cord — 
{after  Erb). 

Oblique  shading  at  a  signifies  mo- 
tor and  vasomotor  paralysis  ; 
vertical  shading  cutaneous 
anesthesia  at  b  and  d ;  dots 
on  a  cutaneous  hypereesthesia. 
b.  Small  anesthetic  zone.  c. 
Small  hyperesthetic  zone. 


nerves  emanating  from  segments  below  it.  In  less  complete  lesions 
correspondingly  limited  degree  and  extent  of  motor  paralysis  succeed. 
Such  paralysis  may  extend  to  the  bladder  and  rectum.  After  com- 
plete or  nearly  complete  section,  the  muscles  are  usually  flaccid  and 
the  deep  reflexes  absent.  There  is  no  rapidity  developing  atrophy,  and 
the  muscles  respond  normally  to  ele'ctricity.  No  satisfactory  explanation 
has  as  yet  been  offered  of  the  abolition  of  the  deep  reflexes  in  complete 
or  nearly  complete  transverse  lesion  of  the  cord ;  even  above  the  level  of  the 
reflex  arcs,  although  neuritis  is  supposed  by  some  to  be  the  cause  of  this 


896 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


c/v 


CM 


Pig.  99._Diagram  of  Skin  Areas  Corresponding  to  Different  Spinal  Segments— (^/^z>/?/ 
after  Starr.      Trun/e  areas  from  Head). 

Roman  numerals  refer  to  nerves. 


AFFECTIOXS  OF  THE  SPIXAL  CORD. 


897 


CP7 


cf.# 


Fig.  100.— Diagram  of  Skin  Areas  Corresponding  to  Different  Spinal  Segments— (<r/^z^ 
a/^er  Starr.      Tj'unk  areas  fro»i  Head). 

Arabic  numerals  refer  to  vertebrae,  Roman  to  nerves. 


57 


898  DISEASES  OF  THE  NERVOUS  SY STEAL 

loss  of  the  deep  reflexes,  it  is  probably  not  the  cause  in  all  cases.  Second, 
there  is  •  impaired  sensibility  in  the  parts  supplied  by  sensory  nerves  as- 
sociated with  corresponding  segments  below  the  lesion.  Anesthesia  does 
not,  however,  reach  quite  to  the  level  of  the  lesion,  because  of  the  overlapping 
of  sensory  areas  by  nerves  which  enter  the  cord  above  the  section.  Thus,  if 
the  lesion  be  in  the  segment  of  the  sixth  thoracic,  the  anesthesia  may  extend 
only  as  high  as  the  area  supplied  by  the  seventh.  Moreover,  above  the  anes- 
thetic area  there  is  also  at  times  an  area  of  increased  sensibility, — the  effect 
of  the  section  possibly  being  to  increase  the  sensitiveness  of  the  cord  above 
it  by  increasing  its  vascularity, — due  to  section  of  vasomotor  nerves  by  the 
lesion.  By  means  of  these  facts  we  may  be  enabled  to  ascertain  the  level  of 
the  disease.  Muscular  sense  or  sense  of  position  is  lost.  Reflex  excitability,, 
at  first  slightly  impaired,  may  subsequently  be  increased  when  the  lesion  is 
not  complete  and  is  above  the  reflex  arcs,  but  may  remain  impaired  in  com- 
plete transverse  lesions  of  the  cord  or  in  those  portions  of  the  body  whose 
reflex  arcs  are  situated  in  the  damaged  region  of  the  cord. 

The  phenomena  are  modified  if  the  lesion  be  a  hemi-\es\on  of  the  cord. 
In  such  an  event  there  is,  first,  motor  paralysis  in  the  portion  of  the  body 
on  the  same  side  supplied  by  nerves  whose  cells  of  origin  are  below  the 
lesion  (Fig.  106  a), varying,  however,  with  the  seat  of  the  lesion.  If  the 
lesion  is  in  the  cervical  part  of  the  cord,  the  motor  paralysis  is  of  the  arm 
and  leg  on  the  same  side,  while  if  in  the  lumbar  part  of  the  cord  there  is  loss 
of  motion  in  the  leg  only  of  the  same  side.  On  the  other  hand,  there  is  loss, 
of  sensation  in  the  arm  and  leg  of  the  opposite  side.  The  anesthesia  may  be 
to  pain  and  to  thermic  sense  only,  the  tactile  sense  being  unimpaired.  Such, 
anesthesia  exists  on  the  opposite  side,  because  of  the  fact,  already  mentioned, 
that  one  of  the  many  routes  of  sensory  impressions  crosses  the  cord  soon 
after  it  enters  it  from  the  periphery.  More  than  this :  the  sensibility  on  the 
same  side,  below  the  segment  of  the  lesion,  so  far  from  being  diminished  as 
to  touch,  pain,  and  temperature,  may  even  be  slightly  increased,  possibly 
owing  to  the  vasomotor  paralysis  caused  by  the  lesion,  in  consequence  of 
which,  too,  there  may  be  a  sHght  rise  of  temperature  on  the  same  side. 
Slight  pricks  may  be  painful,  and  the  soles  of  the  feet  may  be  unusually  sen- 
sitive. In  the  area  corresponding  exactly  to  the  segment  involved  on  the 
same  side  there  is  anesthesia,  while  just  above  it  on  the  same  side,  again, 
there  is  a  small  zone  of  hyperesthesia.  The  anesthesia  is  due  to  the' 
fact  that  the  sensory  nerves  coming  from  the  same  side  are  cut  just  as 
they  enter  the  cord.  It  begins  somewhat  lower  down  than  the  exact  seat 
of  the  lesion,  because  of  the  overlapping  of  the  upper  sensory  area.  The 
hyperesthesia  in  the  lower  portions  of  the  body  on  the  side  of  the  lesion  has 
been  said  to  be  inexplicable,  but  may  it  not  depend  on  hyperemia  due  to  sec- 
tion of  vasoconstrictor  nerves  ?  It  may  be  for  this  reason  also  that  the  tem- 
perature is  higher  on  the  side  of  the  lesion — from  1°  to  2°  F.  (0.5°  to  1°  C). 
The  upper  hyperesthetic  zone  above  the  anesthetic  area  on  the  side  of  the 
lesion  may  be  explained  as  the  result  of  irritation  of  senson^  nerve  fibers, 
entering  just  above  the  lesion.  The  muscular  sense  or  sense  of  position  on 
the  same  side  is  impaired,  a  condition  ascribed  by  Brown-Sequard  to  the. 
fact  that  the  fibers  of  this  sense  run  on  the  same  side  uncrossed,  and  probably 
in  the  posterior  columns,  until  the  medulla  oblongata  is  reached.  Reflex 
excitability,  at  first  diminished  on  the  side  of  lesion,  is  subsequently  increased 
and  there  is  often  a  good  ankle  clonus,  explainable  by  the  interruption  of  the 
inhibitine  influence  from  above. 


AFFECTIONS  OF  THE  SPINAL  CORD.  899 

The  phenomena  detailed  in  the  foregoing  paragraph  are  those  of  the 
so-called  Brown-Scquard's  paralysis,  due  to  unilateral  lesion  of  the  spinal 
cord,  caused  by  knife-cuts,  stabs,  by  pressure  from  tumors  or  inflammatory 
products. 

On  the  opposite  side  muscular  power  is  intact,  sensibility  is  impaired, 
and  the  derangement  may  include  the  senses  of  pain,  touch,  and  temperature, 
or  any  one  or  two,  touch  sometimes  escaping;  there  is  no  elevation  of  tem- 
perature, the  muscular  sense  is  intact,  and  reflex  action  is  noi-mal. 

All  these  results,  as  described,  may  be  produced  by  the  experiments  on 
the  spinal  cord  originally  suggested  by  Brown-Sequard,  which  included  also 
section  along  the  median  line  of  the  spinal  cord,  which  impaired  sensation  on 
both  sides,  leaving  motion  intact.  So  far  as  completed,  minute  anatomical 
studies  furnish  results  quite  consistent  with  the  derangements  of  motion  pro- 
duced by  diseased  states,  and,  to  a  less  extent,  also  with  the  morbid  piie- 
nomena  of  sensation  as  illustrated  by  disease.  Thus,  anatomy,  experiment 
and  pathology  contribute  to  the  same  conclusion.  It  should  be  mentioned, 
however,  that  the  explanation  of  the  Brown-Sequard  type  of  paralysis  here 
given  has  not  been  fully  accepted. 

More  circumscribed  lesions  produce  more  limited  results.  Thus,  a 
local  lesion  may  produce  paralysis  in  only  a  few  groups  of  muscles.  De- 
structive lesion  of  the  anterior  cornua  produces  lower  segment  paralysis  in 
the  parts  innervated  by  nerves  arising  in  the  injured  cornua,  with  secondary 
degeneration  and  muscular  atrophy,  the  reaction  of  degeneration,  dimin- 
ished reflexes,  and  diminished  muscular  tension ;  while  irritative  lesions  in 
the  central  motor  tract  cause  spastic  conditions,  including  exaggerated  ten- 
don reflexes,  all  of  which  have  been  described.  More  commonly  such  symp- 
toms are  the  result  of  diminished  inhibition  of  the  brain. 

It  is  also  a  matter  of  importance  to  know  whether  a  lesion  lies  in  a  nerve 
or  in  the  cord  itself.  Frequently  this  is  at  once  apparent.  At  other  times  it 
is  more  difficult  to  settle.  It  has  already  been  said  that  hemiplegias  are  almost 
invariably  cerebral  in  their  origin,  while  paraplegias  are  usually  of  nerve 
origin  or  spinal.  It  is  chiefly  with  localized  palsies  that  difficulties  in  diag- 
nosis arise.  Etiology  aids  us  somewhat.  Thus,  localized  palsies  succeeding 
localized  exposure  to  cold  are  apt  to  be  peripheral.  •  Some  assistance  is  ren- 
dered if  there  be  an  associated  anesthesia.  Thus,  if  a  part  be  anesthetic  and 
palsied  as  to  motion,  and  if  the  same  nerve  supplies  sensory  and  motor  fibers 
to  the  muscles,  the  lesion  is  in  that  nerve.  If,  on  the  other  hand,  the  muscles 
are  supplied  by  several  nerves  from  a  given  segment  of  the  cord,  and  the 
anesthesia  corresponds  to  the  area  of  distribution  of  nerves  from  the  same 
segment  of  the  cord,  the  lesion  is  probably  in  the  cord  or  in  the  nerves  at 
their  origin  from  it. 


Affections  of  the  Membranes  of  the  Cord. 

As  in  the  case  of  the  brain,  the  dura  mater  and  pia  arachnoid  may  be 
separate  seats  of  disease,  chiefly  inflammatory,  not  quite  so  well  understood 
nor  quite  so  definitely  separated  in  their  clinical  features.  As  in  the  case  of 
the  brain,  too,  we  call  inflammation  'of  the  dura  mater  pachymeningitis ;  of 
the  pia  mater,  leptomeningitis. 


900  DISEASES  OF  THE  NERVOUS  SYSTEM. 


SPIXAL  PACHYMENINGITIS. 

The  dura  mater  is  separated  by  loose  connective  tissue  from  the  bony 
canal  which  surrounds  it,  and  an  inflammation  may  invade  this  outer  or  the 
inner  layer,  affording  a  pacJiyiiieiiiiigitis  externa  or  interna,  though  it  is  not 
easy  to  separate  these  two  conditions  symptomatically  or  even  anatomically  as 
the  external  form  is  apt  to  extend  to  the  inner  layer  and  even  the  pia  mater. 

External  Pachymexixgitis. — This  is  usually  secondary  to  disease  of 
the  vertebrae  or  similar  morbid  processes  or  to  trauma  or  aneurysmal  erosion. 
\Miile  an  acute  condition  may  thus  supervene,  it  is  much  more  commonly 
chronic. 

Etiology  and  Morbid  Anatomy. — Perhaps  its  most  frequent  cause  is 
tuberculosis  of  the  spine,  with  its  pathological  cheesy  product  and  its  trau- 
matic result — the  spinal  curvature  known  as  Pott's  disease.  It  may  be  con- 
fined to  a  limited  area,  corresponding  to  the  primar}^  seat  of  the  disease,  or 
it  may  extend  over  a  large  area  of  the  meninges,  corresponding  to  six  or 
eight  vertebrae.  As  already  mentioned,  such  inflammations  spread  to  the 
inner  layer  and  pia. 

Symptoms. — These  are  those  of  the  vertebral  lesion,  together  with 
those  of  the  internal  form  detailed  below. 

IxTERXAL  Pachymexixgitis. — This  occurs  in  two  forms,  first  as  an 
inflammation  of  the  internal  layer  of  the  dura,  usually  confined,  primarily, 
at  least,  to  the  cerv-ical  part  of  the  cord.  It  was  first  fully  described  by 
Charcot  in  1871,  and  later  by  his  pupil  Joffroy.  under  the  name  of  "pachy- 
meningitis cen'icalis  hypertrophia'' ;  second,  as  a  pachymeningitis  interna 
hccmorrhagica,  in  ever\-  way  anatomicall)-  identical  with  the  same  disease  to 
be  described  in  connection  with  the  dura  of  the  brain. 

Etiology  and  Morbid  Anatomy, — Cervical  hypertrophic  pachymenin- 
gitis, ascribed  to  exposure  to  cold,  to  the  abuse  of  alcohol,  and  to  syphilis,  is 
a  chronic  process,  consisting  in  an  accumulation  on  the  inner  surface  of  the 
dura  of  concentric  layers  of  a  firm,  fibrinous  growth,  covering  either  a  small 
extent  or  a  considerable  portion  of  the  cervical  enlargement,  and  sometimes 
causing  adhesion  of  the  dura  to  the  pia. 

Symptoms. — To  the  subjective  symptoms  of  the  inflammation  itself  are 
naturally  added  compression  symptoms,  Avhich.  in  fact,  overshadow  the  for- 
mer. The  former  include  pain,  not  merely  at  the  seat  of  inflammation  in 
the  back,  but  also  in  the  area  of  distribution  of  the  spinal  nen^es,  the  roots  of 
which  are  involved  in  the  process. 

The  compression  of  the  cord  and  of  the  nerve  roots  which  are  involved 
produces  symptoms  divisible  into  three  stages : 

1.  The  Painfnl  Stage. — In  this  there  is  pain  in  the  region  supplied  by 
the  nerves  whose  roots  are  thus  compressed, — ^\'-iz.,  that  of  the  arms,  cervical 
region,  and  occiput, — pain  at  times  of  great  severity.  In  addition  are 
observed  paresdiesia,  numbness,  and  tingling,  rarelv  herpes. 

2.  The  Stage  of  Paralysis. — After  two  or  three  months  the  second 
period,  or  stage  of  paralysis,  sets  in — an  atrophic  paralysis,  in  which  there 
is  weakness  of  the  arms,  resulting  from  pressure  on  the  anterior  nerve-roots. 
The  wasting  affects  certain  muscular  groups,  as  the  flexors  of  the  hands, 
supplied  by  the  ulnar  and  median  nen^es.  while  the  distribution  of  the  pos- 
terior interosseous  to  the  antagonistic  extensors  remains  free.  The  result  is 
the   very   striking  claw-hand,   or   main    en  griffe.     In   extreme   cases   the 


SPINAL  LEPTOMENINGITIS.  901 

atrophy  of  the  arms  and  shoulders  becomes  very  great.  There  may  be  anes- 
thesia of  the  skin  at  this  stage. 

3.  The  Stage  of  Spastic  Paralysis  in  the  Lower  Extremities. — If  the 
com,pression  of  the  cord  continues,  we  reach  the  third  stage  of  the  disease. 
The  motor  fibers  to  the  lower  extremities  which  pass  through  the  cervical 
cord  become  involved,  and  the  result  is  a  spastic  paralysis  of  the  lower 
extremities — a  paresis  with  in  creased  reflexes^  and  without  wasting  of  the 
muscles,  because  the  trophic  centers  for  the  muscles  of  the  lower  extremities 
in  the  anterior  cornua  of  the  lumbar  cord  remain  intact.  In  cases  of  long 
duration,  however,  the  compression  of  the  cervical  cord  may  lead  to  anes- 
thesia of  the  lower  extremities,  paralysis  of  the  bladder,  and  bed-sores. 

The  symptoms  of  internal  hemorrhagic  pachymeningitis  are  not  essen- 
tially difterent  from  those  detailed,  but  are  commonly  superadded  to  those 
of  hematoma  of  the  dura  mater  of  the  brain,  with  which  it  is  usually  concur- 
rent. It  has  generally  been  observ-ed  in  the  same  class  of  persons,  general 
paralytics  and  drunkards.  It  may  occur  at  any  part  of  the  cord,  or  it  may 
be  limited  to  the  cervical  region,  producing  corresponding  symptoms,  but 
it  is  rarely  recognized  before  death  and  is  an  extremely  rare  finding. 

Diagnosis. —  The  superaddition  to  the  symptoms  of  spinal  caries  of 
those  detailed  as  characteristic  of  spinal  pressure  determines  at  once  the  con- 
dition. The  forms  arising  in  other  ways  are  to  be  distinguished  from 
amyotrophic  lateral  sclerosis,  syringomyelia,  and  tumors.  From  the  first  it 
can  be  differentiated  by  the  presence  of  the  characteristic  severe  pain  in  the 
neck  and  arms,  and  by  the  absence  of  bulbar  symptoms ;  from  syringomyelia, 
by  the  absence  of  the  sensory  changes  peculiar  to  that  disease ;  but  from 
tumors  in  the  same  locality  it  is  often  distinguished  with  difficulty  because 
the  pressure  symptoms  in  both  are  the  same. 

Prognosis. — Cases  are  described  in  which  decided  improvement  has 
taken  place,  if  not  recover}\ 

Treatment. — The  usual  methods  of  treating  spinal  caries  by  exten- 
sion or  operation  constitute  the  treatment  of  the  external  forms  thus  arising. 
The  symptoms  are  to  be  relieved  by  appropriate  measures.  Baths,  iodid  of 
potassium,  counterirritation,  and  electricity  have  been  recommended. 

The  first  three  are  reasonable ;  the  last  is  of  doubtful  value.  Iodid  of 
potassium  is  indicated  in  cases  of  syphilitic  origin.  Joiifroy  recommends  the 
application  of  the  hot  iron  to  the  neck.  Paquelin's  cautery  would  answer  the 
purpose  as  well. 


SPINAL  LEPTOMENINGITIS. 

Acute  Spinal  Leptomexixgitis. 

Etiology. — As  a  disease  separate  and  distinct  from  epidemic  cerebro- 
spinal meningitis,  described  under  infectious  diseases,  acute  leptomeningitis 
may  occur : 

1.  As  the  result  of  tuberculosis,  its  most  common  cause.  When  thus 
occurring,  it  is  as  a  tuberculous  infection  separate  and  independent  of  the 
tuberculous  extension  in  Pott's  disease. 

2.  From  localization  of  the  poison  of  the  infectious  diseases,  as  syphilis 
and  typhoid  fever. 

3.  As  the  result  of  extension  by  contiguity. 

4.  Possibly  as  the  result  of  exposure  to  cold. 


902  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Morbid  Anatomy, — The  pathological  changes  are  similar  to  those  of 
epidemic  cerebrospinal  meningitis.  Injection,  accumulation  of  fluid  in  the 
pia-arachnoid  space,  either  a  serofibrinous  or  a  purulent  exudate,  round-cell 
infiltration,  and,  finally,  thickening  of  the  membrane,  all  are  more  or  less  in 
evidence.  As  determined  by  the  position  of  the  body,  the  fluid  exudate  tends 
to  gravitate  downward  or  toward  the  posterior  aspect.  Not  infrequently  the 
morbid  process  more  or  less  extensively  invades  the  cord,  especially  at  its 
peripheral  portions,  producing  a  meningomyelitis. 

Symptoms. — The  symptoms  are  those  of  the  disease  with  which  the 
meningitis  is  associated,  in  addition  to  fever  and  such  other  symptoms  as  are 
the  result  of  vascular  derangement  and  mechanical  interference.  These 
have  already  been  detailed  under  cerebrospinal  meningitis,  including  pain  in 
the  back  of  varying  severity,  stiffness,  sensitiveness  of  the  spine,  symptoms 
of  irritation  of  nerve  trunks,  and  disturbances  of  sensation.  The  reflexes 
may  be  increased.  Kemig's  sign  of  "  flexion  contraction  "  at  the  knee-joint, 
described  in  connection  with  cerebrospinal  fever  (p.  171),  should  be  looked 
for. 

Paralytic  symptoms  are  a  late  and  also  a  rare  development.  At  such 
time  the  reflexes  are  sometimes  diminished  or  abolished  on  account  of  the 
destructive  involvement  of  nerve-roots  or  of  the  spinal  cord.  The  urinary 
and  bowel  functions  are  sometimes  deranged. 

Diagnosis. — The  diagnosis  of  simple  acute  meningitis  in  association 
with  the  infectious  diseases  should  not  be  too  hastily  made,  because  of  its 
simulation  by  these  diseases.  Such  simulation  is,  however,  less  common 
with  spinal  meningitis  than  with  cerebral.  Here,  as  in  cerebral  meningitis, 
the  etiological  factor  may  help  us  out;  while,  on  the  other  hand,  given  the 
disease,  the  special  variety  present  cannot  ahvays  be  told.  The  tuberculous 
form  is  most  easily  recognized,  because  of  possible  pre-existing  symptoms 
of  the  disease.  Stiffness  and  pain  in  the  back  are  not  so  distinctive  as  hyper- 
esthesia and  pain  in  distant  parts  supplied  by  nerves  from  the  seat  of  special 
spinal  involvement.  Again,  cases  of  spinal  meningitis  have  been  found  on 
the  autopsy  table  in  which  no  symptoms  were  recognized  during  life. 

Prognosis, — This  is  generally  unfavorable  in  all  forms.  Except  in  the 
cerebrospinal  form  recovery  rarely  occurs,  though  it  is  more  likely  to  occur 
when  the  disease  is  secondary  to  the  infectious  diseases. 

Treatment. — This  is  mainly  symptomatic,  and  the  details  are.  those 
given  under  the  head  of  cerebrospinal  meningitis. 

Chronic  Spinal  Leptomeningitis. 

Etiology, —  So  rare  is  primary  chronic  meningitis  that  its  existence  as 
a  separate  disease  may  be  doubted.  It  may,  however,  remain  as  a  remnant 
of  an  acute  inflammation,  especially  of  epidemic  meningitis.  The  possibility 
of  its  occurrence  secondary  to  chronic  disease  of  the  cord,  such  as  tabes 
dorsalis,  is  admitted,  but  it  then  almost  never  gives  rise  to  symptoms.  It  is 
regarded  as  a  possible  consequence  of  syphilis  and  alcoholism. 

Morbid  Anatomy. — The  distinctive  morbid  change  would  be  a  thicken- 
ing and  opacity  of  the  membrane,  and  adhesions  between  the  dura  and 
arachnoid,  localized  or  general.  Certain  white  cartilaginous  plates  some- 
times found  on  the  posterior  surface  of  the  spinal  arachnoid  are  not  to  be 
regarded  as  inflammatory. 

Symptoms, — The   symptoms   would  be  those   described   in   connection 


HEMORRHAGE  IXTO   THE  SPIXAL  MEMBRAXES.        903 

with  the  acute  form,  milder  in  degree  and  less  definite.  In  fact,  the  diag- 
nosis is  rarely  made.  A  long-continued,  otherwise  inexplicable  stiffness  in 
the  trunk  and  extremities  would  justify  suspicion. 

Treatment. — This  is  symptomatic.  Counterirritation  would  naturally 
be  indicated  if  the  diagnosis  is  made ;  Paquelin's  cautery  is  the  best  instru- 
ment for  the  purpose. 


HEMORRHAGE    IXTO    THE    SPIXAL    ME^IBRAXES. 
Syxoxyms. — Hcuiatorrhachis ;  Meningeal  Apoplexy. 

Hemorrhage  may  take  place  between  the  dura  mater  and  its  bony  col- 
lar, extrameningeal,  or  within  the  dura  mater,  intrameningeal.  A  third 
variety  of  spinal  hemorrhage,  medullary,  into  the  substance  of  the  cord,  is 
described  eslewhere,  p.  909. 

Etiology. — Extrameningeal  hemorrhage  is  usually  the  result  of  trauma, 
such  as  concussion  or  fracture  of  the  spinal  column,  puncture,  or  gunshot 
wound.  The  blood  comes  from  the  rich  plexus  of  veins  that  surrounds  the 
dura.  A  considerable  amount  of  blood  may  be  thus  effused  without  com- 
pressing the  cord,  because  of  the  free  communication  of  the  subdural  space 
in  the  brain  and  cord.  An  aneurysm  may  burst  into  the  spinal  canal  with 
fatal  consequences. 

Intrameningeal  hemorrhage  is  rare,  and  is  naturally  more  limited,  as 
-are  the  sources  of  the  hemorrhage.  Punctiform  hemorrhages,  such  as  occur 
in  cerebrospinal  meningitis,  are  possibly  of  little  significance.  Intramenin- 
geal hemorrhages  occur  sometimes  in  connection  with  the  infectious  diseases, 
and  William  Osier  observed  two  such  cases  in  malignant  smallpox,  while 
they  have  been  found  after  death  from  convulsive  diseases,  such  as  epilepsy, 
tetanus,  and  strychnin  poisoning.  So,  also,  in  ventricular  apoplexy  the  same 
••observer  has  found  blood  in  transit  down  from  the  fourth  ventricle  into  the 
meninges.  Aneurv'sm  of  the  basilar  or  vertebral  arteries  is,  however,  the 
most  frequent  cause  of  this  form  of  hemorrhage. 

Symptoms. — The  symptoms  in  both  varieties  are  those  of  pressure  on 
the  cord,  and  may  be  slight  and  scarcely  recognizable,  or  decided,  with  result- 
ing paralysis  and  pain  on  the  one  hand,  or  anesthesia  on  the  bther.  The 
symptoms  are  as  sudden  as  is  usually  the  event  which  causes  them.  Some- 
times, how^ever,  the  extravasation  is  slower  and  the  symptoms  are  cor- 
respondingly gradual  in  their  appearance.  The  absence  of  all  cerebral  symp- 
toms from  a  complex  including  the  above  points  to  spinal  rather  than  cere- 
bral hemorrhage. 

The  extent  of  the  paralysis  and  the  other  nervous  symptoms  depend  on 
the  seat  of  the  hemorrhage.  If  in  the  lumbar  region,  the  legs  are  alone 
involved,  the  lower  deep  reflexes  may  be  absent,  and  the  functions  of  bladder 
and  rectum  are  im.paired.  If  in  the  thoracic,  there  may  be  complete  para- 
plegia, while  the  reflexes  are  retained,  and  there  may  be  girdle  pains.  Herpes 
may  be  present.  If  in  the  cervdcal  region,  arms  and  legs  may  be  paralyzed, 
and  there  may  be  pain  or  anesthesia  in  the  upper  extremities  and  neck. 
Embarrassed  breathing,  stillness  of  the  muscles  of  the  neck,  and  even  pupil- 
lary symptoms  may  be  added  when 'the  hemorrhage  is  thus  situated. 

Diagnosis. — The  diagnosis  is  based  on  the  absence  of  brain  symptoms 
in  connection  with  the  suddenness  of  the  symptoms  due  to  the  disease  and 
the  history  of  possible  cause. 


904  DISEASES  OF  THE  XERVOUS  SYSTEM. 

Prognosis. — In  certain  cases  in  which  the  hemorrhage  is  small,  con- 
traction and  absorption  of  the  clot  ma}-  take  place,  and  the  symptoms  may- 
pass  away.  In  others  the  hemorrhage  is  fulminating  and  death  follows  earl}- 
from  involvement  of  the  medulla  oblongata  in  the  pressure.  In  intermediate 
states  there  is  corresponding  improvement. 

Treatment. — Conditions  favoring  the  arrest  of  hemorrhage  and  the 
absorption  of  blood  should  be  secured.  Absolute  rest  is  most  important. 
If  symptoms  remain  permanent,  without  aggravation,  iodid  of  potassium 
may  be  used  to  promote  absorption,  and  the  usual  measures  intended  to 
restore  muscular  and  nervous  power,  such  as  massage,  baths,  and  electricity, 
should  be  employed. 


AFFECTIOXS  OF  THE  SUBSTAXCE  OF  THE  CORD. 

Gexer.\l    Coxsiderations. 

Two  separate  sets  of  pathological  changes  invade  the  substance  of  the 
spinal  cord.  In  one  they  are  confined  with  marked  constancy  to  certain 
definite  areas  which  have  precise  functions,  residing  in  "  systems  of  fibers," 
so  that  the  clinical  phenomena  of  the  disease  are  exactly  defined.  These 
affections  are  called  system-  or  systeuiic  diseases.  Thev  include  such  as 
tabes  dorsalis,  an  affection  of  the  posterior  columns ;  amyotrophic  lateral 
sclerosis,  a  disease  of  the  lateral  columns  and  anterior  horns.  Why  certain 
definite  areas  of  the  cord  are  specially  involved,  and  why  this  peculiar 
selective  systemic  implication,  we  do  not  know  any  more  than  w^e  know 
why  certain  poisons,  such  as  curare,  strychnin,  and  lead,  select  certain 
tissues  for  their  operation. 

In  the  second  group  there  is  no  such  limitation  of  area  invaded,  but 
the  cord  in  its  entire  transverse  section  is  involved  in  one  large  focus,  or 
several  combined  foci  separated  by  areas  of  sound  tissue  are  invaded.  In 
this  group  are  included  acute  and  chronic  diffuse  inflammations,  the  hemor- 
rhages and  traumatic  lesions,  multiple  sclerosis,  etc.  These  are  the  non- 
systeiiiic  diseases.  Since,  in  the  diffuse  affections,  all  the  parts  involved  in 
the  systemic  lesions  are  also  affected,  the  symptoms  of  the  latter  are  found 
associated  with  those  growing  out  of  the  diffuse  lesion.  The  diagnosis, 
arrived  at  by  a  study  of  these  SATnptoms  is  still,  however,  mainly  a  "  topical  " 
one,  for  it  is  an  important  fact  ^growing  out  of  the  functions  of  the  cord 
that  all  diseases  involving  certain  areas  produce  the  same  symptoms,  whence 
we  infer  the  seat  of  the  lesion  rather  than  its  nature  or  exact  cause.  This 
may,  however,  be  determined  with  a  varying  degree  of  certainty  from  other 
symptoms.  A  further  peculiarity  of  all  disease  of  the  substance  of  the  cord 
is  that  its  symptoms  are  commonly  bilateral  This  depends  upon  two  causes : 
first,  the  fact  that  the  two  halves  of  the  cord  are  in  such  close  proximity  that 
almost  any  cause  of  a  violent  kind,  such  as  hemorrhage,  affecting  one  half, 
must  also  extend  its  influence  to  the  other;  and,  second,  the  causes  of  system 
diseases  commonly  select  corresponding  parts  in  two  halves  of  the  cord  for 
their  operation.  Again,  symptoms  vary  according  as  the  lesion  affects  the 
conducting  path  to  and  from  the  brain,  or  portion  of  the  peripheral  system 
of  fibers  w'ithin  or  without  the  spinal  cord.  The  symptoms  are  accordingly 
knowm  as  "  central."  and  as  "  root  "  symptom.s. 


SECONDARY  DEGENERATIONS  OF  SPINAL  CORD.       905 

SECONDARY    SYSTEMIC    DEGENERATIONS    OF    THE 
SPINAL   CORD. 

Very  important  in  connection  with  nervous  diseases  is  the  subject  of 
secondary  degenerations.  These  succeed  cerebral  lesions  and  lesions  in 
the  spinal  cord  itself.     They  depend  upon  the  fact,  several  times  referred  to, 


Fiff   loi  —Secondary  Descending  Degeneration  of  the  Pyramidal  Tracts  in  a  Primary 

Lesion  of  the  Left  Half  of  the  Cerebrum— (^//^r  Erd). 
The  lateral  pyramidal  tract  of  rz£-/il  half  is  degenerated  down  to  the  lowest  part  of  the 

lumbar  region.     1-8.     The  anterior  pyramidal  tract  at  left  half  is  degenerated  to 

beginning  of  lumbar  enlargement.       , 

that  a  trophic  influence  is  exerted  by  ganglion  cells  upon  the  fibers  originating 
from  them,  so  that  the  latter  degenerate  when  the  conduction  of  the  trophic 
influence  is  interrupted  or  when  the  trophic  ganglion  cells  are  destroyed. 


9o6  DISEASES  OF  THE  NERVOUS  SYSTEAI. 

For  motor  fibers  such  ganglion  cells  exist  in  two  situations — in  the  motor 
areas  of  the  cortex  cerebri  and  in  the  anterior  cornua  of  the  spinal  cord. 
The  former  exert  on  the  motor  fibers  arising  from  them  a  trophic  influence 
which  extends  down  the  cord  as  far  as  the  latter.  For  sensory  fibers  in  the 
cord  the  trophic  influence  resides  in  cells,  probably  on  the  posterior  spinal 
root  ganglia,  and  also  ganglion  cells  in  the  posterior  gray  matter.  The  fibers 
of  the  lateral  cerebellar  column  in  the  periphery  of  the  cord  arise  in  the  cells 
of  the  column  of  Clarke,  or  posterior  vesicular  column — the  group  of  cells 
in  the  inner  part  of  the  neck  of  the  posterior  horn. 

Secondary  Degeneration  in  the  Spinal  Cord  after  Cerebral  Lesions. — 
If  there  be  disease  in  the  motor  area  of  the  cortex  or  in  any  part  of  the 
motor  tract  in  the  brain, — that  is,  in  the  motor  fibers  of  the  corona  radiata, 
the  internal  capsule,  the  crus,  or  the  pons, — interrupting  conduction,  a 
secondary  degeneration  of  the  motor  fibers  takes  place  below  in  the  related 
pyramidal  tracts,  anterior  on  the  same  side  of  the  cord,  lateral  on  the  oppo- 
site side,  as  far  as  the  anterior  cornua  of  the  gray  matter.  In  many  cases 
there  is  slight  degeneration  in  the  lateral  tract  on  the  same  side  as  far  as 
the  lumbar  region,  showing  that  some  fibers  of  each  anterior  pyramid  find 
their  way  to  the  lateral  tract  on  the  same  side.  The  relative  proportion  of 
the  crossed  lateral  fibers  and  the  anterior  fibers  that  remain  uncrossed  varies 
within  limits.  In  cases  in  w^hich  no  anterior  pyramidal  tracts  exist — that 
is,  where  all  the  fibers  pass  over  to  the  lateral  column  of  the  opposite  side — 
there  is  no  descending  degeneration  of  the  anterior  column.  Fig.  loi,  after 
Erb,  shows  secondary  descending  degeneration  of  the  pyramidal  tracts  suc- 
ceeding a  primary  lesion  of  the  left  half  of  the  cerebrum.  Fig.  102,  after 
Edinger,  shows  graphically  the  descending  degeneration  in  the  pyramidal 
tracts  due  to  a  lesion  in  the  left  internal  capsule.  Fig.  103  shows  second- 
ary ascending  and  descending  degeneration  of  the  cord  as  occurring  after 
transverse  section  of  the  cord  in  the  upper  dorsal  region. 

Secondary  Degeneration  of  the  Spinal  Cord  after  Transverse  Lesion  of 
the  Cord  Itself. — If  a  lesion  be  seated  in  any  part  of  the  cord  affecting  more 
or  less  its  transverse  section,  the  interruption  of  conduction  in  these  fibres 
is  also  followed  by  secondary  degeneration,  which  may  be  traced  in  two 
directions  upward  and  downward,  ascending  and  descending.  Such  lesions 
may  be  transverse  myelitis,  compression  of  the  spinal  cord,  and  tumors — any 
lesion,  in  fact,  involving  the  whole  of  the  cord. 

The  descending  degeneration  of  the  pyramidal  tract  is  like  the  descend- 
ing degeneration  after  cerebral  lesions,  except  that  after  spinal  lesions  the 
degeneration  of  the  pyramidal  tract  is  usually  more  extensive ;  as  the  trans- 
verse disease  afifects  the  pyramidal  tract  on  the  two  sides,  the  secondary  de- 
scending degeneration  wall  afifect  both  lateral  pyramidal  tracts  below  the  seat 
of  lesion.  The  ascending  secondary  degeneration  developing  upward  from  the 
seat  of  lesion  afifects  the  columns  of  Goll — i.  e.,  the  posterior  median 
columns — and  the  columns  of  Burdach, — /.  e.,  the  posterior  lateral  columns 
and  the  lateral  cerebellar  tracts  on  the  periphery  of  the  lateral  columns, 
because  the  conduction  in  those  parts  which  receive  their  trophic  influence 
from  the  more  peripheral  ganglionic  cells  is  interrupted.  The  ganglionic 
cells  which  act  trophically  on  the  fibers  of  Goll  are  probably  in  the  ganglia 
on  the  posterior  roots.  The  lateral  cerebellar  tracts  share  in  the  ascending 
degeneration,  because  they  are  cut  ofT  from  the  cells  of  the  column  of  Clarke, 
and  when  this  occurs  or  these  cells  are  destroyed,  such  degeneration  may  be 
traced  upward  into  the  restiform  bodies. 


SECONDARY  DEGENERATIONS  OF  SPINAL  CORD.       907 

Clinical  Effect  of  the  Secondary  Degenerations. — This  is  disputed, 
Charcot  and  some  of  the  French  clinicians  ascribing  to  them  the  contractures 
and  increase  of  the  tendon  reflexes  in  the  paralyzed  limbs  of  hemiplegia, 
while  Striimpell  and  others  think  they  have  no  clinical  import.  It  is  more 
probable  that  the  symptoms  are  caused  by  an  interruption  of  the  nerve-fibers 
and  that  the  sclerotic  tissue  in  the  degenerated  tracts  produces  no  clinical 
signs  of  disease. 

Secondary  Degeneration  in  the  Spinal  Cord  after  Injuries  of  the  Cauda 
Equina. — After  fractures,  caries,  or  other  injuries  to  the  lower  lumbar 
vertebrae  or  sacrum  producing  injury  to  the  cauda  equina,  or  as  the  result 


Bardacl 


IFig.  102. — Diagram  of  Descending  Degen- 
eration of  the  Pyramidal  Tracts  Due 
to  a  Lesion  in  the  left  Internal  Cap- 
sule— {after  Edinger). 


Goll 


Fig.  103. — Secondary  Ascending  and  De- 
scending Degeneration  in  a  Trans- 
verse Section  of  the  Upper  Dorsal 
Region — {after  Striimpell). 

The  columns  of  Goll  and  the  direct  cere- 
bellar tracts  are  degenerated  upward, 
shown  in  i  and  2,  the  anterior  and 
lateral  pj'ramidal  tracts  downward, 
as  in  3  and  4, 


of  new  growths  in  this  region,  a  secondary  ascending  degeneration  takes 
place  in  the  cord  after  the  rupture  of  continuity  has  existed  for  some  time. 
This  is  due  to  involvement  of  the  posterior  nerve-roots;  whence  the  degen- 
eration is  confined  to  the  posterior  columns  of  the  spinal  cord,  and  in  its 
■distribution  it  resembles  closely  the  state  of  the  cord  in  tabes  dorsalis.  In 
the  lumbar  cord  all  of  the  posterior  column  is  degenerated  except  a  small 
median  zone  and  the  most  anterior  portion.  The  ascending  degeneration 
grows  smaller  as  we  ascend,  and  finally  is  confined  in  the  cervical  cord  to 
the  regions  of  the  columns  of  Goll,  which  include,  in  part  at  least,  the  pro- 
longation of  the  fibers  from  the  root  zones  of  the  lumbar  and  sacral  cord. 


908  DISEASES  OF  THE  NERVOUS  SYSTEM. 


Acute  Affections   of  the   Spinal  Cord. 

DISTURBANCES  OF  THE  CIRCULATION  OF  THE  SPINAL 

CORD. 

Congestion. — From  the  standpoint  either  of  dinical  observation  or 
postmortem  examination  but  Httle  is  known  of  the  phenomena  of  conges- 
tion of  the  cord  as  differentiated  from  inflamxmation.  It  is  a  well-known 
fact  that  active  hyperemia  may  partly  disappear  after  death.  Congestion 
of  the  vessels  is  found  under  so'  many  conditions  that  a  diagnosis  of  inflam- 
mation based  on  this  finding  alone  would  not  be  justifiable. 

Anemia  of  the  cord  has  been  studied  clinically  and  experimentally. 
The  phenomena  of  paraplegia  which  succeed  profuse  hemorrhages  as  of 
the  uterus  postpartum,  and  from  the  stom.ach,  are  fairly  ascribable  to  anemia 
of  the  cord. 

This  is  confirmed  by  som'e  experiments  of  Stenson,  who  compressed 
the  abdominal  aorta  of  an  arJir.sl  with  the  effect  of  causing  almost  imme- 
diate paralysis  of  the  extremities;  and  of  C.  A.  Herter,  at  Johns  Hopkins 
Hospital,  in  which  paraplegia  supervened  a  few  minutes  after  the  appli- 
cation of  a  ligature  to  the  aorta,  followed  more  slowly  by  paralysis  of  the 
sphincters.  Within  thirty-six  hours  there  were  marked  changes  in  the 
ganglion  cells  of  the  anterior  horns  in  the  lumbar  segment,  and,  later,  signs 
of  myelitis.  Within  fourteen  days  contracture  of  the  limbs  set  in  with 
atrophy  of  the  muscles  and  with  fibrillar  twitchings.  Similar  results  have 
followed  the  experiments  of  others  on  animals.  Obstruction  of  the  aorta 
by  thrombi  and  emboli  has  been  followed  by  similar  clinical  phenomena,  but 
it  is  questionable  whether  the  results  of  these  experiments  can  be  applied  to 
man,  as  ligation  of  the  abdominal  aorta  in  man  may  be  done  without  causing 
paralysis.  In  intense  degrees  of  general  anemia,  such  as  is  found  in  per- 
nicious anemia,  the  cord  is  not  so  rarely  affected.  Observations  showing 
that  the  posterior  and  lateral  columms  are  involved  in  pernicious  anemia  are 
numerous. 

Embolism  and  thrombosis  of  the  spinal  arteries  have  been  produced, 
experimentally,  with  resulting  choreiform  movements.  Embolism  of  the 
smaller  vessels  possibly  occurs  in  connection  with  endocarditis.  Endarteritis 
or  its  results  are  frequently  found  postmortem  in  syphilitic  subjects  as  a 
nodular  periarteritis  or  endarteritis,  sometimes  associated  with  gummy 
tumors  of  the  meninges ;  and  as  an  endarteritis  obliterans  with  thickening  of 
the  intima  and  consequent  narrowing  of  the  lumen,  involving  chiefly  the 
arteries  of  medium  and  larger  size.  Miliary  aneurysm  and  aneurysm  of  the 
larger  vessels  of  the  spinal  cord  are  very  rare. 

Hemorrhage  into  the  Substance  of  the  Cord. 

Etiology. — Hematomyelia  is  at  most  a  rare  event.  That  it  ever  occurs 
primarily  independent  of  disease  is  reasonably  questioned.  Its  possibility 
must,  however,  be  admitted,  at  least,  as  the  result  of  traumatic  causes,  such 
as  falls.  Great  physical  exertion  is  another  possible  primary  cause ;  so  are 
cold  and  exposure  and  tetanic  and  other  convulsions.  Repeated  coitus  is 
mentioned  by  Cowers  as  having  been  followed  by  hemorrhage  in  the  gray 
substance  at  the  top  of  the  bulbar  enlargement,  and  this  cause  may  have- 


DERANGED  CIRCULATIOX  OF  THE  SPIXAL  CORD.      909 

operated  in  a  patient  of  my  own  who  was  suddenly  seized  with  a  paraplegia 
during  one  of  a  number  of  closely  repeated  acts  of  coition  and  while  in 
vigorous  heahh.     Secondary  hemorrhage  is  more  frequent. 

Morbid  Anatomy, — The  cord  may  be  distended,  infiltrated,  or  lacer- 
ated bv  the  hemorrhage  escaping  into  the  meninges  ;  if  not  too  copious,  the 
bleeding  may  be  limited  to  the  gray  matter  and  may  extend  up  and  down 
the  cord  to  a  considerable  extent.  The  blood  undergoes  the  usual  changes 
after  effusion,  /.  e.,  coagulates,  becomes  darker  hued,  then  yellow,  and, 
finally,  at  times,  the  seat  of  the  hemorrhage  is  occupied  by  a  cyst,  while 
numerous  hematoidin  crystals  will  be  found  in  the  residue.  The  blood  may 
remain  liquid  for  a  long  time. 

Symptoms, — If  the  hemorrhage  is  in  the  lumbar  enlargement  or  the 
thoracic  region  of  the  spinal  cord,  the  effect  is,  as  a  rule,  sudden  paraplegia. 
If  the  cervical  part  of  the  cord  is  the  seat  of  the  hemorrhage,  the  arms  as 
well  as  the  legs  are  involved,  and  there  may  be  embarrassed  respiration,  and 
possibly  sharp  pain  in  the  extremities  supplied  by  the  nerves  passing  to  the 
cord  at  the  seat  of  the  eflfusion.  Loss  of  sensation  follows  later,  while  the 
reflexes  also  disappear.  ^Myelitis  is  often  developed  as  a  consequence  of  the 
irritative  presence  of  the  clot,  and  there  follow  its  usual  symptoms,  including 
trophic  changes  and  fei'er. 

Diagnosis. —  This  is  based  upon  the  suddenness  of  the  consequent 
events — acute  pain  and  paraplegia — under  the  etiological  conditions 
described,  viz.,  trauma,  and  other  causes.  Hemorrhage  into  the  spinal 
meninges  is,  of  course,  equally  sudden  or  nearly  so.  but  the  symptoms  of 
injur}'  to  the  cord  are  less  prominent,  and  there  is  little  or  no  fever.  In 
meningeal  hemorrhage  the  pain  is  m_ore  severe  and  symptoms  of  irritation 
are  more  apt  to  precede  the  paralysis,  while  the  paralytic  symptoms  are  less 
persistent. 

Prognosis, — The  accident  is  rapidly  fatal  in  the  severest  cases.  In 
others  paralysis  may  exist  for  a  long  time  or  may  be  permanent.  In  others 
there  is  slow  but  persistent  improvement,  and  the  patient  may  even  recover. 
Hemorrhage  into  the  cervical  region  of  the  cord  is  more  serious  because 
the  center  of  the  phrenic  nerve  which  innervates  the  diaphragm  is  apt  to  be 
invaded.  The  presence  of  trophic  changes  renders  the  prognosis  as  to 
recovery  more  unfavorable. 

Treatm-ent, — This  is  identical  with  that  for  hemorrhage  into  the 
membranes.  Absolute  rest  is  the  primary  essential  condition.  Ice  may  be 
applied  to  the  spine  over  the  seat  of  the  hemorrhage,  and  leeches  or  wet- 
cups  by  the  same  locality,  although  the  benefit  obtained  by  these  measures 
is  somewhat  doubtful. 

If  the  case  is  not  immediately  fatal,  improvement  is  apt  to  follow  the 
contraction  of  the  clot,  as  in  cerebral  hemorrhage.  Then,  from  the  theo- 
retical standpoint,  ergot  is  indicated.  Full  doses.  1-2  dram  (2  c  c.)  to  one 
dram  (4  c.  c.) ,  of  the  fluid  extract,  or  from  three  to  five  grains  (0.2  to  0.32 
gm.)  of  ergotin,  repeated  in  two  or  three  hours  with  a  view  to  producing  a 
profound  effect  early,  should  be  given.  Later  muscular  nutrition  should  be 
kept  up  by  massage  and  electricity. 


910  DISEASES  OF  THE  XERVOUS  SYSTEM. 

CAISSON    DISEASE. 
Syxoxvm. — Dkcr's  Paralysis. 

Definition. —  A  paraplegia  and  sometimes  general  paralytic  affection 
which  happens  to  workers  in  caissons  after  their  return  to  the  surface  from 
the  compressed  atmosphere  of  the  caisson. 

Pathology, — This  is  not  thoroughly  determined.  That  it  is,  however, 
a  spinal  lesion  a  study  of  the  symptoms  goes  to  show.  It  is  ascertained 
that  the  pressure  about  the  body  required  to  produce  it  must  exceed  three 
atmospheres,  that  the  symptoms  do  not  come  on  until  the  patient  returns  to 
the  surface,  and  that  they  are  more  prone  to  occur  the  longer  the  exposure. 
Under  these  circumstances  it  has  been  suggested  that  the  symptoms  are 
due  to  the  escape  from  the  blood  of  gases,  especially  oxygen  and  nitrogen, 
with  which  it  has  become  charged  in  breathing  in  the  highly  compressed  air 
— gases,  which,  under  ordinary  circumstances,  escape  gradually  bv  the  lungs. 
Gas  escaping  in  the  more  rapid  manner  exerts  a  pressure  which  arrests  the 
function  of  the  nen^ous  system  for  the  time  being.  At  one  time  local 
hemorrhages  were  supposed  to  be  the  cause,  but  in. the  few  autopsies  which 
have  been  made  nothing  has  been  found  which  would  explain  the  symptoms 
from  that  standpoint.  In  a  case  dying  on  the  fifteenth  dav  Leyden  found- 
small,  irregular  fissures  in  the  middorsal  region,  chiefly  within  the  posterior 
and  in  the  hinder  part  of  the  lateral  column,  filled  with  round  cells,  but  con- 
taining no  blood-corpuscles.  It  has  been  suggested  that  the  fissures  were 
produced  by  the  sudden  escape  of  gas,  and  were  finally  occupied  by 
wandered-out  round  cells.  In  a  case  dying  at  two  and  a  half  months  Schult- 
zer  found  these  fissures,  together  with  signs  of  myelitis.  Leyden  suggests 
that  the  dorsal  region  suffers  because  of  its  relative  softness  as  compared 
with  other  parts  of  the  nervous  system.  Andrew  H.  Smith,  of  New  York- 
City,  who  had  excellent  opportunities  for  studying  the  disease  in  connection 
with  the  building  of  the  Brooklyn  Bridge,  ascribed  the  phenomena  to  a 
congestion  followed  by  stasis,  supposing  that  under  the  high  pressure  the 
blood  is  driven  from  the  periphery  into  internal  organs,  especially  the  cord 
and  brain,  dilating  and  paralyzing  the  blood-vessels.  When  the  pressure  is 
removed,  the  blood  rushes  to  the  periphery.  Smith  supposes  that  within 
the  .cord,  when  the  pressure  is  relieved,  the  circulation  is  retarded  and  a 
stasis  results.  Is  it  not  possible  that  the  anemia  resulting  in  the  cord  from 
the  sudden  withdrawal  of  blopd  from  the  brain  and  cord  may  cause  the 
symptoms  ?  It  should  be  stated  that  in  three  fatal  cases  studied  by  Leyden, 
Schulze,  and  \^an  Rensselaer,  diffuse  parenchymatous  m5'elitis  with  degen- 
eration was  found  in  the  posterior  and  adjacent  lateral  columns. 

Symptoms. — These  come  on,  as  stated,  not  during  exposure  to  the 
abnormal  conditions,  but  on  return  to  the  normal  atmospheric  pressure,  often 
immediately,  always  within  a  half-hour.  Paraplegia  or  hemiplegia  is  char- 
acteristic and  essential,  although  the  onset  is  usually  preceded  by  pain  in 
the  ears  and  joints,  especially  in  the  larger  joints.  The  latter  may  be  affected 
without  paraplegia  after  shorter  periods  of  exposure,  and  there  may  be 
tenderness  in  the  Ivnbs.  There  may  also  be  di::zincss  and  headache.  The 
onset  of  the  paraplegia  is  sudden.  Sensation  may  also  be  impaired,  though 
the  impairment  is  imperfect  and  irregular.  In  severe  cases  the  sphincters 
are  affected.     ^Monoplegia  and  hemiplegia  are  rare,  and  when  present,  they 


DIFFUSE  MYELITIS.  911 

are  apt  to  be  transient.  The  cerebral  symptoms  rnay  be  more  severe, 
amounting  to^  sudden  loss  of  consciousness  and  continuing  as  coma.  Ab- 
dominal pain  and  vomiting  may  be  present.  Severe  cases  are  usually  fatal  in 
a  few  hours.  Those  who  are  less  accustomed  tO'  the  work -are  the  most 
liable  to  suffer,  but  the  power  of  resistance  also  varies  in  different  indi- 
viduals. 

Diagnosis, — The  diagnosis  is  not  usually  difficult,  the  history  of  the 
case  furnishing  the  conditions  and  explaining  the  symptoms. 

Prognosis. — The  prognosis  is  usually  favorable,  the  symptoms  gen- 
erally passing  away  in  the  course  of  a  few  days,  although  in  severe  cases 
they  may  last  for  weeks  or  months,  and  may  even  be  permanent.  In  fatal 
cases  death  may  occur  in  a  week,  or  as  late  as  the  end  of  two  or  three  months, 
with  the  symptoms  of  myelitis.  Of  no  cases  occurring  in  connection  with 
the  building  of  the  Brooklyn  Bridge,  three  died. 

Treatment. —  None  of  an  active  character  is  usually  required.  Mor- 
phine may  be  needed  to  relieve  pain.  The  prophylactic  treatment  is  of 
greatest  importance.  This  consists  in  avoiding  too  long  continuance  of 
work  under  pressure,  and  care  should  be  taken  to  make  the  transition  from 
the  higher  to  the  lower  pressure  gradually.  Dr.  Andrew  H.  Smith  advises 
that  in  passing  through  the  lock,  from  the  low  to  the  high  pressure,  at  least 
five  minutes  should  be  taken. 

DIFFUSE  MYELITIS  (Acute  and  Chronic). 
Synonyms. — Myelitis;  Transverse  Myelitis. 

Definition. — The  line  of  demarcation  symptomatically  between  acute, 
subacute,  and  chronic  myelitis  is  not  sharp,  but  the  term  acute  is  applied  to 
that  form  of  inflammation  in  which  the  symptoms  come  on  suddenly.  When 
requiring  from  two  to  six  weeks  for  their  development,  it  is  called  suhacute. 
When  a  still  longer  time  elapses  before  the  symptoms  reach  a  decided  degree 
of  intensity,  it  is  chronic.  At  the  same  time  it  is  plain  that  no  very  sharp 
line  of  demarcation  can  be  drawn  between  these  forms.  When  the  whole 
thickness  of  the  cord  is  involved  to  a  small  vertical  extent, — a  common 
form, — it  is  said  to  be  transverse ;  if  an  extensive  area,  diffuse;  when  one 
small  area,  focal;  when  many  foci,  contiguous  or  distant,  it  is  disseminated. 
Inflammation  of  the  gray  matter  around  the  central  canal,  extending  into 
the  intermediate  gray  substance,  is  called  central  myelitis,  which  may  be 
parenchymatous  and  interstitial. 

Etiology. —  The  cause  is  often  undiscoverable.  There  is  an  occasional 
hereditary  tendency  to  it.  It  may  occur  at  any  age,  but  is  more  common 
in  adult  males.     It  may  result : 

1.  From  repeated  exposure  to  wet  and  cold,  or  from  overexertion,  or 
from  both  combined. 

2.  Rarelv  from  the  infectious  diseases,  as  smallpox,  typhoid  fever,  or 
puerperal  fever. 

3.  From  syphilis,  either  as  the  direct  result  of  primary  infection,  or  sec- 
ondarily from  invasion  of  the  cord  by  syphilitic  tumors ;  the  fonner  appears 
within  a  few  m.onths  or  several  ye^rs  after  the  primary  inoculation,  the 
latter  as  a  late  manifestation,  but  a  macroscopic  gumma  of  the  spinal  cord 
is  a  very  rare  finding. 

4.  From  tumors  other  than  syphilitic. 


912  DISEASES  OF  THE  NERVOUS  SYSTEM. 

5.  From  injuries  to  the  spinal  column,  especially  fractures,  and  from 
caries  of  the  vertebras.  It  is  extremely  difficult,  nay,  often  impossible,  to 
distinguish  the  inflammatory  results  of  tumors  and  caries  from  those  of 
compression;  and,  indeed,  the  symptoms  due  to  tumors  and  caries  are 
chiefly  the  result  of  pressure. 

The  seat  of  invasion  varies,  the  upper  half  of  the  dorsal  cord  being 
most  frequently  involved,  but  there  may  be  cervical  myelitis  and  rarely 
lumbar  myelitis.  There  may  be  a  central  focus  and  numerous  small  foci 
in  the  vicinity.  The  extent  of  the  involvement  varies  at  different  levels. 
The  softer  reddish  conditions  indicate  the  more  acute  stage ;  the  harder, 
grayer,  and  more  contracted,  the  chronic  stage — sclerosis. 

Morbid  Anatomy. — Considerable  experience  is  necessary  to  be  able 
to  recognize  the  changes  in  many  cases  of  myelitis.  The  separation  of 
the  process  into  different  stages  is  difficult  or  impossible.  To  the  untrained 
naked  eye  the  cord  often  appears  quite  normal.  The  expert  examiner  may 
recognize  by  touch  that  over  a  certain  extent  the  cord  may  be  either  softer 
or  harder  and  firmer.  On  section,  the  substance  of  the  cord  rises  up  more 
than  in  the  normal  state,  the  contour  of  the  gray  matter  is  less  distinct,  and 
sometimes  has  a  hyperemic,  reddish  coloring,  while  the  white  matter  is 
reddish-gray.  There  may  be  minute  hemorrhages.  The  consistence  may 
be  diffluent,  constituting  red  softening.  These  foci  of  hemorrhage  may 
give  place  to  cavities.  The  gra}^  matter  may  be  involved  throughout  con- 
siderable extent.     The  meninges  may  be  affected. 

These  changes  become  much  more  evident  if  the  cord  is  allowed  to 
remain  from  eight  to  ten  weeks  in  Miiller's  fluid,*  and  only  after  hardening 
can  the  lesions  be  satisfactorily  studied. 

Microscopic  examination  of  the  fresh  cord  recognizes  nvimerous  gran- 
ular fatty  cells.  Blood  discs  and  leukocytes  may  be  present,  the  latter  rarely 
in  quantity  to  justify  the  name  of  pus  or  abscess.  Thin  sections  stained 
by  carmine  give  a  very  different  picture  even  to  the  naked  eye,  the  diseased 
tissues  taking  on  the  darker  staining  because  of  their  greater  richness  in 
neuroglia.  By  the  microscope  it  is  found  that  in  these  portions  the  normal 
nerve  tissue  has  partly  or  almost  wholly  disappeared.  In  some  places  axis- 
cylinders  remain,  possibly  much  swollen,  and  having  lost  only  their  medul- 
lary sheaths  ;  in  others  the  nerve  tissue  has  disappeared.  The  changes  in  the 
i^aiiglion  cells  are  also  definite ;  they  have  lost  their  processes  and  are 
rounder,  or  are  entirely  destroyed,  while  the  increase  of  neuroglia  goes  on 
pa/i'i  passu  with  the  destruction  of  the  proper  nervous  matter.  The  former 
occupies  the  enlarged  meshes  ^caused  by  the  disappearance  of  the  latter. 
The  cells  of  the  neuroglia  increase,  and  Dieters'  spider  cells  may  be  numer- 
ous. The  granular  fatty  cells  may  also  be  recognized,  provided  no  alcohol 
has  been  used  in  hardening.  The  blood-vessels  are  dilated  and  distended, 
and  their  walls  are  hyaline. 

In  localized  acute  myelitis  affecting  the  white  and  gray  matter  after 
injury  the  cord  is  swollen,  the  pia  injected  and  soft,  and  on  cutting  the 
membrane  an  almost  diffluent  fluid  may  escape.  In  less  degree  the  appear- 
ances first  described  are  present.  It  is  these  cases  which  arise  particularly 
by  invasion  from  without  or  from  compression  in  which  the  white  matter  is 
involved.  In  extensive  involvement  the  membranes  are  often  invaded,  pro- 
ducing myelomeningitis. 

*  Potassium  bichromate  aj^  parts,  sodium  sulphate  i  part,  water  100  parts. 


DIFFUSE  MYELITIS.  913 

Localized  areas  of  softening  with  blood  accumulation  constitute  red 
-softening.  Abscess  of  the  substance  of  the  cord  exists,  and  at  least  nine  or 
ten  cases  have  been  reported.  Pus  forms  in  the  cord  in  considerable  quan- 
tity only  in  purulent  meningitis. 

Symptoms. — The  distinctive  symptoms  of  myelitis  may  be  preceded 
by  constitutional  disturbance,  including  headache  and  general  malaise,  and 
even  chill,  fever,  and  delirium.  A  temperature  of  107"  to  108"  F.  (417^ 
to  42.2°  C.)  has  been  noticed.     These  symptoms  are,  however,  unusual. 

The  characteristic  symptoms  vary  greatly  with  the  part  of  the  cord 
involved,  and  no  picture  can  be  drawn  to  suit  such  differences  of  locality. 
I  prefer,  therefore,  following  Striimpell,  to  describe  the  symptoms  more  or 
less  common  to  all  localities,  and.  after  this,  such  modifications  or  peculiar- 
ities of  these  as  enable  us  to  locate  more  precisely  the  process.  The  former 
include : 

1.  Symptoms  of  Motor  Parlysis. — They  are  the  most  conspicuous  and 
commonly  the  first  recognized  sign  of  developing  transverse  meyelitis. 
Beginning  with  a  tired  feeling  in  one  or  both  legs,  followed  by  evident  weak- 
ness and  then  dragging,  the  paresis  continues  to  grow  until  the  patient  is 
totally  unable  to  make  any  active  movement  with  his  legs.  This  implies 
that  the  lateral  columns  of  the  cord,  and  especially  the  posterior  part  of  the 
lateral  columns,  carrying  the  lateral  part  of  the  pyramidal  tract,  are  involved, 
cutting  off  the  motor  impulses.  The  motor  paraplegia  can  occur  in  every 
form  of  myelitis — lumbar,  thoracic,  or  cervical ;  but  in  the  first  two  the  upper 
extremities  are  intact.  In  the  cervical,  however,  paralysis  of  the  upper 
extremities  also  takes  place.  If  one  side  of  the  body  is  involved  more  than 
another,  it  implies  that  one-half  of  the  cord  is  more  intensely  affected. 

2.  Symptoms  of  Motor  Irritation. — These  consist  in  spontaneous  twitch- 
ings  of  the  muscles  of  the  paretic  limbs,  either  rapid  and  short  or  slow  and 
persistent.  They  occur  at  the  beginning  and  during  the  course  of  the  dis- 
ease, and  are  variously  severe.  It  is  not  always  easy  to  distinguish  them 
from  increased  reflexes,  hence  their  diagnostic  value  is  not  great.  Ataxia 
and  intention  tremor  may  occur  in  connection  with  involvement  of  the  upper 
extremities  and  in  the  convalescence  of  acute  cases,  but  they  are  very  rare. 

3.  Disturbances  of  Sensibility. — These  occur  in  marked  degree  much 
later  in  the  disease  than  the  motor  phenomena.  At  the  beginning  there  may 
be  numbness,  formication,  tingling,  and  even  girdle  sensations,  but  severe 
pain  is  rarely  present.  When  pain  is  present,  it  is  an  evidence  of  involve- 
ment of  the  vertebrae  or  meninges.  There  may  be  slight  impairment  of  sen- 
sibilitv.  but.  on  the  whole,  sensibility  is  normal  in  all  except  advanced  stages. 
In  such  advanced  stages,  in  addition  to  anesthesia,  there  may  be  paresthesia 
and  even  striking  hyperesthesia.  The  involvement  of  sensibility  probably 
means  that  the  whole  transverse  area  of  the  spinal  cord  is  intensely  affected. 

Disturbances  of  sensibility  are  useful  in  determining  the  segment  of  the 
cord  involved  because  the  lesion  corresponds  very  nearly,  or  sufficiently  so 
for  practical  purposes,  to  the  level  of  the  seat  of  the  modified  sensibility. 
Thus,  in  myelitis  of  the  lumbar  region  the  altered  sensation  extends  nearly 
to  the  umbilicus,  in  the  lower  thoracic  to  the  ensiform  cartilage,  in  the  upper 
thoracic  to  the  level  of  the  axillae,  while  in  the  cervical  the  sensibility  of  the 
upper  extremities  is  impaired,  but  total  anesthesia  is  very  rare. 

4.  The  ReH exes.— The  effect  of  myelitis  on  the  reflexes  varies  greatly 
with  the  seat  of  the  disease  and  the  degree  and  extent  of  the  lesion.  In  the 
very  incipiency  of  an  inflammation  of  the  cord  we  may  expect  all  the  reflexes, 

?8 


914  DISEASES  OF  THE  NERVOUS  SYSTEM. 

cutaneous  and  tendon,  centering  in  the  part  involved  to  be  increased,  but 
with  the  progress  of  the  disease  the  effect  varies  greatly  and  must  be  dis- 
cussed in  detail. 

{a)  Skill  Reflexes.— The  reflex  arcs  of  the  cutaneous  reflexes  are  not 
definitely  determined.  Their  connection  with  reflex  inhibitory  fibers  from 
above  is  to  be  remembered,  irritation  of  which  fibers  possibly  diminishes, 
and  interruption  of  which  possibly  increases  the  sensitiveness  of  the  reaction. 
In  extensive  lumbar  myelitis  the  reflex  path  is  broken  and  the  cutaneous  re- 
flexes of  the  lower  extremities  are  diminished,  running  about  pari  passu  with 
altered  sensibility.  In  thoracic  and  cervical  myehtis  the  arc  for  the  lumbar 
reflexes  is  intact,  and  if  the  reflex  inhibitory  influence  is  removed,  these  skin- 
reflexes  may  even  be  increased.  Experience  shows,  however,  that  the  skin 
reflexes  in  the  leg  may  be  diminished  even  in  dorsal  or  cervical  myelitis,  in 
which  event  there  must  be  loss  of  irritability  in  the  fibers.  The  cremaster 
reflex  has  its  arc  at  about  the  level  of  the  first  lumbar  nerve,  hence  its  loss 
means  disease  there.  The  lower  abdominal  reflex  corresponds  to  the  lower 
thoracic  cord  and  the  upper  to  the  level  of  the  fourth  to  the  seventh  thoracic 
vertebra.  There  is  much  need  for  careful  study  on  the  behavior  of  the  cuta- 
neous reflexes,  as  this  subject  is  far  from  being  fully  understood. 

(b)  Tendon  Reflexes. — The  reflex  arc  of  the  patellar  reflex  lies  at  about 
the  level  of  the  second  to  the  fourth  lumbar  segment.  Hence  the  knee  jerk 
fails  in  disease  of  the  lumbar  cord  involving  the  lateral  part  of  the  posterior 
columns  and  the  anterior  cornua  of  the  gray  matter.  The  ankle  clonus  prob- 
ably has  its  reflex  arc  at  the  level  of  the  first  sacral  segment.  It  is  always 
absent  in  extensive  disease  of  the  posterior  columns  and  gray  matter  of  the 
sacral  cord  in  this  vicinity.  The  absence  of  deep  reflexes  of  the  lower 
extremities  is,  therefore,  one  of  the  most  valuable  signs  of  myelitis  of  the 
lumbar  cord.  In  almost  all  inflammations  above  the  lumbar  cord — that  is, 
of  the  thoracic  and  cervical  portions — there  is  a  decided  increase  in  the  ten- 
don reflexes  of  the  lozver  extremity,  because  these  lesions  destroy  the  reflex 
inhibitory  influence.  When,  therefore,  alongside  of  this  it  is  remembered 
that  the  fibers  which  influence  the  condition  of  the  tendon  reflexes  run  chiefly 
in  the  lateral  columns  of  the  cord,  we  may  conclude  that  the  lateral  columns 
are  involved.  In  cervical  myelitis  the  tendon  reflexes  of  the  upper  extremi- 
ties are  often  increased.  It  should  be  remembered  that  complete  or  nearly 
complete,  transverse  lesion  of  the  cord  in  the  thoracic  or  cervical  region  may 
cause  a  loss  of  the  deep  reflexes  of  the  lower  limbs. 

5.  Disturbances  of  the  Bladder  and  Rectum. — These  are  common  in 
mj'elitis.  There  is,  first,  delay  in  micturition,  finally  accomplished  by  extra 
straining,  but  later  all  power  to  empty  the  bladder  is  lost — the  detrusor  urines- 
is  paralyzed.  Still  later  the  spliiuctcr  vesicce  is  paralyzed,  and  then  there  is 
incontinence  of  urine.  These  symptoms  occur  in  connection  with  paralysis 
in  any  part  of  the  cord.  The  ultimate  effect  is  almost  invariably  a  cystitis, 
the  result  partly  of  decomposition,  induced  by  germs  introduced  through 
repeated  catherization,  even  when  most  cautiously  conducted,  partly  by  the 
entrance  of  germs  through  the  patulous  sphincter.  Such  cystitis  has  also 
been  ascribed  to  trophic  influence.  To  the  cystitis  may  succeed  pyelitis  and 
purulent  pyelonephritis. 

In  myelitis  there  is  at  first  obstinate  constipation,  followed  by  paralysis 
and  incontinence  of  feces.  This  symptom  does  not  give  any  information  as 
to  the  seat  of  the  myelitis.  Defecation  and  micturition  are  sometimes 
reflexly  aroused  in  abnormal  degree  when  there  is  increased  reflex  irritability. 


DIFFUSE  MYELITIS.  915 

Sexual  functions,  the  centers  of  which  probably  reside  in  the  sacral  cord,  are 
also  often  deranged  in  myelitis. 

6.  Trophic  Disturbances. — These  are  most  important  symptoms,  and 
valuable  also  in  diagnosis.  In  cervical  and  thoracic  myelitis  the  trophic 
centers  in  the  lumbar  cord  are  intact.  The  paralyzed  muscles,  therefore,  do 
not  atrophy,  though  they  may  be  somewhat  softened  from  want  of  use. 
They  retain  their  normal  electrical  excitability,  or  at  least  the  reactions  are 
not  c[ualitatively  altered,  although  they  may  be  quantitatively.  On  the  other 
hand,  genuine  atrophy  and  the  presence  of  the  reaction  of  degeneration  show 
that  the  anterior  gray  cornua  or  the  fibers  of  the  anterior  roots  of  the  lumbar 
cord  are  involved ;  in  the  upper  extremities  they  show  that  the  same  portions 
of  the  cervical  cord  are  involved.  Bed-sores  are  among  the  trophic  phe- 
nomena, the  possibility  of  the  occurrence  of  which  should  always  be  vividly 
present.  They  are  among  the  most  unpleasant  and  most  unmanageable 
s}»mptoms,  yet  they  may  be  guarded  against ;  for,  although  favored  by  the 
deranged  trophic  influence,  they  require  an  exciting  cause  such  as  pressure, 
the  irritation  of  secretions,  or  foreign  substances  to'  originate  them.  They 
occur  over  the  sacral  and  gluteal  regions,  more  rarely  on  the  feet  and  inner 
sides  of  the  knees.  The  total  anesthesia  often  associated  with  advanced 
stages  of  the  disease  co-operates  to  permit  the  action  of  the  exciting  causes. 

Other  trophic  effects  often  met  are  drying  and  hardening  of  the  skin ; 
glossy  skin,  also  thick  and  brittle  nails.  Vasomotor  disturbances  also  occur, 
producing  congestion  and  mottling,  and  there  may  be  slight  edema  of  the 
paralyzed  parts ;  also  sweating,  which  may  be  localized.  The  temperature 
of  the  affected  limbs  may  be  lowered,  and  multiple  arthritis  may  occur. 

7.  Disturbances  in  the 'area  of  distribution  of  the  cranial  nerves  almost 
never  occurs,  though  bulbar  S3'mptoms  are  mxCt  in  rare  cases  of  cervical 
myelitis,  when  the  process  has  extended  to  the  medulla  oblongata.  Optic 
neuritis  and  pupillary  changes,  vomiting,  hiccough,  slow  pulse,  diminishing 
to  20  or  30,  dysphagia,  dyspnea,  and  syncope,  have  been  observed  in  cervical 
myelitis. 

Further,  in  cervical  myelitis  there  is  paraplegia  of  the  legs,  along  with 
various  degrees  of  deranged  function  in  the  arms,  especially  if  the  lesion  is 
in  the  lower  part  of  the  cervical  cord,  when  the  arm  paralysis  is  more  or  less 
complete.  Ultimately  there  may  be  loss  of  sensation.  Sometimes  the 
muscles  of  the  shoulder  are  spared,  this  depending  on  the  location  of  the 
lesion.  In  rare  instances  the  arms  only  are  involved,  the  so'-called  cervical 
paraplegia,  but  it  is  questionable  whether  the  lesion  in  such  cases  is  merely 
myelitis.  In  most  the  lower  limbs  are  affected  in  the  early  stages  of 
the  affection.  There  may  be  atrophy  of  separate  muscle  regions  in  the 
arms,  without  atrophy  of  the  muscles  of  the  legs,  but  if  the  lesion  is  an  exten- 
sive one,  the  legs  are  also  paralyzed  on  account  of  the  destruction  of  the  cen- 
tral motor  tract.  The  tendon  reflexes  are  usually  increased  in  the  legs  and 
often  in  the  arms,  while  there  may  be  spastic  symptoms  in  each.  Cutaneous 
reflexes  are  retained  in  the  legs,  often  increased.  Disturbances  in  the  blad- 
der and  rectum  are  present. 

In  thoracic  myelitis  the  arms  are  intact,  but  there  is  motor  and  possibly 
sensory  paraplegia  of  the  legs,  without  degenerative  atrophy.  In  some 
cases  a  transverse  myelitis  of  the  region  involves  the  anterior  horns  above 
and  below  it,  producing  flaccid  muscles,  wasting,  fibrillar  contractions,  and 
reactions  of  degeneration.  Tendon  reflexes  are  increased ;  skin  reflexes  are 
present,  rarely  increased ;  also  disturbances  of  the  bladder  and  rectum.     The 


gi6 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


pyramidal  fibers  below  the  lesion  may  undergo  the  secondary  degeneration, 
and  there  may  be  ascending  degeneration  of  the  posterior  median  columns, 
as  in  cervical  myelitis. 

In  lumbar  myelitis  the  arms  are  intact;  legs  as  in  thoracic  myelitis;  ten- 
don and  skin  reflexes  diminished  or  absent ;  usually  degenerative  muscular 
atrophy  with  some  reaction  of  degeneration ;  disturbances  of  bladder  and 
rectum. 

By  uniting  the  symptoms  detailed  and  their  mode  of  manifestation  we 
may  draw  conclusions  with  a  certain  degree  of  positiveness  as  to  the  por- 
tion of  the  cord  involved.  The  following  table  by  Morton  Prince  in  Der- 
cum's  "  Text-book  "  will  be  helpful : 


Paralysis. 


Sensation. 


Atrophy. 


Electrical      reac- 
tion. 


Bladder. 


Bowels. 


Reflexes,   superfi- 
cial. 
Reflexes,  deep. 

Priapism. 


Lumbar  Myelitis. 


Paraplegia. 


Pains  in  legs,  or  girdle  pains 
around  loins ;  hyperes- 
thetic  zone  around  loins  ; 
anesthesia  of  legs,  com- 
plete or  uneven  distribu- 
tion. 

Of  legs. 


Reaction  of  degeneration  in 
atrophied  muscles  ;  or,  in 
mild  cases  quantitative 
dimi'nution. 

Incontinence  from  paralysis 
of  sphincter. 


Incontinence  from  paralysis 
of  sphincter,  disguised  by 
constipation. 

Lost. 

Lost. 
Absent. 


Dorsal  Myelitis. 


I.  Dorsal,  abdominal,  and 
intercostal  muscles,  accord 
ing  to  height  of  lesion.  2 
Legs. 

Girdle  pain  and  hyperes- 
thetic  zone  between  ensi- 
form  cartilage  and  pubes. 


Of  dorsal  and  "abdominal 
(and  intercostal  muscles, 
not  subject  to  examination) 
corresponding  to  height  of 
lesion  ;  sometimes  mild  and 
slow  of  legs. 

R.  d.  in  dorsal  and  abdom- 
inal muscles;  slight  quanti- 
tative changes  only  in  legs 
when  wasted. 

Retention,  or  intermittent  in- 
continence from  reflex  ac- 
tion ;  later  from  overflow. 
Cystitis  common. 

Involuntary  evacuation  from 
reflex  spasm,  or  constipa- 
tion. 

Temporary  loss,  then  rapid 
increase. 

Temporary  loss,  then  slow 
increase. 

Often  present. 


Cervical  Myelitis. 


Neck  muscles,  dia- 
phragm, arms, 
trunk,   and  legs. 

Hyperesthesia  and 
pains  in  certain 
nerve  distributions 
of  arms;  below  this, 
anesthesia  of  arms, 
body,  and  legs. 

Atroph}'  of  neck 
muscles  (rare)  or 
more  commonly  of 
arms. 


R.     d.    in    atrophied 
muscles. 


Same    as     in    dorsal 
myelitis. 


Same    as    in     dorsal 
myelitis. 

Same    as    in    dorsal 

myelitis. 
Same    as    in    dorsal 

myelitis. 
Often  present. 


Diagnosis. — The  difficulty  of  diagnosis  is  sometimes  very  great,  because 
identical  symptoms  may  be  produced  by  other  diseases,  especially  pressure 
diseases  of  the  cord,  such  as  are  caused  by  tumors  or  hemorrhages,  possible 
conditions  which  must  be  carefully  sought. 

Landry's  cuciite  ascending  paralysis  and  viultiple  neuritis  present  some 
striking  resemblances,  and  in  some  cases  Landry's  paralysis  is  due  to  myelitis. 
Both  Landry's  paralysis  and  multiple  neuritis  present  rapidly  progressive 
motor  paralysis,  but  though  sensory  derangement  may  be  a  late  development 
in  myelitis,  it  is  still  a  symptom  belonging  to  it  rather  than  to  Landry's 
paralysis,  which  is  a  motor  aff^ection,  while  the  trophic  symptoms,  the  paral- 
ysis of  the  bladder  and  rectum,  rapid  wasting,  electrical  disturbances,  and 
fever,  pertain  to  myelitis.  The  resemblance  to  multiple  neuritis  is  closer. 
In  this,  however,  anesthesia  is  less  complete,  the  wasting  less  rapid,  and 
bladder  and  rectum  involvement  almost  never  present,  and  the  parts  affected 
are  in  nerve  distributions. 

Prognosis. — Almost  all  cases  of  myelitis  are  chronic  after  a  more  or 
less  acute  beginning,  seldom  lasting  less  than  a  year,  often  two  or  three  years 
and  even  longer.  The  term  acute  is  not  therefore,  applied  in  its  ordinary 
imeaning,  implying  rapid  course  and  early  termination,  but  it  is  used  to  indi- 


DIFFUSE  MYELITIS.  917 

cate  cases  which  develop  rapidly  to  their  acme  as  contrasted  with  those  that 
are  slow.  Even  these  cases  become  chronic.  There  are  many  who  doubt  the 
existence  of  a  myelitis  which  begins  in  a  chronic  form.  They  hold  that  all 
so-called  chronic  cases  of  myelitis  have  an  acute  commencement.  Rapidly 
developing  cases  passing  to  a  fatal  termination  in  from  five  to  ten  days  may 
occur,  but  are  rare.  Aloreover,  recoveries  are  not  impossible,  though  also 
rare.  Certain  cases,  after  reaching  a  given  stage,  remain  as  to  symptoms 
ill  statiio  quo,  by  which  it  is  understood  that  the  local  lesion  has  healed,  while 
function  has  not  been  regained  because  of  the  impossibility  of  restoring  the 
normal  structure  of  the  cord.  Remissions  and  improvements  are  less  infre- 
quent. Death  is  usually  the  result  of  exhaustion,  although  it  may  result 
from  intercurrent  disease. 

Treatment. — This  is  for  the  most  part  to  be  directed  to  the  relief  of 
symptoms,  no  curative  means  existing  beyond  what  nature  herself  provides. 
In  cases  with  acute  onset  and  pain,  cups  may  be  applied  to  the  back.  Even 
in  syphilis  it  is  thought  by  some  useless  to  give  the  usual  remedies,  but  it  is 
safer  in  cases  of  suspected  disease  to  give  iodid  of  potassium  in  ascending 
doses  to  the  extent  permitted  by  the  stomach,  while  the  mercurial  effect 
should  be  brought  about  by  inunctions,  thirty  grains  (2  gm.)  to  a  dram 
(4  gm.)  of  mercurial  ointment  being  rubbed  in  daily  in  the  armpits  or  inner 
surface  of  the  thigh.  Tonics,  such  as  iron,  quinin,  and  strychnin,  are  useful 
in  this  as  in  other  prolonged  affections. 

The  most  painstaking  attention  must  be  given  to  the  skin  by  bathing 
with  alcohol  and  thoroughly  drying  after  all  washing,  in  order  to  prevent 
the  excoriations  which  are  often  the  beginnings  of  bed-sores,  while  the  irri- 
tating effects  of  the  excretions  must  be  carefully  watched,  and  if  catheteriza- 
tion is  necessary,  it  must  be  practiced  with  the  closest  attention  to  antisepsis. 
It  may  even  be  desirable  to  keep  a  soft  catheter  permanently  in  the  bladder, 
to  which  a  long  tube  is  attached  and  the  bladder  thus  kept  drained.  Should 
cystitis  superv^ene,  the  bladder  is  to  be  washed  out  as  directed  on  page  763. 
When  possible,  the  rectum  should  be  emptied  by  enema  rather  than  by  pur- 
gatives, w^hich  should  be  cautiously  used. 

Electricity  is  elaborately  directed  by  the  German  authors,  although  they 
admit  that  in  the  majority  of  instances  it  is  principally  a  diversion  to  the 
patient.  In  the  later  stages,  however,  of  the  forms  in  which  there  is  atrophy 
of  the  muscles,  some  advantage  may  be  expected.  The  constant  current  is 
most  highly  commended,  by  large  electrodes  placed  over  the  vertebral  column, 
and  a  moderate  stabile  current  or  slowly  labile  current  is  passed  for  four  or 
five  minutes  through  the  supposed  seat  of  the  disease.  Peripheral  galvaniza- 
tion or  faradization  of  the  paralyzed  muscles  and  nerves  should  also  be 
employed.  Massage  is  useful,  perhaps  more  so  than  electricity.  The  blad- 
der may  also  be  treated  by  electricity. 

The  bath  treatment  is  carried  out  to  various  degrees  of  elaboration. 
The  simple  tub-bath  with  warm  water  furnishes  the  easiest  form  and  may 
be  quite  useful,  at  a  temperature  of  85°  or  90°  F.  (24°  to  26°  C),  in  the 
cases  with  spastic  symptoms.  The  baths  should  be  at  first  limited  to  ten  or 
fifteen  minutes  three  or  four  times  a  week,  and  if  well  borne,  may  be  in- 
creased to  an  hour  daily.  The  water  may  be  impregnated  with  sodium 
chlorid,  using  either  the  sea-salt  or  common  salt,  from  four  to  six  pounds  of 
the  former  or  from  five  to  ten  pounds  of  the  latter  to  the  bath.  When  the 
patient  is  able  to  travel  and  avail  himself  of  the  actual  sea  baths,  they  may 
be  expected  to  be  beneficial.     The  Hot  Springs  of  Arkansas  and  Virginia  in 


91 8  DISEASES  OF  THE  NERVOUS  SYSTEM. 

this  country  may  be  resorted  to.  In  Europe  the  thermal  waters  at  Rehme 
and  Nauheim  in  Hesse,  Ragatz  in  Switzerland,  Teplitz  in  Austria,  Wildbad 
in  Wiirtemburg,  Gastein  in  Salzburg,  Austria,  and  Wiesbaden  in  Baden  are 
among  those  recommended ;  also  the  mud-baths  of  Carlsbad  and  Alarienbad 
in  Bohemia  and  Elster  in  Southern  Saxony. 


ACUTE  ANTERIOR  POLIOMYELITIS  OF  CHILDREN. 

Synonyms. — Myelitis  of  Children;  Spinal  Paralysis  of  Children;  Atrophic 
Spinal  Paralysis;  Infantile  Palsy ;  Essential  Paralysis  of  Children. 

Definition. — An  acute  febrile  disease  of  children,  usually  under  three 
years  of  age,  in  which  there  is  paralysis  with  rapid  wasting  of  certain 
muscles. 

Historical. — The  clinical  phenomena  of  this  disease  were  described  as  early  as 
1S40  bv  Jacob  von  Heine.  The  same  physician  twenty  years  later  suggested  that  a 
spinal  malady  la^-  at  the  bottom  of  it,  but  it  was  reserved  for  Prevost  and  Velpeau, 
Charcot  and  Joff'roy,  to  demonstrate  the  lesion  which  justifies  the  use  of  the  term 
"spinal  paralj'sis  of  children,"  for  the  older  "  essential  paralysis  of  children." 

Etiology. — Especially  a  disease  of  later  infancy,  it  may  occur  at  all 
periods  of  life,  but  is  ten  times  more  frequent  in  the  first  decade  than  in  all 
the  rest  of  life.  It  is  more  common  in  boys  than  in  girls,  and  in  the  warm 
months,  as  pointed  out  by  Wharton  Sinkler,  who  ascertained  that  in  Phila- 
delphia four-fifths  of  the  cases  occurred  in  ]\Iay  to  September.  There 
seems  to  be  a  slight  family  tendency.  It  has  appeared  in  epidemic  form  in 
Stockholm,  w^here  ]\Iedin  reports  twenty-nine  cases  from  August  9  to  Sep- 
tember 23.  A  very  remarkable  epidemic  in  this  country,  occurring  at  Rut- 
land, Vt.,  was  reported  by  Caverly  in  the  "New  York  ]\Iedical  Record,'" 
volume  ii.,  1894,  in  which  190  cases  occurred  during  the  summer,  of  which 
85  were  under  six  years  of  age,  and  18  died.  Other  epidemics  have  been 
recorded.  Acute  anterior  poliomyelitis  has  been  ascribed  without  founda- 
tion to  dentition,  to  cold,  and  to  overexertion,  and  is  very  frequently  errone- 
ously attributed  by  parents  to  falls  and  the  carelessness  of  nurses.  Most 
children  are  attacked  while  in  perfect  health,  although  previous  exhausting 
diseases  may  reasonably  be  held  responsible.  It  is  probably  due  to  bacterial 
invasion.  Among  predisposing  diseases  are  typhoid  fever,  measles,  and 
diphtheria.  Striimpell,  however,  says  that  though  the  paralyses  arising 
after  these  diseases  are  of  spinal  origin,  they  cannot  be  identified  with  the 
idiopathic  spinal  paralyses  of  children. 

Morbid  Anatomy. — The  disease  occupies  more  frequently  the  cervical 
or  lumbar  enlargement.  The  usual  lesion  found  in  old  cases,  which  are 
those  which  commonly  come  to  autopsy,  is  an  atrophy  of  one  anterior  cornu, 
which  is  changed  to  a  dense  sclerosed  tissue,  whence  the  ganglion  cells  have 
almost  or  totally  disappeared,  often  pierced  by  thickened  and  dilated  vessels. 
A  similar  condition  is  found  in  the  corresponding  cornua  of  the  cervical 
enlargement  if  the  paralysis  is  in  the  arm,  and  of  the  lumbar  if  in  the  leg. 
If  bilateral,  both  cornua  would  be  involved.  The  corresponding  anterior 
nerve-roots  are  atrophied  and  the  muscles  supplied  by  them  are  wasted, 
undergoing  a  fatty  and  sclerotic  change.  The  white  matter  of  the  cord  in 
the  vicinity  may  be  involved  to  some  extent,  resulting  in  sclerosis  and  slight 
reduction  in  size.     Opportunities  for  autopsy  m  the  earlier  stages  are  rare, 


ACUTE  ANTERIOR  POLIOMYELITIS  OF  CHILDREN.     919 

but  a  condition  of  acute  myelitis  predominating  in  the  gray  matter,  with 
degeneration  and  rapid  destruction  of  the  ganghon  cells,  has  bsen  found  by 
a  number  of  investigators. 

Symptoms. — Sudden  onset  is  characteristic  of  the  disease,  although 
there  may  be,  and  probably  oftener  than  is  noticed,  slight  previous  indisposi- 
tion with  feverishness.  A  child,  apparently  perfectly  well  and  lively,  may  be 
suddenly  taken  with  fever,  loi''  to  103°  F.  (38.3°  to  38.9°  C),  sometimes 
reaching  105'  to  106°  F.  (40°  to  41°  C.)  ;  headache  and  sometimes  pain  in 
the  loins  and  limbs  and  aching  in  the  joints,  drowsiness,  and  even  stupor. 
Rarely  there  may  be  convulsions  and  loss  of  consciousness.  These  initial 
symptoms  do  not  often  last  longer  than  a  couple  of  days,  when  paralysis  sets 
in  abruptly,  reaching  its  climax  usually  in  twenty-four  hours.  The  extent 
varies,  involving  one  or  both  arms,  one  or  both  legs,  more  rarely  one  arm 
and  one  leg,  or  there  may  be  crossed  paralysis,  as  of  the  right  arm  and  left 
\tg.  Groups  only  of  muscles  mav  be  affected,  as  those  of  the  upper  or  lower 
arm,  upper  or  lower  leg,  corresponding  to  the  ner\^e-cells  involved.     Less 


Fig.  104. — Section  through  the  Cervical  Enlargement  in  Anterior  Poliomyelitis;  the 
Left  Anterior  Column  {b)  is  very  much  Contracted  and  is  without  Ganglion 
Cells — {from  Charcot  aiid  Joffroy). 

frequently  the  paralysis  comes  on  more  slowly,  taking  from  three  to  five  days 
to  develop.  It  commonly  also  diminishes  in  extent  after  its  first  invasion,  in 
rare  cases  even  totally  disappearing,  but  usually  withdraws  itself  to  a  definite 
set  of  muscles,  which  remain  more  or  less  permanently  affected.  In  the  legs 
the  tibialis  anticus  and  extensor  groups  of  muscles  are  more  commonly 
affected  than  the  glutei  and  the  hamstrings ;  in  the  arm,  the  deltoid.  The 
child,  in  the  mean  time,  has  regained  its  health  in  other  respects. 

At  first  the  affected  limbs  remain  natural,  and  hence  the  child,  too, 
appears  vigorous,  especially  as  the  face  is  not  involved.  This  may  be  the 
case  for  some  time,  but  usually  in  a  few  weeks  atrophy  sets  in  and  progresses 
rapidly,  producing  a  soft,  flaccid,  wasted  limb.  The  changes  in  the  electrical 
reaction  of  the  nen^e  and  muscle  appear  at  the  same  time,  commonly  more 
rapidly  than  the  visible  atrophy.  Usually  as  early  as  the  first  week  the  reac- 
tion of  degeneration  is  present.  Faradic  excitability  of  both  nerve  and 
muscle  is  gone,  and  galvanic  excitability  in  the  ner\'e.  In  muscle?  there  is 
at  first  increased  responsiveness.  To  galvanism-  with  a  predominance  of 
slow  anodic  closure  contraction  (An  CI  C),  while  after  two  or  three  months 


920  DISEASES  OF  THE  NERVOUS  SYSTEM. 

even  galvanic  excitability  falls  decidedly,  though  the  muscular  contraction 
maintains  its  characteristic  quality  of  slow  vermicular  motion. 

Often  the  growth  of  bo>ic  in  the  affected  limb  is  delayed,  and  even 
arrested,  and  a  stunted  development  results.  After  a  time  there  also  ensue 
relaxation  of  the  joints  and  deformity  from  secondary  muscular  contraction. 
In  the  lower  extremities  the  paralytic  club-foot  {talipes  varo-equinus) 
develops,  resulting  from  the  paralysis  of  peroneal  muscles  and  the  tibalis 
anticus,  permitting  the  point  of  the  foot  to  drop,  while  a  contracture  develops 
in  the  antagonistic  muscles  of  the  calf.  In  paralysis  of  muscles  of  the  calf 
there  results,  on  the  other  hand,  a  moderate  degreee  of  talipes  calcaneus,  from 
contraction  of  the  antagonistic  muscles.  In  the  arms  and  vertebral  column 
numerous  contractures  and  deformities  arise,  mainly  due  to  the  contracture 
of  unparalyzed  antagonistic  muscles  and  to  external  mechanical  conditions,, 
such  as  weight  and  pressure. 

Sensation  remains  intact,  as  also  does,  fortunately,  bladder  and  rectum 
control.  At  the  onset  micturition  is  sometimes  slightly  deranged,  but  sub- 
sequently this  disappears.  The  tendon  retlexes,  and  almost  always  the  skin 
reflexes,  are  lost  in  parts  affected  by  the  atrophy.  The  skin  sometimes 
exhibits  trophic  disturbances,  being  cool  and  cyanotic. 

Diagnosis. — This  is  usually  easy.  There  are  few  diseases  in  which  one 
can  reason  so  soundly  from  characteristic  symptoms  to  morbid  states  causing- 
them.  The  paralysis  of  one  or  more  limbs,  the  flaccidity,  the  rapid  wasting, 
the  reaction  of  degeneration,  and  the  absence  of  reflexes,  with  integrity  of 
sensibility  and  undisturbed  mental  state,  point  only  to  disease  of  the  anterior 
cornua.  The  pseudoparesis  of  rickets  presents  some  similarity  in  paretic 
and  muscle  phenomena.  There  is  not,  however,  in  rickets  true  paralysis— 
simply  pain  on  motion,  to  which  are  added  the  peculiar  head-sweating  and 
hyperesthesia,  together  with  rachitic  symptoms  elsewhere. 

Prognosis. — This  is  always  unfavorable  so  far  as  recovery  is  concerned, 
but  improvement,  at  first  general,  and  afterward  in  groups  of  muscles,  is 
often  decided,  so  much  so,  indeed,  as  to  be  somewhat  delusive.  In  pro- 
tracted cases  we  must  expect  the  superaddition  of  contractures,  while 
deformities  must  be  mentioned  to  parents  as  possible.  The  initial  period 
passed,  there  is  no  danger  to  life,  and  subjects  may  live  to  old  age. 

Treatment. — Notwithstanding  the  unfavorable  prognosis,  treatment 
should  not  be  ignored.  Paralysis  is  established,  of  course,  before  the  diag- 
nosis is  made,  and  atrophy  nearly  as  soon.  The  early  symptoms  can,  there- 
fore, only  be  treated  symptomatically.  An  aperient  should  be  given  and 
febrifuges  ordered.  Should  an  opportime  circumstance  favor  an  early  diag- 
nosis, cold  applications  may  be  made  to  the  spine ;  it  is  doubtful  whether  they 
will  accomplish  much.  Paralysis  supen-ening,  the  little  patient  must  imme- 
diately be  put  at  rest  in  bed  and  w-rapped  in  cotton.  No  active  measures 
should  be  taken  at  this  stage. 

The  acute  stage  passed,  electricity  is  the  most  important  therapeutic 
measure  to  be  employed.  It  is  used  both  for  curative  purposes  and  to  keep 
up  the  nutrition  of  the  muscles.  In  attaining  the  former,  galvanism  is  pre- 
ferred, a  broad  electrode  being  placed  on  the  vertebral  column  over  the  spot 
supposed  to  be  diseased, — on  the  cervical  region,  if  the  upper  extremity  is 
paral3-zed,  and  over  the  lumbar  if  the  lower, — while  the  other  pole  is  placed 
over  the  paralyzed  muscles  and  nerves.  The  latter  is  moved  about,  the 
current  being  at  times  reversed.  Interruptions  may  also  be  made.  While- 
the  galvanic  current  is  commonly  employed,  faradization  may  be  used. 


ACUTE  POLIOMYELITIS  IN  ADULTS.  921 

The  second  purpose  of  the  electrical  treatment,  keeping  up  the  nutrition 
of  the  muscles,  is  more  likely  to  be  effectual.  For  this  purpose  massage  and 
baths,  after  the  method  laid  down  under  treatment  of  myelitis,  are  also  useful. 
The  electrical  treatment  must  be  persisted  in  for  months  and  even  years  in 
order  that  the  muscles  may  be  in  a  condition  to  resume  their  function  should 
the  integrity  of  the  cord  be  restored.  Both  massage  and  electrical  treatment 
may  be  carried  out  by  members  of  the  family  after  a  little  instruction. 

Tonics  are  employed  for  the  usual  purposes,  and  orthopedic  appliances 
may  be  necessary  to  overcome  the  effect  of  muscular  relaxation  on  the  one 
hand  and  of  contractures  on  the  other. 


ACUTE  POLIO^IYELITIS  IN  ADULTS. 
Synonym. — Acute  Atrophic  Spinal  Paralysis  of  Adults. 

The  existence  in  adults  under  thirty  of  a  disease  with  all  the  clinical 
manifestations  of  the  one  just  described  as  comparatively  frequent  in  chil- 
dren must  be  admitted,  since  an  undoubted  anatomical  lesion  of  the  same 
kind,  associated  with  such  manifestations,  has  been  found  by  investigators. 
On  the  other  hand,  it  must  be  conceded  that  the  disease  is  very  rare  and  that 
many  of  the  cases  so  diagnosticated  were  really  cases  of  multiple  neuritis. 
Landry's  paralysis  in  some  cases  may  be  the  clinical  manifestation  of  polio- 
myelitis. In  view  of  the  fact  that  the  symptomatology  is  almost  the  same  as 
that  of  the  infantile  form,  no  separate  description  is  necessary.  Among 
pecuharities  may  be  mentioned  the  possible  involvement  of  all  four  extremi- 
ties, as  contrasted  wdth  a  monoplegia  or  a  paraplegia  at  other  times.  Again, 
there  may  be  the  involvement  of  groups  of  muscles.  Thus,  in  paralysis  of 
the  crural  region  the  sartorius  muscle  often  remains  free.  In  the  leg  the 
tibialis  anticus  may  be  separately  involved  or  the  extensor  digitorum.  In 
the  forearm  the  supinator  longus  supplied  by  the  musculospiral  nerve  may 
remain  free  w^hile  all  the  other  muscles  on  the  extensor  side  of  the  forearm 
are  paral3-zed,  furnishing  "  the  forearm  type  "  of  E.  Remak ;  or  the  supinators 
may  be  paralyzed  alone  or  together  with  the  biceps,  brachialis  anticus,  and 
deltoid,  furnishing  "  the  upper  arm  type  "  of  Remak.  The  latter  form  is  said 
to  correspond  to  a  lesion  at  the  level  of  the  fifth  and  sixth  cervical  roots,  and 
the  former  to  a  lesion  of  the  eighth  cervical  and  first  thoracic  roots. 

Diagnosis. — This  is  mainly  from  multiple  neuritis,  in  which  the  palsy 
is  symmetrical  instead  of  irregular  in  distribution,  pain  is  more  character- 
istic and  persistent,  while  the  nerve  trunks  are  inflamed  and  painful. 

Prognosis  and  treatment  are  similar  to  those  of  the  same  affection  in 
children,  except  that  the  prognosis  is  rather  more  favorable,  recovery  being" 
reported,  though  such  cases  may  have  been  multiple  neuritis. 

Subacute   and   Chronic   Poliomyelitis. 

Synonyms. — Subacute  and  Atrophic   Spinal  Paralysis;   General  Anterior 
Spinal  Paralysis,  Subacute  of  Duchenne. 

All  that  w^as  said  of  the  probable 'confounding  of  acute  poliomyelitis  of 
adults  with  acute"  multiple  neuritis  may  be  said  of  the  subacute  and  chronic 
form.  Yet  it  would  seem  that  undoubted  cases  have  been  studied.  Oppen- 
heim  especially  studied  a  case — in  which  the  anterior  cornua  of  the  cord 


922  DISEASES  OF  THE  NERVOUS  SYSTEM. 

were  found  markedly  diseased  at  necropsy.  There  were,  clinically,  paralysis 
and  atrophy  of  all  four  extremities  without  sensory  disturbance.  The  cases 
differ  from  the  acute  form  in  the  absence  of  the  severe  initial  symptoms, 
fever,  headache,  somnolence,  delirium,  and  vomiting. 


ACUTE  ASCENDING   SPINAL   PARALYSIS. 
Synonym. — Landry's  Paralysis. 

Definition. —  A  disease  first  described  by  Landry,  in  1859,  character- 
ized by  an  advancing  paralysis  beginning  in  the  lower  extremities,  passing 
upward  to  the  trunk  and  arms,  and  finally  to  muscles  supplied  from  the 
medulla  oblongata,  including  those  of  respiration,  sensibility  and  bladder 
and  rectum  control  remaining  intact. 

Etiology  and  Pathology. — It  is  most  common  in  men  between  20  and 
30,  and  usually  those  who  are  strong  and  healthy.  Cases  have,  however, 
been  seen  in  children  and  old  persons.  No  anatomical  lesions  pathognomonic 
of  the  disease  have  been  shown  to  be  associated  with  it.  Hence  attempts 
have  been  made  to  classify  it  elsewhere,  and  H.  Oppenheim,  James  Ross, 
Neuwerk,  Barth,  and  others  regard  it  as  a  form  of  peripheral  neuritis,  Ross 
having  found  an  interstitial  form  confined  to  nerve  roots,  while  Neuwerk 
and  Barth  described  a  case  confined  to  peripheral  nerves.  Other  carefully 
studied  cases  failed  to  disclose  such  lesion.  In  some  cases  myelitis,  espe- 
cially poliomyelitis,  is  the  cause.  A  toxic  cause  seems  not  unlikely.  It  is 
quite  consistent  with  such  cause  that  it  should  leave  no  local  lesion,  as  well  as 
that  it  should  always  seek  the  same  spot.  Gowers  is  especially  disposed  to 
ascribe  the  disease  to  such  a  cause.  Some  cases  have,  however,  followed 
trauma. 

Symptoms. — The  characteristic  symptoms  are  commonly  preceded  by  a 
prodrome,  in  which  loss  of  appetite,  general  malaise,  moderate  fever,  head- 
ache, backache,  and  tingling  in  the  extremities  are  conspicuous.  These 
symptoms  vary  in  severity  and  last  from  a  few  days  to  several  weeks,  when 
a  paresis  suddenly  sets  in,  first  of  one  leg  and  then  of  another,  increasing 
rapidly,  so  that  in  a  few  days,  sometimes  in  a  few  hours,  an  almost  total 
motor  paraplegia  is  developed.  The  paresis  next  extends  to  the  trunk ;  in 
a  few  days  or  even  less  the  arms  are  paralyzed.  The  muscles  of  the  neck 
are  next  involved,  and  ultimately  those  of  respiration,  deglutition,  and  articu- 
lation, producing  bulbar  symptoms.  Finally,  facial  paralysis  and  other  dis- 
turbance of  facial  muscles  may  ensue.  The  paralysis  is  a  flaccid  one,  and 
there  is  no  tendency  to  spasm  or  resistance  to  passive  motion.  There  is  not 
usually  a  change  in  electrical  reaction,  although  there  is  sometimes  a  rapid 
loss  of  faradic  muscular  excitability.  The  reflexes  are  diminished  or  absent, 
but  the  muscles  do  not  zvaste,  because  death  usually  occurs  before  atrophy 
has  had  time  to  develop. 

There  is  no  definite  loss  of  sensation,  but  in  addition  to  the  primary  tin- 
gling referred  to  there  is  sometimes  hyperesthesia  and  musctilar  tenderness. 
In  other  characteristic  cases  sensation  is  intact.  More  rarely  there  is  a 
blunted  and  delayed  sensation.  The  special  senses  are  not  affected,  nor  are 
the  bladder  and  rectum.  Sometimes  there  are  vasomotor  edema-  and  sweat- 
ing. The  spleen  has  been  found  enlarged  and  slight  albuminuria  has  been 
observed. 


ACUTE  ASCEXDIXG  SPIXAL  PARALYSIS.  923 

Diagnosis. — This  is  not  always  easy,  the  disease  being  simulated  by 
multiple  neuritis,  acute  auterior  poliomyelitis,  and  ascending  myelitis.  All 
these  mav  cause  difficulty,  and  sometimes  a  distinction  clinically  and  patho- 
logically is  impossible.  The  rapid  motor  paralysis,  advancing  from  below, 
in  the  feet  and  hands,  instead  of  from  above,  the  absence  of  anesthesia,  of 
wasting,  and  of  electrical  changes,  are  characteristic  of  Landry's  paralysis. 

Prognosis. — This  is  grave,  and  the  possibility  of  a  rapidly  fatal  termi- 
nation, even  in  a  few  days,  is  to  be  remembered,  the  danger  being  from  inter- 
ference with  the  cardiac  and  respiratory  functions  of  the  medulla  oblongata. 
Other  cases  terminate  similarly  in  three  or  four  weeks.  If,  on  the  other 
hand,  the  acute  stage  passes  off,  the  symptoms  of  paralysis  may  cease  to 
extend,  and  recover}^  is  possible  and  has  occurred  in  some  cases. 

Treatment.— The  patient  should  be  put  to  bed  immediately,  and  coun- 
terirritation  should  be  applied  to  the  back  by  dry  cups,  and  maintained  by 
gentler  means,  as  by  a  mustard  plaster.  The  thermocautery  has  been 
recommended,  but  is  of  doubtful  value.  Paquelin's  cautery  is,  at  least, 
harmless. 

Of  internal  remedies  the  apparent  results  from  ergotin  and  mercury 
justifv  their  further  use.  Cowers  relates  a  remarkable  case  of  recovery 
under  the  use  of  the  former  drug,  twenty  grains  (1.32  gm.)  having  been 
given  in  the  course  of  a  night  in  divided  hourly  doses.  Likewise  cases  of 
syphilitic  origin  have  been  reported,  in  which  the  iodid  of  mercury  has 
seeminglv  proved  of  service.  The  biniodid  may  be  given  in  doses  of  from 
1-50  to  1-30  grain  (0.003  to  0.006  gm.).  The  salicylates  have  been  advised. 
Both  remedies  are  indicated  if  its  toxic  origin  be  admitted.  Perchlorid  of 
iron  is  recommended  in  traumatic  cases,  especially  when  there  is  evidence  of 
septic  poisoning. 

If  swallowing  is  difficult  the  patient  must  be  nourished  by  the  rectum 
or  through  the  nasal  tube,  and  if  symptoms  of  respiratory  failure  come  on, 
electrical  stimulation  of  the  phrenic  ner^-e  and  respiraton,^  muscles  may  be 
used.  If  the  acute  symptoms  pass  away  and  paralysis  persists,  the  usual 
application  of  galvanism  and  faradization  may  be  made  for  restoring  mus- 
cular and  nervous  power. 


924  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Chronic   Affections   of  the   Spinal   Cord. 

SPASTIC    SPINAL   PARALYSIS. 

Synonyms. — Primary  Lateral  Sclerosis;  Spasmodic  Tabes  Dorsalis. 

Definition. — A  chronic  disease  of  the  spinal  cord,  characterized  by  stiff- 
ness and  weakness  of  limbs  with  greatly  exaggerated  tendon  reflexes,  but 
without  atrophy  or  sensory  or  vesical  derangement. 

History. — In  1875  Erb,  and  independently  Charcot,  called  attention  to  a  form  of 
paralysis  characterized  by  "a  gradualh'  increasing  paresis  and  paralj-sis,  usually 
advancing  from  below  upward,  with  muscular  tension,  reflex  contractions  and  con- 
tractures, with  marked  increase  of  the  tendon  reflexes  and  complete  absence  of  sensory 
and  trophic  dtsturbaiices  of  vesical  and  sexual  weakness,  and  of  any  cerebral  dis- 
tjtrbance."  Both  observers  agreed  on  a  "  primary  symmetrical  sclerosis  of  the  lateral 
columns  "  as  the  anatomical  condition  of  the  disease.  Since  then  numerous  cases 
have  been  observed  corresponding  in  clinical  features,  but  while  the  anatomical 
features  described  as  essential  have  been  found,  they  have,  with  one  or  two  excep- 
tions, been  accompanied  b}^  other  lesions,  which  are  not  alike  in  different  cases.  A  few 
cases  have  been  described,  which  seem  to  show  the  possibility  of  the  occurrence  of 
primary  lateral  sclerosis,  without  complications,  but  most  foreign  writers  discard  the 
name  of  lateral  sclerosis,  and  some  speak  of  it  by  its  most  prominent  symptom,  spastic 
paraplegia. 

Etiology. — The  etiology  is  not  always  apparent,  although  the  causes 
are  probably  many.  The  cases  mostly  begin  between  the  20th  and  40th  years. 
It  may  occur  in  children.  It  has  been  traced  to  syphilis,  several  times  to 
trauma,  after  acute  infectious  fevers,  lead  poisoning,  and  to  the  puerperium ; 
the  diagnosis  in  such  cases  usually  has  been  without  anatomical  confirmation. 
Striimpell  has  called  attention  to  hereditary  family  type,  found  in  male  mem- 
bers, between  the  20th  and  30th  years,  and  in  some  families  the  symptoms 
are  first  manifested  in  early  childhood.  A  form  closely  related,  but  resulting 
from  arrested  development  rather  than  from  atrophy  of  the  central  motor 
tracts,  is  the  spastic  paraplegia  occurring  in  children  born  prematurely,  and 
sometimes  classed  as  one  type  of  Little's  disease. 

Morbid  Anatomy.  — The  lesion  which  would  be  expected  in  spastic 
spinal  paralysis  is  degeneration  of  the  pyramidal  tracts.  In  point  of  fact 
this  condition  is  found,  but  it  is  apt  to  be  part  of  a  mixed  lesion  which  may 
include  that  of  myelitis,  meningomyelitis,  multiple  sclerosis,  compression  of 
the  cord  by  tumors  or  by  caries  of  the  vertebrae.  In  a  few  cases,  however, 
the  lesion  almost  uncomplicated  has  been  found  by  INIunkowski,  Striimpell, 
Dejerine,  and  Sottas. 

Symptoms. — The  conditions  may  begin  with  a  sense  of  fatigue  and 
weariness  in  the  legs,  but  the  two  essential  and  predominating  symptoms  are 
increase  of  the  tendon  reilexes  and  motor  paresis.  The  first  is  the  more 
unmistakable,  constant,  and  characteristic.  In  decided  degrees  of  this  in- 
crease the  contractions  come  on  even  with  that  amount  of  tension  on  the 
tendons  which  is  produced  by  the  weight  of  the  limbs  or  any  active  or  passive 
movem.ents,  while  the  reflex  muscular  tension  or  rigidity  opposes  any 
attempt  at  motion.  The  muscles  feel  rigid  and  firm,  and  the  legs  are  found 
in  almost  permanent  extension,  while  the  feet  are  in  plantar  flexion.  Any 
attempt,  especially  if  sudden,  to  flex  the  leg  at  the  knee  or  the  foot  dorsally 
meets  with  resistance.  Yet  if  slow  eft'ort  is  made,  flexion  may  generally  be 
accomplished,  the  leg.  while  undisturbed,  remaining  in  the  position  assumed, 


SPASTIC  SPINAL  PARALYSIS.  925 

whence  the  graphic  term  of  Weir  ^Mitchell — "  lead-pipe  contraction."  If 
the  thigh  be  placed  over  the  edge  of  the  bed,  the  traction  of  the  leg  on  the 
quadriceps  extensor  may  be  sufficient  to  excite  vigorous  extensor  tetanus 
and  a  convulsive  tremor  of  the  whole  leg,  like  that  of  ankle  clonus.  If  the 
patient  is  examined  in  a  bath,  the  spasms  are  less  violent  because  the  effect 
of  the  weight  of  the  legs  is  diminished.  The  superficial  reflexes  are  also 
increased. 

Walking  is  interfered  with  in  two  ways,  first  by  the  stiffness  in  the  legs, 
and  second  by  the  paresis.  The  legs  are  only  partially,  if  at  all,  flexed  at 
the  knee,  and  the  foot  is  not  raised,  but  is  pushed  along  the  floor  in  short, 
difficult  steps.  Owing  to  the  contraction  of  the  calf  muscles  the  toes  are 
brought  to  the  ground,  and  thus  the  patient  walks  on  his  toes ;  sometimes  an 
ankle  clonus  is  developed  by  contact  of  the  toes  with  the  ground.  The  legs 
are  kept  close  together,  the  knees  touch,  and  in  certain  cases  adductor  spasm 
may  cause  cross-legged  progression.  Stiffness  is  not  always  so  marked. 
The  effect  is  the  so-called  spastic  gait.  In  some  cases  there  is  no  paresis, 
and  the  peculiarity  of  the  gait  depends  purely  on  the  muscular  spasm.  The 
effect  is  what  Striimpell  calls  pseudoparesis,  or  spastic  pseudoparesis.  The 
absence  of  actual  paresis  is  shown  by  the  fact  that,  notwithstanding  the  stifif- 
ness  in  the  gait,  the  patient  can  still  walk  some  distance,  even  miles.  With 
all  this,  the  patient  is  zcell  nourished  and  there  is  no  wasting  of  muscles, 
which  may  even  be  hypertrophied,  and  outside  of  these  symptoms  he  may 
enjoy  excellent  health.     Nor  is  there  vesical  disturbance. 

There  is  no  sensory  disturbance.  Ocular  symptoms  are  rare.  The 
tendency  is  to  grow  gradually  worse,  but  very  gradually ;  finally  the  patient 
cannot  walk  at  all,  nor  can  he  stand.  Rarely  the  muscles  of  the  trunk  and 
arms  become  involved,  presenting  also  a  paresis  with  decided  increase  in  the 
tendon  reflexes  without  disturbance  of  sensibility  or  muscular  atrophy. 
Such  is  the  picture  of  spastic  palsy,  rarely,  perhaps,  seen  in  an  uncompli- 
cated form. 

Diagnosis. — As  stated  at  the  outset,  there  is  absence  of  sensory  and 
trophic  disturbance.  The  onset  may  be  sudden,  but  is  never  so  in  typical 
cases,  with  numbness  in  the  extremities,  progressive  loss  of  strength,  but  no 
emaciation.  Spastic  symptoms,  with  increased  knee-jerk,  appear,  followed 
by  gradually  developing  paresis.  The  arms  are  often  affected,  but  less  so 
than  the  legs,  and  may  escape.  The  course  of  the  disease  is  slow,  and  mental 
symptoms  similar  to  those  of  dementia  paralytica  may  be  present  at  the  close ; 
also  amyotrophic  lateral  sclerosis  in  some  of  its  symptoms,  but  it  differs  in 
the  absence  of  muscular  atrophy. 

Hysterical  spastic  paraplegia  ma.y  furnish  in  the  most  striking  manner 
the  symptoms  detailed.  Every  symptom  to  be  mentioned  may  repeat  itself 
more  or  less  identically.  It  is,  therefore,  not  necessary  to  name  them. 
Moderate  wasting  is  sometimes  added.  It  occurs  more  commonly  in  women, 
and  usually  careful  examination  will  reveal  some  distinct  stigmata  of  hysteria. 

Prognosis. — Spastic  paraplegia  of  all  forms  except  the  hysterical  is  of 
long  duration  with  little  prospect  of  recover\\  The  upper  extremities  are 
tolerably  free  from  derangement,  and  the  mind  is  usually  clear.  Hysterical 
spastic  paraplegia  may  end  in  recover}^,  if  properly  managed.  \"\''hen  the 
cause  is  transient,  also,  recovery  may  be  expected  with  removal  of  pressure, 
as  in  caries. 

Treatment. — If  caries  is  present,  mechanical  measures  should  be  used 
to  remove  pressure.     If  syphilis  is  suspected,  treatment  by  iodids  and  mer- 


926  DISEASES  OE  THE  XERVOUS  SYSTEM. 

curials  should  be  persevered  in.  ^Mercurial  inunction  is  the  most  ready  way 
of  bringing  about  mercuriaHsm.  Galvanism  and  faradization  are  less  useful 
in  spastic  conditions  of  the  muscle  than  in  those  in  which  nutritional  changes 
are  more  decided,  but  in  hysterical  spastic  disease  they  are  of  signal  use  for 
their  moral  effect.  The  electrical  brush  is  here  the  most  useful  instrument. 
It  should  be  associated  with  massage  and  passive  motion,  and  early  attempt 
at  locomotion  should  be  encouraged  and  a  positively  favorable  prognosis 
made.     These,  at  least,  tend  to  defer  the  immovable  stage. 

In  any  case  friction,  massage,  and  forcible  flexion  may  be  of  benefit,  but 
should  be  used  cautiously,  as  the  irritation  produced  in  this  way  may  pos- 
sibly hasten  premature  contracture.  Hydrotherapy  is  commended.  The 
effect  of  the  prolonged  warm  bath  at  90°  to  95°  F.  (32.2°  to  35°  C.)  is  often 
an  amelioration  of  the  spastic  symptoms.  The  bath  should  be  kept  up  for 
half  an  hour  and  manipulation  practiced  during  it. 


TABES  DORSALIS. 

Syxoxyms. — Posterior  Spinal  Sclerosis;  Duchenne's  Disease;   Locomotor 

Ataxia. 

Definition. — A  disease  especially  characterized  clinically  by  loss  of 
co-ordinating  power,  and  by  sensory  and  trophic  symptoms ;  anatomically  it 
is  pre-eminently  a  disease  of  the  posterior  spinal  roots  and  posterior  columns 
of  the  cord,  although  the  cerebrum  does  not  always  escape,  and  the  optic 

nerves  are  commonly  affected. 

Historical. — Inco-ordination  of  movement  in  cases  of  spinal  cord  disease  was 
noticed  in  the  first  third  of  the  last  century,  but  the  cases  in  which  it  was  present  were 
not  separated  from  those  with  loss  of  power.  The  association  of  this  distinctive 
symptom  with  disease  of  the  posterior  columns  was  first  announced  hy  Stanley  in 
1840.  and  the  first  accurate  account  of  the  disease  was  published  by  R,  Bentle}-  Todd 
in  1847.  He  distinguished  inco-ordination  without  weakness  from  paraplegia,  inferred 
involvement  of  the  posterior  columns,  and  confirmed  his  inference  bv  autops}-.  In 
1851  Romberg  described  the  disease  and  the  lesion  in  the  posterior  columns,  but 
failed  to  eliminate  loss  of  power  from  the  symptoms.  In  1855  Russel  Revnolds 
accurately  described  the  symptoms  and  ascribed  ataxia  to  muscular  anesthesia, 
giving  thus  the  first  correct  explanation  of  this  symptom.  Tiirck  first  recognized 
with  the  microscope  the  wasting  of  the  fibers  in  the  posterior  columns  of  the  cord. 
In  185S-59  Duchenne,  without  adding  anything  essential  to  the  s^-mptomatologj" 
or  pathology  of  the  disease,  published  a  monograph  which  so  attracted  attention 
that  the  disease  has  come  to  be  called  by  his  name,  although,  as  Gowers  correctlv 
savs.  if  the  name  of  anv  man  should  be  associated  with  tabes  dor5alis,it  is  that  of 
Todd. 

Etiology. — The  etiology  of  tabes  dorsalis  is  not  a  satisfactory  chapter. 
The  disease  is  more  common  in  cities,  affects  ten  men  to  one  woman,  is  rare 
in  the  negro,  and  is  pre-eminently  a  disease  of  middle  life,  about  one-half  the 
cases  beginning  between  thirty  and  fort}-,  one-fourth  between  forty  and  fifty. 
and  less  than  one-fourth  between  twenty  and  thirty.  It  has  been  met  as  late 
as  sixty-six,  and  occasionally  before  the  age  of  twenty.  Direct  inheritance, 
independent  of  inherited  syphilis,  is  almost  unknown,  but  a  slight  tendency 
is  found  in  neurotic  families. 

Of  the  direct  causes,  syphilis  is  believed  to  be  the  most  frequent.  From 
50  to  90  per  cent,  of  cases  have  been  ascribed  to  it  by  different  authors,  Erb 
and  Striim.pell  leading  with  the  latter  figure.  Mobius  even  believes  that  all 
cases  of  tabes  are  due  to  syphilis.  Yet  there  are  difficulties  in  tracing  the 
relation   growing  out  of  the  facts,  first,  that  the  pathological  product  is  not 


TABES  DORSALIS. 


927 


anatomically  a  syphilitic  one,  and,  second,  that  it  does  not  respond  to  the 
treatment  of  syphilis.  A  reasonable  explanation  ascribes  it  to  a  toxic  cause 
analogous  to  that  of  the  paralysis  which  follows  diphtheria,  acting  especially 
on  the  centripetal  sensory  fibers. 

Prolonged  exposure  to  cold  and  wet,  such  as  belongs  to  certain  occu- 
pations, as  lumbering,  is  a  commonly  admitted  cause,  but  simple  overexer- 
tion, physical  and  mental,  especially  sexual  excesses,  formerly  held  respon- 
sible, are  probably  not  causes.  Alcoholism  is  also  held  responsible  less 
commonly  than  formerly.     On  the  other  hand,  Tuczek  has  shown  that  in 


^t-i^f-L^f-^^^'  h 


rife 


Fig,  105. — Lumbar  Region.  £' ^,  degenerated  posterior  roots,  A  h,  normal  anterior 
roots,  f  f,  degenerated  posterior  columns,  e  e,  ventral  fields  of  the  posterior 
columns  intact — {after  Spiller). 


chronic  ergot  poisoning  symptoms  like  those  of  tabes  develop,  and  with  them 
a  lesion  appears  in  the  posterior  columns  of  the  cord. 

Traumatism  affecting  the  spine  has  been  believed  to  be  a  cause  in  a  few 
instances,  but  this  relation  has  not  been  established. 

Morbid  Anatomy. —  Tabes  dorsalis  is  pre-eminently  a  disease  of  the 
posterior  spinal  roots  and  posterior  columns,  although  the  cerebrum  does 
not  always  escape,  and  the  optic  nerves  are  usually  affected. 

Directing  our  attention  to  the  spinal  cord,  in  which  are  found  the  most 
manifest  changes,  we  find  that,  at  times,  even  when  inclosed  in  the  mem- 
branes, its  smallness  and  thinness  are  noticeable,  while  through  the  pia  we 
may  see  the  posterior  columns  distinctly  as  a  gray  band  throughout  the 
length  of  the  cord.  The  pia  is,  howe^ver,  commonly  thickened  and  opaque, 
especially  on  the  posterior  surface,  sometimes  more  firmly  adherent  than  is 
natural,  while  the  blood-vessels  also  show  signs  of  arterial  sclerosis.  The 
contraction  of  the  posterior  columns  is  more  conspicuous  on  section.  They 
are  flattened  instead  of  convex,  while  the  gray  translucent  appearance  of 


928 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


the  posterior  column  is  also  evident,  being  due  to  the  fact  that  the  nerve- 
fibers  have  been  substituted  by  neuroglia  tissue.  Hence,  also,  the  name 
"  gray  degeneration."  In  the  cord  hardened  in  Miiller's  fluid  the  difference 
in  hue  is  even  more  striking  than  in  the  fresh  state.  The  posterior  cornua 
and  the  posterior  nerve-roots  are  small  and  gray. 

On  minute  examination,  in  transverse  sections  stained  by  carmine  or 
other  staining  fluid,  the  affected  areas  are  more  conspicuous,  because  of  the 
deeper  staining  of  the  sclerosed  tissue,  while  all  parts  of  the  posterior  col- 
umns are  not  equally  affected.  In  the  lumbar  cord,  which,  with  the  lower 
thoracic  region,  is  usually  the  most  frequently  and  seriously  involved,  the 
change  affects  chiefly  the  middle  and  posterior  parts  of  the  columns,  while 


_  c         b    c 

Fig.  io6. — Thoracic  Region,  ii  d,  degenerated  posterior  roots,  c  c,  degenerated  pos- 
terior columns,  d  b,  degenerated  columns  of  Clarke,  a,  small  group  of  normal 
fibers  from  one  or  more  posterior  roots,  lower  in  the  cord,  which  were  not  entirely- 
degenerated,     e,  normal  anterior  root — {after  Spiller). 


the  extreme  anterior  portion,  the  so-called  ventral  fields,  remains  intact. 
The  sclerosis  is  commonly  most  intense  in  the  part  adjacent  to  the  posterior 
cornua,  into  which  the  posterior  roots  enter,  also  near  the  surface  of  the 
cord.  Ascending  into  the  thoracic  cord,  the  intensity  of  the  disease  gradually 
diminishes  in  the  external  parts  of  the  posterior  columns,  and  increases  in 
their  median  portions.  It  presents  also  the  distribution  of  an  ascending 
degeneration,  which  in  fact  it  is,  receding  from  the  commissure  in  the 
upper  cervical  region. 

In  the  cervical  cord  the  columns  of  Goll  are  chiefly  affected,  sometimes 
with  the  fibers  in  the  root  zones — that  is,  those  portions  of  the  columns  of 
Burdach  in  which  fibers  enter  directly  from  the  posterior  nerve-roots,  and 
from  which  fibers  may  be  traced  further  into  the  gray  matter  of  the  posterior 


TABES  DORSALIS. 


929 


cornua;  but  two  anterolateral  areas  in  the  columns  of  Burdach  remain  free 
from  disease,  at  least  for  a  long  time. 

Figure  108  shows  how  the  beginnings  of  the  disease  are  localized  in  the 
posterior  columns.  It  is  in  consequence  of  involvement  of  the  posterior 
roots  that  the  corresponding  posterior  cornua  into  which  they  enter  are  also 
affected.  The  same  is  true  of  the  meduUated  Hhers  of  Clarke's  columns 
(Fig.  106),  which  are  also  direct  processes  of  the  posterior  roots,  while  the 
cells  of  the  columns  remain  normal.  Lissauer's  tract,  a  narrow  strip  at  the 
periphery  of  the  posterior  cornu,  is  early  involved. 

In  advanced  cases,  in  the  larger  peripheral  nerve  trunks,  such  as  the 
sciatic,  and  in  the  finer  branches  of  the  sensory  nerves,  many  degenerated 
fibers  can  be  recognized.  Some  of  these  atrophies  may  be  secondary,  but 
modern  clinicians  are  disposed  to  regard  the  peripheral  degenerations  of 
tabes  as  independent  and  primary,  especially  since,  in  addition  to  these, 
decided  degenerative  processes  sometimes   occur  in   the   trunks  of   certain 


Fig.  107. — Cervical  Region.    The  degeneration  of  the  posterior  columns  is  now  nearly 
limited  to  the  columns  of  GoU,  e  e.     b,  normal  fibers  from  roots  lower  in  the  cord 
which  were  not  entirely  degenerated — {after  Spill er'). 
Figures  105,  106  and  107,  from  an  advanced  case  of  tabes. 


cranial  nerves,  such  as  the  optic  and  oculomotor,  and  more  rarely  the  vagus 
and  auditory.  They  will  be  referred  to  in  treating  the  diseases  of  special 
nerves. 

Finally,  there  are  even  cerebral  changes  of  various  kinds.  While  the 
spinal  ganglia  on  the  posterior  roots  have  been  found  invaded  in  a  few  cases 
only,  it  is  the  disposition  of  some  observers  to  place  the  initial  changes  of 
the  morbid  process  constituting  tabes  dorsalis  in  these  ganglia,  and  thence 
the  fibers  ascending  into  the  posterior  columns.  Thus  considered,  tabes 
dorsalis  would  be  a  general  disorder  of  the  central  and  peripheral  nervous 
system,  but  limited  mainly  to  sensory  tracts  though  motor  ganglia  and 
nerves  do  not  altogether  escape. 

Symptoms. — The  characteristic  symptoms  of  tabes  are  easily  divisible 
into  three  sets :  motor,  sensory,  and  reflex.     In  addition  to  these  there  are 

59 


930 


DISEASES  OF  THE  NERVOUS  SYSTEAI. 


others  not  essential,  but  striking,  including  modifications  of  special  sense 
and  certain  visceral  symptoms  characterized  by  pain  and  known  as  "  crises."' 
The  special  sense  modifications  include  especially  that  of  vision,  while  of 
"  crises  "  the  gastric  is  most  striking. 

The  motor  phenomena  are  usually  the  most  prominent,  whence  the  dis- 
ease takes  the  name  of  locomotor  ataxia,  but  this  symptom  may  be  absent 


Fig.  io8. — Lumbar  Region.     ^  h,  posteromedian  root  zones  (Flechsig)  only  slightly- 
degenerated,     i  j ,  middle  root  zones  (Flechsig)  degenerated,     g,  normal  ventral 
fields.     This  section  represents  the  earlier  lesions  of  tabes. 
Figure    108  should  be  compared  with  Figure  105 — {after  Spiller). 


for  years,  and  hence  the  inappropriateness  of  the  term.  The  dis- 
tinctive symptom  is  a  loss  of  co-ordinating  pozver  in  the  legs,  having  its 
simplest  illustration  in  the  unsteady  gait  of  a  drunken  man.  It  is  intensi- 
fied when  the  patient  attempts  to  walk  with  his  eyes  closed — that  is,  when 
the  guiding  sense  is  removed,  and,  indeed,  in  its  early  development  does 
not  appear  except  when  the  eyes  are  closed.  It  is  usually  unacco'>npanied 
by  a  loss  of  pozver  or  muscular  zmsting,  but  the  latter  may  be  extreme. 
On  the  other  hand,  inco-ordination  is  by  no  means  alzvays  the  earliest 
symptom  and  it  may,  indeed,  never  be  developed,  while  there  is  usually  a 
preataxic  stage  in  most  cases  of  tabes.  The  inco-ordination  may  be  shown 
sometimes,  before  otherwise  evident,  by  directing  the  patient  to  place  the 
heels  and  toes  together  and  then  to  close  the  eyes,  when  a  swaying  appears,  as 
though  the  patient  were  going  to  fall — Romberg's  symptom,  or  "  tabetic 


TABES  DORSALIS.  931 

swaying."*  In  health  a  sHght  unsteadiness  under  these  circumstances  is 
present,  which  varies  in  different  persons.  Higher  degrees  develop  the 
"  sway  "  even  when  the  eyes  are  open.  The  symptom  often  exists  for  a  long 
time  before  being  recognized  by  the  patient,  but  is  sometimes  discovered 
quite  early  through  an  accidental  production  of  the  favoring  conditions. 
Soon  the  peculiar  gait  is  noticeable.  The  foot  is  thrust  forward  too  far, 
and  brought  down  suddenly,  with  the  heel  first  on  the  ground,  with  a  stamp. 
This  is  the  typical  tabetic  or  "  heel  "  gait.  The  patient  cannot  walk  in  a 
straight  line,  and  the  staggering  becomes  worse  when  the  eyes  are  closed, 
because  the  power  of  orientation  through  vision  is  lost.  The  movements 
of  the  lower  limbs  are  excessive  and  unnecessary.  Ultimately,  he  can  walk 
only  with  the  aid  of  a  cane  or  by  keeping  the  eyes  fixed  upon  the  floor. 
He  rises  from  the  sitting  posture  with  difficulty,  often  after  three  or  four 
efforts.  The  loss  of  co-ordinating  power  may  also  be  shown  in  the  recum- 
bent posture  when  the  patient  attempts  to  touch  the  knee  with  his  heel, 
when  he  will  carry  it  around  and  in  front  and  behind  without  accomplishing 
his  purpose.  The  tabetic  gait  is  not  confined  to  tabes,  but  may  occur  in 
disseminated  sclerosis  and  cerebellar  disease.  In  the  latter  closure  of  the 
eyes  may  not  increase  the  ataxia  of  the  gait. 

Iiico-ordinaiion  also  develops  in  the  hands,  but  much  more  rarely,  and 
late  in  the  disease,  though  it  may  appear  in  them  first.  It  is  shown  in 
connection  with  more  delicate  acts,  such  as  picking  up  a  pin,  buttoning,  and 
writing.  It  may  be  demonstrated  also  by  asking  the  patient  to  bring  the 
ends  of  two  of  his  fingers  together  with  his  eyes  closed,  or  to  touch  the 
end  of  his  nose  with  one,  which  he  may  not  be  able  to  do.  With  all  this 
ataxia  the  muscular  potver  remains  intact.  The  patient  lying  in  bed  can  kick 
out  with  great  force,  and  resist  successfully  any  effort  to  flex  the  extended 
leg,  while  the  grip  of  the  hand  is  strong. 

The  sensory  symptoms  are  less  distinctive,  especially  at  first.  The  most 
frequent  of  these — indeed,  among  the  most  frequent  of  all  symptoms — are 
pains  of  a  darting,  shooting,  or  stabbing  character,  whence  they  are  called 
lightning-pains.  They  are  said  to  occur  in  nine-tenths  of  all  cases.  They 
resemble  closely  those  of  neuralgia,  lasting  but  a  second  or  two.  They  are 
most  common  in  the  legs,  and  are  often  accompanied  by  burning  or  tingling, 
especially  in  the  feet.  They  may  be  felt  in  the  trunk,  arms,  and  even  in  the 
head.  Commonly  they  do  not  correspond  with  nerves  or  affect  joints. 
They  are  often  considered  by  the  patient  as  rheumatic  pains.  A  sensation 
of  cold  is  felt,  also  a  feeling  as  though  the  limb  were  immersed  in  cold 
water.  The  pains  are  induced  by  fatigue  or  excesses  or  by  temporary  ill 
health  from  other  causes,  and  are  apt  to  come  on  at  night.  They  may  last 
hours  or  a  day  or  two.  There  may  be  areas  of  hyperesthesia  and  anes- 
thesia. A  very  curious  sensation  is  felt  in  the  soles  of  the  feet  when  walk- 
ing, a  feeling  as  though  soft  carpet  or  cotton  were  interposed  between 
them  and  the  floor.  A  painful  sense  of  constriction  about  the  limb  or 
waist  or  around  the  entire  trunk — girdle  pains — is  regarded  as  char- 
acteristic. 

There  are  other  disturbances  of  sensation,  such  as  retardation  of  tactile 
sensation,  wher'ein  the  prick  of  a  pin,, instead  of  being  instantaneously  felt, 
is  delayed  for  several  seconds.     Another  sensory  symptom  is  difficulty  in 

*  This  symptom  is  classed  bv  Striimpell  among  those  of  impaired  sensibility  in  the  soles  of  the 
feet  and  the  muscles,  whence  follows  defective  control  of  muscular  movements  necessary  to  equili- 
brium. 


932  DISEASES  OF  THE  NERVOUS  SYSTEM. 

locilization,  manifested,  for  example,  in  referring  a  pin-prick  to  the  right 
foot  when  it  is  made  in  the  left, — allochiria, — or  it  may  be  felt  in  both  feet 
— polyesthesia.  In  advanced  stages  the  muscular  sense  is  also  impaired, 
and  the  patient  is  unable  to  indicate  correctly  the  position  of  a  limb.  There 
may  be  other  perversions  of  sensibility.  The  sense  of  pain  may  be  lost  or 
perverted;  also  the  temperature  sense — that,  too,  without  derangement  of 
the  pain-sense  or  common  sensibility.  All  varieties  of  sensation  may  be 
lost  in  the  most  diverse  parts  of  the  body  and  most  irregularly. 

Visceral  pains,  known  as  tabetic  crises,  among  which  the  gastric  is  the 
most  common,  are  also  among  the  sensory  phenomena.  They  may  be 
laryngeal,  rectal,  nephritic,  urethral,  and  are  sometimes  exceedingly  severe. 
The  gastric  crises  are  sometimes  accompanied  by  vomiting  of  strongly  acid 
gastric  secretion.  On  the  other  hand,  the  vomited  matters  may  be  alkaline, 
the  result  of  a  reflux  of  the  intestinal  contents  into  the  stomach.  Xor  are 
gastric  crises  limited  to  tabes.  They  may  occur  in  other  cerebrospinal 
disease,  including  general  paralysis,  sclerose  en  plaques,  and  subacute  or 
chronic  central  myelitis.  The  laryngeal  crises  may  be  associated  wuth 
spasm  and  dyspnea,  with  noisy  breathing.  Death  is  a  possible  termination 
from  this  cause.  Rectal  crises  consist  in  paroxysmal  pain  and  tenesmus, 
with  a  sensation  as  of  a  foreign  body  in  the  rectum. - 

The  reflex  symptoms  consist  in  impairment  in  reflexes,  both  tendon  and 
cutaneous.  The  loss  of  the  knee-jerk  is  one  of  the  most  frequent  and  early 
of  these,  occurring  sometimes  years  before  ataxia  appears.  Of  itself  it  is  not 
diagnostic,  as  it  may  be  absent  in  healthy  persons,  but  in  association  with 
lightning  pains  and  ocular  symptoms  it  is  almost  conclusive  evidence  of 
the  disease.  In  by  far  the  greater  number  of  tabetics — at  least  70  per 
cent. — the  patellar  reflex  is  wanting,  with  or  without  the  Argyll  Robertson 
pupil.  The  skin  reflexes  fail  pari  passu  with  the  loss  of  tactile  sensibility. 
and  it  is  doubtful  whether  they  are  ever  present  without  this.  The  plantar 
skin  reflex  is  that  most  frequently  impaired,  and  after  this  are  successively 
involved  the  gluteal,  cremasteric,  and  abdominal.  It  happens  rarely  that 
in  the  early  stages  of  the  disease  the  skin  reflex  is  increased,  sometimes 
considerably,  but  even  then  the  knee-jerk  is  absent  or  diminished. 

Of  the  remaining  symptoms  the  ocular  are  the  most  important.  They 
include  ptosis  of  one  or  both  eyelids,  producing  a  very  striking  appearance. 
It  may  be  unaccompanied  or  associated  with  external  strabismus  and  double 
vision.  Rarely  there  may  be  paralysis  of  all  the  external  muscles  of  the  eye, 
producing  ophthalmoplegia  externa.  The  most  remarkable  eye  symptom 
is.  however,  the  Argyll  Robertson  pupil,  in  which  ther'e  is  loss  of  reflex  con- 
traction of  the  iris  in  response  to  light,  while  the  contraction  in  accommo- 
dation remains.  According  to  Gowers,  the  loss  of  this  reflex  occurs  in  five- 
sixths  of  all  cases.  The  contraction  in  accommodation  is,  however,  not 
always  maintained.  \^ery  rarely  the  reverse  of  the  Argyll  Robertson  pupil 
exists.  Wendell  Reber  has  made  a  clinical  study  of  the  correlation  between 
the  iris  and  patellar  tendon  reflexes,  and  finds  that  in  non-specific  cases  of 
tabes  they  are  both  involved  in  70  per  cent.,  and  in  the  specific  cases  in  yy  per 
cent.  He  holds  that  the  co-involvement  of  these  distant  reflexes  is  evidence 
in  favor  of  the  view  held  by  Sachs.  Trevelyan.  and  Hirt.  that  tabes  is  a  sec- 
ondan,-  degenerative  process  in  which  the  entire  nervous  system  takes  part, 
and  of  Nageotte  that  the  three  separate  clinical  pictures  of  general  paresis. 
tabes,  and  cerebrospinal  syphilis  are  only  the  result  of  the  preponderance 
of  the  inflammatory  process  in  different  localities,  the  nature  of  the  process 


TABES  DORSALIS. 


933 


being  essentially  the  same,  the  initial  change  being  vascular  starvation." 
Often  the  dilatation  of  the  pupil  which  takes  place  in  health  when  the  skin  of 
the  neck  is  pinched  cannot  be  produced  and  coincident  with  this  is  often 
unnatural  smallness  of  the  pupil — spinal  miosis. 

Finally,  there  is  sometimes  atrophy  of  the  optic  nerve,  producing  the 
amaurotic  form.  When  it  occurs,  it  is  often  an  early  symptom,  usually  com- 
mencing before  inco-ordination ;  and,  what  is  more  singular,  the  ataxia  often 
does  not  supervene — that  is,  there  seems  to  be  a  tendency  for  the  spinal 
malady  to  become  stationary  when  the  optic  nerve  is  affected  early.  The 
failure  of  vision  usually  begins  with  peripheral  limitation  and  progresses 
slowly  to  total  blindness,  sometimes  to  a  considerable  extent  before  the 
patient  notices  it.  Occasionally  it  ceases,  and  there  may  even  be  slight 
impairment.     Hemianopsia  may  occur  from  disease  at  the  optic  chiasm. 

Deafness  may  be  present  from  disease  of  the  auditory  nerve;  also, 
more  rarely,  anosmia,  from  atrophy  of  the  olfactory  nerve.  Attacks  of 
vertigo  are  common  in  these  cases.  Abnormalities  in  function  of  other 
cranial  nerves  may  be  due  to  similar  involvement.  Among  these  may  be 
mentioned  pain  at  one  time  and  anesthesia  at  another  in  the  area  of  the 
fifth  nerve ;  also  unilateral  atrophy  of  the  tongue. 

There  may  be  delayed  micturition  from  weakness  of  the  detrusor  muscle 
of  the  bladder,  or  incontinence  from  paralysis  of  its  sphincter,  with  partial 
evacuation  of  the  bladder,  and  resulting  cystitis.  The  anal  sphincter  is  less 
frequently  affected. 

Vasomotor  and  trophic  phenomena  also  occur,  and  may  be  predominat- 
ing symptoms.  They  include  local  sweating  of  the  palms  and  soles,  or  of 
half  the  head,  edema,  skin  ecchymoses,  herpes,  and  modified  haif  growth, 
loss  of  pigment  from  hair  and  skin,  thickening  of  the  epidermis  of  the  sole, 
succeeded  by  blisters  under  it.  Alteration  in  the  nails,  and  onychia  with 
ulceration,  may  be  present ;  also  decay  of  the  teeth  and  the  so-called  per- 
forating ulcer  of  the  foot,  which  is  almost  peculiar  to  this  disease.  Only 
late  in  the  disease  may  atrophy  of  muscles,  sometimes  associated  with  neuritis 
or  involvement  of  the  anterior  cornua,  occur.  Paroxymai  diarrhea  occurs, 
and  has  been  regarded  as  vasomotor  in  origin. 

The  so-called  arthropathies  are  an  interesting  trophic  symptom  and 
are  directly  the  result  of  the  disease.  The  most  common  is  that  known  as 
Charcot's  joint,  anatomically  similar  to  chronic  affections  in  which  the  dis- 
ease begins  in  the  bone  as  contrasted  with  the  synovial  membrane,  resulting 
in  atrophy  and  in  the  destruction  of  bone  and  cartilage,  while  brittleness  of 
bones,  attended  with  spontaneous  fracture  or  luxation,  may  occur.  If  union 
takes  place,  there  is  a  superabundance  of  callus,  with  ossification  or  calcifi- 
cation of  adjacent  structures  and  of  any  newly  for'med  inflammatory  tissue. 
The  large  joints  are  those  commonly  affected  and  are  painless  when  the  seat 
of  arthropathy.  There  may  be  effusion  and  even  pus  in  the  joints.  The 
arthropathies  may  even  occur  in  the  preataxic  stage.  They  may  be  excited 
by  injury.  The  joints  may  also  become  greatly  relaxed,  while  changes  in  the 
tarsal  bones  and  articulations  may  cause  the  foot  to  become  flat,  with  pro- 
jection backward  or  inward  of  the  tarsometatarsal  articulations  and  of  the 
tarsal  bones,  producing  the  "  tabetic  club-foot." 

Cerebral  symptoms  also  occur,  but  are  rare,  and  may  resemble  those  of 

*  Reber's  paper,  published  in  the  "  Annals  of  Ophthalmoloary  and  Otolog-y,"  vol.  v.  No.  3,  July, 
i8g6,  showed  also  that  in  non-specific  cases  the  patellar  reflex  alone  was  involved  in  23_p_er  cent.,  the 
iris  alone  in  77  per  cent.;  in  specific  cases,  the  patellar  reflex  alone  in  7  per  cent.,  and  iris  alone  in  16 
per  cent. 


934  DISEASES  OF  THE  NERVOUS  SYSTEM. 

dementia  paralytica.  It  is  not  always  easy  to  decide  whether  the  dementia 
or  the  tabes  is  primary.  The  final  stage  of  the  disease,  in  which  the  patient 
is  bed-ridden,  is  known  as  the  paralytic  stage. 

Diagnosis. — The  diagnosis,  commonly  easy  when  the  characteristic 
symptoms  are  developed,  may  demand  critical  judgment  in  the  early  stage. 
The  combined  presence  of  lightning  pains,  absence  of  knee-jerk,  early  ocular 
palsies,  including  the  Argyll  Robertson  pupil,  ptosis  or  squint,  and  ataxia 
are  conclusive.  Lightning  pains  and  ocular  palsies  should  always  stimulate 
to  thorough  examination.  The  same  is  true  of  severe  attacks  of  gastralgia 
in  middle-aged  men. 

Differential  Diagnosis. — Disease  of  the  vertebral  column  with  resulting 
compression  of  the  spinal  nerves  is  also  associated  with  lancinating  pain  and 
absence  of  the  patellar  reflex,  but  the  later  symptoms  ar'e  widely  different. 
The  same  is  true  of  deep-seated  tumors  impinging  on  the  spmal  cord. 

Peripheral  alcoholic  neuritis  and  arsenical  neuritis  also  may  be  asso- 
ciated with  diminished  knee-jerk,  a  pseudotabetic  gait,  and  sharp  pains,  but 
the  gait  differs  from  the  true  tabetic  gait,  the  leg  being  lifted  high  in  order 
that  the  toes  may  clear  the  floor.  The  pain  also  follows  the  course  of  the 
nerves,  which  are  tender  on  pressure,  and  there  is  none  of  the  shooting 
character.  Nor  is  there  reflex  immobility  of  the  pupils,  and  seldom  bladder 
disturbance,  while  atrophic  paralysis,  always  absent  in  tabes,  also  develops. 
Multiple  sclerosis  in  rare  instances  presents  similar  symptoms,  but  defective 
speech,  nystagmus,  mental  weakness,  and  ultimate  apoplectiform  seizures 
serve  to  distinguish  it.  In  diphtheritic  palsy  and  ocular  palsies  there  is 
absence  of  knee-jerk,  but  the  history  of  the  case,  the  throat  palsy,  and  all 
absence  of  pain  are  distinctive.  Ataxic  paraplegia  also  displays  ataxia,  but 
here  again  eye  symptoms  and  pain  are  absent.  In  cerebellar  disease  there  is 
also  loss  of  co-ordination,  and  the  knee-jerk  may  be  absent,  there  may  be 
headache,  optic  neuritis,  and  vomiting,  but  no  lightning  pains  or  sensory 
disturbance.  Occasionally  neuritis  may  present  a  clinical  picture  closely 
resembling  tabes,  known  as  peripheral  pseudotabes.  The  rapidity  of 
development,  the  absence  of  the  Argyll  Robertson  sign,  and  of  implication 
of  the  bladder,  and  in  some  cases  recovery,  are  the  most  important  dif- 
ferential features. 

General  paresis  and  tabes  sometimes  merge,  the  latter  developing  on 
the  former,  and  the  former  on  the  latter  toward  the  end.  Rapidly  devel- 
oped ataxia  with  mental  symptoms  often  resolves  itself  into  general  paresi^;. 
Yet  acute  involvement  of  the  posterior  columns  may  be  possible,  producing 
ataxia.  v 

Finally,  there  is  the  nicotin  tabes  of  Striimpell,  w^ho  has  twice  met,  in 
men  long  working  in  tobacco  factories,  a  set  of  symptoms  consisting  in  pain- 
ful sensation,  absence  of  patellar  reflex,  contracted  pupil,  wuth  reflex  immo- 
bility and  uncertain  gait,  differing,  however,  from  tabes  in  the  presence  of 
tremor  and  marked  increase  in  the  skin  reflexes,  especially  in  the  lower 
extremities. 

Course  and  Prognosis. — It  is  generally  conceded  that  no  case  of 
thoroughly  developed  tabes  has  ever  recovered.  The  disease  may,  however, 
be  arrested.  This  happens  especially  if  optic  nerve  atrophy  has  set  in  early, 
after  which  ataxia  rarely  develops  further,  while  the  other  svmptoms  sub- 
side. In  most  cases  of  the  disease,  however,  the  advance  is  slow  but  irre- 
sistible. The  duration  of  the  first  stage,  characterized  by  absence  of  knee- 
jerk,  and  by  the  presence  of  the  Arg}^ll  Robertson  pupil  and  of  lancinating 


TABES  DORSALIS.  935 

pains,  lasts  from  a  few  months  to  twenty  years.  The  second  stage, — that  of 
ataxia, — from  which,  indeed,  the  patient  often  dates  the  disease  if  the  initial 
.symptoms  were  slight,  may  then  supervene  gradually  or  suddenly.  Finally, 
the  paralytic  stage  supervenes,  to  be  soon  followed  by  death.  Tabes  is 
believed  by  some  to  assume  a  mild  type  more  commonly  now  than  was  the 
case  twenty  or  twenty-five  years  ago. 

Treatment. — While  recovery  from  tabes  dorsalis  probably  never  occurs, 
much  may  be  accomplished  by  treatment  in  arresting  progress  and  relieving 
symptoms.  There  is  no  specific  treatment,  although  this  effect  has  been 
claimed  for  more  than  one  remedy.  Nitrate  of  silver,  first  recommended 
by  Wunderlich,  has  probably  had  most  reputation,  but  has  latterly  fallen 
into  comparative  disuse,  and  coincidently  the  number  of  cases  of  chronic 
argyria  has  diminished.  The  dose  administered  is  from  1-6  to  1-4  grain 
(o.oii  to  0.0165  gm.)  three  times  a  day.  A  proper  question  is  as  to  the  length 
of  time  the  remedy  may  be  used  without  danger  of  producing  this  unfortu- 
nate result.  Professor  E.  Harnock  asserts  that  in  no  recorded  case  of 
argyria  were  less  than  450  grains  (30  gm.)  of  the  salt  taken  before  the  dis- 
coloration appeared.  To  consume  this  much  in  1-4-grain  doses  three  times  a 
day  would  take  six  hundred  days.  If,  therefore,  it  is  given  in  the  usual  doses 
for  a  month  and  then  suspended  for  one  week,  as  commonly  directed,  it 
does  not  seem  possible  that  unpleasant  effect  can  result.  In  this  manner, 
then,  it  may  be  kept  up  indefinitely ;  or  it  may  be  alternated  with  arsenic, 
of  which  last  Gowers  at  least  says  that  it  does  distinct  good  more  frequently 
than  any  other  remedy.  The  favorite  preparation  in  this  country  is  Fowler's 
solution,  of  which  five  minims  (0.3  c.  c.)  are  given  three  times  a  day  for  an 
adult.  The  edema  beneath  the  eyes,  which  results  from  its  accumulated 
effect,  is  a  sign  that  the  dose  should  be  reduced  or  the  drug  temporarily  sus- 
pended. Arsenious  acid  in  doses  of  from  1-30  to  1-20  grain  (0.0022  to 
0-0033  gm.)  or  sodium  arsenite  in  doses  of  from  1-30  to  i-io  grain  (0.002 
to  0.006  gm.)  may  be  substituted.  Sometimes  a  smaller  dose  only  is  borne. 
Gowers  has  also  found  the  chlorid  of  aluminium  useful  in  doses  of  from  two 
to  four  grains  (0.132  to  0.264  gm.)  three  or  four  times  a  day.  More  recently 
it  has  been  recommended  in  doses  of  five  to  ten  grains  three  or  four  times 
a  day. 

The  supposed  frequent  causal  relation  between  syphilis  and  tabes 
renders  the  antisyphilitic  treatment  appropriate  in  all  cases  in  which  such 
relation  can  be  traced.  To  this  end  mercurials  are  to  be  administered  until 
the  specific  effect  is  produced.  This  is  best  accomplished  by  inunction,  a 
dram  to  a  dram  and  a  half  being  rubbed  into  the  armpit  or  inner  surface 
of  the  thigh  daily,  to  be  discontinued  when  the  gums  are  affected.  After 
this  the  hichlorid  may  be  given  in  doses  of  1-24  grain  (0.0027  ^^•)  three 
times  a  day,  in  association  with  the  iodid  of  potassium  in  ascending  doses 
if  well  borne,  or  the  biniodid  of  mercury  may  be  given  in  doses  of  1-24  grain 
(0.027  gm.)  three  times  a  day.  If  this  treatment  is  found  effectual,  the 
iodid  should  be  continued  in  the  minimum  doses,  which  will  keep  up  the 
effect.  Calabar  bean  in  doses  of  from  i-io  to  1-5  grain  (0.0064  to  0.0128 
gm.)  three  times  a  day  and  the  fluid  extract  of  ergot  in  doses  of  from  five  to 
thirty  minims  (0.3  to  1.6  c.  c.)  or  more,  are  recommended,  but  the  results  have 
not  been  such  as  to  give  them  a  permanent  reputation.  Iodid  of  potassium 
may  be  tried  apart  from  the  indications  of  syphilis.  The  rest  treatment, 
originally  suggested  by  Weir  Mitchell,  has  been  found  useful  in  arresting 
the  disease,  but   I  do  not  know  that  it  has  been  followed  by  permanent 


536  DISEASES  OF  THE  NERVOUS  SYSTEM. 

results.  Extension  of  the  spina!  column  and  presumably  of  the  cord  by 
suspension  of  the  body  for  from  one  to  three  minutes  daily  was  used  for  a 
time,  among  others  by  Mitchell,  but  it  has  been  discontinued,  perhaps  too 
soon,  for  instances  of  undoubted  improvement  have  been  reported  under  its 
use :  vide  one  reported  by  Charles  S.  Potts  in  the  "  University  Aledical  Alaga- 
zine  "  for  September,  1891,  and  several  by  De  Forest  Willard  and  Guy  Hins- 
dale in  the  "  :\Iedical  News,"  November  24.  1894. 

In  Germany  electricity  is  still  a  popular  remedy,  and  failure  with  it  in 
this  country  may  be  due  to  imperfect  and  too  brief  trial.  Erb's  directions 
for  galvanism  are  to  place  a  moderate-sized  anode  in  the  vicinity  of  the  sym- 
pathetic in  the  neck,  and  a  large  kathode  on  the  side  of  the  vertebral  column 
for  four  or  five  minutes,  moving  it  at  intervals  from  above  downward. 
Severe  pain  and  vesical  weakness  are  treated  by  galvanization  and  the 
faradic  brush.  The  latter,  as  recommended  by  Rumpf,  should  be  brushed 
over  the  skin  of  the  back  and  extremities  for  five  or  ten  minutes,  using  a 
strong  current.  Counterirritation  by  blisters  is  of  no  use,  although  simple 
rubefacients  may  relieve  slight  degrees  of  pain. 

Hydrotherapy  likewise  maintains  its  popularity  in  Germany,  although 
claimed  by  some  authorities  to  be  sometimes  harmful,  especially  in  the  shape 
of  hot  baths  and  vapor  baths  and  wet  packs.  The  tepid  hath  is  entirely  safe 
and  often  symptomatically  useful.  Its  temperature  should  be  from  80°  to 
90°  F.  (26.6°  to  32.1°  C.),  accompanied  by  gentle  rubbing.  Wet  compresses 
upon  the  abdomen  or  legs  at  night  sometimes  relieve  the  pains.  In  Germany, 
too,  there  are  numerous  water-cure  establishments  in  the  hands  of  experi- 
enced directors,  to  which  patients  may  be  advantageously  sent,  but,  unfor- 
tunately, there  is  nothing  of  the  kind  in  this  country  which  can  be  recom- 
mended. Oeynhausen-Rehme  in  ]\Iinden  has  the  best  reputation  for  its 
carbonic  acid  thermal  salt  baths,  but  the  baths  at  Nauheim  in  Hess  are 
shnilar.  Mud  and  iron  baths  are  found  at  Pyrmont,  near  Brunswick ;  Dri- 
burg,  in  Westphalia,  Prussia ;  Elster,  pleasantly  situated  in  Saxony ;  Karls- 
bad, Marienbad,  and  Frazenbad,  in  Bohemia. 

The  painful  attacks  are  often  not  relieved  by  the  measures  thus  far  sug- 
gested, and  require  more  powerful  treatment.  The  first  to  be  used  should  be 
phenacetin,  ocetanilid,  exalgin,  salophin,  aspirin,  and  antipyriii,  while  mor- 
phin  should  be  deferred  as  long  as  possible.  It  may,  however,  be  necessary, 
when  it  should  be  used  hypodermically.  Cocain  used  in  the  same  manner  in 
doses  of  from  1-6  to  1-4  grain  (o.oii  to  0.165  gm.)  is  also  sometimes  effi- 
cient, while  cannabis  indica  in  doses  of  1-4  to  1-2  grain  (0.0165  to  0.033  g^'^'^-) 
of  the  extract  may  also  be  tried.  Bandaging  with  a  broad  flannel  bandage 
from  toes  to  thighs  has  been  recommended  for  the  sciatic  pain  and  pressure 
for  the  relief  of  painful  spots.  Massive  doses  of  strychnin  have  been  sug- 
gested for  the  same  purpose. 

Fatigue  of  all  kinds  as  well  as  anxiety  of  mind  should  be  avoided,  while 
moderate  exercise  may  be  encouraged.  Excesses  in  smoking,  and  espe- 
cially in  the  use  of  alcohol,  are  harmful,  as  is  also  sexual  indulgence.  Over- 
eating and  the  use  of  indigestible  articles  of  food  should  be  avoided,  as  gas- 
tric crises  are  invited  by  them. 

Great  benefit  has  been  claimed  for  the  so-called  Frankel  movements. 
They  are  "  based  upon  the  education  of  the  central  nervous  system  by  means 
of  repeated  exercises,  whereby  it  is  enabled  to  receive  sufficiently  distant 
stimuli  from  the  limbs  as  to  their  position  and  so  on,  although  the  available 
quantity  of  sensation  is  rather  small.     It  is  necessary,  of  course,  that  the 


HEREDITARY  ATAXIA.  937 

movements  be  attempted  and  carried  out  repeatedly  and  with  great  atten- 
tion." They  are  too  complex  to  be  repeated  here,  and  the  student  is  referred 
to  Frankel's  book.* 


HEREDITARY  ATAXIA. 

Synonyms. — Hereditary  Ataxic  Paraplegia;  Friedreich's  Disease. 

DefinitiotL — A  disease  whose  clinical  features  are  especially  ataxia  and 
paraplegia,  occurring  in  families  and  at  an  age  much  earlier  than  ordinary 
tabes,  from  which  it  differs  also  in  the  addition  of  peculiar  symptoms  asso- 
ciated anatomically  with  lesions  in  the  posterior  and  lateral  columns. 

Historical. — Friedreich  reported  in  1861  six  cases  of  this  disease  and  a  further 
number  in  1870,  whence  the  association  of  his  name  with  it,  but  as  the  name  Fried- 
reich's disease  is  also  applied  to  paramyoclonus  multiplex,  confusion  results.  On 
the  other  hand,  the  term  hereditary  ataxia  is  scarcely  correct,  because  while  some- 
times it  is  hereditary  and  even  congenital,  it  is  not  always  so.  It  usually  occurs  in 
families,  several  brothers  and  sisters  being,  as  a  rule,  affected.  Yet  isolated  cases 
occur.  In  one  case  of  William  Osier's  three  generations  were  involved.  A  neurotic 
tendency  is  sometimes  noticed.  Alcoholism  and  syphilis  were  present  in  parents  in  a 
few  instances,  consanguinity  of  parents  in  a  very  few  only. 

Etiology. — Its  etiology  is  unknown.  It  is  more  common  in  males  than 
in  females,  affecting  86  males  and  57  females  out  of  143  cases  collected  by 
J.  P.  C.  Griffith.  Striimpell  makes  the  opposite  statement  as  to  sexes,  but 
other  observers  agree  with  Griffith.  Of  Griffith's  cases,  15  occurred  before 
the  age  of  two,  39  before  the  age  of  six,  45  between  six  and  ten,  20  between 
eleven  and  fifteen,  18  between  sixteen  and  twenty,  and  6  between  twenty  and 
twenty-four. 

Morbid  Anatomy. — There  is  decided  degeneration  of  the  posterior  and 
lateral  columns,  and  the  degeneration  in  the  posterior  columns  may  extend 
throughout  the  cord,  leaving  a  narrow  band  of  normal  tissue  near  the  pos- 
terior cornua.  Different  opinions  are  held  in  regard  to  the  condition  of  the 
posterior  roots.  The  degeneration  of  the  lateral  columns  involves  the  area 
of  the  pyramidal  tracts,  but  it  is  disputed  whether  the  pyramidal  fibers  are 
actually  diseased.  The  degeneration  is  found  also  in  the  direct  cerebellar 
and  Gowers'  tracts  as  well  as  in  the  column  of  Clarke.  As  yet  no  changes 
have  been  found  in  the  cells  of  the  posterior  horns.  The  pia  mater  over  the 
posterior  columns  is  sometimes  thickened. 

The  disease  seemis  to  consist  of  a  double  morbid  process,  consisting  in 
early  degeneration  of  nerve  elements,  associated  with  a  tendency  to  over- 
growth of  interstitial  or  neuroglia  tissue.  According  to  Dejerine  and 
Letulle,  it  is  a  gliosis  of  the  posterior  and  lateral  columns,  due  possibly  to 
defect  in  development. 

Symptoms. — The  essential  symptoms  are  ataxia  ivith  paraplegia. 
Initial  pains  are  rare.  The  ataxia  is,  however,  peculiar.  As  in  tabes,  it  be- 
gins in  the  legs,  but  it  is  swaying  and  irregular,  more  like  that  of  drunken- 
ness. The  feet  are  not  often  raised  too  high,  and  while  there  is  stamping, 
as  in  true  tabes,  it  is  less  marked.  Tabetic  swaying — Romberg's  symptom — 
may  or  may  not  be  present.  The  ataxia  of  the  arms  occurs  early  and  is 
striking,  the  movements  being  choreiform,  jerky,  irregular,  and  swaying. 
The  hand  first  moves  an  object  in  its  efforts  to  secure  it  and  then  pounces 

*"  The  Treatment   of  Tabetic  Ataxia  by  means  of  Systematic  Exercise,"  Freyberger's  Trans- 
lation, Philadelphia,  1902. 


938  DISEASES  OF  THE  NERVOUS  SYSTEM. 

upon  it.  There  seems  to  be  a  superabundance  of  effort  in  voluntary  move- 
ments, action  is  overdone,  and  prehension  is  claw-Hke.  Again,  the  fingers 
may  be  spread  out  or  overextended.  The  first  manifestation  of  the  disease 
in  children  is  often  a  tendency  to  fall. 

As  the  disease  advances,  irregular,  jerky  movements  aft'ect  the  head  and 
shoulders,  sometimes  tremor-like.  In  most  cases  there  is  nystagmus  when 
the  eyes  are  moved  laterally  or  upward,  usually  a  late,  sometimes  an  early, 
symptom.  Atrophy  of  the  optic  nerve  is  rare,  and  the  pupils  are  normal. 
Speech  is  sometimes  impaired,  generally  as  a  late  symptom — three,  five,  or 
ten  years  after  the  initial  symptoms.  Syllables  are  elided, — the  speech  is 
scanning, — with  occasional  movements  of  the  tongue,  but  no  twitching  of 
the  lips. 

The  paresis  is  at  first  slight, — indeed,  the  power  of  the  muscles  is  at 
first  unimpaired, — while  there  is  rarely  ever  total  paralysis.  Some  patients, 
however,  never  walk.  The  nutrition  of  the  muscles  is  good.  The  knee-jerk 
generally  disappears  early,  or  is  at  least  absent  when  the  cases  come  under 
observation.  In  a  few  this  symptom  appears  late,  while  in  some  atypical 
cases  this  reflex  has  been  reported  increased.  Sensory  symptoms  are  not 
usually  conspicuous.  There  may  be  none,  even  in  bad  cases.  At  times 
there  is  delayed  sensation  or  impaired  sensibility  to  pain  and  temperature. 
Increased  sensitiveness  may  be  present.     No  visceral  crises  occur. 

While  trophic  lesions  of  the  usual  kind  are  rare,  there  occur  peculiar 
deformities,  especially  of  the  feet.  There  is  talipes  equinus  or  equinovarus, 
and  the  patient  walks  on  the  outer  edge  of  the  foot.  The  great  toe  is  over- 
extended or  dorsally  flexed,  and  occasionally  this  is  the  first  sign  of  the  dis- 
ease.    There  may  be  lateral  curvature  of  the  spine. 

Diagnosis. — This  is  not  difiicult,  although  sometimes  the  disease  is  con- 
founded with  chorea,  with  the  hereditary  form  of  which  it  has  certain  points 
in  common.  The  ataxia  in  early  life,  the  club-foot,  overextended  great  toe, 
spinal  curvature,  lost  knee-jerks,  nystagmus,  and  scanning  speech  form  a 
complex  of  symptoms  not  found  in  any  other  disease. 

It  resembles  ataxic  paraplegia  in  more  than  its  symptomatology,  but 
the  increased  knee-jerk,  foot  clonus,  and  spasm  of  the  latter  disease  are  want- 
ing. In  cases  of  combined  lateral  sclerosis  and  posterior  sclerosis  in  which 
the  knee-jerk  is  absent  the  family  history  and  youth  of  the  subject  can  alone 
settle  the  question.  The  loss  of  iris  reflex  in  children  points  to  tabes,  the 
result  of  inherited  syphilis.  Disseminated  sclerosis  presents  inco-ordination, 
nystagmus,  and  defective  articulation,  but  the  knee-jerks  are  almost  always 
exaggerated,  and  intention  tremor  is  characteristic. 

Prognosis. — This  is  invariably  bad,  so  far  as  recovery  is  concerned, 
although  the  disease  lasts  many  years. 

Treatment. — There  is  no  treatment  except  such  as  will  overcome  tend- 
ency to  deformity.     The  remedies  used  in  locomotor  ataxia  may  be  tried. 

Cerebellar  Hereditary  Ataxia  has  been  described  by  Marie,  Sanger- 
Brown,  Klippel,  and  Durante.  It  starts  after  twenty  years  of  age.  There 
are  ataxia,  disordered  speech,  nystagmus,  and  heredity,  but  the  knee-jerks 
are  normal  or  exaggerated,  there  is  Argyll  Robertson  pupil,  optic  nerve 
atrophy  with  limitation  of  the  field  of  vision,  while  there  is  no  scoliosis  or 
club-foot.  The  opposite  is  true  of  hereditary  ataxia.  Many  do  not  recog- 
nize the  cerebellar  hereditary  ataxia  as  a  distinct  symptom-complex. 

Progressive  Interstitial  Hypertrophic  Neuritis  of  Childhood  is 
also  a  family  disease.     The  symptoms  are  a  combination  of  those  of  tabes 


ATAXIC  PARAPLEGIA.  939 

■dorsalis  with  those  of  neurotic  muscular  atrophy  (peroneal  type  of  pro- 
gressive atrophy).  There  are  hypertrophy  and  hardening  of  peripheral 
nerves.     It  was  first  described  by  Dejerine  and  Sotas. 

Toxic  Sclerosis,  especially  of  the  posterior  and  lateral  columns,  results 
from  such  diseases  as  pellagra,  ergotism,  and  pernicious  anemia 

ATAXIC  PARAPLEGIA. 

Synonyms. — Combined  Sclerosis;   Progressive  Spastic   Paraplegia;   Com- 
bined Lateral  and  Posterior  Sclerosis. 

Definition. — A  chronic  disease  of  the  spinal  cord,  characterized  by 
symptoms  which  point  tO'  lesions  of  both  lateral  and  posterior  sclerosis, 
including,  therefore,  both  spastic  and  ataxic  features,  the  symptoms  of  one 
lesion  being  more  or  less  modified  by  the  other. 

Etiology. — This  is  obscure.  It  is  more  common  in  males,  is  a  disease 
of  adult  life  in  which  overexertion,  exposure,  spinal  traumatism,  and  sexual 
excess  each  have  been  antecedent  events.  Less  frequently  than  tabes  does 
it  follow  in  the  wake  of  the  syphilitic  taint.  It  is  always  associated  with 
general  paralysis  of  the  insane.  Hereditation  has  been  observed  in  one- 
tenth  of  the  cases,  and  the  neurotic  constitution  seems  to  favor  it.  It  is 
probably  most  frequently  associated  with  anemia. 

Morbid  Anatomy. — As  the  name  suggests,  lesions  are  found  in  both 
posterior  and  lateral  columns.  In  the  posterior  columns  they  resemble  those 
of  uncomplicated  tabes  dorsalis,  and  are  most  intense  in  the  cervical  and 
thoracic  portions  of  the  cord,  variously  distributed,  sometimes  equally,  at 
others  preponderating  in  one  or  the  other.  The  changes  in  the  posterior  root 
zones  are  less  pronounced  than  in  true  tabes.  In  the  lateral  columns  the 
crossed  pyramidal  tracts  and  in  the  anterior  columns  the  direct  pyramidal 
tracts  are  chiefly  involved,  though  the  mixed  zones  of  the  lateral  columns, 
the  lateral  limiting  layers,  and  the  direct  cerebellar  tracts  may  also  be 
invaded.  The  gr'ay  matter  and  membranes  remain  intact.  In  most  cases 
the  lesions  are  diffuse  and  the  apparent  systemic  degeneration  is  usually 
the  result  of  secondary  degeneration. 

Symptoms. — The  symptoms  are  slow  in  their  development,  though  occa- 
sionally a  more  rapid  course  is  pursued,  the  only  modification  in  this  being 
that  occasionally  months  instead  of  years  are  sufficient  to  develop  the 
distinctive  features.  Those  of  either  lesion  may  predominate  at  first.  More 
usually  those  of  ataxia  are  the  first  to  appear,  including  fatigue  and  even 
pain  after  comparatively  slight  exertion,  unsteadiness  of  gait,  increased  with 
the  eyes  closed,  though  an  associated  stiffness,  may  prevent  the  typical  gait 
of  tabes.  There  is  also  more  or  less  paresis.  There  may  be  dull  pain  or 
numbness  in  the  lower  extremities  and  in  the  back  or  sacral  region,  but  the 
lightning  pains  of  tabes  are  rarely  present ;  nor  is  the  girdle  sensation,  while 
visceral  crises  very  rarely  occur.  The  Argyll  Robertson  pupil  is,  also,  com- 
monly absent,  but  nystagmus  is  not  infrequent.  The  most  striking  dift'erence 
in  the  symptomatology  of  ataxic  paraplegia,  as  contrasted  with  true  tabes, 
is  the  presence  of  exaggerated  reflex,es  in  the  former,  including  knee-jerk 
and  ankle  clonus.  Simple  tapping  of  the  patella  or  the  belly  of  the  quadri- 
ceps extensor  brings  out  the  former.  The  upper  extremities  are  also  often 
involved,  and  the  chief  symptoms  here  are  weakness,  inco-ordination  with 
exaggerated  wrist-  and  elbow- jerks. 


940  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Sensibility  is  also  diminished  in  combined  sclerosis,  but  less  so  than  in 
pure  tabes.  Electrical  reactions  are  unaltered,  at  least  in  the  early  stages  of 
the  disease.  With  advance  of  the  disease  the  features  of  a  purely  lateral 
sclerosis  become  very  pronounced ;  those  of  tabes  less  so.  Muscular  paresis 
and  rigidity  become  marked,  and  the  patient  is  unable  to  leave  his  bed. 
There  is  no  localized  atrophy  of  the  muscles,  although  general  wasting  is 
not  uncommon  in  the  late  stages  of  the  disease.  Very  rarely  there  may  be 
atrophy  of  the  optic  nerve,  the  ocular  muscles  remaining  intact.  The 
sphincters  of  the  bladder  and  rectum  are  sometimes  involved ;  at  others  not, 
those  of  the  bladder  more  frequently,  producing  difficult  micturition.  On 
the  other  hand,  by  rest  and  tonic  treatment  the  spastic  symptoms  may  be 
diminished,  while  ataxia  remains  unchanged  and  the  symptoms  of  this  con- 
dition become  more  pronounced.     The  mind  remains  normal. 

Diagnosis. — This  is  usually  easy,  enough  of  the  symptoms  of  each 
lesion  being  present  to  show  the  existence  of  a  combined  disorder.  The 
absence  of  co-ordination  on  the  one  hand  and  increase  of  knee-jerk  on  the 
other  are  the  two  antipodal  symptoms  around  which  others  of  each  lesion 
cluster.  Then,  as  to  differential  diagnosis,  myelitis  may  present  similar 
symptoms.  On  the  other  hand,  myelitis  is  usually  a  disease  of  sudden  devel- 
opment, characterized  by  a  rapid  increase  of  symptoms  as  contrasted  with 
the  slower  course  of  the  disease  under  consideration.  Friedreich's  ataxia 
resembles  ataxic  paraplegia  closely  in  its  pathology,  but  the  exaggeration  of 
the  tendon  reflexes  and  the  spasticity  are  absent  in  the  former.  Cerebellar 
tumor  may  be  mentioned  with  better  reason  as  a  disease  which  may  be  con- 
founded, but  in  this  disease  headache,  optic  neuritis,  and  vomiting  are 
peculiar,  and  while  there  is  ataxic  gait,  it  is  the  reel  of  a  drunken  man,  and 
not  the  inco-ordination  of  tabes.  So,  too,  there  may  be  spastic  symptoms  in 
cerebellar  disease,  but  they  are  less  decided  than  in  combined  sclerosis.  Dis- 
seminated sclerosis  is  a  disease  with  which  combined  sclerosis  may  be  con- 
founded, and  although  it  is  the  less  pronounced  forms  of  each  which  give 
rise  to  doubt,  it  is  important  to  remember  that  the  former  has  been  found 
postmortem  in  cases  which  presented  the  clinical  symptoms  of  spastic  para- 
plegia during  life.  Whence  it  is  not  impossible  that  it  may  also  present  in 
its  earlier  stages  symptoms  of  ataxic  paraplegia. 

Prognosis. — This  is  unfavorable  as  to  recovery,  but  the  disease  is  so 
slow  in  its  development  that  death  commonly  results  from  intercurrent  dis- 
ease or  from  complications  favored  by  the  disease  itself,  such  as  diseases  of 
the  urinary  organs,  bed-sores,  and  septic  complications.  It  does  happen  also 
that  the  disease  is  arrested  for^  time. 

Treatment. — The  treatment  is  mainly  symptomatic :  warm  baths  and 
a  warm  climate  for  the  spastic  symptoms ;  massage  and  exercise  for  the 
ataxic  symptoms.  Electricity  and  spinal  stimulants  like  strychnin  are  con- 
tra-indicated as  calculated  to  increase  the  spastic  symptoms,  while  bromids 
and  belladonna  may  be  of  service  in  controlling  these.  If  a  specific  history 
can  be  traced,  the  disease  should  be  appropriately  treated  by  iodids  or  mer- 
curials, and  when  anemia  is  present  the  treatment  should  be  directed  to  the 
improvement  of  this  condition. 


SYRINGOMYELIA.  941 


SYRINGOMYELIA. 

Definition. — A  term  applied  to  all  cavities  in  the  spinal  cord,  most  of 
which  are  surrounded  by  an  overgrowth  of  neuroglia. 

Etiology  and  Morbid  Anatomy. — The  cavities  are  formed  by  defective 
closure  of  the  central  spinal  canal  or  by  the  breaking  down  of  residual 
embryonal  tissue  or  of  gliomatous  tissue.  The  cavity  of  a  syringomeylia  is 
usually  in  the  posterior  part  of  the  cord,  extending  toward  the  posterior 
cornua.  It  may  prevail  throughout  the  entire  extent  of  the  cord,  but  in 
most  cases  involves  only  the  cervical  or  thoracic  regions  or  more  limited 
areas.  The  transverse  section  is  oval  or  circular,  but  it  may  be  fissure-like 
or  quadrilateral,  even  irregular.  On  the  other  hand,  a  primary  hemorrhage 
of  traumatic  origin,  or  even  without  trauma,  may  be  the  starting-point  of  a 
syringomyelia,  and  it  has  been  supposed  that  such  a  hemorrhage  into  the 
spinal  cord,  occurring  at  birth  from  difficult  labor,  may  later  in  life  cause 
the  symptoms  of  syringomyelia.  So,  also,  compression  of  the  cord  due  to 
fracture  or  dislocation  may  furnish  the  condition  which  will  result  in  dilata- 
tion of  the  cervical  canal  of  the  cord.  The  cavities  may  be  multiple.  The 
term  hydromyelia,  applied  to  the  forms  in  which  the  cavity  is  merely  the 
dilated  central  canal,  is  falling  into  disuse,  and  there  is  no  real  difference 
between  this  and  the  other  varieties.  It  is  probable  that  hydromyelia  may 
change  into  syringomyelia. 

Symptoms. — The  milder  degrees  are  without  symptoms  and  are  often 
overlooked.  Symptoms  usually  make  their  appearance  about  the  period  of 
adolescence.  They  are  mostly  gradual  in  development,  and  are  partly  the 
result  of  the  secondary  processes  of  distention  which  derange  natural 
function.  The  symptoms  are  influenced  also  by  the  situation  of  the  cavity, 
which  is  found  most  frequently  in  the  cervico-thoracic  region,  whence  the 
arms  and  neck  are  correspondingly  affected.  They  depend  also  on  the 
greater  involvement  of  the  gray  matter  of  the  cord. 

The  essential  symptoms  are  modified  sensibility;  chiefly  to  pain,  tem- 
terature,  and  to  a  less  degree  simple  touch ;  also  muscular  atrophy,  the 
latter  progressive  in  development;  and  trophic  disturb an^ces.  The  sensory 
symptoms  are  the  earlier  and  more  constant.  The  sense  of  tactile  im- 
pression is  lost  by  involvement  of  its  path,  which,  as  has  been  said,  is  not 
precisely  known  after  it  enters  the  posterior  roots,  though  it  is  possibly, 
partly  in  the  posterior  columns.  The  comparative  rarity  of  this  involve- 
ment may  be  said  to  be  due  to  the  difficulty  in  destroying  this  path  com- 
pletely. Derangement  of  the  sense  of  pain  and  thermal  sense  is  probably 
due  to  implication  of  the  central  gray  matter,  since  it  is  through  it  that  these 
impressions  probably  radiate  to  the  white  conducting  tracts  of  the  opposite 
side.  The  extension  of  the  process  to  the  lateral  columns  probably  explains 
the  derangement  of  these  senses  in  portions  of  the  body  below  the  level  of  the 
cavity  in  the  spinal  cord.  There  may  not  only  be  a  loss  of  thermal  sense, 
but  it  may  be  reversed  in  that  heat  is  felt  as  cold,  and  vice  versa.  So,  also, 
subjective  sensations  are  felt,  including  heat  and  cold,  or,  in  their  absence, 
pain,  which  mav  be  neuralgic  in  character  and  irregular. 

The  muscular  atrophy  is  the  result  of  injury  to  the  motor  cells  of  the 
anterior  cornua  from  compression  or  destruction  of  these  cells.  This 
causes  degeneration  of  the  nerves  and  wasting  of  the  muscles,  and  along 
with  it  is  a  lowered  electrical  irritability.     There  is  also  muscular  weak- 


942  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ness,  involving  the  trunk  muscles,  and  possibly  to  this  is  due  the  lateral  cur- 
vature. If  the  legs  are  affected,  it  is  generally  from  simple  spastic  paralysis 
from  pressure  on  the  pyramidal  tracts,  but  sensory  changes  in  the  lower 
limbs  occur.  Great  wasting  of  the  legs  indicates  lumbar  involvement,  and 
the  presence  of  ataxic  symptoms  points  to  involvement  oi  the  posterior 
columns.  The  remaining  symptoms  are  not  essential,  but  may  be  incidentally 
present  from  the  action  of  the  causes  which  usually  produce  them.  The 
reiiexes  may  or  may  not  be  increased,  and  myotatic  irritability  may  in  rare 
cases  be  lost,  while  tremor  of  the  limbs  has  been  noticed  in  some  cases. 

Trophic  symptoms  are  not  rare  in  the  parts  affected  by  sensory  loss. 
The  skin  may  be  glossy  and  thin,  or  thick  and  horny,  while  there  may  be 
eczema,  herpes,  bullae,  and  even  ulceration  and  gangrene.  The  nails  may 
become  fissured  and  drop  off.  There  may  be  deformity  and  absence  of  the 
end  phalanges  and  lingual  hematrophy.  Vasomotor  disturbances  are  more 
common,  including  coldness,  lividity,  or  redness  with  swelling  and  heat. 
There  may  be  sweating,  brittleness  of  bone,  and  joint  changes  like  those  of 
tabes. 

The  area  of  the  cranial  nerves  may  be  invaded  when  there  is  involve- 
ment of  the  medulla  oblongata.  The  phenomena  may  include  paralysis  of 
one  vocal  cord,  the  tongue  and  face,  difficulty  in  swallowing,  of  breathing, 
and  embarrassed  heart's  action.  The  eyes  may  be  disordered,  and  the  pupils 
unequal,  but  the  other  special  senses  escape. 

Diagnosis. — This  is  based  upon  the  sensory  S3aiiptoms,  and  of  these 
thermo-anesthesia  and  analgesia  rather  than  tactile  insensibility,  together 
with  muscular  atrophy  succeeding  after  some  interval.  Cervical  pachymen- 
ingitis causes  like  symptoms  similarly  distributed.  J.  Hendrie  Lloyd,  in 
an  important  paper,*  has  also  called  attention  to  certain  traumatic  affections 
of  the  cervical  region  of  the  cord  simulating  syringomyelia.  Cervical  pachy- 
meningitis runs  a  more  rapid  course;  the  anesthesia  includes  all  varieties 
of  sensation  and  corresponds  more  nearly  in  its  distribution  to  that  of  the 
muscular  atrophy,  pain  is  more  conspicuous,  and  the  reaction  of  degeneration 
is  commonly  present  in  the  wasting  muscles,  and  later,  signs  of  compression 
of  the  cord  are  observed. 

The  symptoms  of  syringomyelia  are  sometimes  simulated  by  the  anes- 
thesia and  wasting  of  anesthetic  leprosy,  but  in  the  latter  disease  the  trophic 
changes  are  more  marked,  the  phalanges  often  drop  off,  while  the  sensory 
symptoms  include  all  varieties  of  sensation. 

Progressive  muscular  atrophy  differs  in  the  absence  of  altered  sensation. 
An  intramedullary  spinal  tumour  in  the  same  situation  as  a  syringomyelia 
furnishes  almost  identical  symptoms,  and  may  have  an  identical  origin  if 
it  starts  from  the  neuroglia,  but  the  symptoms  may  be  more  rapid  in  their 
development. 

The  diagnosis  of  syringomyelia  is  sometimes  exceedingly  difficult  to 
make,  as  the  characteristic  disturbances  of  sensation  may  be  absent. 

Prognosis. — This  is  ultimately  fatal,  although  the  course  is  slow, 
extending  over  a  period  from  fifteen  to  twenty  years.  Toward  the  end  the 
course  is  more  rapid,  death  resulting  from  exhaustion  or  interference  with 
the  functions  of  the  medulla  oblongata. 

Treatment. — This  can  only  consist  in  measures  to  combat  symptoms 
and  tendencies  to  them,  such  as  cystitis,  bed-sores,  and  the  like. 

*  Read  before  the  Philadelphia  Neurological  Society,  March  26,  1894. 


COMPRESSION  OF  THE  SPINAL  CORD.  943 


Morvan's  Disease. 

Synonyms. — Analgia  Panaritium;  Analgesic  Paresis  with  Panaritium; 

Painless  Whitlows. 

Definition. — This  term  is  applied  to  a  chronic  affection  described  in 
1883  by  a  Breton  physician  named  Morvan,  which  is  characterized  by  neu- 
ralgic pains,  tactile  and  thermal  anesthesia,  analgesia,  and  painless 
destructive  felons  (paronychia).  The  disease  is  probably  in  most  cases  the 
same  as  syringomyelia;  in  some  instances  it  is  leprosy.  Twenty  cases  were 
recognized  in  a  population  of  50,000  in  Brittany.  One  or  two  cases  have 
been  reported  in  America. 

Zambuco,  of  Constantinople,  found  in  the  broken-down  matter  of  the 
syringomyelic  cavity  of  what  seemed  a  typical  case,  Hansen's  lepra  bacillus. 
In  two  well-studied  cases  reported  by  Marinesco  and  Jeanselme  to  the 
Societe  Medicale  des  Hopitaux  de  Paris,  February  12,  1897,  the  typical 
lesions  were  found,  but  no  bacilli. 


COMPRESSION    OF    THE    SPINAL    CORD. 

Synonyms. — Compression  Myelitis;  Pressure  Paralysis  of  the  Spinal  Cord. 

Definition. — Under  this  head  are  included  all  forms  of  paralysis  due 
to  gradual  compression  of  the  cord  from  whatever  cause. 

Etiology. — A  large  number  of  causes  may  operate  in  the  way  indi- 
cated, among  which  are  tumors  or  inflammatory  new  formations,  including 
syphilitic  products  either  in  the  membranes  or  outside  of  them,  caries  of  the 
vertebrae,  especially  the  form  known  as  Pott's  disease  or  tuberculosis  of 
the  vertebrae,  cancer  of  the  vertebrae,  echinococci  and  cysticerci  in  the  ver- 
tebral canal.  Extraspinal  causes  may  also  produce  erosion  of  the  vertebrae 
and  compression  of  the  cord ;  among  these  are  aneurysm  of  the  aorta,, 
retroperitoneal  sarcoma,  lymphadenoid  growths,  and  suppurating  kidney; 
also  retropharyngeal  abscess.  Pott's  disease  is  by  far  the  most  frequent 
cause. 

Morbid  Anatomy. — The  changes  in  the  cord  as  the  result  of  com- 
pression are  best  studied  in  the  compressions  due  to  dislocation  of  the  ver- 
tebrae in  the  breaking  down  of  the  bodies  of  one  or  more  from  tubercular 
infiltration,  or  as  the  result  of  intrusion  into  the  spinal  canal  of  foci  of 
cheesy  pus  from  the  posterior  surface  of  the  bodies  of  the  vertebrae.  Macro- 
scopically,  the  cord  is  often  smaller,  softer,  and  sometimes  bent.  In  old 
cases  it  may  be  harder.  The  term  myelitis  has  been  applied  to  the  changes 
thus  produced  in  the  cord,  but  careful  examination  fails  in  some  cases  to  find 
any  of  the  usual  histological  products  of  inflammation.  In  the  early  stages 
the  axis-cylinders  are  swollen,  and  fatty  granular  cells  may  be  present.  The 
nerve-cells  suffer  more  or  less  alteration  depending  on  the  degree  of 
pressure.  At  a  later  stage  may  be  seen  a  secondar}^  overgrowth  of  neu- 
roglia, replacing  the  destroyed  nervous  tissue,  first  loose,  later  firm  and 
fibrillated.  After  a  certain  duration  there  may  be  ascending  and  descending 
secondary  degeneration  of  certain  systems  of  fibers  in  the  spinal  cord. 

Symptoms. — When  tubercular  disease  of  the  spine  is  the  cause,  the 
resulting  deformity — kyphosis — is  usually  seen  long  before  the  symptoms 


944  DISEASES  OF  THE  NERVOUS  SYSTEM. 

of  compression  of  the  cord  are  present.  On  the  other  hand,  when  the 
erosion  is  due  to  aneurysm  or  growths  within  the  thorax  or  abdomen,  the 
subjective  symptoms  appear  before  the  deformity,  or  more  frequently  with- 
out external  deformity.  The  first  of  these  symptoms  is  usually  pain  at  the 
seat  of  the  compression,  which  often  does  not  amount  to  more  than  a  dull 
ache,  w^hile  at  another  time  it  is  extremely  severe.  It  is  also  aggravated 
by  bending  or  straightening  the  body.  Again,  the  pain  is  distributed  along 
the  course  of  the  nerves,  when  the  compression  is  exerted  on  the  nerve- 
roots.  Previous  to  such  pain  and  associated  with  it  are  paresthesias  of 
various  kinds,  such  as  numbness,  tingling,  and  formication.  More  rarely 
there  is  impaired  sensibility,  the  same  degree  of  pressure  which  deranges  the 
function  of  motor  fibers  having  often  no  effect  on  the  sensory.  Marked 
anesthesia  is  rare,  and  then  only  in  the  last  stages. 

With  the  foregoing  soon  become  associated  motor  symptoms,  which 
may  consist  in  stiffness,  giving  rise  to  difficulty  in  moving  arms  or  legs,  with 
peculiarity  of  gait,  or  there  may  be  simple  w^eakness  or  paresis,  increasing 
to  complete  motor  paralysis.  These  symptoms  rarely  affect  both  arms  or 
legs  at  once,  but  rather  first  one  and  then  the  other. 

The  seat  of  the  more  pronounced  sensory  and  motor  symptoms  varies 
with  the  segment  compressed.  Thus,  when  the  caries  is  in  the  upper  cer- 
vical region,  between  the  axis  and  the  atlas,  or  between  the  latter  and  the 
occipital  bone,  there  may  be  spasm  of  the  cervical  muscles,  the  head  may 
be  fixed,  and  movements  may  either  be  impossible  or  extremely  painful. 
Retropharyngeal  abscess  may  be  the  cause  of  such  a  symptom,  as  in  a  case 
in  the  Montreal  General  Hospital  mentioned  by  Osier,  where  movement 
was  liable  to  be  followed  by  transient  instantaneous  paralysis  of  all  four 
extremities  from  the  compression  of  the  cord,  the  patient  dying  in  one  of 
the  attacks. 

If  in  the  lozver  cervical  region,  there  may  be  dilatation  of  the  pupils 
from  interference  with  the  ciliospinal  center  or  nerve-fibers  arising  in  this 
center.  There  may  be  flushing  of  the  face  and  ear  on  one  side  or  nnilateral 
szveating,  rigidity  of  the  muscles  of  the  neck,  while  the  sensory  and  motor 
symptoms  described,  if  present,  will  be  found  in  the  arms.  The  deformity 
of  tuberculous  caries  is  not  always  marked  in  this  locality,  but  after  recovery 
evidence  of  its  presence  may  be  found  in  a  conspicuous  callus,  which  may 
cause  permanent  rigidity  of  the  neck.  The  cortical  inhibitory  influence 
"being  suspended,  both  tendon  and  cutaneous  reflexes  are  increased,  some- 
times so  markedly  as  to  produce  in  the  lower  extremities  a  pronounced  type 
of  the  spastic  paralysis,  with^  increased  patellar  reflex  and  ankle  clonus. 
The  increase  of  the  skin  reflexes  is  less  marked  than  that  of  the  tendons. 

When  the  thoracic  and  lumbar  segments  are  involved,  only  the  lozver 
extremities  suffer  from  the  effect  of  compression ;  commonly  the  paresis  is 
late,  though  rarely  it  may  appear  before  the  deformity  of  Pott's  disease. 
When  the  lesion  is  confined  to  the  thoracic  region,  there  may  be  girdle  sen- 
sation and  pain  in  the  course  of  the  intercostal  nerves.  Here,  as  elsewhere, 
motion  is  affected  before  sensation.  As  to  the  reflexes,  since  the  reflex  arc 
for  the  lower  tendon  reflexes  is  in  the  lumbar  region,  compression  of  the 
thoracic  cord  should  produce  an  increase  in  them,  and  this  is  usually  the 
case.  On  the  other  hand,  they  are  diminished  when  the  lumbar  cord  is 
compressed.  If  the  lower  thoracic  and  lumbo-sacral  region  is  aft'ected,  the 
sphincters  are  apt  to  be  involved,  and  there  is,  first,  difficulty  in  micturition, 
then  retention,  and  finally  incontinence  with  cystitis,  but  the  sphincters  may 


COMPRESSION  OF  THE  SPINAL  CORD.  945 

also  be  involved  from  lesions  higher  in  the  cord.     Yet  all  these  symptoms 
may  disappear,  and  recovery  take  place  after  many  months'  duration  of  the 

disease. 

Trophic  symptoms  may  be  present  in  the  paralyzed  parts.  These  may 
include  herpetic  eruptions  in  the  course  of  the  nerves,  at  other  times  derange- 
ment of  nutrition,  manifested  by  bed-sores  forming  on  slight  irritative 
provocation,  rapid  shedding  of  the  epidermis,  and  brittleness  of  the  nails. 
With  the  involvement  of  their  trophic  center  the  muscles  may  waste. 

Diagnosis. — This  is  easy  when  there  are  evident  signs  of  caries  of  the 
spine,  manifested  by  prominence  of  spinous  processes  of  the  vertebrse  and 
by  tenderness  on  pressure.  Repeated  examination  of  the  spine  should  be 
made.  Nerve-root  symptoms,  or  symptoms  resulting  from  pressure  of  nerve- 
roots,  as  they  pass  out  between  the  vertebrse,  are  always  significant.  They 
include  radiating  pains,  girdle  sensation,  and  hyperesthesia  or  anesthesia, 
spasm  and  wasting.  Stiffness  on  motion  in  separate  parts  of  the  spinal 
column  is  also  significant.  Root  symptoms  are  said  to  be  more  common  in 
cancer  than  in  caries,  but  any  of  the  symptoms  named  have  increased 
diagnostic  value  if  there  has  been  cancer  elsewhere,  especially  of  the  breast, 
and  if  the  age  exceeds  forty.  There  is  much  more  pain  attending  the 
paraplegia  of  cancer — whence  the  term  paraplegia,  dolorosa,  and  when  the 
pain  is  referred  to  areas  anesthetic  to  tactile  and  painful  im^pressions, 
ancesthesia  dolorosa.  Such  is  the  case  whenever  erosion  is  wrought  from  the 
abdomen  outward,  as  by  retroperitoneal  growths  or  aneurysm. 

Prognosis, — This  is  unfavorable  in  all  cases  except  tuberculous  spon- 
dylitis, which  often  terminates  in  cure,  for,  sooner  or  later,  especially  with 
suitable  treatment,  the  tuberculous  process  may  cease  and  the  symptoms  of 
paralysis  disappear,  although,  of  course,  the  kyphosis  remains.  Some  cases 
perish  from  miliary  tuberculosis,  others  from  the  exhaustion  incident  to  bed- 
sores, cystitis^  and  pyelonephritis. 

Treatment. — Only  when  tuberculous  spondylitis  is  responsible  is  there 
hope  of  cure.  The  treatment  is  general,  by  the  usual  measures  found  useful 
in  tuberculosis,  such  as  cod-liver  oil  and  creasote  or  creasotol,  with  such 
tonics  as  iron  and  iodin,  good  food,  fresh  air,  and  mechanical  appliances 
suggested  by  the  orthopedic  surgeon.  These  should  be  so  adjusted  as  not 
to  produce  pain.  Their  object  is  to  produce  extension  and  thus  relieve  com- 
pression, and  if  this  is  not  accomplished,  they  are  useless.  The  method  of 
extension  by  suspension,  originally  suggested  by  the  late  Dr.  J.  K.  Mit- 
chell, and  more  recently  revived  by  Weir  ]\Iitchell  and  extensively  prac- 
ticed of  late  years,  has  again  fallen  into  comparative  disuse,  partly  because 
of  the  difficulties  in  carrying  it  out,  and  perhaps  because  there  have  been 
some  unfortunate  accidents.  Good  results  have,  however,  followed  its  use. 
Especiallv  may  such  results  be  hoped  for  if  the  extension  is  used  early, 
although  they  have  followed  even  after  paralysis  had  supervened. 

Along  with  the  extension,  rest  in  bed  is  a  most  important  measure, 
and  many  cases  are  arrested  by  such  rest.  Local  measures,  like  counter- 
irritation  and  the  hot  iron,  are  of  no  use — rather  harmful  than  otherwise. 
The  same  may  be  said  of  electrical  treatment  and  massage,  except  so  far 
as  they  are  useful  to  keep  up  the  nutrition  in  the  paralyzed  muscles.  On  the 
other  hand,  warm  bathing  is  useful  in  relieving  pain  and  allaying  dis- 
comfort. 

Operative   treatment — laminectomy — has   lately   been   practiced   with   a 
good  showing  of  result,  and  it  should  be  considered,  at  least,  after  other 
60 


946 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


measures  have  failed.  Treatment  should  be  persevered  in,  as  recovery 
takes  place  sometimes  after  paralysis  has  long  persisted,  and  in  no  form 
of  tuberculosis  has  the  general  treatment  previously  recommended  been  so 
useful. 

In  the  incurable  forms  anodynes  must  be  resorted  to  to  relieve  pain, 
including  even  the  hypodermic  use  of  morphin,  which  should  never  be 
used  without  bearing  in  mind  the  possibility  of  the  patient  acquiring  the 
morphin  habit. 


TUMORS    OF    THE    SPIXAL    CORD    AXD    ^lEMBRAXES. 

Both  the  memibranes  and  the  substance  of  the  cord  may  be  seats  of 
tumors,  while  the  cord  may  also  be  invaded  from  the  spinal  column  by 
enchondroma  or  sarcoma. 

Varieties. — From  the  spinal  column,  enchondroma,  sarcoma,  and  can- 
cer may  intrude  into  the  canal.  External  to  the  dura  mater  in  the  extra- 
dural space  occur  fatty  and  malignant  tumors,  while  parasites  are  also  found 
in  this  region.  The  extradural  tumors,  all  rare,  may  spring  from  the  dura 
or  from  the  tissue  between  it  and  the  bone,  or  may  arise  outside  and  pass 


Fig.  109. — Sarcoma  of  the  Lower  Cervical        Fig.    no. — Sarcoma    Compressing    the 
Cordi—{Ada}nkze2uzcs).  Cervical  Cord— (£".  Long  Fox). 


through  the  intervertebral  foramina.  Within  the  dura  are  found  myxomata, 
fibromata,  lipomata,  and  neuromata  on  the  nerve-roots.  Subdural  tumors 
may  arise  from  the  inner  surface  of  the  dura,  the  arachnoid,  or  from  the 
pia,  and  may  include  sarcomata,  syphilitic,  tuberculous,  and  parasitic 
growths.  The  last  two  are  rare,  but  both  echinococci  and  cysticerci  have 
been  met,  developing  in  the  meshes  of  the  arachnoid.  Schlesinger  collected 
forty-four  cases  of  ecchinococcus  disease.  When  the  parasite  is  intradural 
it  is  round  or  oval  and  compresses  the  cord.  The  dura  is  not  usually  impli- 
cated, merely  distended.     Of  the  forty-four  cases  onlv  five  were  intradural. 


TUMORS  OF  THE  SPINAL  CORD.  947 

so  that  the  extradural  location  is  seven  times  more  frequent  than  the  intra- 
dural. They  are  usually  on  the  posterior  surface  of  the  cord  and  in  the 
thoracic  portion  of  the  vertebral  canal,  at  least  in  the  extradural  variety. 
They  may  be  the  size  of  a  pea,  of  a  walnut,  or  even  larger.  Their  contents 
are  clear  and  they  often  contain  daughter  cysts.  Their  growth  is  usually 
slow.  It  is  said  that  the  hydatids  are  sometimes  found  in  the  substance  of 
the   bone. 

Fatty  tumors  are  also  rare,  but  have  been  found  and  are  probably  con- 
genital, because  they  were  usually  found  associated  with  spina  bifida.  In  the 
cord  itself  and  attached  to  the  pia  occur  tuberculous,  syphilitic,  and  glio- 
matous  tumors ;  sarcomata  and  myxomata  have  been  found.  Syphiloma 
and  sarcoma  are  the  most  common.  Most  of  these  tumors  spring  from  the 
pia  mater,  but  tuberculous  growths  also  develop  in  the  gray  matter.  Some 
tumors  are  compound,  as  myxosarcoma,  etc. 

The  size  attained  by  tumors  of  the  spinal  cord  and  membranes  is  neces- 
sarily limited  by  the  surrounding  space.  The  largest  do  not  exceed  two 
inches  (5  cm.)  in  diameter,  and  many  are  very  small,  not  larger  than  a  pea. 
They  are  usually  single,  rarely  multiple,  as  seen  in  the  instance  oi  neuromata, 
and  occasionally  sarcomata.  Tumors  developing  within  the  cord  may  lead 
to  syringomyelia. 

Symptoms. — These  vary  with  the  seat  of  the  tumor  and  the  degree 
of  pressure  exerted.  When  the  latter  increases  slowly,  the  growth .  may 
reach  quite  a  large  size  before  serious  mischief  is  done.  Pain  is  a  frequent 
and  conspicuous  symptom,  and  is  apt  to  be  maintained  by  pressure  on  nerve- 
roots  which  are  in  the  way  of  the  growth.  The  seat  of  pain  varies  with  the 
course  of  the  nerves  impinged  upon,  and  may  be  of  every  variety,  such  as 
"  burning,"  "  tearing,"  '*  stabbing,"  "  aching,"  "  girdle  sensations."  and  the 
like.  It  may  be  unilateral  or  bilateral,  and  is  worse,  according  to  Horsley, 
when  the  tumor  presses  forward.  Sometimes  the  pain  is  in  the  spine  itself, 
which  may  also  in  rare  instances  be  tender  to  pressure.  When  the  growth 
is  in  the  lower  lumbar  region,  the  pain  may  be  referred  to  the  soles  of  the 
feet,  and  may  ascend  from  this  seat.  In  other  cases  there  is  hyperesthesia 
of  the  skin,  which  may  be  associated  with  pain  felt  at  the  level  of  the  tumor, 
or  pain  may  be  felt  in  anesthetic  areas.  Very  rarely  pain  is  absent,  chiefly 
in  extradural  lipoma. 

Muscular  spasm  is  also  frequent,  especially  when  the  tumor  springs 
from  the  membranes,  when  it  may  be  very  decided.  There  may  be  rigidity 
at  the  seat  of  the  growth,  most  marked  when  the  disease  is  at  the  more 
mobile  parts  of  the  spine,  as  the  cervical  region.  Then  there  is  apt  to  be 
pain  in  the  vicinity,  increased  by  motion.  Spasm  in  the  abdominal  muscles 
may  also  be  associated  with  girdle  pains.  Contractures  may  arise  in  the 
limbs,  both  those  supplied  by  nerves  directly  irritated  by  the  tumor  and  by 
those  gi,ven  off  lower  down.  It  is  important  to  note  the  seat  of  the  rigidity 
and  its  character,  which  may  aid  us  in  diagnosing  the  seat  of  the  tumor, 
whether  it  is  on  the  nerve-roots  or  conducting  tract  of  the  cord.  Thus,  a 
tumor  in  one-half  of  the  cord,  in  the  cervical  region,  may  cause  persistent 
contraction  of  the  arm  and  leg  on  the  side  of  the  growth,  and  in  the  early 
stage  of  thoracic  tumors  one  leg  only, may  be  rigid  at  a  time  or  one  may 
be  more  so  than  the  other.  In  the  dorsal  region  the  level  of  the  pain  is  apt 
to  correspond  accurately  with  the  level  of  the  growth,  and  the  reflexes 
centering  at  this  level  may  be  lost,  but  retained  in  the  legs. 

Paralysis  occurs  sooner  or  later  as  constantly  as  pain,  increasing  grad- 


948  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ually  with  the  pressure.  Paraplegia  is  more  common,  but  all  four  limbs  may 
be  paralyzed  by  a  tumor  in  the  cervical  region,  one  limb  being  usually 
affected  before  the  other,  though  when  the  tumor  is  exactly  central,  both 
sides  are  affected  simultaneously.  Loss  of  sensation  follows  paralysis  sooner 
or  later.  It  corresponds  in  distribution  to  the  motor  palsy  when  the  tumor 
is  below  the  middle  of  the  dorsal  region,  but  if  higher  and  on  one  side,  the 
sensory  loss  may  be  greater  on  the  opposite  side;  especially  is  this  the  case 
when  the  tumor  is  within  the  cord,  when  the  symptoms  may  be  those  already 
described  under  the  head  of  Brown-Sequard's  paralysis. 

Atrophy  follows  involvement  of  the  anterior  cornua,  and  vasomotor  dis- 
turbances may  be  marked.  In  cases  of  prolonged  interruption  ascending 
and  descending  degenerations  may  occur.  Tumors  not  infrequently  cause 
subacute  or  acute  myelitis,  whose  symptoms  may  mask  the  clinical  picture. 

Diagnosis. — The  characteristic  symptoms  are  slow  development  of 
severe  and  constant  unilateral  root  symptoms,  later  bilateral,  at  the  level  of 
the  growth,  and  a  progressive  paralysis,  motor  and  sensory.  The  radiating 
pain  is  usually  at  the  level  of  the  tumor  or  below.  Pain  in  the  spine  itself  is 
an  important  sign.  Rigidity  of  the  muscles  of  the  spine,  muscular  contrac- 
tions in  the  limbs,  early  and  marked  exaggeration  of  reflex  action  when  the 
cord  itself  is  involved,  are  also  important  signs,  especially  when  associated 
with  the  history  of  syphilis  or  tuberculous  disease.  Caries  of  the  spine  may 
produce  the  same  symptoms,  but  the  radiating  pains  are  less  severe  and  the 
effects  of  compression  of  the  cord  are  more  likely  to  be  bilateral,  either  from 
the  first  or  soon  after  their  commencement.  Tenderness  of  the  spine  may 
generally  be  elicited  by  careful  examination,  while  irregularity  of  surface, 
from  the  breaking  down  of  the  bone,  sooner  or  later  makes  its  appearance. 
When  the  tumor  is  in  the  bone  itself,  the  symptoms  at  first  scarcely  dift'er 
from  those  of  caries,  though  the  pain  on  motion  is  usually  worse  in  the 
former. 

The  symptoms  of  cervical  meningitis  also  closely  resemble  those  of 
tumor.  They  are,  however,  usually  bilateral  from  the  first  and  have  con- 
siderable vertical  extent.  Central  tumors  covering  a  like  area  may  produce 
identical  symptoms.  Pain  and  muscular  atrophy  in  the  arms  without  wast- 
ing occur  in  both,  but  are  usually  less  severe  in  tumor,  while  the  early  and 
localized  impairment  of  all  forms  of  sensation  is  less. 

Chronic  transverse  myelitis  also  closely  simulates  tumor  in  its  radiating 
pain,  sense  of  constriction,  progressive  paralysis,  and  a  differential  diag- 
nosis is  sometimes  impossible.  The  symptoms  here,  too,  are  from  the  first 
bilateral,  while  the  radiating  pain  is  commonly  not  severe  in  myelitis,  which 
invades  also  larger  areas  of  the  cord. 

As  to  the  exact  seat  of  the  tumor,  in  general  terms  it  may  be  said  that 
when  ivithin  the  cord,  the  symptoms  are  those  of  a  gradually  increasing  para- 
plegia or  of  a  Brown-Sequard's  paralysis,  while  vasomotor  disturbances  are 
marked,  and  reflexes  are  bilaterally  influenced,  according  to  the  law 
explained.  Atrophy  means  involvement  of  the  ventral  cornua.  Acute  or 
subacute  myelitis  may  be  associated  and  complicate  the  clinical  picture. 
Tumors  in  the  membranes  are  characterized  by  early  "  root  symptoms," 
including  radiating  pains,  girdle  sensation,  and  hyperesthesia  or  anesthesia. 
Irritation  of  motor  nerves  may  cause  spasm  or  wasting,  with  paralysis  late 
in  the  disease. 

The  nature  of  the  tumor  may  be  inferred  only  from  the  history  of  the 
case,  syphilis  and  tuberculosis  giving  the  most  valuable  assistance.     Its  seat 


LESIONS  OF  THE  CAUDA  EQUINA.  949 

is  suggested  by  the  level  of  the  transverse  symptoms.  It  is  never  below 
these,  while  it  may  be  a  distance  of  three  or  four  vertebrae  above  the  nerves 
corresponding  to  the  highest  level  of  anesthesia  or  pain.  The  diagnosis  of 
tumor  from  other  transverse  lesions  of  the  cord  may  be  at  times  impossible. 

Prognosis. — Only  when  the  tumor  is  syphilitic  may  any  relief  be  ex- 
pected from  medical  treatment.  In  all  other  forms  the  symptoms  gradually 
increase  until  paralysis  results,  unless  operative  interference  produces  a 
more  favorable  termination — a  practice  which  modern  methods  are  rendering 
more  frequent  and  justifiable. 

Treatment. — When  there  is  reason  to  believe  syphilis  is  present,  the 
antisyphilitic  treatment  may  be  used  with  reasonable  expectation  of  success.. 
Beyond  this,  symptoms  must  be  met  as  they  arise.  Attempts  made  of  late 
years  to  formulate  the  laws  governing  surgical  operations  in  these  cases  have 
been  more  or  less  successful,  but  wider  experience  is  necessary  before  they 
can  be  thoroughly  relied  upon.  I  may,  however,  close  this  subject  wnth  the 
advice  of  Victor  Horsley,  whose  studies  on  surgery  of  the  nervous  system 
entitle  his  opinion  to  the  highest  respect :  "  If  it  is  clear  that  the  growth  is 
not  syphilitic,  and  that  no  good  can  be  done  by  other  treatment,  delay  in  an 
operation  can  only  cause  harm — can  only  result  in  a  less  favorable  state  for 
the  proceeding,  less  chance  of  recoverv',  longer  and  greater  suffering,  and 
should,  on  every  ground,  be  avoided." 


LESIONS  OF  THE  CAUDA  EQUINA  AND  CONUS 
MEDULLARIS. 

The  Cauda  equina  is  the  bundle  of  nerves  coming  oiif  from  the  lower 
cord  and  occup3"ing  the  spinal  canal  from  the  second  lumbar  vertebra  down- 
ward. At  this  vertebra  the  cord  itself  terminates  in  the  conns  medullaris, 
prolonged  into  the  thread-like  iilujn  terminale.  Fractures  and  dislocations 
in  the  lumbosacral  region  may  impinge  on  these  parts,  while  the  filaments  of 
the  nerves  of  the  cauda  equina  may  be  invaded  by  tumors  or  compressed  by 
cicatrices. 

Symptoms. —  Compression  of  the  conus  and  of  the  IcDst  sacral  nerves 
given  off  from  it,  such  as  may  be  caused  by  a  dislocation  of  the  first  lumba^- 
vertebra,  produces  paralysis  of  the  bladder  and  rectum  and  loss  of  sexual 
power,  whence  it  has  been  inferred  that  the  anovesical  center  and  the  center 
for  the  sexual  function  are  seated  in  this  part  of  the  cord.  This  paralysis 
may  be  the  only  symptom  or  it  may  be  associated  with  disturbance  of  sensa- 
tion about  the  anus  and  in  the  perineum  and  external  genital  organs  except 
the  testicle,  the  latter  being  supplied  with  sensation  from  a  higher  segment  d 
the  cord. 

When  the  lumbar  nerve-roots'^^  are  involved,  from  the  second  to  the 
fourth  inclusive,  there  is  paralysis  embracing  all  the  muscles  of  the  thigh  and 
leg  except  the  outer  rotators  of  the  thigh  the  flexors  of  the  knee  and  of  the 
ankles,  the  peroneal  muscles,  the  long  flexors  of  the  toes,  and  the  small  foot 
muscles.  There  is  also  loss  of  sensation  in  the  front,  inner,  and  outer  parts 
of  the  thighs  and  the  inner  side  of  the  I'eg  and  foot. 

Involvement  of  the  fifth  lumbar  and  first  and  second  sacral  produces 

*  Of  the  lumbar  nerves,  the  first  root  appears  between  the  first  and  second  lumbar  vertebra,  the 
fifth  between  the  last  lumbar  and  the  base  of  the  sacrum.  The  four  upper  sacral  nerves  pass  from 
the  spinal  canal  through  the  sacral  foramina,  the  fifth  between  the  sacrum  and  coccyx. 


950  DISEASES  OF  THE  NERVOUS  SYSTEM. 

paralysis  of  the  muscles  just  excepted,  and  loss  of  sensation  in  the  outer  and 
posterior  part  of  the  leg,  foot,  and  sole  of  the  foot.  Lesion  of  the  third, 
fourth,  and  fifth  sacral  and  coccygeal  nerves  causes  paralysis  of  the  perineal 
muscles,  the  bladder,  rectum,  and  of  the  external  genitals,  the  cocc}geus, 
with  loss  of  sensation  in  the  back  of  the  thigh,  anus,  perineum,  genital 
organs,  and  skin  about  the  anus  and  coccyx. 


SPINA  BIFIDA. 

Synonyms. — Split  Spine ;  Hydrorrachis;  Myelocele;  Meningocele. 

Definition. — A  name  applied  to  a  congenital  defect  in  the  closure  of  the 
spinal  canal,  through  which  protrudes  a  sac-like  portion  of  the  dura  contain- 
ing cerebrospinal  fluid,  at  times  a  part  of  the  cord,  either  normal  or  altered, 
and  forming  also,  as  a  rule,  an  external  prominence  of  tumor  covered  by 
skin. 

Description. — The  tumor  is  found  commonly  in  the  lumbar  and  sacral 
portions  of  the  spine,  rarely  in  more  than  one  place,  very  rarely  throughout 
the  whole  column.  Its  size  ranges  from  that  of  a  small  nut  to  that  of  an 
orange,  and  occasionally  it  is  so  large  as  to  interfere  with  the  birth  of  a  child 
afflicted  with  it.  On  section  of  the  skin  the  protruding  sac  of  the  dura  is 
seen  and  beneath  this  the  arachnoid.  Barely  is  the  dura  cleft  so  that  the  sac 
is  formed  by  the  arachnoid  only.  There  may  be  a  dilatation  of  the  central 
canal, — hydromyelia, — when  the  substance  of  the  cord  is  found  more  or  less 
atrophied,  while  the  central  canal  communicates  directly  with  the  cavity  of 
the  spina  bifida.  At  other  times  the  cord  is  normal,  while  its  lower  end  may 
be  adherent  to  the  sac.  A  tumor  of  similar  character  is  occasionally  seen 
protruding  through  the  skull. 

Symptoms. — At  first  there  are  usually  no  clinical  symptoms.  By  pres- 
sure the  contents  of  the  tumor  can  often  be  forced  into  the  spinal  canal,  caus- 
ing expansion  of  the  fontanels  and  increase  of  cerebral  pressure  with  its  con- 
sequences— viz.,  somnolence,  with  changes  in  the  pulse  and  breathing,  which 
may  be  fatal  if  the  pressure  is  continued.  The  absence  of  such  symptoms 
goes  to  show  that  communication  of  the  tumor  with  the  spinal  cord  is  cut 
ofif. 

With  the  lapse  of  time  the  tumor  usually  grows  slowly,  and  the  effects 
of  pressure  on  the  spinal  cord  or  cauda  equina  appear.  These  are  paralysis, 
atrophy,  anesthesia,  bed-sore^,  vesical  derangements,  talipes  varus,  and 
trophic  phenomena,  of  w^hich  perforating  ulcer  of  the  foot  is  one.  The  sac 
may  burst,  or  the  walls  become  inflamed,  converting  the  contents  into  pus. 

Prognosis  and  Treatment. — Unless  removed  by  surgical  interference, 
the  child  dies  sooner  or  later  of  exhaustion.  The  tumor  has  been  rarely 
obliterated  by  gradually  increasing  pressure  or  by  injecting  the  cavity,  after 
evacuation  of  the  fluid,  with  iodin,  producing  obliteration  through  an  inflam- 
matory process.  Other  surgical  measures  m^y  be  found  in  text-books  on 
surgery. 


PROGRESSIVE  BULBAR  PALSY, 


951 


PROGRESSIVE  BULBAR  PALSY. 

Synonyms. — Polioencephalitis  inferior  chronica;  Glossolahiolaryngeal  Par- 
alysis; Paralysis  of  the  Tongue,  the  Soft  Palate,  and  the  Lips;  Du- 
chenne's  Disease;  Atrophic  Bulbar  Paralysis. 

Definition. —  Bulbar  palsy  is  a  progressive  paralysis  invading  the  lips, 
the  tongue,  the  palate,  the  pharynx  and  larynx,  and  in  more  advanced  cases 
the  low^er  face  muscles,  due  to  lesion  of  the  motor  nuclei  in  the  medulla 
oblongata  (or  bulb),  whence  arise  the  nerves  distributed  to  those  parts. 

Historical. — Bulbar  palsy  was  first  completely  described  in  its  clinical  aspects  by 
Duchenne  in  i860,  but  the  exact  seat  of  the  disease  was  not  determined  until  1870, 
when  Charcot  in  France  and  E.  Leyden  in  Germany  confirmed  the  earlier  suggestion 
that  it  was  a  progressive  degeneration  and  atrophy  of  the  nuclei  in  the  medulla 
oblongata. 

Etiology. — Primary  progressive  bulbar  palsy  is  difficult  to  account  for. 
It  is  more  frequent  in  men,  and  sometimes  heredity  or  family  tendency  is 
noted.     It  has  been  ascribed  to  the  overuse  of  the  muscles  of  the  mouth,  as 


Fig.  III. — Situation  of  the  Cranial  Nerves — {after  Editiger). 
Cranial  nerve  nuclei,  oblongata,  and  pons  represented  as  transparent.     Motor  nuclei, 

black;  sensitive  nuclei,  red. 


in  the  blowing  of  wind-instruments ;  to  a  tumor  in  the  medulla  oblongata  or 
vicinity ;  while  syphilis,  to  which  so  many  of  the  unaccountable  lesions  of 
the  nervous  system  are  ascribed,  is  less  commonly  held  responsible  for  this 
affection  than  for  some  others.  Q>ld,  emotional  excitement,  and  extreme 
fatigue  have  all  been  named  as  causes.  Most  frequently,  however,  no  cause 
is  traceable. 

Morbid  Anatomy. — Most  writers  concede  that  the  lesion  starts  in  the 
nuclei  of  the  medulla  oblongata.  It  may  be  that  the  entire  motor  apparatus 
from  the  muscular  fiber  to  the  gangHonic  cell  is  invaded  simultaneously. 
Certain  it  is  that  bulbar  paralysis  is  often  associated  both  with  progressive 
spinal  muscular  atrophy  and  amyotrophic  lateral  sclerosis,  the  symptoms  now 
o£  one  and  now  of  the  other  preceding.  There  can  be  no  doubt  that  these 
three  conditions  are  closelv  allied.     The  nature  of  the  lesion  is  the  same  in 


952  DISEASES  OF  THE  NERVOUS  SYSTEM. 

each,  the  motor  cells  in  each  are  involved,  the  muscles  are  wasted  in  each, 
though  the  particular  ones  involved  vary  as  the  situation  of  the  motor  cells 
is  different. 

The  anatomical  lesion  is  an  atrophy  of  the  motor  cells  of  the  medulla 
oblongata.  The  nucleus  of  the  hypoglossus,  the  nucleus  of  the  pneumogas- 
tric,  to  a  less  degree,  that  of  the  facial  and  that  of  the  glossopharyngeal  are 
all  involved,  while  the  sensory  nuclei  are  intact.  Very  rarely  the  nuclei  of 
the  ocular  nerves,  third,  fourth,  and  sixth,  are  involved.  From  these  nuclei 
the  degeneration  extends  to  the  nerves  which  have  their  origin  in  them,  and 
thence  to  the  muscles  to  which  they  are  distributed. 

The  nature  of  the  degeneration  is  a  more  or  less  complete  destruction 
of  the  motor  cells.  In  addition,  there  is  an  overgrowth  of  neuroglia  tissue 
and  a  thickening  of  the  walls  of  the  blood-vessels.  The  nerve-fibers  of  the 
pyramidal  tract  may  undergo  degeneration. 

Symptoms. — The  symptoms  of  progressive  bulbar  paralysis  are  exceed- 
ingly gradual  in  their  development.  The  first  symptom  noticeable  is  usually 
a  diMculty  in  the  pronunciation  of  zvords  containing  letters  which  require 
the  use  of  the  tongue  in  their  formation,  such  as  E,  R,  L,  S,  G  (hard),  K, 
D,  T,  and  N.  Still  later  there  is  difficulty  in  pronunciation  of  words  requir- 
ing the  aid  of  the  lips,  as  P,  B,  F,  V,  O,  A  (long),  and  the  sound  of  O  in 
tool,  while  whispering  becomes  impossible. 

Concurrently  with  these  symptoms  the  tongue  and  lips  are  observed  to 
waste,  the  tongue  becomes  thinner  and  narrower,  the  lips  thin  and  com- 
pressed in  appearance,  the  loss  of  power  being  commensurate  with  the  degree 
of  wasting.  Fibrillar  tremors  are  usually  seen  in  the  tongue,  and  the 
mucous  membrane  may  be  thrown  into  transverse  folds.  Finally,  the 
tongue  cannot  be  protruded,  or  can  be  brought  only  to  the  edge  of  the  teeth, 
while  the  mouth  cannot  be  closed  because  of  complete  paralysis  of  the  orbicu- 
laris oris  muscle.  In  more  advanced  stages  other  muscles  of  the  face  become' 
involved,  the  labionasal  fold  is  less  distinct,  and  the  face  becomes  expres- 
sionless. 

Before  this  degree  has  been  attained,  however,  the  muscles  of  the 
palate  have  commenced  to  fail  in  their  action,  and  thus  a  further  difficulty 
in  the  articulation  of  words  is  added,  while  the  z'oice  is  nasal.  Fluid  begins 
to  pass  through  the  nose  when  swallowing  is  attempted.  The  difficulty  in 
swallowing  is  increased  by  growing  paralysis  of  the  pharyngeal  muscles,  and 
is  further  aggravated  by  the  inability  of  the  tongue  to  carry  the  bolus  of 
food  backward.  Feeding  the  patient  is  a  troublesome  and  disgusting  proc- 
ess, the  food  being  scattered  all  about  and  sometimes  thrown  to  a  consid- 
erable distance,  by  the  act  of  coughing  facilitated  by  absence  of  power  in  the 
lips  to  retain  substances  in  the  mouth.  By  this  time,  too,  the  larnygeal 
muscles  are  involved,  and  the  patient's  efforts  to  speak  result  in  mere 
grunts. 

Thus  he  cannot  talk,  he  cannot  swallow,  he  cannot  close  his  mouth  r 
he  cannot  expectorate,  yet  the  saliva  flows  from  his  mouth  because  he  can 
neither  swallow  nor  close  his  lips,  and  the  term  "  driveling  idiot "  well  covers 
the  impression  caused  by  his  appearance.  Yet  his  mental  powers  are  unim- 
paired, and  may  remain  so  until  the  last.  The  motor  electrical  phenomena 
in  the  muscles  involved  may  be  altered,  and  the  reaction  of  degeneration  may 
be  present. 

To  these  symptoms  are  to  be  added  complications  due  to  the  paralysis. 
From  the  difficulty  in  swallowing,  particles  of  food  may  enter  the  larynx,  be 


PROGRESSIVE  BULBAR  PALSY.  953 

insufflated  to  the  deeper  parts  of  the  lungs,  and  there  cause  a  pneumonia 
which  may  be  fatal,  or  the  fragment  which  enters  the  larynx  may  be  so  large 
as  to  cause  death  by  suft'ocation. 

In  rare  cases  the  lower  distribution  of  both  facial  nerves  is  involved, 
producing  diplegia  facialis;  but  the  upper  distribution  usually  escapes.  Or 
there  mav  be  paralysis  of  the  ocular  nerves  to  which  it  may  be  confined  ( an- 
terior bulbar  paralysis  or  progressive  ophthalmoplegia  of  von  Graefej. 
Even  the  muscles  supplied  by  the  spinal  accessory  and  the  motor  branch  of 
the  trifacial  may  be  invaded.  In  all  these  instances  the  nuclei  of  the  cor- 
responding nerves  are  afifected. 

Diagnosis. — The  diagnosis  is  generally  easy,  the  symptoms  are  so 
characteristic  and  so  evident.  For  a  typical  case  they  must  be  purely 
motor;  they  must  be  disassociated  from  other  nmscular  involvements  which 
would  go  to  make  them  a  part  oi  progressive  spinal  muscular  paralysis 
or  amxotrophic  lateral  sclerosis.  If  there  are  disturbances  of  sensation, 
invasion  of  the  upper  division  of  the  facial,  of  nerves  of  special  sense,  the 
disease  is  not  true  bulbar  paralysis.  There  must  be  some  general  involve- 
ment of  the  medulla,  thrombosis,  or  embolism,  a  tumor  developing  near  it  or 
diffuse    sclerosis   through   it. 

There  is  a  glossolabiopharyngeal  paralysis  of  cerebral  origin  known  as 
"  pseudobulbar  paralysis,"  in  which  there  is  complete  paralysis  of  the  tongue 
and  lips,  due  to  bilateral  and  possibly  even  unilateral  cerebral  lesions.  Close 
examination  will,  however,  detect,  sooner  or  later,  deviations  from  the  typical 
course,  which  include  absence  of  fibrillary  tremor,  and  of  atrophy,  and  of 
reaction  of  degeneration.  The  symptoms  tend,  too,  to  occur  first  on  one 
side  and  later  on  the  other.  ^Mentality  is  much  affected,  and  the  reflexes  may 
be  exaggerated.  Bulbar  tumors  run  a  like  chronic  course,  but  almost  always 
presents  unilateral  symptoms. 

Prognosis. — This  is  invariably  sooner  or  later  fatal,  although  it  is 
said  that  the  progress  of  the  disease  may  be  delayed  by  treatment. 

Treatment. — If  there  be  any  suspicion  that  syphilis  is  the  cause,  iodid 
of  potassium  should  be  used,  but  the  treatment  which  has  been  found  most 
effectual  is  electrical.  Galvanism  is  recommended,  electrodes  being  applied 
to  the  tw^o  mastoid  processes  daily  for  two  or  three  minutes,  the  current 
often  reversed.  The  sympathetic  nerve  and  the  affected  muscles  of  the  lips 
and  the  tongue  may  be  similarly  treated,  faradization  being  also  substituted 
for  galvanism  in  the  case  of  the  muscles.  Deglutition  may  even  be  excited 
by  galvanism  when  it  begins  to  be  impaired.  This  is  accomplished  by 
placing  the  anode  on  the  nape  of  the  neck  and  the  cathode  on  one  side  of  the 
lar3"nx.  At  everv  cathodal  closure,  or  every  time  that  the  cathode  is  carried 
across  the  side  of  the  larynx,  there  is  a  reflex  act  of  deglutition.  When 
deglutition  becomes  very  difficult,  the  stomach-tube  should  be  used  and 
nutrient  substances  thus  introduced.  Great  care  should  be  exercised  in 
feeding  the  patient  without  the  tube,  lest  the  food  pass  into  the  trachea  and 
cause  suffocation.  Hence,  too,  the  use  of  the  tube  should  not  be  too  long 
deferred. 

In  addition  to  iodid  of  potassium,  nitrate  of  silver  and  ergot  are  also 
recommended.  The  first  should  be  given  in  such  doses  as  the  stomach  will 
tolerate,  while  salivation  may  be  controlled  by  atropin — i-ioo  to  1-60  grain 
ro.ooo66  to  o.ooii  gm.).  Silver  should  be  given  in  the  usual  doses  of  1-6 
to  1-4  gr.  (0.0106  to  0.016  gm.)  ;  ergot  in  usual  doses. 


954  DISEASES  OF  THE  NERVOUS  SYSTEM. 


Acute  Bulbar  Palsy. 

Etiology. — Besides  the  chronic  or  progressive  form  of  bulbar  palsy, 
there  is  an  acute  variety  which  is  caused  by  hemorrhage  into  the  pons  and 
medulla,  or  possibly  by  thrombosis  or  embolism  of  the  vessels  supplying 
these  centers — viz.,  the  anterior  spinal,  vertebral,  and  basilar.  Inflamma- 
tion of  the  medulla  oblongata  is  also  a  cause.  Thrombosis  mav  occur  in 
any  of  the  vessels,  and  is  commonly  due  to  atheromatous  or  syphilitic  en- 
darteritis.    Inflammation  is  a  rare  affection,  but  does  occasionallv  occur. 

Hemorrhage,  thrombosis,  and  embolism  are  subject  to  the  same  causes 
here  as  elsewhere  in  the  brain,  but  the  cause  of  the  inflammatory  form  of 
acute  bulbar  palsy  is  unknown.     It  is  probably  infection  or  intoxication. 

Symptoms. — In  any  event  the  symptoms  are  sudden.  They  are  those 
already  detailed  in  connection  with  progressive  bulbar  paralysis,  but  others 
are  added.  There  is  usually  no  loss  of  consciousness,  though  there  may 
be.  There  may  also  be  deranged  cardiac  action  and  respiration,  including 
irregular  and  frequent  pulse,  vasomotor  derangements,  and  Cheyne-Stokes 
breathing.  The  temperature,  normal  at  first,  may  rise  to  105°  to  107°  F. 
(40.5°  to  40.71°  C.)  and  higher  as  a  fatal  termination  is  approached.  Sen- 
sation is  rarely  aft'ected.  ]\Iost  characteristic  of  all  is  the  so-called  crossed 
paralysis,  described  on  page  844,  which  attends  most  hemorrhages  into  the 
pons,  in  which  there  is  paralysis  of  the  face  on  one  side  and  of  the  extremities 
on  the  other;  but  the  motor  tract  may  not  be  involved,  and  in  that  case 
paralysis  is  not  obsen'ed. 

Diagnosis. — Suddenness  of  occurrence  of  the  symptoms  named  indi- 
cates one  of  the  accidents  previously  mentioned,  while  a  crossed  hemiplegia 
is  conclusive.  \Mien  inflammation  of  the  medulla  oblongata  is  present,  the 
phenomena  of  bulbar  paralysis  do  not  occur  quite  so  suddenly.  They  may 
"be  several  days  or  even  a  few  weeks  in  developing,  and  may  be  preceded  by 
prodromal  symptoms  such  as  vertigo  and  painful  sensations  in  the  back  of 
the  neck. 

Treatment. — The  treatment  is  the  same  as  for  similar  lesions  else- 
where in  the  brain. 


PSEUDOPARALYTIC   MYASTHENIA. 

Synonyms. — Bulbar  Palsy  zvifhoiif  Discernible  Anatomical  Changes;  As- 
thenic Bulbar  Paralysis:  General  Profound  Myasthenia ;  Erb's  Disease; 
Hoope-Goldflam  Symptom  Complex;  Myasthenia  Gravis. 

Definition. — A  disease  beginning  usually  with  weakness  of  the  muscles 
of  the  tongue,  lips,  lar\-nx.  and  eyes,  followed  by  rapid  exhaustion  and  tem- 
porary paralysis  of  the  muscles  of  the  extremities ;  by  temporary  recoverv' 
of  power  after  rest ;  occasionally  terminating  in  persistent  paralysis.  It  is 
more  common  than  the  true  bulbar  palsy. 

History. — The  disease  was  first  described  by  Wilkes  in  1877  as  "  an  tinusual  form 
of  glosso-labio-]arynp;-eal  paralysis."  In  1879  Erb  reported  three  cases  which  he 
described  as  a  new  SA-ndrone,  probably  of  bulbar  ori.sfin.  It,  however,  attracted  little 
attention  until  the  publication  of  Goldflam's  paper  in   1891.     In  1891  and  1892  Jolly, 


PSEUDOPARALYTIC  MYASTHENIA.  955 

and  in  1892  Hoope  published  reports  of  cases;  also  in  1892  Goldflam  published  his 
paper  in  which  were  collected  all  cases  published  up  to  that  date  with  four  new  cases. 
In  1S96  Striimpell  collected  twenty  cases.  In  1900  Harry  Campbell  and  Edwin 
Bramwell  made  the  most  complete  study  of  the  cases  so  far  as  published — in  all  about 
seventy.  They  give  the  details  of  sixty.  In  a  later  paper*  Edwin  B'-amwell  says  up 
to  the  present  time  only  some  eighty  or  possiblj^  ninety  cases  have  been  reported. 

Etiology  and  Pathology. — The  disease  occurs  usually  in  those  from 
twenty  to  forty  years  of  age,  and  in  both  sexes  alike.  It  is  believed  to  be 
due  to  an  autogenetic  toxin.  Congenital  defect  or  abnormality  either  in  the 
construction  or  mode  of  functionating  of  the  neuro-motor  apparatus  rather 
than  in  the  muscles,  has  been  suggested  by  E.  Bramwell,  and  especially 
the  lower  motor-neuron.  It  has  followed  the  infectious  diseases,  and  in 
about  one-fourth  of  the  cases  neuropathic  heredity  has  been  noted.  At 
necropsy  no  lesion  has  been  found  which  would  account  for  the  symp- 
toms. 

Symptoms. — These  include  ptosis,  paresis  of  the  facial  muscles,  difficult 
mastication,  and  difficulty  in  swallowing  and  talking.  They  are  due  to 
fatigue  of  the  muscles  involved,  and  the  patient  can  talk  a  few  sentences 
quite  glibly,  but  his  speech  soon  grows  indistinct  and  ultimately  incom- 
prehensible. So  with  chewing  and  swallowing  so  far  as  the  first  mouthfuls 
are  concerned,  but  these  acts  soon  become  impossible.  The  muscles  of  the 
extremities  and  trunk,  as  well  as  those  innervated  by  the  cranial  nerves  are 
involved,  the  same  rapid  fatigue  supervening  on  effort.  Thus  one  of  Striim- 
pell's  patients  could  ascend  a  flight  of  stairs  very  well  once,  but  in  making  a 
second  effort  had  to  invoke  the  aid  of  a  bannister,  while  the  third  and 
fourth  efforts  were  ineffectual.  Such  a  condition  is  known  as  the  myas- 
thenic state.  At  times  the  abnormal  fatigue  and  consequent  symptoms  are 
limited  to  the  lower  extremities.  A  similar  effect  succeeds  on  continued 
faradization  of  the  muscles,  first  detected  by  Jolly,  and  is  called  the  myas- 
thenic reaction.  Almost  equally  characteristic  is  the  disappearance  of  fatigue 
after  the  muscles  have  been  put  at  rest  for  a  time. 

Diagnosis. — In  well-marked  cases  this  is  easy,  but  when  the  symptom? 
are  less  pronounced,  there  may  be  difficulty.  Cases  are  often  met,  especially 
in  hysterical  women,  who  complain  of  inability  to  hold  up  the  head,  which 
clearly  do  not  belong  to  this  class.  But  it  is  to  be  remembered  that  true 
myasthenia  gravis  is  something  very  different  from  hysteria.  An  ability  to 
use  the  muscles  at  first,  followed  rapidly  by  an  opposite  state,  must  always  be 
looked  for,  and  these  conditions  must  be  applicable  to  the  muscles  of  the 
lower  extremities,  as  well  as  to  those  of  the  bulbar  nerves.  The  absence 
of  muscular  atrophy  is  essential  to  myasthenia  gravis ;  there  is  more  apt  to  be 
ocular  and  upper  face  paralysis  as  contrasted  with  bulbar  palsy.  The 
myasthenic  reaction  should  be  sought.  The  muscles  respond  normally  to 
galvanism. 

Prognosis. — This  is  not  always  unfavorable,  but  one  must  not  be  mis- 
led by  the  apparent  improvement  succeeding  rest,  which  is  often  temporary. 

Treatment. — It  is  evident  from  what  has  been  said  that  rest  is  most 
important.  Prolonged  rest  and  the  avoidance  of  mental  excitement,  and  the 
use  of  massage  and  mild  galvanization  of  muscles  are  recommended,  and 
even  central  galvanization  of  the  spiral  cord  and  medulla  oblongata.  Since 
faradization  excites  the  myasthenic  state,  it  should  not  be  used. 

The  nourishment,  or  mode  of  nourishment,  is  most  important,  in  view 


*  "  Scottish  Med.  and  Sur.  Journal,"  May,  igoi. 


956  DISEASES  OF  THE  NERVOUS  SYSTEM. 

of  the  fact  that  the  muscles  of  mastication  and  degkitition  are  at  fault.  The 
food,  therefore,  should  either  be  liquid,  or  very  finely  minced,  and  unless 
deglutition  is  natural  and  easy,  the  stomach  tube  should  be  used. 

The  drugs  recomm'ended  are  the  usual  ones :  strychin,  arsenic,  phos- 
phorus, and  other  tonics,  but  no  direct  results  have  been  traced  to  them. 


AMYOTROPHIC    LATERAL    SCLEROSIS. 
Synonym. — Charcot's  Disease. 

Notwithstanding  the  similarity  of  the  clinical  phenomena,  and,  to  a 
certain  extent,  of  the  morbid  anatomy  of  amyotrophic  lateral  sclerosis  to 
those  of  the  so-called  progressive  spinal  muscular  atrophy,  to  be  next  con- 
sidered, there  appears  to  me  sufficient  difference  to  justify  a  separate  con- 
sideration. 

Definition. —  Amyotrophic  lateral  sclerosis  is  a  systemic  degeneration 
of  the  pyramidal  tracts  of  the  spinal  cord,  with  atrophy  of  motor  cells  in 
the   anterior   cornua   and   medulla   oblongata,    and    consequent   wasting   of 
muscles,  depending  upon  these  cells  for  their  trophic  influence. 

History. — The  confusion  which  has  long  existed  between  this  disease  and  pro- 
gressive spinal  muscular  atrophy  was  first  cleared  up  by  Charcot  and  his  pupil, 
Joffroy,  who  published  a  fairly  accurate  account  of  the  disease  in  T869  and  a  complete 
description  in  1874.  Such  description  became  possible,  however,  only  after  Flechsig's 
studies  of  the  pattas  of  motor  conduction  in  the  spinal  cord.  That  there  are,  however, 
certain  common  features  in  the  two  affections  appears  not  only  from  the  clinical 
history,  but  also  from  the  morbid  anatomy. 

Etiology. — The  causes  of  this  condition  are  still  essentially  unknown. 
Severe  muscular  exertion  has  been  assigned  as  a  cause,  as  it  has  also  of 
the  allied  affection,  progressive  spinal  muscular  atrophy.  As  in  it,  too,  the 
male  sex  suffers  most.  It  is  a  disease  of  young  adult  life  and  middle  age, 
from  twenty-five  to  forty-five.  It  is  probably  due  to  the  degeneration  of 
an  imperfectly  formed  central  motor  system. 

Morbid  Anatomy. —  A  sclerosis  of  the  crossed  pyramidal  tracts  in  the 
two  lateral  columns  and  the  direct  pyramidal  tracts  in  the  anterior  columns  is 
essential  to  the  morbid  anatomy  in  a  typical  case.  As  important  is  atrophy 
of  the  corresponding  large  ganglion  cells  in  the  anterior  cornua  and  medulla. 
The  degeneration  has  been  traced  in  the  pyramidal  tracts  from  the  sacral  cord 
upward  to  the  pyramids  in  the  medulla  oblongata,  sometimes  even  through 
the  pons  and  crura  into  the  internal  capsule  and  central  convolutions,  in 
which,  too,  the  large  ganglion  cells  have  been  found  atrophied.  The  nerve 
nuclei  which  are  affected  in  the  medulla  oblongata  are  especially  those  of 
the  vagus  and  hypoglossal  nerves.  The  motor  cranial  nerves  are  sometimes 
degenerated. 

The  changes  in  the  motor  ganglion  cells  of  the  cord  and  the  nerve 
nuclei  in  the  medulla  oblongata  are  analogous  and  produce  corresponding 
results  in  the  muscles  supplied  by  the  motor  nerves  originating  from  them. 
These  results  are  an  atrophy  present  in  various  degrees,  some  fibers  disap- 
pearing almost  entirely,  others  partially.  The  process  is  by  fatty  meta- 
morphosis and  absorption  of  resulting  fat,  leaving  a  residue  of  connective 
tissue. 

Symptoms. — The  clinical  phenomena  are  in  strict  accord  with  what 
would  be  expected   from  the  pathological   lesions,   consisting  in   muscular 


AMYOTROPHIC  LATERAL  SCLEROSIS.  957 

■wasting  and  corresponding  paresis.  Before  the  muscular  wasting  appears,  a 
sense  of  fatigue  succeeding  slight  effort  may  be  manifested,  followed  by  a 
positive  weakness,  primarily  almost  always  in  the  upper  extremity,  first  one 
and  finally  both.  This  is  followed  by  zcasting  of  the  muscles  of  the  same 
extremity,  usually  first  seen  in  the  thenar  and  hypothenar  eminences,  the 
interossei  and  the  muscles  of  the  extensor  side  of  the  forearm,  while  the 
flexors  of  the  hand  and  fingers  remain  longer  uninvaded.  The  atrophy  is 
particularly  well  seen  in  the  deltoid,  and  to  a  less  degree  in  the  triceps,  still 
less  in  the  biceps  and  shoulder  muscles.  Usually  symptoms  do  not  appear  in 
the  lower  extremities  until  some  time  after  they  have  appeared  in  the  upper, 
but  occasionally  the  disease  begins  in  the  lower  limbs. 

When  the  lower  limbs  are  affected,  the  patient  tires  easily  in  walking, 
the  gait  becomes  unsteady  and  stiff',  and  rising  from  the  chair  becomes 
difficult.  Tremor  may  appear  in  the  legs.  The  paresis  in  both  extremities 
is  proportionate  to  the  destruction  of  muscle,  though  first,  at  least,  it  is 
independent  of  the  atrophy.  Associated  with  muscular  atrophy,  sooner  or 
later,  is  a  diminished  electrical  excitability.  Some  excitability,  however, 
remains  as  long  as  the  muscles  are  intact,  diminishing  as  their  destruction 
spreads.  A  reaction  of  degeneration  may  also  develop  in  the  muscular 
fibers  still  intact.  The  excitability  remains  for  the  most  part  intact  in  the 
nerve-trunk  because  in  any  event  a  large  number  of  fibers  are  preserved  in 
their  normal  state. 

A  distinctive  feature  of  amyotrophic  lateral  sclerosis  is  found  in  the 
reflexes,  which,  in  strong  contrast  to  progressive  muscular  atrophy,  are 
markedly  increased.  Even  in  the  early  stages  of  the  disease  vigorous  con- 
tractions are  obtained  by  gently  tapping  the  tendons  of  almost  any  of  the 
muscles  in  the  extremities.  Always  most  conspicuous  is  the  patellar  reflex, 
while  more  rarely  ankle  clonus  may  be  obtained.  The  same  is  true  of  the 
masseter  reflex.  In  the  arms  the  biceps  and  triceps  and  the  flexors  of  the 
hands  may  be  excited  to  strong  contraction. 

Contractures  may  take  place  in  the  later  stages  of  the  disease  in  ihe 
arms  and  hands,  but  not  always.  In  the  lower  extremities,  where  the  atro- 
phic symptoms  develop  some  months  later  and  are  less  marked,  spastic 
symptoms  are  a  more  prominent  feature.  The  legs  become  rigid  and  some 
strength  is  required  to  flex  them,  though  the  muscles  themselves  are  paretic. 
A  typical  spastic  paraplegia  may  be  produced,  which  is  due  mainly  to  the 
increase  of  the  tendom  reflexes,  and  a  spastic  paretic  gait  is  common — that 
is,  at  first. 

Later  on  in  the  disease  bulbar  symptoms  may  present  themselves,  mani- 
fested first  by  defects  of  speech,  difficulty  in  retaining  the  saliva  and  in 
swallowing ;  and  later  still  the  lips  and  tongue  may  be  seen  to  be  atrophied, 
and  ultimately  there  is  difficulty  in  taking  food,  whence  nutrition  is  im- 
paired, and  the  patient  gradually  sinks.  In  some  cases  the  disease  may 
begin  without  bulbar  symptoms. 

Throughout,  sensibility  remains  normal  in  the  upper  and  lower  extrem- 
ities, and  the  superficial  reflexes  are  not  much  altered.  The  sphincters  are, 
as  a  rule,  unaffected.  ^Micturition  is  natural.  Only  in  the  event  of  involve- 
ment of  the  reflex  center  in  the  lumbar  cord  may  there  be  incontinence  at 
night  when  the  inhibitory  power  is  in 'abeyance.  There  may  be  constipation, 
but  no  actual  paralysis  of  the  bowel.     Sexual  power  may  be  lost. 

The  successive  involvement  of  the  upper  extremities,  the  lower  extrem- 
ities, and  the  bulbar  centers  marks  quite  vrell-defined  stages  of  the  disease. 


958  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Death  comes  ultimately  from  exhaustion,  or  more  frequently  through 
an  inspiration  pneumonia,  caused  by  entrance  of  foreign  matter  into  the 
air-passages  as  a  result  of  defective  deglutition. 

Diagnosis. — The  disease  is  distinguished  from  progressive  spinal  mus- 
cular atrophy  by  the  invariable  increase  in  the  tendon  reflexes,  even  in  the 
early  stages,  as  contrasted  with  their  absence  in  the  latter  disease. 

Prognosis  and  Treatment. — The  prognosis  is  very  unfavorable  and 
the  disease  cannot  be  arrested.  By  rest  in  bed,  massage,  electricity,  and 
hot  bathing  we  may  be  able  to  defer  the  end  somewhat.  (See,  also,  Treat- 
ment of  Progressive  Spinal  ^luscular  Atrophy.) 


PROGRESSIVE    SPIXAL   MUSCULAR    ATROPHY. 

Syxoxyms. — Wasting  Palsy;  Progressive  Mitseular  Atrophy,  Type  Duch- 
enne-Aran;  Diichcnnc-Aran's  Disease;  Cruveilhiefs  Atrophy;  Chronic 
Anterior  Polioinxelitis;  Chronic  Degeneration  of  the  Motor  Nuclei. 

Definition. — Progressive  spinal  muscular  atrophy  is  a  progressive 
zvcsting  of  more  or  less  limited  groups  of  voluntary  muscles,  associated  with 
degenerative  atrophy  of  the  corresponding  portion  of  the  motor  nerve  tract, 
including  the  ganglion  cells  of  the  anterior  cornua,  but  unaccompanied  by 
disease  of  the  pyr ami-da!  tracts.  The  existence  of  this  condition  has  been 
disputed,  but  degeneration  of  the  cells  of  the  anterior  horns  without  degen- 
eration of  the  pyramidal  tracts  has  been  seen  by  most  reliable  investigators. 
It  is  well  to  include  the  word  spinal  in  the  description  of  this  disease,  as 
thereby  the  disease  is  distinguished  from  progressive  muscular  atrophy  from 
other  causes. 

Historical.— The  history  of  the  development  of  our  knowledge  of  this  disease  is 
very  interesting.  A  few  facts  only  can  be  given  here.  Although  a  number  of  isolated 
cases  were  described  at  an  earlier  date,  Duchenne's  memoir  on  -'Atrophic  Micscu- 
laire  avec  Transformation  Graisseitse,"  Y>^h\\'t,\i&A  in  1849,  and  Aran's  '•  Recherches 
sur  line  Maladie  non  encore  decidce  dii  Systemc  Musculaire"  published  in  the  next 
year,  contained  the  first  accurate  descrip'tion  of  this  malady.  Cruveilhier's  studies 
were  commenced  in  1832.  but  were  not  given  out  until  1S53.  All  of  these  observers 
believed  at  first— Cruveilhier  reluctantly— that  the  disease  w-as  purely  muscular.  In 
his  third  case,  however,  Cruveilhier  found  atrophy  of  the  anterior  roots  of  the  spinal 
nerves,  and  in  his  fourth,  lesion  of  the  grav  matter  of  the  cord,  whence  the  anterior 
roots  take  their  origin,  and  first  asserted  the  belief  that  the  disease  of  the  gray  matter 
in  the  spinal  cord  was  the  special  anatomical  lesion  of  the  disease.  The  researches 
of  Lockhart  Clarke  in  1S66  and  1867  and  of  Charcot  in  1S69  mav  be  said  to  have 
established  the  spinal  nature  of  tl^e  disease  ;  while  Friedreich  in  1873  still  maintained 
its  muscular  nature,  and  Gowers  and  Leyden  regard  it  as  identical  with  amyotrophic 
lateral  sclerosis.  Striimpell  also  separates  the'  two  diseases  of  progressive  spinal 
muscular  paralysis  and  amyotrophic  lateral  sclerosis,  and  it  appears  to  me  there  is 
quite  enough  reason  for  doing  so.  The  close  relation  of  these  two  diseases  cannot  be 
disputed,  but  most  unquestionable  proof  has  been  furnished  by  Dejerine  and  others 
that  they  are  not  identical. 

Etiology. —  In  the  majority  of  instances  we  fail  to  find  a  sufficient 
cause.  Heredity  has  been  regarded  as  playing  an  important  role  in  its 
causation,  but  Striimpell  considers  the  cases  thus  originating  as  instances 
of  the  juvenile  myopathic  variety  of  atrophy — that  in  which  no  nervous 
lesion  is  traceable.  On  the  other  hand,  e.vcessive  muscular  exertion  seems  to 
be  more  than  an  accidental  coincidence.  Exposure  to  cold,  especially  to  very 
cold  water,  and  the  infections  diseases — typhoid  fever,  influenza,  diphtheria, 
and  syphilis — have  all  been  held  accountable,  but  it  is  likely  that  some  of 


PROGRESSIVE  SPINAL  MUSCULAR  ATROPHY. 


959 


the  atrophies  thus  resuUing  include  other  forms  than  the  true  progressive 
spinal  muscular  atrophy. 

It  is  a  disease  commonly  of  adult  males,  most  supposed  cases  among 
those  who  are  younger  being  probably,  as  held  by  Erb,  instances  of  the 
juvenile  form  of  muscular  dystrophy,  although  a  very  rare  family  form  of 
progressive  spinal  muscular  atrophy  has  been  observed  in  children. 

Morbid  Anatomy. — The  anterior  horns  of  the  gray  matter  are  Vv^asted 
and  reduced  in  size ;  their  ganglion  cells  wholly  or  partially  destroyed ;  the 
neuroglia  is  proliferated  and  is  intercalated  in  places  with  spider  cells.  The 
ante}iGr  nerve-roots  passing  from  the  horns  are  atrophied,  as  are  also  the 
motor  nerve  filaments  in  the  peripheral  nerves.  But  the  crossed  pyramidal 
tracts  in  the  lateral  columns  containing  the  crossed  motor  fibers  descending 
from  the  brain  to  the  cells  in  the  anterior  cornua  are  intact.     A  slight  degen- 


Fig.   112. — Position  of  Hands  and  Fingers  in   Ulnar  Paralysis   of  Long  Standing; 

Bird-claw  Hand,  "  Main  en  Griffe" — {after  Duckeniie). 
A,  A.    Wound  of  the  ulnar  nerve.     B,  B,  B,  B,  B.    Ends  of  the  metacarpal  bones. 

D.     Tendons  of  the  flexor  sublimis  digitorum.     C.    Muscles  of  the   ball   of  the 

thumb. 


eration  may  be  seen  in  some  cases  in  the  anterolateral  columns  about  the 
anterior  horns.  The  muscles  see^n  to  be  wasted  before  death  are  found  con- 
verted into  fat  and  connective  tissue,  a  remnant  of  true  muscular  tissue 
remaining.  At  times  also  they  are  the  seat  of  waxy  change,  at  others  still, 
narrowed  but  retaining  their  transverse  striation. 

As  to  the  relation  of  the  nervous  changes  to  the  muscular  atrophy,  the 
conspicuous  symptom  of  the  disease,  there  is  more  than  one  possible  explana- 
tion. As  in  bulbar  palsy,  according  to  one  view,  the  atrophy  of  the 
anterior  cornua  is  primary,  the  result  of  chronic  poliomyelitis  anterior,  the 
degeneration  of  the  peripheral  nerves  and  muscles  being  secondary  to  it. 
According  to  another  view,  the  muscular  atrophy  is  primary,  possibly  due, 
as  Friedreich  sought  to  prove,  to  a  myositis,  followed  by  fatty  metamor- 
phosis of  the  sarcous  substance  and  subsequent  absorption  of  fat,  or  to  a 
simple  primary  fatty  metamorphosis.     In  such  event  it  m.ay  be  inferred  that 


960  DISEASES  OF  THE  NERVOUS  SYSTEM. 

the  nerves  atrophy  from  want  of  use.  According  to  a  third,  the  degen- 
eration begins  in  the  last  terminal  branches  of  the  motor  nerves  and  extends 
upward  along  them  to  the  spinal  cord.  Finally,  it  is  held  that  there  may 
be  a  simultaneous  degeneration  of  the  whole  motor  system  involved,  includ- 
ing muscle  and  nerve,  and  nerve  cell.  It  is  more  in  accord  with  the  office 
of  the  spinal  cord  as  a  nutritive  center,  as  well  as  with  its  morbid  anatomy, 
to  suppose  the  disease  is  a  chronic  poliomyelitis  anterior,  the  essential  infan- 
tile paralysis  of  Relliet  and  Barthez  being  an  acute  form  of  the  same  disease. 
Very  important  is  the  anatomical  fact  that  the  pyramidal  tracts  are  quite 
normal. 

Symptoms. — One  of  the  most  striking  features  of  the  disease  is  its 
slow  dcTclopuieiit.  Like  its  congener,  amyotrophic  lateral  sclerosis,  it  begins 
most  frequently  in  the  upper  extremities,  7  out  of  9  times  in  Aran's 
cases.  Of  the  upper  extremities,  the  right  was  first  invaded  in  37  out  of 
62  of  Sandahl's  cases,  the  left  14  times,  while  the  involvement  was  simul- 
taneous in  II.  The  disease  may  begin  in  the  lozver  extremities,  as  shown  by 
Friedreich's  statistics,  according  to  which  these  were  first  invaded  2y  times 
out  of  146,  the  upper  extremities  iii,  the  lumbar  muscles  in  8. 

The  atrophy  usually  begins  with  the  short  muscles  of  the  thumb,  the 
abductor  policis  brevis  first,  then  the  opponens  .and  the  abductor.  The 
consequent  flattening  of  the  ball  of  the  thumb  and  its  persistent  approxi- 
mation to  the  second  metacarpal  bone  produces  the  so-called  "  ape-hand." 
Simultaneously,  or  almost  simultaneously,  the  interossei  begin  to  waste,  pro- 
ducing conspicuous  depressions  between  the  metacarpal  bones,  associated 
V.  ith  loss  of  power  to  extend  completely  the  terminal  phalanges  of  the 
fingers.  Atrophy  of  the  lumbricales  follows,  producing  a  flattening  of  the 
hollow  of  the  hand.  The  ultimate  result  is  the  characteristic  iiiain  en  griff e 
of  Duchenne,  in  which  the  extensor  tendons  on  the  dorsum  of  the  hand,  and 
the  flexors  in  the  palm,  become  as  distinct  as  if  dissected  out. 

From  the  hand  the  wasting  creeps  up.  the  forearm  and  thence  to  the 
arm,  or  it  may  skip  the  forearm  and  pass  into  the  arm,  sparing  usually  the 
triceps  extensor.  In  the  forearm  the  muscles  on  the  extensor  (external) 
side  are  usually  first  aft'ected,  then  the  abductor  pollicis  and  extensor  longus 
pollicis,  and  later  the  supinators  and  flexors.  It  may  come  to  a  standstill 
at  either  of  these  stages,  or  may  involve  the  muscles  of  the  shoulder,  espe- 
cially the  deltoid,  in  which,  indeed,  it  may  begin,  preferably  in  the  right, 
passing  thence  to  the  scapular  and  trapezius  muscles,  the  pectorals,  the  rhom- 
boidei  and  latissimus  dorsi,  while  a  grotesqueness  of  efifect  is  often  produced 
by  reason  of  certain  adjacent  muscles  retaining  their  natural  size  or  being 
even  seemingly  hypertrophied.  This  is  particularly  the  case  with  the  in- 
ferior part  of  the  trapezius  and  platysma  myoides,  which  are  almost  never 
involved.     The  disease  may  be  arrested  at  almost  any  of  these  stages. 

The  lower  extremities  may  escape  altogether,  and  the  atrophy  always 
develops  late.  The  small  m.uscles  of  the  foot  would  naturally  be  the  first 
affected.  Very  rarely  there  may  be  exceptions  to  this  rule.  The  muscles 
of  the  face  are  invaded  late  or  not  at  all.  but  ultimately  even  the  intercostal 
and  abdominal  muscles  may  be  involved.  The  result,  then,  is  a  veritable 
living  skeleton,  instances  of  which  are  sometimes  exhibited.  Deformities, 
including"  lordosis  or  anterior  curvature  of  the  spine  may  result. 

With  all  this,  sensibility  is  unaffected  in  the  vast  majority  of  cases,  but 
the  patient  may  complain  of  a  numbness  and  coldness  of  the  affected  limbs. 
Very  rarely  pains  precede  the  wasting  in  the  muscles,  when  they  are  some- 


PROGRESSIVE  SPINAL  MUSCULAR  ATROPHY.  961 

times  regarded  as  rheumatic.  The  galvanic  and  faradic  irritability  of  the 
muscles  progressively  diminishes  and  disappears  with  the  complete  destruc- 
tion of  the  muscle,  the  galvanic  persisting  longer.  The  reaction  of  degen- 
eration may,  however,  be  elicited  late  in  the  disease  in  certain  muscles,  more 
especially  in  the  modified  form  known  as  "  partial  reaction  "  of  degenera- 
tion. If  the  disease  runs  a  rapid  course,  it  may  occur  earlier  and  be  more 
typical.  Fibrillary  muscular  contractions  may  be  present,  and  idiopathic 
muscular  contractions,  or  myoid  tumors  brought  out  by  a  blow,  may  be  thus 
produced.  The  bladder  and  rectum  remain  intact,  but  suxual  functions  may 
be  lost. 

Sweating  and  other  vasomotor  disturbances  may  occur  in  the  affected 
muscles,  such  as  pemphigoid  bullous  eruptions,  thickening  and  fissuring  of 
the  skin,  and  curving  and  grooving  of  the  nails.  In  certain  places  there  is 
an  overaccumulation  of  fat,  producing  an  appearance  of  hypertrophy  when 
there  is  actual  atrophy. 

Along  with  wasting  there  is  a  corresponding  paresis,  the  result  of 
the  atrophy  and  not  its  cause.  The  arms  are  flaccid  and  toneless  and  hang 
loosely  at  the  sides.  The  patient  can  no  longer  dress  himself,  and  various 
devices  are  resorted  to  in  order  to  accomplish  certain  acts.  Especially  char- 
acteristic is  one  of  these — when  the  shoulders,  being  first  afifected,  the  arm 
and  forearm  retain  their  usefulness.  Under  these  circumstances  the  power 
of  lifting  the  arm  from  the  side,  and  especially  of  raising  it  above  the  head, 
is  lost,  while  that  of  the  forearm  remains.  Hence,  if  the  patient  wishes  to 
lay  hold  of  anything,  he  swings  the  arm  forward  with  a  jerk  until  the  ob- 
ject is  brought  within  reach  of  his  fingers,  when  it  may  often  be  caught  by 
the  pathologically  hooked  terminations  of  these.  So  long  as  the  neck 
muscles  remain  effective,  objects  may  be  grasped  by  the  mouth. 

In  true  progressive  spinal  muscular  atrophy  the  reflexes  are  entirely 
absent,  at  least  in  the  wasted  extremities,  a  natural  result  of  the  atrophy  of 
the  ganglion  cells  in  the  anterior  cornua  and  of  the  centrifugal  motor  fibers 
of  the  reflex  arc.     The  special  senses  and  the  sphincters  remain  normal. 

Toward  the  close  of  the  disease  sometimes,  and  then  only  after  it  has 
existed  for  a  long  time,  the  phenomena  of  bulbar  paralysis  may  present 
themselves  after  invasion  of  the  ganglia  of  the  medulla  oblongata.  These 
have  been  detailed  in  the  section  on  that  subject.  They  are  by  no  means 
always  present,  even  in  advanced  cases. 

Diagnosis. — Muscular  atrophy  is  not  confined  to  the  disease  under 
consideration.  It  occurs  in  diffuse  myelitis,  in  tumors  of  the  cord  and  when 
cavities  are  formed  in  its  interior,  in  multiple  neuritis,  and  especially  in 
amyotrophic  lateral  sclerosis.  From  all  these  named,  except  the  last,  it  is 
easily  distinguished  by  strict  attention  to  the  conditions  and  order  of  devel- 
opment of  the  symptoms — viz.,  insidious  and  progressive  atrophy  of  groups 
of  muscles  to  the  exclusion  of  others,  beginning  usually  in  the  hand  or 
more  rarely  in  the  shoulder  and  upper  arm ;  accompanied  by  a  correspond- 
ing loss  of  power  in  the  affected  muscles  and  partial  or  complete  reaction 
of  degeneration  in  the  same,  hy  diminished  reflexes  and  fibrillar  twitchings. 

Differential  Diagnosis — From  amyotrophic  lateral  sclerosis  it  is  to  be 
distinguished  by  its  greatly  slower  co'drse  and  absence  of  the  reflexes  and  of 
spastic  symptoms.  It  is  also  to  be  distinguished,  from  muscular  dystrophy 
in  its  various  forms — the  ■  myopathic  juvenile  muscular  atrophy  of  Erb, 
pseudohypertrophic  mAiscular  paralysis,  and  Duchenne's  infantile  hereditary 
palsy,     in  the  juvenile  progressive  muscular  atrophy  of  Erb  there  is  also 

6i 


962  DISEASES  OF  THE  NERVOUS  SYSTEM. 

slow  symmetricai,  and  intermittent  wasting,  with  weakness  in  certain  groups 
of  muscles,  especially  those  of  the  shoulder  girdle  and  upper  arm,  and  later 
possibly  the  pelvis,  upper  thigh,  and  back,  associated  at  times  with  true  or 
false  muscular  hypertrophy,  but  usually  unassociated  with  fibrillar  contrac- 
tion or  reaction  of  degeneration.  The  average  age,  also,  in  the  juvenile  form 
is  much  less,  Erb's  cases  ranging  from  seven  to  forty-six  and  one-half,  or  an 
average  of  twenty-six  and  one-half,  while  in  the  spinal  form  or  true  pro- 
gressive spinal  muscular  atrophy  the  average  age  is  much  greater.  Of 
Roberts'  cases,  all  of  which  seem  to  be  true  cases  of  progressive  spinal  mus- 
cular atrophy,  the  youngest  was  twenty,  while  the  ages  of  the  remaining 
four  were  thirty-eight,  thirty-nine,  forty-seven,  and  sixty-seven. 

While  in  the  pseudohypertrophic  form  there  are  also  great  weakness  and 
wasting  of  muscles,  though  the  latter  may  be  obscured  by  the  fatty  deposit, 
there  are  no  alterations  in  the  spinal  cord.  It  is  a  disease  of  childhood,  and 
strikingly  liercditary,  beginning  in  the  lower  extremities,  while  progressive 
muscular  atrophy  is  a  disease  of  adults,  is  not  hereditary,  and  begins  usually 
in  the  upper  extremities. 

Duchenne's  hereditary  infantile  atrophy  is  characterized  by  onset  at  an 
early  age,  infancy  or  adolescence,  and  by  beginning  in  the  facial  muscles.  It 
is  often  hereditary.  The  distribution  of  the  atrophy  is  very  similar  to  that 
of  Erb's  form,  when  the  disease  has  involved  the  muscles  of  the  shoulders, 
but  it  begins  in  the  face  and  may  fie  confined  to  the  face.  The  muscles  of  the 
hands  and  fingers  are  spared  in  Ducherme's  form ;  fibrillar  tremors  are  not 
present,  and  there  is  no  reaction  of  degeneration. 

Prognosis. — Alany  years  are  required  to  develop  these  symptoms  in 
their  entirety,  and  there  may  be  spontaneous  arrest,  during  which  the  patient 
may  die  of  other  causes.  Sooner  or  later,  if  the  patient  lives,  they  recur,  and 
their  march  is  irresistible. 

Treatment. — It  has  already  been  said  that  cure  is  impossible,  although 
well-authenticated  cases  of  arrest  are  reported.  Mercurials  and  iodid  of 
potassium  should  be  used  in  cases  of  suspected  syphilitic  origin.  Cooke 
reports  a  case  of  arrest  under  a  course  of  mercury,  after  the  disease  had 
progressed  for  five  years,  during  which  many  remedies  were  tried.  In  the 
main  the  treatment  must  consist  of  measures  intended  to  maintain  the  health 
and  strength  of  the  patient  and  to  counteract  the  muscular  wasting.  To  the 
former  end  an  abundance  of  nutritious  food,  fresh  air,  and  outdoor  life 
should  be  supplied,  while  tonics,  including,  especially,  cod-liver  oil,  iron, 
arsenic,  and  strychnin,  are  indicated.  The  muscular  wasting  may  be  com- 
bated by  electricity  and  judicious  massage.  Both  kinds  of  electricity  may  be 
used,  the  faradic  with  rapid  interruption  to  stimulate  the  circulation,  or  with 
slow  interruption  to  excite  individual  muscles  to  contraction.  The  current 
should  be  of  moderate  strength,  not  too  frequently  interrupted,  and  con- 
tinued for  a  few  minutes  only.  Duchenne  recommended,  particularly,  treat- 
ment of  important  muscles,  like  the  diaphragm  through  the  phrenic  nerve,  or 
the  intercostal  muscles  and  the  deltoids  before  they  are  actually  invaded  by 
the  disease.  In  evidence  of  its  usefulness  he  relates  the  case  of  a  man  who 
had  lost  many  of  his  trunk  muscles,  and  who  was  beginning  to  suffer  from 
dyspnea,  on  whom  faradization  of  the  phrenic  nerves,  repeated  three  or  four 
times  a  week,  was  of  great  sendee,  enabling  him  to  walk  considerable  dis- 
tances and  to  go  upstairs  without  fatigue.  Another  patient,  whose  arms 
were  much  wasted,  was  again  able  to  support  his  family.  The  direct  cur- 
rent— galvanism — is   useful  in  advanced   stages  of  the  disease,  when  the 


LOCALIZATION  OF  CEREBRAL  DISEASE.  963 

strongest  faradic  currents  fail  to  produce  response.  When  galvanic  currents 
fail  to  excite  contractions,  the  treatment  ought  to  be  persevered  in  for  a  long 
time,  using  very  strong  currents  at  the  onset,  gradually  reducing  them  as 
contractiUty  returns.  Remak,  who  especially  advocated  the  use  of  the  con- 
tinuous current,  advised  placing  the  positive  pole  in  the  front  of  one  mastoid 
process  and  the  negative  pole  on  the  opposite  side  of  the  neck,  near  the 
spinous  process  of  the  vertebrae,  not  higher  than  the  fifth  cervical,  by  which 
he  produced  the  contractions  already  described  as  diplegic  in  the  fingers  and 
other  paralyzed  parts.  Galvanization  of  the  sympathetic  has  been  apparently 
useful  in  the  hands  of  some,  Erb  reporting  a  case  of  complete  cure. 

Massage  is  especially  important,  and  should  be  used  in  connection  with 
electricity,  but  at  a  different  time  of  day.  Eulenberg  refers  to  a  case  said 
to  have  been  brought  to  a  standstill  by  it. 

Hypodermic  injections  of  strychnin,  from  i-ioo  to  1-40  grain  (0.0005 
to  0.002  gm.),  are  said  to  have  arrested  the  disease  011  the  authority  of 
Gowers. 

In  families  in  which  a  hereditary  tendency  exists  prophylactic  treatment 
should  be  used.  It  should  include  hygienic  measures  of  the  kind  already 
referred  to  and  the  avoidance  of  undue  fatigue  and  exposure,  and  in  the 
selection  of  an  occupation  these  matters  should  be  kept  in  view.  On  the 
supposition  that  the  disease  is  a  purely  local  one,  gymnastics  involving  the 
exercise  of  the  groups  of  muscles  prone  to  attack  are  indicated,  but  assume 
less  importance  from  the  standpoint  that  it  is  a  spinal  cord  disease.  At  the 
same  time  the  patient  should  have  the  benefit  of  any  doubt  in  the  pathogeny, 
and  as  gymnastics  are  eminently  calculated  to  improve  the  general  health  and 
thus  indirectly  to  avert  disease,  their  use  is  indicated  on  these  grounds. 


DISEASES  OF  THE  BRAIN 

LOCALIZATION  OF  CEREBRAL  DISEASE. 

Synonyms. — Cerebral  Localisation;   Relation    of   Locality    to   Symptoms; 
Topical  Diagnosis  of  Cerebral  Lesions. 

Physiology. — The  brain  is  the  organ  of  consciousness  and  of  percep- 
tion of  impressions  and  sensations — o£  memory,  of  thought,  of  origination 
of  voluntary  motion,  and  of  speech.  It  is  also  the  seat  of  the  instinctive 
acts.  It  has  been  learned  from  clinical  observation  in  connection  with 
studies  at  the  autopsy  table  and  from  experiment  that  certain  parts  of  the 
cortex  are  concerned  with  corresponding  offices,  especially  motion,  speech, 
vision,  and  hearing,  so  that  from  the  presence  of  given  symptoms  the  involve- 
ment of  corresponding  localities  may  be  inferred.  Allusion  has  already  been 
made  to  the  subject  of  topical  diagnosis,  on  page  842.  Such  diagnosis,  it  is 
important  to  remember,  gives  no  information  as  to  the  nature  of  the  lesion, 
the  result  being  the  same  whether  it  be  abscess,  hemorrhage,  or  softening. 
We  are  simply  informed  that  such  and  such  area  is  involved. 

Historical. — As  early  as  1825  Botiillaud  asserted  that  derangements  of  speech  are 
produced  only  by  disease  of  the  anterior  lobes  of  the  brain.  In  1836  Marc  Dax,  also  a 
French  physician,  pointed  out  that  aphasia  was  caused  only  by  lesions  in  the  left 
half  of  the^brain.  In  1861  Broca  announced  that  aphasia  results  from  a  lesion  of  the 
third  left  frontal  convolution,  which  was  accordingly  called  the  convolution  of  Broca. 


964 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


More  recent  observations  show  that  it  is  the  posterior  part,  or  the  pars  opercitlaris — 
the  part  of  the  frontal  lobe  covering  the  island  of  Reil,  which  is  the  speech  center, 
and,  further,  that  lesions  here  are  the  cause  of  motor  aphasia  only.  In  1S70  Fritsch 
and  Hitzig  published  the  results  of  their  experiments  in  irritating  the  surface  of  the 
brain  in  animals,  such  irritation  being  followed  by  muscular  contractions  in  definite 
portions  of  the  opposite  side  of  the  body.  These  observations  were  rapidly  confirmed 
and  extended  in  further  experiments  by  Meynert  and  Flechsig  among  anatomists 
Ferrier,  Munk,  Goltz,  and  others  among  physiologists,  and  Charcot,  Nothnagel, 
Hughlings  Jackson,  and  Horsley  among  clinicians.  Our  knowledge  in  this  depart- 
ment is,  however,  still  inexact,  and  is  likely  to  be  altered  as  well  as  increased  by 
further  studies. 

I.  The  Motor  Areas  of  the  Cortex. 

An  examination  of  the  following  illustrations  (Figs.  113  and  114)  from 
Ecker  will  furnish  a  sufficient  knowledge  of  the  gyri  and  sulci  of  the  sur- 
face of  the  brain,  which,  therefore,  need  no  further  description  in  the  text. 

Functional  Assignments. — The  motor  region  is  made  up  of  the  two 
central  convolutions,  anterior  central  and  posterior  central,  also  known  as 
ascending  frontal  and  ascending  parietal,  the  posterior  part  of  the  three 
frontal  convolutions,  the  upper  part  of  the  parietal  lobe  adjoining  the  ascend- 
ing parietal  convolution  and  the  paracentral  lobule  (Fig.  114)  on  the  median 


MINOBLINONESS., 


MEMOKV  OP 
'p<zrte6o.  occtp 


AIOTOK  SPeiCH  BKOCAS  CONt'OlUTK. 

■SCNSOKY  SP££Cf/ 


Word  deafness 


Fig.  113. — Lateral  Aspect  of  the  Brain — {after  Ecker,  modified). 


surface  of  the  hemisphere.  All  diseases  which  destroy  any  considerable  por- 
tion of  this  cortical  area  invariably  produce  paralysis  of  the  opposite  half  of 
the  body,  while  no  matter  how  extensive  the  destructive  processes  elsewhere 
in  the  cortex,  motion  remains  intact  if  this  is  not  touched.  It  is  more  than 
likely,  however,  that  an  acute  cortical  lesion  sufficient  to  involve  all  the 
centers  and  cause  total  hemiplegia  would  be  fatal,  while  a  smaller  lesion, 
extending  into  the  white  matter,  involving  fibers  coming  from  uninjured  por- 
tions of  the  cortex,  might  produce  a  more  extensive  palsy  than  a  purely  cor- 
tical lesion. 


LOCALIZATION  OF  CEREBRAL  DISEASE. 


965 


We  can  even  point  out  separate  regions  which  act  as  separate  centers 
for  various  groups  of  muscles.  The  center  for  the  movements  of  the  facial 
muscles  lies  at  the  lower  end  of  the  central  convolutions,  and  particularly 
of  the  anterior  central  convolution.  (Fig.  115.)  Near  by  and  lower  down  is 
the  center  for  movements  of  the  tongue  and  vocal  cords,  while  the  center  for 
the  movements  of  the  arm  lies  somewhat  higher  than  that  for  the  face — that 
is,  about  the  middle  of  the  anterior  central  convolution.  From  above  down- 
ward the  various  segments  are  represented  as  follows :  Shoulder,  elbow, 
wrist,  fingers — the  index-finger  and,  lowest  of  all,  the  thumb.  The  center 
for  the  leg  lies  in  the  uppermost  part  of  the  central  convolutions,  but  mostly 
in  the  paracentral  lobule.  Alost  anterior  is  the  hip,  next  the  knee  and  ankle, 
next  the  great  toe,  the  center  for  the  movement  of  which  surrounds  the  upper 
end  of  the  fissure  of  Rolando ;  still  further  back  are  the  centers  for  the  small 
toes.  The  centers  for  the  trunk  are  situated  in  the  paracentral  lobule  in  the 
marginal  gyrus  just  within  the  longitudinal  fissure.  The  different  regions 
are  not  sharply  defined,  but  merge  into  one  another. 


Cyrus  cleniatus 


Fig.  114. — Aspect  of  the  Median  Surface  of  the  Cerebrum  as  it  appears  when  the  Two 

Hemispheres  are    Separated — {after  Ecker). 

The  gyri  and  fissures  are  indicated  by  the  lettering. 


As  to  the  so-called  niiisciilar  sense,  it  has  been  believed  that  it  resides 
also  in  the  motor  area,  while  there  have  been  those  who  have  claimed  for  it 
also  a  separate  and  different  localization.  M.  Allen  Starr  and  A.  J.  McCosh  * 
have  reported  a  case  of  injury  wnth  symptoms  which  go  to  prove  the  latter 
view  and  to  show  that  the  seat  of  the  muscular  sense  is  "  a  spot  in  the  brain 
about  at  the  junction  of  the  superior  and  inferior  parietal  convolutions, 
clearly  posterior  to  the  posterior  central  convolution."  The  so-called  mus- 
cular sense  is  probably  largely  represented  in  the  parietal  lobe. 

These  cortical  motor  areas  are  united  with  spinal  -centers  by  nerve-fibers 
which  proceed  from  cell  to  cell  in  each,  without  connection  with  intervening 
cells.  Their  route  is  through  the  white  matter  of  the  hemispheres,  where 
they  form  the  corona  radiata,  the  fibe^rs  of  which  converge  to  the  internal 
capsule  which  lies  between  the  optic  thalamus  and  the  caudate  nucleus  on 

*  "  Amer.  Jour,  of  the  Med.  Sciences,"  November,  1894,  p-  520. 


966 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


the  inside,  and  the  lenticular  nucleus  on  the  outside.  The  anterior  portion 
of  the  capsule — the  knee — is  occupied  by  the  fibers  from  the  face,  tongue, 
eye,  and  speech  centers ;  behind  these  lie  the  fibers  from  the  upper  extremities, 
while  those  from  the  lower  extremities  occupy  the  middle  of  the  posterior 
part.  Thence  the  fibers  of  the  motor  path  pass  into  the  crus  cerebri  through 
its  middle  third,  then  through  the  pons,  covered  by  the  superficial  transverse 
fibers  of  this  body,  into  the  medulla  oblongata,  of  which  they  form  the 
anterior  pyramids.  At  the  lower  portion  of  the  medulla  oblongata  a  large 
portion  of  these  pyramidal  fibers  cross  over  into  the  opposite  half  of  the 
spinal  cord,  constituting  the  crossed  pyramidal  tract  of  the  lateral  column, 


Atmregion        \     Leg  region, 

20  19  18  17  16  IS  14  13  12  mo  9 


y^fter  disintegration  of 
this  spot, mo/ements  of 
the  fovr finders  cease.  The 
thumb  remains  free. 


20    19  18  17  16  15  14  13  L2  11  10  9 

Head  region  (face) 

Fig.  115. — Lateral  Aspect  of  the  Brain — {after  v.  Monakoiv). 
Lateral  aspect  of  the  human  cerebral  hemisphere.  Motor  fields  (principal  foci) 
after  Allen  Starr,  W.  W.  Keen,  Charles  K.  Mills,  Victor  Horsley,  and  the  author's 
observations,  y.  Spot  on  the  posterior  central  convolutioiis  whose  isolated  irritation 
causes  thumb  movements,  and  whose  destruction  in  a  case  of  cranial  injury  caused 
continued  defect  of  motion  of  the  thumb  and  finger;  also  derangement  of  the 
stereognostic  sense.  The  lines  q-g,  lo-io,  etc.,  to  20-20  indicate  certain  planes  of 
section  in  other  figures  in  Monakow's  monograph  in  Nothnagel's  system — {after 
Monakow). 

while  a  small  bundle  of  fibers  descends  into  the  anterior  column  of  the  same 
side,  forming  the  direct  pyramidal  tract,  or  Tiirck's  column ;  some  fibers 
probably  pass  to  the  lateral  column  of  the  same  side.  Both  pyramidal  tracts 
diminish  in  bulk  as  they  descend,  because  they  give  off  fibers  which  pass  into 
the  gray  matter,  dividing  and  subdividing,  to  come  into  contact  with  the  pro- 
toplasmic processes  which  are  continuous  with  the  large  nerve-cells  of  the 
anterior  cornua. 

These  motor  fibers  form  the  upper  or  cerebrospinal  segment  of  the 
motor  system.  Between  the  motor  nerve-cells  in  the  anterior  cornua  and 
the  muscles  to  which  the  motor  nerve-fibers  are  distributed  is  the  lovcer  or 
sp'mo-muscular  segment.     In  response  to  the  law  already  mentioned  as  to 


LOCALIZATION  OF  CEREBRAL  DISEASE. 


967 


the  nutritive  independence  of  each  neuron,  each  of  these  segments  has  a 
certain  nutritional  independence,  depending  for  its  integrity  upon  the  in- 
tegrity of  its  neuron,  the  upper  or  cerebral  depending  upon  the  cortical  cells 
and  the  lower  upon  the  large  cells  in  the  anterior  cornua. 

Lesions  of  the  Upper  Motor  or  Cerebrospinal  Segment. — If,  therefore, 
the  cortical  cells  of  the  motor  area  degenerate,  the  fibers  attached  to  them 
will  waste  as  far  as  the  beginning  of  the  lower  segment,  and  if  the  cells  in 
the  latter  degenerate  or  are  cut  off,  not  only  do  the  nerve-fibers  below  them 
waste,  but  the  muscles  to  which  they  are  distributed  as  well.  Accordingly, 
all  the  cases  of  paralysis  due  to  destructive  disease  in  the  motor  cortical 


^pr  \  eq_ 


Fig.  116. — The  Motor  Tract — {after  Starr). 
S,  S.  Fissure  of  Sylvius.  NL,  NL.  Lenticular  nucleus.  OT,OT.  Cptic  thalamus. 
Nc,  NC.  Caudate  nucleus.  C.  Crus.  P.  Pons.  Af.  Medulla.  O.  Olivary  body. 
The  tracts  for  the  arm,  leg,  and  face  gather  in  the  capsule  and  pass  together  to 
the  lower  pons,  where  the  face  fibers  cross  to  the  opposite  seventh  nerve  nucleus, 
while  the  others  pass  to  the  lower  medulla,  where  they  partially  decussate,  to 
enter  the  lateral  columns  of  the  cord.  The  non-decussating  fibers  pass  into  the 
anterior  median  columns. 

region  have  been  found  associated  with  descending  degeneration  of  the 
motor  tract  previously  outlined,  into  the  direct  pyramidal  tract  in  the  anterior 
column  of  the  cord  on  the  same  side,  and  the  crossed  pyramidal  tract  in  the 
lateral  column  of  the  other  side.  At  the  same  time  the  paralysis  is  accom- 
panied by  a  spastic  condition,  manifested  by  an  exaggeration  of  the  tendon 
reflexes  and  an  increase  in  the  tension  of  the  muscles,  ascribed  to  a  loss  of 
the  inhibitory  control  exerted  by  the  cells  of  the  cortex  in  the  normal  state. 
This  explanation,  however,  is  not  entirelv  satisfactory.  In  other  respects 
the  paralysis  due  to  cortical  lesion  do^s  not  differ  from  that  due  to  focal  dis- 
ease lower  down  in  the  upper  tract,  except  that  the  latter  is  apt  to  involve 
more  muscles  because  of  the  compactness  of  the  tract  at  this  point.  Atrophy 
has  been  observed  in  muscles  paralyzed  by  disease  of  the  upper  segment,  but 


968 


DISEASES  OF  THE  XERVOUS  SYSTEM. 


the  reaction  of  degeneration  does  not  occur.  Lesions  of  the  cortex  arc 
usually  hmited,  causing  correspondingly  limited  paralvsis  and  even  mono- 
plegias, never,  however,  affecting  less  than  a  whole  limb  or  a  segment  of  a 
hmb.  A  lesion  may  involve  two  centers  lying  close  to  each  other,  producing 
paralysis  of  the  face  and  arm  or  of  the  arm  and  leg,  but  rarely  of  the  face 
and  leg  without  involvement  of  the  arm.  It  may  happen  that  the  whole  cor 
tex  is  involved,  producing  paralvsis  of  one  side— cortical  hemipleo-ia 

Fcls         -   ■  --"  ^    t,    • 


Med.  oblong 


Muscle 


Fig.  ii7.-Sensory  and  Motor  Paths  in  the  Spinal  Cord— (a//er  Barker). 

Description  of  Fig.  117. 

^^"^^iTd^^A-  ^^^^'^^•.  transverse  section  through  the  medulla  oblongata  at  the  level 

tVLfT^^'"''    emniscorum  ;  Med.  sp.  pars  cerv.^  transverse  section  through 

through  Si  Zru'   P^'-%^e^^i^^l's:  i^^d.    sp.  pars  lumb.,  transverse  sectifn 

tnrough  the  medulla  spinalis  pars  lumbalis  ;  Med.    si    -Aars  thorac     tran^vpr-^f. 

surface.        °"^''   "^^  "''^""'    'P'""^"  P"^^   thoracafis  f  JJ^^.    .ij^^.^senso?^ 


LOCALIZATION  OF  CEREBRAL  DISEASE.  969 

J?ed. — The  areas  of  white  matter  in  the  spinal  cord  and  medulla  oblongata  occupied 
by  sensory  axons  are  indicated  by  red  lines  or  dots.  The  cell  bodies  and  axons 
of  sensory  neurons  are  also  colored  red.  D.  /.,  decussatio  lemniscorum  ;  D.  r.  /., 
dorsal  root  fiber  (central  axon  of  peripheral  centripetal  neuron);  K  c,  axon  of 
fasciculus  cuneatus  ;  F.  els.,  axon  of  fasciculus  cerebellospinalis  (direct  cerebellar 
tract);  F.  vl.  G.,  axon  of  fasciculus  ventrolateralis  [Gowersi]  :  St.  i.  /.,  axons  of 
stratum  ifiterolivare  leranisci  ;  /,  cell  bodies  of  peripheral  centripetal  neurons 
(situated  in  the  spinal  ganglia);  /',  ascending  limb  of  bifurcated  central  axon  of 
peripheral  sensory  neuron  extending  from  the  pars  lumbalis  of  the  spinal  cord 
to  the  medulla  oblongata,  being  situated  first  in  the  fasciculus  cuneatus,  in 
higher  levels  of  the  cord  in  the  fasciculus  gracilis,  and  finally  terminating  in  the 
nucleus  funiculi  gracilis.  /",•  ascending  limb  of  bifurcated  central  axon  of 
peripheral  sensory  neuron  pertaining  to  the  thoracic  portion  of  the  spinal  cord. 
It  enters  the  fasciculus  cuneatus,  and  passing  upward,  approaches  the  medial 
border  of  this  fasciculus  without,  however,  entering  the  fasciculus  gracilis.  It  is 
seen  to  terminate  ultimately  in  the  nucleus  funiculi  cuneati.  /'",  ascending  limb 
of  bifurcated  central  axon  of  peripheral  sensory  neuron  pertaining  to  the  pars 
cervicalis  of  the  spinal  cord.  It  passes  upward  in  the  fasciculus  cuneatus  to 
terminate  at  a  level  higher  than  that  indicated  in  the  diagram.  /"",  reflex 
collaterals  extending  from  the  central  axons  (or  their  subdivisions)  of  the  periph- 
eral sensory  neurons  to  the  ventral  horns  of  the  spinal  cord,  there  coming  into 
conduction  relation  with  the  cell  bodies  and  dendrites  of  the  lower  motor 
neurons,  i,  collaterals  from  the  axons  of  the  fasciculus  cuneatus  to  the  nucleus 
dorsalis  [Clarkii]  ;  2,  cell  bodies  in  substantia  grisea  giving  rise  to  axons  of  the 
fasciculus  ventrolateralis  [Gowersi]  ;  2'',  axons  of  fasciculus  ventrolateralis 
[Gowersi]  ;  j,  cell  body  in  nucleus  dorsalis  [Clarkii]  giving  rise  to  axon  of 
fasciculus  cerebellospinalis  ;  j',  axon  of  fasciculus  cerebellospinalis  (direct  cere- 
bellar tract);  4,  cells  of  nucleus  funiculi  gracilis  giving  rise  to  axons  of  fibrae 
arcuatcE  internae  which  undergo  decussation  (decusatio  lemniscorum)  in  the 
raphe  ;  4  ,  continuation  of  axons  of  fibrae  arcuatae  internse  after  decussation. 
They  run  cerebralward  in  the  stratum  interolivare  lemnisci.  5,  cells  of  nucleus 
funiculi  cuneati  which  give  rise  to  axons  of  fibrae  arcuatae  internae  which  undergo 
decussation  (decussatio  lemniscorum)  in  the  raphe,  j',  continuation  of  axons  of 
fibrae  arcuatae  internae  after  decussation.  Having  had  their  origin  in  the  nucleus 
funiculi  cuneati  of  the  opposite  side,  they  now  run  forward  in  the  stratum 
interolivare  lemnisci. 

Blue. — The  areas  of  white  matter  in  the  spinal  cord  and  medulla  oblongata  indicated 
by  parallel  blue  lines  correspond  to  the  position  of  the  fasciculi  cerebrospinales 
(pyramidales).  The  cell  bodies  and  axons  of  the  lower  motor  neurons  are  also 
printed  in  blue.  F.  es.  I.,  fasciculus  cerebrospinalis  lateralis  or  lateral  pyramidal 
tract  ;  F.  es.  v.,  fasciculus  cerebrospinalis  ventralis  or  ventral  pyramidal  tract; 
F.  /•/.,  fasciculi  pyramidales  in  the  medulla  oblongata;  /'j/.,  pyramis  medullas 
oblongatae  ;  v.  r.,  radix  ventralis,  nervi  spinalis  ;  /,  cell  bodies  of  lower  motor 
neurons  situated  in  the  ventral  horns  of  the  gray  matter  of  the  spinal  cord  giving 
off  axons  which  go  to  form  the  ventral  roots  of  the  spinal  nerves  ;  j',  axons  of 
fasciculi  pyramidales  which  undergo  decussation  in  the  decussatio  pyramidum 
and  pass  down  in  the  fasciculus  cerebrospinalis  lateralis  of  the  opposite  side  of 
the  spinal  cord  to  terminate  in  the- ventral  horns  of  the  cervical  region.  They 
throw  the  lower  motor  neurons  which  innervate  the  musculature  of  the  upper 
extremity  of  one  side  under  the  influence  of  the  pallium  of  the  opposite  side.  4  , 
axons  of  fasciculi  pyramidales  which  undergo  decussation  in  the  decussatio 
pj'ramidum  and  pass  down  in  the  fasciculus  cerebrospinalis  lateralis  of  the 
opposite  side  of  the  spinal  cord  to  terminate  in  the  ventral  horns  of  the  lumbo- 
sacral region.  They  throw  the  lower  motor  neurons  which  innervate  the 
musculature  of  the  lower  extremity  of  one  side  of  the  body  under  the  influence  of 
the  pallium  of  the  opposite  side.  4' ,  axon  of  fasciculi  pyramidales  which  does 
not  undergo  decussation  in  the  decussatio  pyramidum,  but  passes  down  in  the 
fasciculus  cerebrospinalis  lateralis  of  the  same  side  (homolateral  fiber).  4" ,  axon 
of  fasciculi  pyramidales  which  does  not  undergo  decussation  in  the  decussatio 
pyramidum,  but  passes  down  in  the  fasciculus  cerebrospinalis  ventralis  to 
terminate  in  the  ventral  horn  of  the  same  side.  It  would  throw  the  lower  motor 
neurons  governing  a  portion  of  the  musculature  of  one  side  under  the  influence 
of  the  pallium  of  the  same  side.  It  is  probable  that  in  addition  to  these  fibers  of 
the  fasciculus  cerebrospinalis  ventralis,  which  terminate  in  the  ventral  horn  of 
the  same  side,  there  are  other  fibers  (not  shown  in  the  diagram)  which,  passing 
through  the  ventral  commissure,  terminate  in  the  ventral  horn  of  the  opposite 
side.     (See  text.) 

Yellow.— Q€[\  bodies,  axons,  collaterals,  and  terminals  belonging  to  the  fasciculi 
proprii  of  the  ventral  and  lateral  funiculi — {Barker). 

Such  is  the  effect  of  destructive  or  negative  lesion  of  the  cortex.     Quite 
different  is  that  of  irritative  lesions.     These  produce   convulsive   seizures 


970  DISEASES  OF  THE  NERVOUS  SYSTEM. 

known  as  Jacksonian  or  cortical  epilepsy,  characterized  by  convulsions  be- 
ginning in  a  single  muscle  or  group  of  muscles  and  proceeding  in  a  definite 
order  to  the  involvement  of  other  muscles  corresponding  to  portions  of  the 
cortex  affected.  Thus,  the  convulsions  may  begin  in  the  face,  and  extend 
thence  to  the  arm  and  thence  to  the  leg.  The  convulsions  may  also  be  accom- 
panied by  sensory  symptoms  and  followed  by  weakness  of  the  muscles 
involved. 

In  point  of  fact  most  lesions  of  the  cortex  are  both  destructive  and  irri- 
tative, consisting  in  the  destruction  of  nerve-cells  in  one  center  and  increas- 
ing the  activity  of  cells  of  neighboring  centers. 

Lesions  of  the  upper  segment  include  hemorrhages,  tumors,  abscesses, 
injuries,  inflammations,  and  degenerations  involving  the  brain  and  spinal 
cord. 

Lesions  of  the  Loivcr  or  Spinomiiscidar  Segment. — Here,  as  in  the 
upper  segment,  the  destructive  lesions  produce  motor  paralysis.  The  added 
peculiarity  is.  however,  a  degeneration  of  the  muscles  as  well  as  the  nerve- 
fibers  distributed  to  them  from  the  motor  cells  of  the  anterior  cornua,  as 
evidenced  by  the  wasting  of  the  muscles,  and  further  characterized  by  the 
presence  of  the  reaction  of  degeneration  described  on  page  857.  In  these 
lesions  there  is  also  a  loss  of  reflex  excitability  in  the  areas  supplied  from 
the  segments  destroyed,  the  reflexes  are  lost,  and  there  is  reduced  muscular 
tension.  Lesions  of  the  lower  segment  may  also  cause  paralysis  of  limited 
groups  of  muscles  when  confined  to  limited  areas  of  the  cord. 

Irritative  lesions  of  the  lower  segment  do  not  occur  unless  we  regard  as 
the  result  of  such  the  slow  atrophy  of  the  ganglion  cells  of  the  anterior 
cornua  in  progressive  spinal  muscular'  atrophy,  and  consider  the  fibrillary 
contractions  found  in  this  affection  as  a  result  of  the  stimulation  of  these 
cells  in  their  slow  degeneration. 


II.  Sensory  Areas  of  the  Cortex   and   Sensory    Paths. 

Our  knowledge  of  the  sensory  areas  is  much  less  definite  than  that  of 
the  motor.  Beginning  at  the  periphery,  we  learn  that  sensory  fibers  emanat- 
ing from  tactile  surfaces,  like  the  skin,  promptly  and  for'  the  most  part 
become  associated  with  motor  nerve  filaments  in  the  lower  motor  segment, 
the  union  of  both  constituting  a  mixed  nerve.  The  two  sets  of  fibers,  how- 
ever, separate  again  within  the  spinal  canal,  the  motor  filaments  are  con- 
tinuous with  the  anterior  roots,  and  the  sensory  enter  the  cord  by  the  pos- 
terior, on  which  is  a  ganglion.  ^  The  areas  whence  the  posterior  roots  gather 
their  nerves  will  be  found  in  Starr's  table  on  page  979.  The  pre- 
cise routes  of  sensory  impressions  to  the  brain  are  not  determined,  but  experi- 
ment and  clinical  pathology  show  that  probably  a  considerable  number  of 
sensory  fibers  cross  at  once  and  ascend  to  the  brain  in  the  opposite  half  of 
the  cord.  The  following  seems  to  be  the  results  of  the  latest  histological 
studies : 

The  sensory  nerve-fibers,  entering  the  spinal  cord  from  the  spinal  gan- 
glion on  the  posterior  root,  pass  to  the  posterior  columns  and  divide  dichoto- 
mously,  one  branch  passing  upward,  the  other  downward.  From  these 
longitudinal  branches  arise  short  transverse  branches  which  penetrate  the 
gray  matter  and  end  in  the  tufts  or  arborizations  which  characterize  the  dis- 
tributary ends  of  nerve  filaments.     These  tufts  or  arborizations  in  which  the 


LOCALIZATIOX  OF  CEREBRAL  DISEASE.  971 

sensory  fiber  ends  in  the  gray  matter  are  apparently  in  close  contact,  but  pos- 
sibly not  in  direct  anatomical  relation  Avith  the  ganglion  cells  in  the  anterior 
and  posterior  horns  and  in  Clarke's  column.  From  these  ganglion  cells 
other  nerve-fibers  are  projected,  the  course  of  which  is  not  clear  except  as  to 
those  which  pass  into  the  anterior  roots,  and  those  from  Clarke's  column 
which  pass  over  to  form  the  ascending  cerebellar  tract.  Some  pass  up  the 
anterolateral  columns,  some  decussate  through  the  gray  commissure  with 
fibers  from  the  opposite  side.  Alan)-  fibers  from  the  posterior  roots  ascend  in 
the  posterior  columns  of  the  same  side  and  decussate  in  the  medulla  oblongata 
to  form  the  fillet  or  lemniscus.  Further  confirmation  of  this  course  is  found 
in  the  fact  that  if  a  posterior  ner\-e-root  is  cut,  the  ascending  Wallerian 
degeneration  is  seen  only  in  the  posterior  columns  of  the  same  side,  and 
ceases  in  the  nuclei  of  the  funicnlns  gracilis  and  funiculus  cuneatiis,  which  are 
ganglionic  bodies  in  the  medulla  oblongata  beginning  another  stage  of  the 
sensorv-  path.  It  is  questionable  whether  there  are  separate  strands  of  con- 
duction for  tactile,  thermal,  or  painful  impressions.  The  experiments  of 
Gotch,  Horsley,  and  Mott  also  go  to  show  that  mild  sensory  impressions  pass 
tip  the  same  side  in  the  posterior  columns,  while  impressions  made  by  pain, 
cold,  and  heat  radiate  into  the  gray  matter  of  the  cord,  and  through  these 
probably  again  into  the  white  conducting  tracts  of  the  lateral  and,  possibly, 
opposite  posterior  column.  Hence  pain  and  painful  temperature  sensations 
are  only  of  different  degrees,  and  excite  a  wider  and  more  complex  nervous 
mechanism  than  simple  touch.  Whence  not  only  diseases  involving  exten- 
sively the  gray  matter,  as  syringomyelia,  cause  alteration  in  the  temperature 
sense,  but  also  diseases  of  peripheral  parts,  as  pachymeningitis  and  neuritis. 
Many  hold  very  different  views  from  those  just  expressed  and  believe  that 
different  fibers  exist  for  the  conduction  of  the  dift'erent  forms  of  sensation. 

Many  investigators  believe  that  all  the  sensory  fibers  of  the  opposite  side 
of  the  body  are  collected  in  the  posterior  third  of  the  posterior  limb  of  the 
internal  capsule,  just  behind  the  motor  fibers  of  the  upper  segment.  Dejerine 
utterly  rejects  this  teaching,  and  holds  that  the  sensory  fibers  are  mingled 
with  the  motor  in  the  posterior  limbs  of  the  internal  capsule. 

jN.Iuch  doubt  exists  as  to  the  seat  of  the  sensory  areas  in  the  cortex. 
Florsley  suggested  that  the  muscular  and  tactile  senses  are  localized  in  the 
motor  cortex,  and  that  two  of  the  three  principal  layers  of  cells  in  this  region 
subserve  these  functions.  The  late  experimental  studies  of  ]\Iunk  lead  to 
the  same  conclusions — that  the  so-called  "  sphere  of  sensation  "  lies  in  the 
same  region  as  the  motor  centers  of  the  cortex.  Dana  also  has  shown  that 
many  lesions  of  the  motor  area,  especially  in  the  hinder  part,  are  associated 
with  anesthesia,  while  Ferrier  considers  the  hippocampal  convolution,  and 
Schafer  the  gyrus  fornicatus,  as  the  sensory  center  in  the  cortex.  Clinical 
evidence  on  this  point  is  not  uniform.  In  some  cases  of  motor  paralysis 
there  is  undoubted  simultaneous  disturbance  of  sensation,  in  others  not. 
By  some  the  parietal  lobe  is  considered  an  important  part  of  the  sensory 
area.  The  muscular  sense  is  also  sometimes  impaired  in  paralyzed  limbs, 
in  consequence  of  which  the  patient  cannot  tell  with  his  eyes  closed  the 
position  of  the  aft'ected  limb. 

Among  the  cortical  areas  covering  sensation  must  be  included  those 
for  sight,  hearing,  smell,  and  taste,  which  will  be  considered  in  connection 
with  affections  of  the  peripheral  nerve.  Suffice  it  to  say,  briefly,  that  the 
auditory  center  is  located  in  the  first  temporal  gyrus,  the  visual  in  the 
occipital  lobe,  the  cortical  visual  center  being  on  the  mesial  surface  in  the 


972  DISEASES  OF  THE  NERVOUS  SYSTEM. 

cnneiis,  especially  about  the  calcarine  ("  calcar,"  a  spur)  fissure,  where 
are  represented  the  opposite  half  visual  fields. 

Lesions  of  the  Sensory  Tract. — These  may  also  be  destructive  or 
irritative.  Destructive  lesious  would,  of  course,  destroy  sensation  in  the 
part  whence  the  nervous  supply  comes  to  the  point  of  lesion.  Most  fre- 
quently it  is  an  injury  to  a  peripheral  nerve,  though  loss  of  sensation  is 
rarely  complete  in  the  part  to  which  such  nerve  is  distributed,  because  that 
area  may  receive  sensory  nerves  from  another  segment  of  the  spinal  cord. 
Complete  transverse  section  of  the  spinal  cord  itself  causes  complete  anes- 
thesia in  the  parts  supplied  from  the  segment  below  the  injury.  The  effects 
of  a  lesion  invading  one-half  of  the  cord  are  detailed  an  page  895. 

Irritative  lesions  of  the  sensory  path  cause  paresthesias,  including  formi- 
cation, tingling,  numbness,  and  finally  pain  corresponding  to  the  degree 
of  irritation.  The  last  is  commonly  due  to  irritation  in  the  course  of  a 
peripheral  nerve,  though  it  may  also  be  caused  by  irritation  to  the  sensory 
path  within  the  central  nervous  system. 


CORTICAL    AREAS    COVERING    SPEECH. 
the  various  forms  of  aphasia  and  their  anatomical  lesions. 

It  has  already  been  stated  that  almost  our  first  accurate  knowledge  of 
cerebral  localization  was  the  discovery  by  Broca,  in  1861,  that,  derange- 
ments of  speech  result  from  lesions  of  the  third  or  inferior  left  frontal  con- 
volution. The  loss  of  power  to  comprehend  words  correctly  and  to  use 
them  properly  is  covered  by  the  general  term  aphasia.  Further  derange- 
ment consists  in  inability  to  articulate  words,  and  is  due  to  lesions  of  nuclei 
situated  for  the  most  part  in  the  pons  and  medulla  oblongata,  regulating  the 
action  of  the  vocal  cords,  the  tongue,  and  the  lips,  and  is  known  as  anarthria 
or  dysarthria. 

The  study  of  the  phenomena  of  aphasia  will  be  facilitated  by  a  brief 
review  of  the  conditions  of  acquired  language.  Language  is  acquired  by 
the  child  gradually  through  imitation.  Thus,  when  the  mother  teaches  it 
to  say  "  cat  "  or  "  bell  "  or'  "  papa,"  she  names  the  word,  and  its  sound 
impresses  the  distribution  of  the  auditory  nerve,  m  (see  diagram,  p.  118) 
whence  it  passes  to  the  accoustic  center,  x,  and  thence  to  the  sensory  speech 
center,  a,  in  the  first  or  upper  temporal  convolution,  where  it  is  stored  as  a 
sound  memory.  From  this  it  passes  from  behind  forward  along  the  asso- 
ciation fibers  to  h,  the  motor  speech  center  in  the  left  inferior  frontal  convo- 
lution (Broca's  center,  propositionizing  center  of  Broadbent),*  whence  the 
muscles  of  articulation  are  put  into  operation  and  the  word  is  spoken.  Thus, 
the  speech  mechanism  consists  of  receptive,  perceptive,  and  emissive  centers. 

The  development  of  voluntary  speech  in  the  child  continues  through 
the  accumulation  of  associated  ideas  in  the  perceptive  and  emissive  centers, 
a  and  h.  The  ivord  image  or  picture  which  is  the  foundation  of  every  word 
is  made  up  of  the  sum  of  a  number  of  partial  conceptions  of  memory  pic- 
tures acquired  by  experience  and  stored  for  further  use  in  the  different  sen- 
sory areas  of  the  cerebral  cortex.     Thus,  the  memory  of  the  sound  of  a 

♦  That  is,  the  center  where  thoughts  are  set  in  a  framework  of  words,  but  through  which 
utterance  is  not  consummated  ;  whence  other  cortical  centers  are  necessary  to  motor  speech,  and 
these  are  found  caudad  of  Broca's  convolutions  at  the  foot  of  the  two  central  convolutions.  This 
region  Broadbent  calls  the  uttering  center. 


CORTICAL  AREAS  COVERIXG  SPEECH. 


973 


word  as  spoken,  the  memory  of  the  appearance  of  a  word  as  written  or 
printed,  as  well  as  the  muscular  movements  needed  to  speak  the  word  or 
write  it,  are  distinct  from  one  another  and  yet  associated.  Loss  of  one  of 
these  memory  pictures  or  derangement  in  their  association  impairs  the  in- 
tegrity of  the  word  image  and  produces  such  defects  in  the  use  of  the  word 
as  are  covered  by  the  different  varieties  of  aphasia.  These  derangements 
have  been  arranged  in  two  divisions,  according  as  the  defect  is  in  ( i )  the 
receptive  and  perceptive  and  (2)  emissive  function  of  the  brain,  the  former 
constituting  the  sensory  aphasias,  the  latter  the  motor. 

The    Physical    Basis    of    Thought  — Apraxia. 

A  word  is  a  means  of  expression  of  a  thought.  Thus,  when  we  say 
the  word  "  bell,"  with  a  full  conception  of  its  meaning,  such  conception 
or  mental  picture  is  made  up  of  as  many  distinct  partial  conceptions 
or  memory  pictures  as  there  are  special  senses,  these  conceptions  being- 
seated  in  the  most  diverse  parts  of  the  brain.  Especially  concerned  in 
the  case  of  the  bell  is  the  acoustic  conception,  c,  derived  from  its  sound; 
the  optic,  c'  from  its  appearance ;  the  tactile,  c,"  from  what  is  learned  by 
touch,  united  to  form  one  conception,  as  shown  in  Figure  119,  where  the 
partial  conceptions,  c,  c,'  c,"  among  others,  taken  together,  give  us  the  idea 
of  a  bell.     In  the  blind,  of  course,  the  sensory  perceptions  are  smell,  taste, 


a 


Emissive  in  third  fron- 
tal convolution. 


Y 
n 


Perceptive    in  first    tem- 
poral convokition. 


)X 


Receptive. 


VI 


Fig.  118. — Primitive   Speech  Apparatus  of  the  Child  in   Mechanical   Repetition   of 

Words,  according  to  Wernicke  and  Lichtheim. 

a.  Sensory  speech  center,     b.  Motor  speech  center,     x.  Acoustic  center  of  pure  sense 

of  hearing.     ;;^-.^■.  Route  to  acoustic  center,     d-n.  Motor  speech  tract. 


touch,  and  hearing  only.  The  schema  of  conscious  voluntary  speech  may 
be  still  further  simplified  by  combining  the  partial  conceptions,  c,  c'  and  c," 
into  one  single  point,  C  (Fig.  120),  gs  the  sum  of  intellectual  concepts,  m 
representing  any  of  the  special  senses — hearing,  vision,  smell,  etc. 

Broadbent  has  gone  a  step  further,  and  suggested  the  existence  of  a 
center  on  the  sensory  side  of  the  nervous  svstem,  to  which  converge  sen- 
sory fibers  from  all  the  receptive  centers  and  in  which  is  combined  all  the 


974 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


evidence  respecting  the  nature  of  the  object,  which  he  called  the  naming- 
ccnlcr.  He  suggested  a  locality  for  this  center  in  an  unnamed  lobule  on 
the  under  surface  of  the  temporal  lobe  near  its  junction  with  the  occipital 
lobe.  Charles  K.  Mills*  has  recently  reported  a  case  of  glioma  with 
autopsy  which  goes  to  confirm  Broadbent's  speculation  and  to  locate  the 
exact  position  of  this  center  in  the  third  temporal  convolution.  Its  correla- 
tive center  is  the  propositionicing  center  referred  to  on  page  972,  in  which 
names  or  nouns  are  set  in  a  framework  for  outward  expression  or  utter- 
ance. 

The  loss  of  these  memory  pictures  is  known  as  apraxia,  which  may 
be  defined  as  a  state  in  which  there  is  impairment  or  loss  of  the  power  to 


Optic  conception. 


Tactile  con- 
ception.   ^ 


Acoustic 
conception. 


)X 


Receptive. 


n 


m 


Fig.  119. — Wernicke's  Schema,  Showing  the  Association  of  the  Various  Partial  Con- 
ceptions to  Form  the  Whole  Conception  or  Word  Image  of  an  Object. 

For  the  sake  of  simplicity  only  three  partial  conceptions  and  three  sensory  areas  are 
shown,  instead  of  the  many  which  go  to  make  up  our  notions  of  complex  objects. 
The  letters  a,  b,  /;/,  and  n  haveL.the  same  application  as  in  the  previous  figure,  but 
X  may  indicate  the  seat  of  any  of  the  special  senses — hearing,  vision,  smell,  touch. 

recognize  the  nature  and  purpose  of  objects,  and  which  is  something  apart 
from  aphasia.  In  one  form  of  it  any  object,  such  -as  a  watch,  a  knife, 
or  a  spoon,  may  be  taken  up  and  handled  by  the  patient,  but  all  knowledge 
of  its  use  or  purpose  is  gone.  Such  a  condition,  when  dependent  on  los-s 
of  the  visual  memories,  was  well  named  by  Munk  mind-blindness.  A  per- 
son formerly  familiar  with  the  tick  of  a  watch  or  the  sound  of  a  bell  no 
longer  interprets  such  sounds  aright;  or  is  unable  to  follow  melodies  or 
appreciate  music  as  he  once  did.  Thus  we  have  mind-deafness,  or  auditory 
amnesia,  or  in  the  case  of  music,  aniusia.  Again,  the  odor  of  the  rose 
and  violet  no  longer  suggests  these  flowers,  giving  mind  anosmia;  or  the 


*Dercura,  "  Diseases  of  the  Nervous  System  "  by  American  authors,  iSgs,  p.  427. 


CORTICAL  AREAS  COVERING  SPEECH. 


97  S 


taste  of  an  orange,  mind  ageusia;  or  the  soft  feel  of  fur  or  velvet  gives 
no  notion  of  these  substances,  mind  atactilia.  For  the  sum  of  these  defects 
the  term  apraxia  is  now  used,  but  mind-blindness  and  mind-deafness  are 
the  most  important  subvarieties.  Apraxia  may  occur  alone,  but  it  is  usually 
associated  with  sensory  or  motor  aphasia.  In  simple  apraxia  the  patient 
may  be  able  to  read,  but  the  words  arouse  no  intelligent  impression  in  his 
mind.  Some  observations  go  to  show  that  the  lesion  in  mind-blindness  is  in 
the  siipramarginal  and  angular  gyri,  or  in  the  tracts  posterior  to  these  in  the 
white  matter  beneath  them ;  and  possibly  mind-blindness  only  occurs  when 
this  area  in  each  hemisphere  is  injured,  as  pointed  out  by  M.  Allen  Starr, 
in  the  left  hemisphere  in  right-handed  persons,  and  in  the  right  hemisphere 
in  those  left-handed.  Alind-blindness  is,  however,  at  times  functional  and 
transitory,  and  as  such  associated  with  many  forms  of  mental  disturbance. 
Starr  also  considers  it  probable  from  the  association  of  psychical  or  mind- 


Fig.  120. — Simplification  of  the  Schema  of  Voluntary  Speech   by  Uniting   the  Ideas 

into  the  point,  C,  and  Omitting  the  Acoustic  Center,  x. 

The  letters  have  the  same  meaning  as  in  Figures  ii8  and  119. 

deafness  with  the  form  of  aphasia  known  as  zvord-deafness,  to  be  considered 
presently,  that  mind-deafness  may  be  due  to  lesion  in  the  upper  temporal  con- 
volution, though  autopsies  are  wanting. 

There  are  as  many  varieties  of  apraxia  as  there  are  organs  of  sense,  but 
the  most  common  appears  to  be  psychical  or  mind-blindness,  generally  asso- 
ciated with  the  form  of  aphasia  known  as  word-blindness. 


Aphasia,  or  Loss  of  the  Faculty  of  Speech. 

Aphasia  is  sensory  or  motor  according  as  it  is  caused  by  a  loss  of 
memory  of  words,  or  by  an  inability  to  enunciate, — according  as  it  is  the 
receptive  or  the  emissive  center  which  is  at  fault. 


976 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Sensory  Aphasia,  including  Word-blindness,  Word-deafness, 
Amnesic  Aphasia. — By  zi.'ord-b!iiidncss  is  meant  loss  of  the  memory  of 
the  appearance  of  a  word.  In  this  condition  the  patient  does  not  recognize 
words  which  he  sees  on  the  written  or  printed  page,  and  although  he  may  be 
able  to  pronounce  them  after  hearing  them  or  write  them  at  dictation  or  copy 
them,  he  does  not  understand  what  he  reads  or  writes.  On  the  other  hand, 
figures  are  sometimes  recalled  when  words  are  forgotten,  and  the  patient  may 
even  be  able  to  solve  mathematical  problems  and  to  recognize  playing-cards. 
Word-blindness  may  occur  alone  or  with  motor  aphasia.  The  lesion  in  most 
cases  of  word-blindness  has  been  in  the  angular  and  supramarginal  gyri  on 
the  left  side,  as  located  by  Ferrier,  but  this  area  is  not  believed  by  all  to  be 
the  center  for  word-seeing.  Alexia,  or  inability  to  read,  is  a  corollary 
growing  out  of  this,  as  is  also  agraphia,  or  inability  to  write,  so  far  as  it 
depends  on  sight.  It  is  often  associated,  as  already  stated,  with  mind-hlind- 
ness,  but  may  occur  independently  of  it. 

Word-deafness  is  a  condition  in  which  the  patient  has  forgotten  the  sig- 
nificance of  spoken  words,  although  he  hears  them  as  sounds.     The  words 


Fig.  121. — Situations  of  Lesions  Causing  Apnasia — {after  Starr). 
Lesion  of  wovdi-deaftiess  and  deafness  for  musical  sounds,  according  to  M.  Allen 
Starr.  2.  Lesion  of  \\or6.-bItndness,  according  to  Ferrier.  3.  Lesion  of  motor 
aphasia.  4.  Supposed  lesion  of  agraphia.  ^'.  First  frontal  convolution. 
F'^.  Second  frontal.  F'K  Third  frontal.  T\  First  temporal.  T^.  Second 
temporal.      T^.  Third  temporal.     /".   First  parietal.     P^.  Second  parietal. 


of  his  own  language  are  as  a  foreign  tongue  which  he  does  not  understand, 
while  there  is  deafness  also  to  musical  sounds — amiisia,  the  '"'  Tontaubheit  " 
of  the  Germans.  Word-deafness  is  commonly  associated  with  other  forms 
of  sensory  aphasia  in  various'^degrees,  but  cases  of  pure  word- deafness  occur 
in  which  the  patient  has  been  able  to  read  and  to  speak,  but  is  unable  to 
recognize  the  meaning  of  a  word  when  spoken.  It  is  a  rare  variety  of  deaf- 
ness whose  lesion  is  placed  by  most  students  of  the  subject  in  the  first 
temporal  convolution  or  its  posterior  part,  but  Starr,  basing  his  conclusion 
on  fifty  cases  which  he  has  collected  with  autopsies,  places  it,  with  Seppilli, 
in  the  posterior  half  of  both  the  first  and  second  temporal  convulsions  of  the 
left  side  in  right-handed  persons,  and  of  the  right  side  in  left-handed  persons, 
as  shown  in  the  drawing. 

A  simple  variety  of  sensory  aphasia  is  amnesic  aphasia,  in  which  the 
patient  simply  forgets  words — just  as  we  are  all,  at  times,  at  loss  for  a 
word.  Such  a  person  sees  a  dog  or  another  animal,  knows  perfectly  well 
what  it  is,  but  cannot  recall  its  name.  The  moment,  however,  the  word 
"  dog  "  is  suggested,  he  knows  all  about  it.     In  disease  usually  a  number  of 


CORTICAL  AREAS  COVERING  SPEECH. 


977 


words  are  thus  lost.  Such  aphasia  is  called  amnesic,  because  it  is  really  a 
loss  of  memory  for  words.  It  may  be  partial,  as  when  a  patient  forgets 
nothing  but  his  own  name  and  remembers  all  other  words,  or  when  he  is  able 
to  express  himself  in  another  tongue.  If  permanent,  it  is  probably  due  to  a 
break  in  the  association  tract,  to  be  later  considered,  and  should  be  so 
limited.  Word-deafness  may  be  distinguished  from  amnesic  aphasia  by 
asking  the  patient  to  do  some  act,  such  as  to  touch  an  object,  when  he 
will  respond  correctly  if  he  has  simple  amnesic  aphasia,  but  will  not  if  he  is 
the  subject  of  word-deafness. 

Allied  to  amnesic  aphasia  is  sensory  or  amnesic  agraphia,  in  which  a 
word  cannot  be  written  because  it  cannot,  be  called  to  mind.  A  person  thus 
affected  may  be  unable  to  write  voluntarily,  but  may  be  able  to  write  at 
dictation  if  he  is  one  who  writes  much.  As  already  mentioned,  agraphia 
also  occurs  as  a  part  of  word-blindness  so  far  as  it  depends  on  sight. 

Motor  or  Ataxic  Aphasia  or  Aphemia — Alalia. — In  this  condi- 
tion the  memory  of  the  muscular  action  necessary  to  transfer  the  word  image 


^oa 


Fig.  122. — The  Left  Hemisphere,  with  the  Fissure  of  Sylvius  Drawn  Apart  in  Order 
to  Sliow  the  Convolutions  in  the  Island  of  Reil  or  5th  Lobe.  The  Island  of  Reil 
is  covered  in  by  the  pars  opercularis  or  posterior  part  of  Broca's  convolution, 
which  is  here  drawn  aside — {after  Henle). 

Sc.  Sulcus  centralis.     Gca,  Gcp.  Gyrus  centralis,  anterior  and  posterior.    Fop.  Fissura 

parieto-occipitalis. 


into  speech  is  lost.  There  is  disturbance  of  the  emissive  center,  h,  in  which 
this  transfer  takes  place.  The  patient  knows  perfectly  well  what  he  wishes 
to  say,  but  cannot  say  it,  though  he  may  make  the  greatest  effort  to  do  so. 
Nor  can  he  repeat  a  word  after  hearing  it.  The  degree  varies  greatly. 
In  complete  cases  he  may  be  able  to  read,  though  not  aloud,  and  under- 
stand what  is  said,  but  cannot  say  a  word  himself.  More  commonly,  he 
can  say  one  or  two  words,  such  as  "  no,"  "  yes,"  while  in  mild  cases  he 
may  simply  misplace  or  omit  letters,  'say  "  widow  "  intsead  of  "  window," 
or  "  wrelsters  "  instead  of  "  wrestles."  Singularly,  too,  when  in  a  passion 
he  may  be  able  to  say  the  right  word  or  to  swear.  This  is  because  such 
words  are  uttered,  to  a  certain  degree,  involuntarily.     A  man  acquainted 

62 


9/8  DISEASES  OF  THE  NERVOUS  SYSTEM. 

with  the  French  and  German  languages  may  lose  the  power  of  expressing 
his  thoughts  in  them  while  retaining  his  mother  tongue,  and  if  completely 
aphasic,  he  may  recover  one  language  before  the  other.  This  is  the  form 
of  aphasia  long  ago  recognized  by  Broca  and  localized  by  him  in  the  third 
left  frontal  convolution,  and  since  this  is  in  contact  with  the  center  for  the 
face  and  arm,  there  is  not  infrequently  partial  or  complete  right-sided  hemi- 
plegia. Alexia,  or  inability  to  read  aloud,  is  a  necessary  corollary  to  motor 
aphasia  so  far  as  it  depends  on  the  power  to  speak. 

Paraphasia,  or  mixed  aphasia,  and  monophasia  are  allied  to  motor  or 
ataxic  aphasia.  Paraphasia  is  a  confounding  of  words,  the  wrong  word 
being  used  instead  of  the  right  one,  because  of  a  confusion  between  the  idea 
and  the  proper  word.  All  degrees  of  this  also  occur,  only  a  single  word 
being  sometimes  erroneously  used,  while  in  others  whole  sentences  are 
wrong.  The  patient  may  also  use  a  wrong  word  which  has  a  certain  resem- 
blance to  the  correct  one,  beginning,  for  example,  with  the  same  syllable, 
as  "  between  "  for  "  bewitch  " ;  or  the  idea  usurps  the  situation,  as  in  the 
case  of  one  of  Striimpell's  patients,  who  called  a  white  handkerchief 
"  snow."  In  these  cases  the  association  or  conduction  tract  between  the 
perceptive  center  and  the  emissive  center  is  broken  (see  in  Fig.  114), 
whence  it  was  called  by  Wernicke  aphasia  of  conduction.  The  lesion  in 
paraphasia  is  usually  in  the  island  of  Reil  and  in  the  convolutions  which 
unite  the  frontal  and  temporal  lobes.  But  any  disturbance  in  the  associa- 
tion processes  of  language,  no  matter  where  the  break  lies,  may  cause  it. 
In  monophasia  the  patient  can  command  but  one  syllable  or  one  word  or 
a  short  phrase,  which  he  repeats  over  and  over  again. 

Motor  agraphia  must  also  be  distinguished  from  sensory.  Sensory 
agraphia  is  sometimes  amnesic — that  is,  the  patient  cannot  write  the  word 
because  he  cannot  call  it  to  mind ;  at  others  it  is  a  part  of  word-blindness. 
Motor  agraphia  is  quite  independent  of  ability  to  read  aloud — that  is,  of 
effort  memories  necessary  to  speech,  the  difficulty  being  connected  with  the 
movements  of  the  hand ;  but  when  motor  aphasia  exists,  motor  agraphia  is 
usually  also  present.  In  sensory  agraphia  he  may  still  be  able  to  write  by 
dictation,  in  the  latter  not.  Agraphia  also  varies  greatly  in  degree.  The 
patient  may  write  one  or  two  letters,  or  he  may  be  totally  unable  to  write 
voluntarily  or  from  dictation.  The  seat  of  the  lesion  of  motor  agraphia 
is  still  unsettled.  It  was  located  by  Charcot  in  the  neighborhood  of  the 
middle  of  the  anterior  central  convolution,  but  recent  studies  by  Victor 
Horsley  furnish  some  ground  for  locating  it  in  the  posterior  central  {ascend- 
ing parietal)  convolution.  Both  Charcot  and  Horsley  therefore  placed  it  in 
the  motor  area.  According  to^some  authorities  the  graphic  center  is  located, 
in  the  second  frontal  convolution  of  the  left  side,  near  the  ascending  frontal 
convolution.  Starr  locates  it  in  the  middle  of  the  convolution  (see  Fig. 
121).  Paragraphia'  is  a  condition  in  which  one  word  is  written  when 
another  is  intended.     It  is  a  corollary  to  paraphasia. 

Aniimia  is  the  loss  or  impairment  of  the  power  of  expression  by  signs 
when  caused  by  cerebral  disease.  Paramimia,  the  misuse  of  signs  in  the 
attempt  to  express  thought,  is  comparable  to  paraphasia  for  speech  and 
paralexia  for  reading,  and  is  dependent  on  a  like  cause — the  destruction  or 
impairment  of  commissural  or  association  tracts  hettveen  sensory  and  motor 
centers.  It  is  not  correct  to  suppose  that  the  aphasic  can  substitute  signs 
for  words  and  thus  express  himself,  for  the  two  defects  go  hand  in  hand, 
even  though  he  retain  the  power  of  moving  his  hands.     A  patient  may. 


CORTICAL  AREAS  COVERING  SPEECH. 


979 


however,  regain  pantomimic  power  before  he  regains  speech.  Loss  of 
pantomimic  power  is  found  often  associated  with  destruction  of  the  third  left 
frontal  convolution,  or  destruction  of  the  receptive  speech  centers  or  their 
connecting  tracts.  It  may  accompany  verbal  amnesia  due  to  disease  of 
these  areas  or  disturbance  of  the  association  tracts.  Just  as  the  aphasic  may 
say  "  yes  "  when  he  means  "  no,"  so  he  may  use  a  sign  which  will  be 
affirmative  when  he  intends  to  be  negative. 

The  following  table  may  aid  somewhat  a  review  of  the  previous  text, 
while  Fig.  121,  from  Starr's  book  of  "  Familiar  Forms  of  Nervous  Disease," 
shows  the  situation  of  the  lesions  causing  aphasia: 


APRAXIA,  inability  to  recognize  the  nature  and  purpose  of  an  object. 


^z«a'-blindness. 


Mznd-6.ea.ines,s,  including  amusia,  or  auditory 
amnesia. 


Mind  atactilia. 

Mind  anosmia. 
Mind  ageusia. 


Seat  of  Lesion. 
Supramarginaland  angularg'yri, 
or  the  white  matter  beneath, 
in  the  left  hemisphere  in  the 
right-handed  and  right  hemi- 
sphere in  the  left-handed. 

Upper  temporal  gyrus  of  left 
hemisphere  in  '  the  right- 
handed. 

Gyrus  fornicatus,  hippocampal 
gyrus,  prascuneus,  and  post- 
parietal  (Mills). 

Uncinate  gyrus  (Ferrier)  and 
hippocampal  gj-rus. 

Temporal  gyrus  (Ferrier). 


Aphasia,  inability  to  comprehend  words  correctly  and  to  use  them  properly. 


Sensory  aphasia,  inability  to  rec- 
ognize word  pictures  and 
word  sounds,  loss  of  memory 
of  word  pictures  and  word 
sounds. 


Word-\)\md-ness,  in  which 
memory  of  the  appearance 
of  a  word  is  lost. 


Angular  and  supramarginal  gy- 
rus. 


Motor  aphasia,  inability  to  utter 
words,  though  knowing  well 
what  to  say. 

Paraphasia. 

A  confounding  of  words  in 
speaking,  in  which  the  wrong 
word  is  used  instead  of  the 
right  one. 

A  mi  mi  a. 

Loss  of  power  of  expression  by 
signs. 


Paramimia. 

Misuse     of     signs     to     express 

thought. 
Agraphia,  inability  to  write. 
Sejisory  Agraphia. 

Inability  to  write  because  («■)  of 
want  of  idea  as  to  what  a 
word  is  or  (J))  looks  like. 

Mo  to  rAgraph  ia . 

Inability  to  write  because  of 
want  of  motor  power  of 
writing,  although  the  other 
movements  of  the  hand  may 
be  excellent. 


fFi^ra^-deafness,  in  which 
memory  of  the  sound  of  a 
word  is  lost. 

Amnesia,  inability  to  recall 
a  word. 

Including  alexia,  or  inability 
to  read  aloud. 


id)  Amnesic  agraphia. 
(Jf)  A  part    of    word-blind- 
ness. 


Posterior  part  of  first  and  second 
temporal  gyri  (Seppilli  and 
Starr). 

Disturbance  of  association  tract. 

Posterior  part  of  third  left 
frontal  (Broca's  convolution). 


Island  of  Rail  and  any  disturb- 
ance of  the  association  tracts. 


Third  left  frontal  convolution, 
receiving  or  concept  center. 

Disturbance  of  association 
tracts. 


Seat. 

Association  tract. 
Angular      and      supramarginal 
gyrus. 


Not  settled,  but  possiblj'  middle 
of  the  ascending  frontal  con- 
volution or  ascending  parietal 
— i.  e.,  in  the  arm  center. 
Possibly  posterior  part  of  sec- 
ond   left  frontal  convolution. 


Availing  ourselves  of  Wernicke's  condensed  schema  (Fig.  120),  most 
aphasic  derangements  met  in  practice  are  easily  explained  by  it  by  suppos- 
ing lesion  and  interruption  of  conduction  in  certain  places.     According  as 


98o 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


the  centripetal  conduction  ui,  a,  C,  or  the  centrifugal  conduction,  C,  b,  n, 
is  interrupted  we  have  sensory  or  motor  aphasia,  while  the  interruption  of 
the  line,  a,  h,  produces  the  conduction  aphasia  of  Wernicke.     Lesions  be 
tween  a  and  b  on  the  one  hand  and  C  on  the  other  are  called  transcortical 


Fig.  123. — Simplification   of   the  Schema  of   Conscious   Speech  by  Reduction  of  the 

Ideas  to  the  Point,  C,  and  Omission  of  the  Acoustic  Center,  x. 

The  letters  have  the  same  application  as  in  previous  figures. 

aphasias;  between  a  and  b,  cortical,  and  between  a  and  b  on  the  one  hand 
and  the  periphery  on  the  other,  subcortical.  These  distinctions  are  sche- 
matic. 


Derangements  of  Speech  of  Irritative  Origin. 

In  addition  to  those  due  to  direct  lesion  of  the  speech  centers  there 
are  also  derangements  of  speech  due  to  irritation.  Such  are  the  different 
kinds  of  stuttering,  the  labio-choreic  and  gutturo-tetanic  stuttering  and 
choreic  speech.  The  first  two^  probably  reside  in  the  cortical  speech  centers, 
but  the  choreic  spasms  not  necessarily,  since  the  function  of  muscles  con- 
cerned in  their  production  may  be  disturbed  from  lesions  in  other  centers 
as  well. 

Diagnosis. — The  study  of  derangements  of  speech  is  by  no  means  an 
easy  matter,  but  it  may  be  facilitated  by  pursuing  a  systematic  method  like 
the  following,  which  is  that  of  Starr,  slightly  modified : 

A.  To  determine   whether  apraxia    is   (  (i)  Test     the    power   of     recognizing    the 
present.  /  nature,  uses,  and  relations  of  objects. 

f  (i)  The  power  to  recall  the  spoken  name  of 

B.  To   test   integrity   of   the  auditory   |  objects  seen,  heard,  handled. 

speech  area  and  association  tracts  j   (2)  The  power  to  understand  speech    and 
between   other   sensory  areas   and  j  musical  sounds. 

the  temporal  convolutions.  (3)  The   power   to    call    to    mind    objects 

[        named. 


To  test  the  condition  of  the  visual 
word  memories  in  the  angular  gyrus 


CORTICAL  AREAS  COVERING  SPEECH.  981 

f  (i)  The   power  to   understand   printed   or 
written  words. 

(2)  The  power  to   read  aloud  and   under- 
stand what  is  read. 

(3)  The   power    to    recall    objects    whose 
^         ^^  names  are  seen. 

andof  the  connections  betweenlhis  ^   (4)  The  power  to  write  spontaneously  and 
area  and  the  surrounding  sensory   I  to   write   the  names    of    objects   seen, 

and  motor  areas.  '  I  heard,  etc. 

(5)  The  power  to  copy  and  write  at  dicta- 
tion. 

(6)  The    power    to    read    understandingly 
(^         what  has  been  written. 

f  (1)  The  power  to  speak  voluntarily  ;  and  if 
D.     To   test    the   integrity   of    Broca's  J  it  is  lost,  the  character  of  its  defects, 

center  and  its  association  tracts.         |   (2)  The  power  of  repeating  words  one  after 

[         another. 

When  aphasia  is  associated,  as  is  so  often  the  case,  with  paralysis  of 
the  right  arm,  the  writing  test  may  be  made  with  the  left  hand,  when  the 
patient  may  produce  the  so-called  aphasic  mirror  writing,  which  can  only 
be  read  by  the  use  of  a  mirror;  or  if  he  cannot  write  with  the  left  hand, 
as  also  happens,  he  may  be  asked  to  form  words  by  letters  cut  out  of 
printed  pages,  or  with  the  letter  blocks  of  children. 

Prognosis  and  Treatment. — Aphasia  is  a  symptom  of  a  disease  and 
not  a  disease  itself.  Yet  it  is  a  symptom  which  in  its  various  phases  informs 
us  so  precisely  of  the  seat  of  the  lesion  that  it  sometimes  suggests  a  point 
of  operative  interference  comparatively  easy  oi  access.  Where  the  symptoms 
of  diffuse  cerebral  disease  are  wanting,  and  where  the  continuation  of  tlie 
symptoms  and  the  addition  of  others  suggest  the  presence  of  a  possible 
circumscribed  cause,  such  as  abscess  or  tumor,  operation  is  justified,  and  by 
it  not  only  cortical,  but  also  subcortical  lesions  and  abscesses  have  been 
relieved.  In  cases  of  sensory  aphasia  the  trephine  should  be  applied  over 
the  upper  parts  of  the  temporoparietal  region,  in  zvord-deafness  over  the 
posterior  part  of  the  first  temporal,  in  zvord-hlindness  over  the  angular 
gyms,  in  word-deafness  and  wor'd-blindness  combined  over  the  inferior 
parietal  and  first  temporal  gyrus,  especially  if.  verbal  amnesia  be  present. 
In  purely  motor  aphasia,  in  which  the  understanding  of  language  is  pre- 
served but  the  power  of  talking  lost,  the  trephine  should  be  applied  over 
the  posterior  part  of  the  third  frontal  convolution,  or  Broca's  center.  The 
lesion  of  simple  agraphia  is  not  sufficiently  determined  to  warrant  surgical 
interference. 

When  urgent  symptoms  do  not  exist,  attempt  should  be  made  to  re- 
educate the  patient,  and  much  may  be  accomplished  in  this  way  by  perse- 
verance, especially  in  the  young.  With  adults,  the  prognosis  is  more 
unfavorable,  especially  in  cases  of  complete  motor  aphasia  associated  with 
right  hemiplegia.  In  them  the  patient  may  be  taught  to  write  with  his  left 
hand :     Sensory  aphasia,  if  it  exist  alone,  is  commonly  transient. 

Cortical  Areas  Whose  Function  is  Unknown  or  Uncertain. 

After  subtracting  the  motor,  visual,  and  speech  areas  of  the  two  hemis- 
pheres there  remain  extensive  cortical  areas,  to  which,  as  yet,  no  definite 
function  can  be  assigned,  and  which  are  unexcitable.     They  include : 

I.  Th-e  Frontal  Region,  Including  all  the  Frontal  Convolutions  except 
the  Posterior  Half  of  the  Third  Frontal  on  the  Left  Side. — Of  this  area  the 
most  that  can  be  said  is  that,  if  injured,  mental  symptoms  are  quite  likely  co 


982  DISEASES  OF  THE  NERVOUS  SYSTEM. 

be  prominent — symptoms  ascribable  to  a  loss  of  self-control.  It  is  to  the 
greater  development  of  the  region  of  the  frontal  lobes  in  man  as  compared 
with  the  lower  animals  that,  his  higher  mental  qualities  are  ascribed.  V^ari- 
ous  forms  and  degrees  of  dementia  have  been  observed  after  such  lesions, 
and  when  such  mental  symptoms  are  present,  it  may  with  reason  be  inferred 
that  there  is  lesion  of  the  frontal  lobes,  especially  of  the  left  frontal  lobe  accord- 
ing to  some  investigators,  more  particularly  when  lesion  elsewhere  can  be  ex- 
cluded. It  should  never  be  forgotten,  however,  that  the  intellectual  develop- 
ment depends  on  the  integrity  of  the  entire  brain. 

2.  TJie  Region  of  the  Cortex  Lying  betzveen  the  Ascending  Parietal 
Conz'olution  and  the  Occipital  Convolutions,  Including  all  the  Parietal  Con- 
volutions  except  the  Left  Inferior  Parietal  Lobule. — In  these,  it  was  at  one 
time  thought,  might  lie  the  centers  of  tactile  sense,  but  the  tendency  at 
present  is  to  make  the  sensory  and  motor  areas  of  the  cortex  the  same, 
although  the  sensory  area  is  probably  more  extensive  than  the  motor,  since 
lesions  of  the  posterior  central  convolution  are  found  associated  with  anes- 
thesia in  the  paralyzed  part,  and  because  the  centers  for  the  parts  in  which 
sensation  is  most  acute — namely,  thumb,  fingers,  and  hand,  toes  and  feet — 
lie  in  this  region.  The  so-called  muscular  sense  is,  however,  probably 
largely  represented  in  this  area. 

3.  The  Region  Covering  the  Entire  Tempdrosphenoidal  Lobe  on  the 
Right  Side  except  the  First  Temporal,  which  probably  has  to  do  with  hear- 
ing of  ordinary  sounds,  and  the  teniporosphenoidai  on  the  left  side,  exclud- 
ing the  parts  not  concerned  in  hearing  of  words,  as  well  as  ordinary  sounds. 
To  the  first  temporal  gyrus  the  function  of  hearing  is  assigned,  but  the  re- 
mainder, so  far  as  the  cortex  is  concerned,  appears  unexcitable.  Abscesses 
are  common  here  after  otitis  media,  and  are  sometimes  reached  with  the 
trephine,  the  diagnosis  being  based  on  the  presence  of  otitis  with  symptoms 
of  brain  disease. 

4.  The  Apex  of  the  Teniporosphenoidai  Lobe,  including  the  uncinate 
convolution.  To  this  the  olfactory  sense  has  been  ascribed  with  some  show 
of  reason. 

5.  Of  the  Entire  Median  Surface  of  the  Hemispheres,  except  the  para- 
central lobule,  which  is  motor,  and  the  cuneus,  which  is  visual,  and  includ- 
ing the  gyrus  fornicatus  and  the  hippocampal  cortex,  the  function  is  un- 
known, although  the  hippocampal  is  probably  a  part  of  the  olfactory  area. 

Tracts    within    the    Brain — Centrum    Ovale,    Internal    Capsule, 
Central  Ganglia,  Corpora  Quadrigemina. 

Centrum  Ovale. — In  the  centrum  ovale,  constituting  the  mass  of 
white  fibrous  substance  beneath  the  cortex  and  above  the  level  of  the  basal 
ganglia,  the  fibers  of  the  motor  paths  are  more  or  less  closely  associated 
with  other  systems  of  fibers.  They  include  three  sets — projection,  com- 
missural, and  association  systems ;  the  first  connecting  the  cortex  with 
nervous  structures  lying  below  it,  the  second  joining  the  two  hemispheres, 
while  the  third,  or  association  fibers,  join  different  parts  of  the  same  hemi- 
sphere. By  these  fibers  adjacent  convolutions,  alternate  convolutions,  and 
more  distant  regions  are  connected,  and  through  these  as  a  physical  basis  the 
activities  of  the  various  cortical  areas  are  harmonized  and  the  different 
memories  united. 

The  diagnosis  of  lesions  involving  this  mass  is  exceedingly  difficult. 


CORTICAL  AREAS  COVERING  SPEECH.  983 

We  can  only  surmise  in  cases  of  disturbance  of  association,  such  as  occur 
with  aphasia  and  kindred  disorders,  rhat  the  association  fibers  have  been 
destroyed.  A  break  in  the  continuity  of  the  fibers  of  the  corona  radiata  must 
produce  the  same  symptoms  as  if  the  corresponding  center  were  destroyed. 
In  hke  manner  disease  of  the  white  substance  of  the  occipital  lobe  may  cause 
hemianopsia;  of  the  left  temporal  lobe,  word-deafness ;  and  if  the  coronal 
fibers  which  proceed  from  the  third  left  frontal  convolution  are  diseased, 
motor  or  ataxic  aphasia  occurs.  Yet  quite  extensive  disease  of  the  white 
substance  of  the  frontal  lobe  has  been  found  postmortem  without  any  symp- 
toms having-  been  present  during  life. 

Internal  Capsule. — Since  in  the  comparatively  narrow  space  in  the 
posterior  limb  of  the  internal  capsule  is  centered  the  pyramidal  tract  on  its 
way  from  the  cerebral  convolutions  to  the  crus  cerebri,  a  very  limited  focal 
disease  in  this  locality  will  lead  to  hemiplegia  on  the  opposite  side,  while 
clinical  experience  shows  that  almost  all  cases  of  persistent  hemiplegia  are 
occasioned  by  disease  in  this  spot. 

According  to  the  views  of  many  neurologists,  a  purely  motor  hemi- 
plegia, unattended  by  impairment  of  sensation,  implies  a  lesion  that  does 
not  involve  the  most  posterior  portion  of  the  internal  capsule,  while  such 
involvement  is  probable  when  there  is  sensory  disturbance  as  well  as  motor 


Pig.  124. — Transverse  Section  through  the  Crura  Cerebri  in  Secondary  Degeneration 

of  the  Right  Pyramidal  Tract — {after  Charcot). 
sn.  Substantia   nigra,    p.  The    degenerated,   and   therefore   translucent,    pyramidal 
tract.     ///.   Oculomotor  nerves.     AS.  Aqueduct  of  Sylvius. 

paralysis.  Dejerine  believes  that  disturbance  of  sensation  in  hemiplegia 
indicates  involvement  of  the  optic  thalamus,  and  that  there  is  no  distinct  sen- 
sory tract  in  the  posterior  part  of  the  posterior  limb  of  the  internal  capsule. 
Central  Ganglia — i.  e..  Caudate  Nucleus,  Lenticular  Nucleus,  and 
Optic  Thalamus. — In  the  writer's  student  days  the  corpus  striatum  was 
regarded  as  the  great  motor  ganglion  and  the  optic  thalamus  as  sensory, 
while  most  hemiplegias  were  ascribed  to  lesions  of  the  former,  and  hemian- 
esthesia was  ascribed  to  lesion  of  the  optic  thalamus.  It  is  conceded  to-day 
that  the  optic  thalamus  may  have  to  do  with  the  movements  of  mimetic  or 
emotional  expression,  such  as  laughing  and  crying,  which  are  lost  in  lesion 
of  the  thalamus,  but  which  remain  when  the  thalamus  is  intact,  even  though 
the  half  of  the  face  is  paralyzed  and  cannot  be  moved  voluntarily.  It  is  also 
likely  that  some  of  the  fibers  of  the  optic  tract  terminate  in  the  posterior  por- 
tion of  the  thalamus  known  as  the  pulvinar,  while  most  of  the  fibers  go  to 


984  DISEASES  OF  THE  XERJ'OUS  SYSTEM. 

the  corpus  geniculatum  externum,  and  possibly  some  to  the  anterior  colU- 
culus  of  the  corpora  quadrigemina.  Hence  destruction  of  the  hinder  part 
of  the  thalamus  produces  complete  hemianopsia  of  the  opposite  side,  usually 
by  destruction  of  the  optic  radiations.  Focal  disease  of  the  thalamus  has 
been  supposed  to  cause  posthemiplegic  chorea  and  other  posthemiplegic 
symptoms  of  irritation. 

Beyond  this,  little  definite  is  known  of  the  effect  of  lesions  strictly 
limited  to  the  central  ganglia,  while  disorganization  of  these  ganglia  has 
been  found  unattended  by  any  symptoms  during  life. 

CoRPOR-\  Quadrigemina  and  Crur.\  Cerebri. — Lesions  of  the  corpora 
quadrigemina  are  rare.  Xot  much,  therefore,  is  known  of  their  function. 
The  anterior  tubercles  are  connected  with  fibers  of  the  optic  tract,  but  the 
extent  of  the  connection  in  man  is  uncertain.  Unilateral,  or  even  bilateral, 
paralysis  of  the  oculomotor  nerv'e  has  been  obser\-ed  in  connection  with 
lesions  of  the  quadrigeminal  bodies,  as  have  also  nystagmus  and  immobility 
of  the  pupil.  But  this  is  because  the  nuclei  of  the  motor  nerves  of  the  eye- 
ball, except  the  sixth,  lie  very  close  to  tlie  tubercles,  and  may.  therefore,  be 
involved  in  such  a  lesion.  According  to  Xothnagel,  a  staggering  gait  with 
oculomotor  paralysis,  associated  with  general  symptoms  of  a  tumor,  points  to 
the  corpora  quadrigemina  as  its  site.  The  oculomotor  paralysis  is  apt  to  be 
of  irregular  distribution,  involving  upward  and  downward  movements  of  the 
eye,  and  should  be  an  early  symptom.  Tumor  of  the  corpora  quadrigemina 
causes  early  optic  neuritis. 

If  the  cms  cerebri  is  diseased,  there  often  result  characteristic  symp- 
toms. — viz.,  paralysis  of  one  side  of  the  body  (arm,  leg.  and  face),  and  on 
the  side  opposite  the  hemiplegia  a  paralysis  of  the  motor  oculi,  or  third  nerve 
— crossed  paralysis.  An  examination  of  Figure  124.  from  Charcot,  will 
explain  this.  A  lesion  on  the  right  side  at  p  in  the  right  pyramidal  tract, 
might  involve  the  oculomotor  nerve.  Ill,  on  that  side,  but  would  produce  a 
hemiplegia  on  the  left  side.  Since  the  crus  contains  sensory  fibers  from  the 
opposite  side,  a  lesion  in  one  crus  may  also  produce  hemianesthesia  of  the 
opposite  side  of  the  body.  Tegmental  lesions  should  also  produce  sensory 
paralysis. 

CEREBELLAR   DISEASE. 

The  cerebellar  hemispheres  may  suffer  extensive  lesions  without  pro- 
ducing symptoms,  but  if  the  central  portion  or  vermiform  process  is  injured, 
two  symptoms  result  which  are  quite  characteristic  of  cerebellar  disease — 
namely,  uncertainty  of  gait,  known  as  cerebellar  ataxia,  and  vertigo.  The 
trunk  and  lower  extremities  alone  are  aitected  in  cerebellar  ataxia,  standing, 
as  well  as  locomotion,  being  interfered  with.  The  patient  can  lie  abed  and 
m^ove  his  legs  almost  as  well  as  ever,  but  as  soon  as  he  rises  he  begins  to  sway 
back  and  forth  with  his  whole  body,  even  while  standing.  Thi«  tendency  is 
increased  if  he  brings  his  heels  together,  but  is  diminished  while  the  legs  are 
widely  separated.  In  this  respect  cerebellar  ataxia  does  not  difter  from  the 
ataxia  of  posterior  sclerosis.  There  may  also  be  present  the  tabetic  gait. 
On  .the  other  hand,  closing  the  eyes  usually  does  not  aggravate  it.  because  the 
cutaneous  and  muscular  sensibility  of  the  lower  limbs  remains  normal.  So, 
too.  when  he  tries  to  walk,  he  totters,  but  there  is  none  of  the  stamping  gait 
of  tabes  dorsalis.     It  is  more  the  true  drunkard's  reel,  at  one  time  forward. 


CEREBELLAR  DISEASE.  985 

and  rolling  now  to  one  side  and  now  to  the  other.  Unfortunately,  it  is  not 
so  peculiar  to  cerebellar  disease  as  to  be  pathognomonic  of  it,  and  we  can 
only  suggest  that  the  cerebellum  or  its  peduncles  may  be  involved.  The 
upper  extremities  are  almost  never  implicated,  but  Hughlings  Jackson  has 
called  attention  to  a  paresis  of  the  trunk  muscles  as  the  result  of  which  the 
movements  of  bending,  erection,  and  lateral  flexion  of  the  trunk  cannot  be 
performed. 

The  vertigo  of  cerebellar  disease,  if  severe,  is  one  of  the  most  distress- 
ing symptoms  with  which  one  can  be  afflicted.  It  varies  greatly  and  is  not 
constant,  while  it  may  substitute  the  ataxia  altogether.  It  occurs,  however, 
under  the  sam.e  circumstances — that  is.  when  the  patient  stands  or  moves 
about,  disappearing  when  he  lies  down.  The  vertigo  and  ataxia  are  not  asso- 
ciated, and  one  may  be  present  and  the  other  absent. 

Headache  is  a  freqtient  symptom  in  cerebellar  disease,  having  been 
present  in  83  out  of  100  cases  collected  by  \A'.  C.  Kraus.  2vIost  frequently  it 
is  occipital ;  more  rarely  there  may  be  pain  in  the  side  of  the  head  or  in  the 
forehead.  Vomiting  is  also  a  result  of  chronic  disorders  of  the  cerebellum, 
being  present  in  69  of  Kraus'  cases.  So  is  visual  disturbance  due  to  optic 
neuritis,  which  was  found  in  66  cases.  Xone  of  these  symptoms  is  pathog- 
nomonic, and  each  one  may  be  a  symptom  of  disease  elsewhere  in  the  brain. 
The  most  valuable,  perhaps,  is  persistent  occipital  headache,  especially  if 
associated  with  the  cerebellar  gait.  It  might  be  expected  that  retained 
reflexes  would  be  a  distinctive  sign  as  contrasted  with  their  absence  in  tabes 
dorsalis ;  but,  in  fact,  they  are  sometimes  absent,  this  being  the  case  no  less 
than  12  times  in  Kraus'  100  cases. 

Other  symptoms  which  suggest  cerebellar  disease,  but  are  not  dis- 
tinctive, are  neuralgic  pains  in  the  region  of  the  neck  and  occiput;  blocking 
of  the  venae  Galeni  and  dilatation  of  the  lateral  ventricles  producing  hydro- 
cephalus in  children ;  pressure  on  the  medulla  oblongata,  causing  paralysis  of 
the  cranial  nerves,  glycosuria,  or  even  sudden  death,  if  a  vital  spot  is  im- 
pinged upon :  finally,  bilateral  rigidity  from  pressure  on  the  motor  paths. 
On  the  other  hand,  there  may  be  cerebellar  disease  without  any  symptoms 
whatever,  especially  as  long  as  the  middle  lobe  is  not  involved. 

■Form  of  Lesion. — By  far  the  most  frequent  cerebellar  lesion  is  tumor-  — 
in  fact,  some  sort  of  tumor  was  found  in  ^  out  of  100  cases,  of  which  10 
were  abscess,  and  there  was  one  each  of  softoiing  and  hemorrhage.  The 
remainder  were:  sarcoma  and  tubercle,  each,  22;  glioma,  18;  nature  of  tumor 
unspecified,  13:  cyst,  7;  and  one  case  each  of  softening,  endothelioma,  cyst 
and  sarcoma,  cancer,  gumma,  and  fibroma.  The  tumor  occupied  one  or  the 
other  hemisphere  32  times  ;  the  middle  lobe.  17  times. 

Disease  of  the  middle  cerebellar  peduncles  may  be  accompanied  by  the 
so-called  forced  positions  and  forced  movements.  As  a  result  of  the  former, 
the  subject  may  lie  in  bed  upon  a  particular  side,  whether  conscious  or  uncon- 
scious ;  and  if  put  on  the  other  side,  may  reassume  his  former  position  invol- 
untarily. Sometimes  this  is  accompanied  by  a  corresponding  forced  position 
of  the  head  and  eyeballs,  the  extremities  being  seldom  affected.  The  forced 
movements  are  less  frequent.  They  consist  either  in  oft-repeated  rotations 
of  the  body  on  its  longitudinal  axis  or.  if  the  patient  can  walk,  in  involuntar\' 
■circular  movements.  There  is  no  guigle  by  which  to  determine  which  of  the 
tw^o  peduncles  is  affected  under  these  circumstances,  while  in  a  few  cases  of 
brain  disease  the  same  symptoms  have  been  observed  without  involvement 
of  the  cerebellum. 


986  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  following  very  convenient  summary  from  Strumpell's  "  Text- 
book," American  edition  of  1901,  contains  the  most  important  facts  bearing 
on  the  localization  of  cerebral  disease,  and  will  be  found  useful  for  reference : 

■'  I.  The  most  frequent  cause  of  ordinary  hemiplegia  is  a  lesion  of  the 
pyramidal  tract  in  the  posterior  limb  of  the  internal  capsule.  If  the  hemi- 
plegia be  persistent,  then  this  tract  is  actually  destroyed ;  if  temporary,  the 
tract  has  been  functionally  deranged  for  a  time  by  focal  disease  in  neighbor- 
ing parts  of  the  brain. 

"  2.  Monoplegic  cerebral  paralysis  is  usually  due  to  affections  of  the 
cortex  of  the  brain — that  is,  the  central  convolutions  and  the  paracentral 
lobule.  Monoplegia  of  the  face  and  tongue  is  the  result  of  lesions  in  the 
lower  extremity  of  the  anterior  central  convolution.  Monoplegia  of  the  arm 
is  referable  principally  to  some  lesion  of  the  middle  third  of  the  anterior 
central  convolution.  Monoplegia  of  the  lower  extremity  implies  some  affec- 
tion of  the  upper  portion  of  the  anterior  central  convolutions  and  the  para- 
central lobule. 

"  3.  Hemiplegia  or  monoplegia,  if  associated  with  epileptiform  convul- 
sions afifecting  either  one-half  or  one  particular  portion  of  the  body,  is  almost 
always  caused  by  cortical  lesions.  These  same  symptoms  of  motor  irritation 
Mdthout  accompanying  paralysis  are  likewise  to  be  ascribed  to  some  irrita- 
tion of  the  above-mentioned  regions  of  the  cortex. " 

"  4.  Hemiplegia  w^ith  crossed  paralysis  of  the  oculomotor  nerve  indi- 
cates a  lesion  of  the  crus  cerebri.  Co-existing  tactile  hemianesthesia  implies 
that  the  tegmentum  is  involved. 

"  5.  Hemiplegia  with  crossed  facial  paralysis  implies,  with  great  cer- 
tainty, that  the  lesion  is  situated  in  the  pons. 

"6.  Posthemiplegic  chorea  (z'ide  infra)  seems  to  occur  especially  w^hen 
there  is  focal  disease  in  the  neighborhood  of  the  posterior  part  of  the  internal 
capsule. 

"  7.  Hemianesthesia  of  the  skin  and  of  the  organs  of  special  sense,  asso- 
ciated with  hemianopsia,  is  due  chieflv  to  lesions  of  the  most  posterior  por- 
tion of  the  internal  capsule. 

"  8.  Hemianopsia  may  be  due  to  a  lesion  of  the  occipital  lobe  cuneus. 
Probably,  also,  a  lesion  of  the  posterior  extremity  of  the  internal  capsule 
may  cause  it,  in  which  case  it  is  usually  associated  with  hemianesthesia. 
Pinally,  it  may  be  produced  by  affections  of  the  pulvinar  of  the  optic  thala- 
mus of  the  lateral  geniculate  body,  or  of  one  of  the  optic  tracts. 

"  9.  Genuine  motor  aphasia  indicates  disease  of  the  foot  of  the  third  left 
frontal  convolution. 

"  10.  Word-deafness  (los's  of  understanding  of  speech)  is  due  to  dis- 
ease of  the  first  left  temporal  convolution;  word  blindness  (loss  of  under- 
standing of  writing)  is  due  to  disease  of  the  left  lower  parietal  lobe  (angular 
gyrus) — supramarginal  gyrus  also,  according  to  Ferrier. 

"11.  Difficulty  in  articulation  implies  disease  of  the  medulla,  as  does 
also  dysphagia. 

''  12.  Staggering  gait  and  vertigo  are  the  most  constant  symptoms  of 
cerebellar  disease,  but  they  may  also  occur  in  diseases  of  the  corpora  quad- 
rigemina  and  of  the  frontal  lobe  (I'ide  supra).  Forced  positions  and  forced 
movements  perhaps  indicate  lesions  of  the  crura  cerebelli  ad  pontem. 

"  13.  Staggering  gait  and  ocular  paralysis  are  indicative  of  lesions  of 
the  corpora  quadrigernina." 


OPTIC  NERVE  AND  TRACT.  987 

DISEASES  OF  THE  CRANIAL  NERVES. 

OLFACTORY  NERVE. 

The  olfactory  nerve  may  be  affected  in  various  parts  of  its  course  and 
distribution ;  at  its  central  portion,  either  in  the  uncinate  gyrus  or  its  frontal 
center  (Flechsig),  in  the  frontal  lobe,  in  the  nerve  trunk,  in  the  olfactory 
bulb  itself,  or  in  its  distribution  to  the  olfactory  region  of  the  nose. 

Morbid  Anatomy. — The  lesions  may  be  tumors  of  the  brain,  instances 
of  which  have  been  found  in  the  hippocampal  gyri,  of  disease  in  the  hemi- 
spheres. There  may  be  congenital  defect  of  the  olfactory  center  or  atrophy 
of  the  nerve,  which  may  explain  the  occasional  anosmia  in  locomotor  ataxia. 
There  may  be  inappreciable  changes,  caused  by  injuries  to  the  head  or  by 
concurrent  disease,  such  as  epilepsy,  the  aura  of  which  is  sometimes  mani- 
fested by  parosmia.  The  area  of  distribution  of  the  olfactory  nerve  in  the 
nose  may  be  destroyed  by  chronic  nasal  catarrh  or  by  polypits.  Hysterical 
neuroses  of  the  olfactory  nerve  are  not  infrequent.  The  sense  of  smell  is 
sometimes  impaired  in  cases  of  tumor  situated  in  portions  of  the  brain  remote 
from  the  olfactory  area.  This  possibly  may  be  caused  by  increased  intra- 
cranial pressure. 

Symptoms. — Lesions  in  any  of  these  localities  may  produce  subjective 
sensations  of  smell,  or  parosmia,  of  which  various  foul  odors  are  illustrations ; 
hypersensitiveness  of  the  normal  sense,  or  hyperosmia,  in  certain  highly 
developed  degrees  of  which  the  patient,  generally  a  highly  sensitive  woman, 
can  distinguish  one  person  from  another  by  the  sense  of  smell ;  or  loss  of  the 
sense  of  smell,  anosmia. 

Diagnosis. — The  nasal  region  should  be  carefully  explored  by  the  rhino- 
scope  and  the  sense  of  smell  should  be  tested.  For  this  purpose  the  essen- 
tial oils,  such  as  anise-seed,  cloves,  or  peppermint,  in  various  degrees  of  dilu- 
tion, are  employed.  Cologne  water,  musk,  or  asafetida  may  be  used  for  the 
same  purpose.  Pungent  substances  should  be  avoided,  as  they  stimulate  the 
fifth  nerve  in  the  nasal  mucous  membrane,  and  thus  the  subject  perceives 
what  he  does  not  smell.  By  such  agents  the  fifth  nerve  is  tested.  No  con- 
clusion can  be  drawn  as  to  anatomical  differences  on  the  two  sides  without  a 
rhinoscopic  examination. 

Treatment  is  useless,  unless  the  condition  be  due  to  curable  or  remov- 
able polypus. 

OPTIC  NERVE  AND  TRACT. 

There  may  be  derangement  of  the  retina,  of  the  optic  nerve,  of  the 
chiasm,  and  of  the  optic  tract. 

L  Affections   of  the   Retina. 
These  may  be  organic  or  functional. 

r 

(a)  Organic  Diseases  of  the  Retina. 
The  orsfanic  aft'ections  include  hemorrhage  and  inflammation,  or  both. 


988  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Hemorrhage  into  the  retina  (arterial  sclerosis)  occurs  as  a  cause  or 
result  of  Bright's  disease,  most  commonly  chronic  interstitial  nephritis,  in 
gout  profoundly  affecting  the  system,  in  leukocythemia,  anemia,  syphilis, 
purpura,  ulcerative  endocarditis,  and  other  forms  of  septicemia.  The  hemor- 
rhages are  in  the  layer  of  the  nerve-tibers.  At  first  bright  red,  and  then 
becoming  darker  and  eventually  lighter  in  color,  they  ultimately  assume  a 
diffuse  cloudiness,  owing  to  serous  infiltration.  The  hemorrhages  vary  in 
extent,  and  often  follow  the  course  of  the  vessels.  In  septicemia  they  are  due 
to  capillary  septic  embolism,  and  often  have  white  spots  in  the  center,  owing 
to  the  massing  of  leukocytes.  Other  white  spots  are  due  to  fibrinous  exu- 
date, fatty  degeneration  of  the  retinal  elements,  or  localized  sclerosis  of  the 
same.  Similar  hemorhages  sometimes  occur  in  the  pia  mater  in  the  same 
cases. 

Retinitis  occurs  under  the  same  circumstances  as  hemorrhage,  espe- 
cially in  chronic  nephritis,  syphilis,  anemia,  leukemia,  and  also  malaria ;  and 
in  diabetes  mellitus,  purpura,  and  chronic  lead  poisoning. 

Albiuiiimiric  retinitis  may  occur  in  all  forms  of  chronic  nephritis,  more 
frequently  in  the  interstitial  variety,  of  which  disease  it  may  be  the  earliest 
symptom  recognized.  It  is  characterized  in  general  by  the  presence  of  white 
spots  of  various  extent  and  distribution,  as  seen  by  the  ophthalmoscope. 
They  are  caused  by  degenerative  processes  and  hemorrhages.  Gowers 
recognizes  three  forms : 

1.  A  degenerative  form,  which  is  the  most  common,  in  which  there  are 
retinal  changes,  but  scarcely  any  alteration  of  the  optic  disc. 

2.  An  inflammatory  form,  in  which  there  are  much  swelling  of  the  retina 
and  obscuration  of  the  optic  disc. 

3.  A  hemorrhagic  form,  in  which  there  are  many  hemorrhages,  but  little 
evidence  of  inflammation. 

In  some  instances  of  the  second  the  inflammatory  changes  in  the  optic 
nerve  predominate  over  those  of  the  retina,  producing  an  optoncuritic  form, 
in  which  the  appearances  are  more  closely  allied  to  those  of  papillitis 
or  choked  disc,  such  as  is  caused  by  intracranial  disease. 

Syphilitic  retinitis  is  a  rare  affection  in  acquired  and  congenital  disease. 
In  the  latter  it  is  called  retinitis  pigmentosa.  Syphilitic  choroiditis  is  less 
rare.  Retinitis  is  not  uncommon  in  chronic  anemia,  especially  in  the  per- 
nicious form.  After  excessive  loss  of  blood  the  patient  often  becomes  blind, 
either  suddenly  or  in  the  course  of  one  or  two  days.  In  such  cases  a  neuro- 
retinitis  has  been  found  quite  sufficient  to  explain  the  blindness,  which,  in 
rare  instances,  may  be  permanent  and  complete.  A  rare  variety  of  anemic 
retinitis  is  malarial  retinitis,  first  described  by  Stephen  MacKenzie.  It  may 
be  associated  with  hemorrhage.  In  leukemic  retinitis  the  retinal  veins  are 
large,  and  hemorrhage  may  also  occur,  with  white  and  yellow  areas.  Tumor 
of  the  brain,  especially  of  the  cerebellum,  has  been  found  in  some  instances 
to  cause  a  condition  of  the  retina  like  that  of  albuminuric  retinitis. 

{h) Functional  Disturbance  of  the  Retina,  or  Amaurosis. 

This  may  be  toxic.  Of  this,  the  most  striking  and  best  known  variety 
is  uremic  amaurosis.  Its  suddenness  is  its  most  striking  feature,  and  it  is 
very  frequently  the  forerunner  of  uremic  convulsions,  although  it  may  occur 
without  them.     It,  too,  may  be  the  first  symptom  noted  in  Bright's  disease. 


OPTIC  NERVE  AND  TRACT.  989 

The  retina  is  free  from  any  changes  visible  by  the  ophthahnoscope.  and  the 
condition  is  probably  due  to  the  action  of  the  poison  on  the  nerve  centers. 
It  generally  disappears,  not  quite  so  suddenly  as  it  comes  on,  but  compara- 
tively quickly,  while  the  impaired  vision  of  retinitis  albuminurica  is  a  more 
or  less  permanent  condition.  Similar  are  the  amauroses  from  lead  poisoning 
and  from  massive  doses  of  qninin.  Hysterical  amaurosis  is  more  frequently 
a  dimness  of  vision, — amblyopia, — but  true  blindness  may  occur  in  one  or 
both  eyes.  Tobacco  amblyopia  is  usually  gradual  in  its  appearance,  and 
affects  more  especially  the  center  of  the  field  of  vision.  There  may  be  con- 
gestion of  the  optic  disc,  and  if  the  use  of  tobacco  is  persisted  in.  there  may 
be  a  permanent  organic  change,  with  atrophy  of  the  discs.  A  scotoma  for 
red  and  green  is  invariably  present. 

In  nyctalopia,  or  night-blindness,  objects  are  clearly  seen  by  the  day  or 
by  strong  artificial  light,  but  are  invisible  in  the  shade  or  at  twilight.  In 
hemeralopia  the  reverse  state  of  affairs  exists,  objects  being  seen  with  dis- 
comfort in  bright  daylight  or  by  strong  artificial  light,  but  being  easily  seen 
in  deep  shade  or  at  twilight.  Retinal  hyperesthesia  is  sometimes  met  in 
hysterical  women. 


2.    Affections  of  the  Optic  Xerve. 

Those  which  are  of  medical  significance  are  optic  neuritis,  or  choked 
disc,  and  optic  atrophy. 

(a)    Intracranial  Trunk. 

The  intracranial  trunk  of  the  nerve  is  rarely  aitected,  by  reason  of  its 
shortness.  It  may,  however,  be  compressed  by  a  tumor  in  adjacent  parts, 
as  of  the  pituitary  body  or  of  the  bone;  by  aneurysm  of  the  ophthalmic  artery 
within  the  orbit  or  of  the  internal  carotid  within  the  skull.  The  trunk  may 
also  be  the  seat  of  inflammation,  which  may  extend  from  carious  bone  or 
meningitis,  or  may  be  rheumatic. 

(b)  Gptic  Neuritis,  Papillitis,  or  Choked  Disc, 

Definition. — Inflammation  of  the  intra-ocular  end  of  the  optic  nerve 
Anatomical. — It  will  be  remembered  that  the  optic  nerve  pierces  the 
sclerotic  and  choroid  coats  about  i-io  inch  (2.5  mm.)  to  the  nasal  side  of  the 
center  of  the  retina,  which  is  occupied  by  the  yellow  spot  of  Sommering. 
In  this  spot  the  sense  of  vision  is  most  nearly  perfect,  while  the  optic  papilla 
or  disc  is  the  only  part  of  the  retina  from  which  the  power  of  vision  is 
absent.  A  central  depression,  or  "  cup."  is  due  to  the  separation  of  the 
nerve-fibers,  pale  because  of  the  absence  of  blood-vessels,  while  the  per- 
iphery of  the  disc  has  a  rosv  tint  from  the  presence  of  the  minute  blood- 
vessels that  lie  among  the  nerve-fibers.  The  "  cup  "  varies  in  size,  and 
may  be  absent,  the  vascular  portion  of  the  disc  at  times  extending  over  it. 
The  tint  of  the  vascular  portion  of  the  disc  also  varies,  and  differences  are 
of  significance  only  when  noted  at  successive  examinations  of  the  same  case. 
Morbid  Anatomy.— It  is  by  swelling  and  diminished  transparency 
rather  than  by  recognizable  signs  of  congestion  that  the  iirsf  stage  of  optic 
neuritis  is  characterized.  Then  there  follows  lessening  of  the  sharpness  of 
the  edge  of  the  disc,  and  finally  its  total  obscuration,  as  seen  in  the  right 


990 


DISEASES  OF  THE  XERVOUS  SYSTEM. 


half  of  Figure  125  as  contrasted  with  the  left  half.  It  is  to  be  remembered 
that  the  normal  contrast  is  sometimes  diminished  within  the  limits  of  health, 
with  this  difference :  that  the  pathological  indistinctness  is  better  seen  wdth 
the  direct  method  of  examination,  while  the  indistinctness  sometimes  nor- 
mallv  present  is  more  evident  to  the  indirect.  The  abnormal  change  is 
earlier  recognized  on  the  nasal  side,  because  there  are  more  nerve-fibers 
there  than  at  the  temporal  edge.  In  the  second  stage  the  swelling  rapidly 
increases  and  the  whole  circumference  of  the  disc  disappears,  though  the 
cup  is  still  represented  by  a  slight  depression.  The  swelling  extends  even 
beyond  the  normal  disc,  becoming  two  or  three  times  as  w'ide.  The  swollen 
disc  assumes  a  red  or  grayish-red  color  to  the  indirect  examination,  but 
bv  the  direct  a  fine  striated  appearance  is  noted,  the  striae  radiating  from 
the  center  of  the  disc  in  the  direction  of  the  fibers.  White  spots  may 
appear  on  its  surface,  due  to  degeneration  of  the  nerve-fibers,  and  may  be 
seen  in  the  illustration.     As  the  swelling  increases  the  retinal  vessels,  at  first 


Fig.  125. — Comm2ncing  Optic  Neuritis  from  a  Case  of  Caries  of  the  Sphenoid  Bone 
with  Secondary  Meningitis — {after  Cowers). 

The  left-hand  figure  shows  the  normal  right  optic  disc  with  clear  outline  and  deep 
central  cup.  The  right-hand  figure  of  the  left  papilla  shows  well-marked  neuritis; 
the  edge  of  the  disc  is  concealed  by  a  swelling  which  extends  bej-ond  the  normal 
limits  of  the  disc.  The  central  cup  is  encroached  upon,  but  not  3'et  quite 
obliterated.  Some  of  the  vessels  are  partly  concealed  at  their  points  of  emergence, 
and  the  veins  lose  their  central  reflection. 


unaflfected,  suffer  from  the  compression,  the  veins  becoming  wider  and  more 
tortuous,  the  arteries  being  narrowed  or  remaining  normal,  while  hemor- 
rhages may  occur.  The  retina  may  also  be  invaded,  producing  a  neuro- 
retinitis. 

In  very  slight  degrees  of  inflammation  the  swelling  subsides  and 
recovery  takes  place.  In  high  degrees  it  remains  for  a  long  time,  owing  to 
the  presence  of  inflammatory  products,  which  gradually,  however,  undergo 
the  usual  contraction  of  cicatricial  tissue,  a  condition  of  "  consecutive 
atrophy  "  resulting,  in  which  the  disc  is  white  and  atrophied. 

Etiology. — j\Iost  commonly  optic  neuritis  is  caused  by  intracranial 
disease :  especially  in  nine-tenths  of  all  cases  tumor  is  said  to  be  present. 
It  gives  no  information  as  to  the  seat  of  the  tumor.  It  is  ascribed  by  some 
to  a  descending  neuritis ;  by  others,  to  intracranial  pressure.  In  over  ninety 
per  cent,  of  cases  the  neuritis  is  bilateral,  though  often  unequal  in  the  two 
eyes.     Unilateral  neuritis  is  generally  due  to  disease  within  the  orbit  or  at 


OPTIC  NERVE  AND  TRACT.  991 

the  optic  foramen,  but  may  be  due  to  intracranial  tumor.  Meningitis,  either 
tubercular  or  simple,  is  the  next  most  frequent  cause.  It  is  said  to  be 
rather  more  common  in  meningitis  of  the  base  than  of  the  convexity.  Such 
optic  neuritis  is  less  severe  than  that  caused  by  tumor.  Cerebral  abscess 
may  cause  it;  so  may  diffuse  cerebritis.  In  thrombotic  softening  and 
hemorrhage  optic  neuritis  is  rare,  but  in  embolic  softening  it  is  more 
common. 

Optic  neuritis  may  result  from  Bright's  disease,  chlorosis,  anemia,  or 
lead-poisoning,  and  may  occur  after  acute  fevers,  especially  scarlet  and 
typhoid.  In  the  latter  it  may  be  associated  with  brain  symptoms,  especially 
headache.  About  six  per  cent,  of  all  cases  of  multiple  sclerosis  are  accom- 
panied by  optic  neuritis,  due  to  inflammatory  or  sclerotic  patches  in  the 
nerve,  usually  slight  and  of  short  duration,  often  one-sided  in  consequence 
of  unilateral  involvement  of  the  nerve  by  a  sclerotic  patch. 

Symptoms. — Mild  degrees  of  optic  neuritis  may  be  without  symp- 
toms, except  such  as  are  revealed  by  the  ophthalmoscope.  With  higher 
degrees,  acuity  of  vision,  color  vision,  and  the  visual  field  all  suffer  and  may 
be  lost.  Its  severest  effect  on  vision  may  not  appear  until  contraction  sets 
in,  because  it  is  at  this  period  that  the  nerve  elements  suffer  most  in 
integrity.  The  defective  sight  is  not,  however,  necessarily  due  to  changes 
in  the  disc  or  retina ;  it  may  be  due  to  intense  inflammation  in  the  nerve 
behind  the  eye  or  to  intracranial  disease. 

Prognosis, — Even  in  severe  cases  there  may  be  some  improvement  of 
vision  with  subsidence  of  the  inflammation.  On  the  other  hand,  vision  may 
be  permanently  lost. 

(c)    Optic  Atrophy. 

There  are  three  varieties  of  atrophy  of  the  optic  nerve : 
(i)  Primary;  (2)  secondary;  (3)  consecutive. 

1.  Primary  or  simple  atrophy  is  that  form  which  is  not  preceded  by 
any  recognizable  inflammatory  change  in  the  papilla  or  surrounding  struc- 
tures. It  occurs  in  degenerative  diseases  of  the  brain  and  spinal  cord, 
more  frequently  in  multiple  or  disseminated  sclerosis  and  tabes  dorsalis.. 
It  is  present  in  about  forty  per  cent,  of  all  cases  of  multiple  sclerosis,  and, 
in  various  degrees,  in  at  least  fifteen  per  cent,  of  those  of  tabes.  In 
dementia  paralytica  it  is  present  in  about  five  per  cent.  Primary  atrophy 
is  sometimes  hereditary,  occurring  in  the  males  of  a  family  after  puberty. 
Other  causes  to  which  the  condition  has  been  ascribed  are  cold,  alcoholism, 
lead-poisoning,  sexual  excesses,  diabetes,  and  the  specific  fevers. 

2.  Secondary  atrophy  is  the  result  of  damage  to  the  optic  nerve  behind 
the  eye  or  at  the  chiasm.  It  is  characteristic  of  it  that  demonstrable  signs 
of  atrophy  follow,  instead  of  accompany,  the  deranged  vision ;  of  which, 
too,  hemianopsia  may  be  a  form. 

3.  Consecutive  atrophy  is  that  form  of  atrophy  which  succeeds  neuritis 
or  papillary  neuritis.  It  has  the  same  causes  and  the  same  significance. 
Only  secondary  and  consecutive  atrophy  are  the  result  of  uncomplicated 
intracranial  diseases ;  for  although  primary  atrophy  accompanies  dissemi- 
nated sclerosis,  tabes  dorsalis,  and  general  paralysis  of  the  insane,  it  is  not 
caused  by  the  associated  brain  disease,  but  is  the  result  of  the  same  wide- 
spread tendency  to  degeneration. 

The  ophthalmoscopic  appearances  in  primary  atrophy  dift"er  somewhat 


992  DISEASES  OF  THE  NERVOUS  SYSTEM. 

from  those  of  the  consecutive  and  secondary  forms,  the  disc  being-  gray- 
tinted, — whence  the  name  gray  atrophy, — with  its  edges  well  defined,  while 
the  arteries  appear  almost  normal.  In  secondary .  and  consecutive  atrophy 
the  disc  has  an  opaque,  white  appearance,  with  irregular  outline,  and  the 
arteries  are  small. 

The  symptoms  of  optic  atrophy  are  the  defects  of  vision  already 
detailed  when  treating  of  optic  neuritis. 

As  to  prognosis,  in  primary  atrophy  the  ultimate  result  is  usually 
blindness,  but  in  secondary  and  consecutive  atrophy  some  vision  remains, 
even  in  severe  cases,  while  in  mild  cases  recovery  is  not  impossible. 

3.    Lesions  of  the  Chiasm  and  Tract. 

Anatomical. — The  decussation  of  the  optic  tracts  at  the  chiasm  is 
peculiar.  As  it  reaches  the  chiasm  each  tract  divides  and  sends  a  portion 
— the  smaller — of  its  fibers  to  the  temporal  half  of  the  corresponding  retina, 
and  the  remaining  portion  to  the  nasal  half  of  the  opposite  retina.  Thus 
the  right  tract  supplies  the  right  or  temporal  half  of  the  right  retina  and  the 
right  or  nasal  half  of  the  left  retina ;  the  left  tract  supplies  the  left  or  tem- 
poral half  of  the  left  retina  and  the  left  or  nasal  half  of  the  right  retina. 
The  decussating  fibers  occupy  the  middle  of  the  chiasm,  and  the  direct  fibers 
the  corresponding  side.      (See  p.  993.) 

Effect  of  Lesion  of  the  Chiasm:  Hemianopsia. —  (a)  If  the  central 
portion  of  the  chiasm,  composed  of  decussating  fibers  only,  is  involved 
(lesions  b  and  c,  Fig.  126),  the  result  will  be  anesthesia  of  the  inner  half  of 
each  retina  and  blindness  of  the  outer  half  of  each  field  of  vision,  it  being 
remembered,  of  course,  that  the  half  field  which  is  blind  is  the  reverse  of  the 
half  of  the  retina  which  is  anesthetic,  since  the  picture  formed  on  each  half 
of  the  retina  is  projected  from  the  opposite  half  of  the  field  of  vision.  Such 
half  blindness  is  known  as  hemianopsia,  and  the  form  just  described,  in 
which  the  outer  or  temporal  half  of  each  field  is  blind,  is  known  as  bi- 
temporal hemianopsia. 

(b)  If  the  whole  chiasm  is  involved,  as  is  not  infrequently  the  case  as 
the  result  of  pressure  by  tumor,  there  will,  of  course,  be  total  blindness. 

(c)  If  the  lesion  is  intermediate,  involving  the  direct  fibers  on  one  side 
of  the  chiasm  as  well  as  the  central  .fibers,  there  will  then  be  blindness  in 
one  eye  and  temporal  hemianopsia  in  the  otfier. 

(d)  The  rarest  of  all  forms  of  hemianopsia  is  bi-nasal  hemianopsia,  due 
to  a  symmetrical  lesion  involving  only  the  direct  fibers  passing  to  the  tem- 
poral half  of  each  retina,  whence  results  blindness  in  the  nasal  field  only. 
It  is  found  sometimes  in  tumors  involving  the  outer  part  of  each  tract,  or  of 
each  optic  nerve. 

Effect  of  Unilateral  Lesion  of  the  Tract. — If  there  be  a  lesion  involving 
the  left  tract  at  d  (Fig.  126),  the  left  or  temporal  half  of  the  left  retina  and 
the  nasal  half  of  the  right  retina  become  anesthetic  and  useless,  the  right 
half  of  each  field  of  vision  is  blotted  out,  and  there  results  a  right  lateral 
hemianopsia  which  is  called  homonymous  hemianopsia.  The  reverse  is  the 
case  if  the  lesion  is  in  the  right  tract.  The  number  of  cases  involving  the 
right  side  is  about  equal  to  the  number  involving  the  left.  When  the  left 
half  of  one  field  and  the  right  half  of  another  are  blind,  or  the  reverse,  the 
condition  is  known  as  heteronymous  hemianopsia. 

In  the  usual  forms  of  bi-temporal  hemianopsia  the  obscure  fields  are  by 


OPTIC  NERVE  AND  TRACT. 


993 


no  means  always  exact  demi-fields,  which  would  be  the  case  if  the  dividing 
line  passed  exactly  through  the  fixing  point,  or  macula  lutea.  It  may 
diverge  to  the  temporal  side  so  as  to  leave  a  small  area  around  this  within 
the  seeing  half.  These  differences  are  due  to  pecuharities  in  the  decussa- 
tion rather  than  to  the  lesion.     The  half  fields  which  remain,  though  com- 


4isvt^ji> 


■^ii-etg. 


"SigJi^  Optic  Tierre 


ihi  OpUc  track 


.Ihnrr- 


Occ^ai&Hcorieso. 


Fig.  126.— Diagram  of  Course  of  Optic  Nerve-fibers  from  the  Cortex  to  the  Retina 
—(after  Sahli,  Modified  and  Extended). 

monly  natural,  are  sometimes  contracted.  This  is  usually  due  to  an  inflam- 
matory affection  of  the  peripheral  fibers  of  the  optic  nerves  in  front  of 
the   chiasm. 

There  are  other  differences  in  the  dividing-line,  such  as  obliquity,  want 
of  sharpness,  etc..  due  to  the  same  cause,  but  minute  description  of  these 
belongs  to  special  works  on  nervous  diseases.     Since  vision  remains  intact 

63 


994  DISEASES  OF  THE  NERVOUS  SYSTEM. 

in  the  central  region,  equally  in  right  and  left-sided  hemianopsia,  it  follows 
that  there  must  be  a  passage  of  fibers  from  the  macular  region  to  the  optic 
tract  of  each  hemisphere,  else  this  region  would  be  blinded  by  disease  of 
one  or  the  other  tract.  There  is  usually  the  same  loss  of  vision  for  color 
in  the  half  field,  but  half  vision  for  color  may  be  lost  in  central  disease 
without  any  change  in  the  field  for  white.  This  is  known  as  hemmchro- 
matopsia. 

4.  Lesion  of  the  Tract  and  Centers. 

The  optic  tract  on  each  side  crosses  the  crus  cerebri  backward  and 
passes  to  the  external  geniculate  body  to  the  pulvinar  of  the  optic  thalamus, 
and  to  the  anterior  coUiculus  of  the  quadrigeminal  body.  From  these  so- 
called  primary  optic  centers  fibers  pass  backward  through  the  posterior 
part  of  the  internal  capsule,  forming  the  fibers  of  the  optic  radiation  in  the 
white  substance  of  the  occipital  lobe,  into  the  visual  area  of  the  cortex,  of 
which  the  area  about  the  calcarine  fissure  is  the  chief  cortical  center,  though 
other  parts  of  the  occiptal  cortex  possibly  also  receive  and  store  up  visual 
impressions. 

Whence  it  is  plain  that  vision  may  be  influenced  by  lesions  in  any  of 
the  following  situations : 

1.  In  the  tract  itself. 

2.  In  the  external  geniculate  body. 

3.  In  the  pulvinar  of  the  optic  thalamus  and  in  the  anterior  colliculus 
of  the  corpora  quadrigemina. 

4.  In  the  fibers  passing  from  the  primary  optic  centers  to  the  occipital 
lobe,  as  at  c  (Fig.  126),  in  the  hinder  part  of  the  optic  radiation. 

5.  In  the  area  about  the  calcarine  fissure. 

The  effect  of  lesion  in  any  one  of  these  situations  is  to  produce  anes- 
thesia of  that  half  of  the  retina  corresponding  to  the  afifected  side  and  a 
homonymous  hemianopsia  of  the  opposite  half  of  the  visual  field. 

Morbid  States  Affecting  the  Optic  Nerve,  Chiasm,  Tract,  and 
Centers. — Outside  of  the  affections  of  the  retina,  which  concern  the  oph- 
thalmologist chiefly,  and  outside  of  optic  neuritis  or  papillitis  as  a  result  of 
intracranial  disease,  already  considered,  the  affections  of  the  optic  nerve 
which  concern  the  physician  are  tumors  springing  from  the  pituitary  body 
or  the  bone,  aneurysm  of  the  ophthalmic  artery  within  the  orbit  or  of  the 
carotid  within  the  skull,  and  interstitial  inflammation  from  an  adjacent 
focus,  or  rarely  from  rheumatism  and  injury. 

The  optic  chiasm  is  encroached  upon  by  tumors  in  the  neighborhood, 
especially  of  the  pituitary  body ;  by  tubercular  or  syphilitic  growths  in  its 
substance,  or  by  inflammation  invading  it  from  the  adjacent  dura  mater  or 
from  carious  bone;  by  internal  hydrocephalus,  the  distended  infundibulum 
of  the  third  ventricle  pressing  on  the  middle  of  the  chiasm ;  by  intersti- 
tial inflammation  of  a  possible  gouty  origin  or  associated  with  tabes  dor- 
salis ;  and,  finally,  by  interstitial  hemorrhage. 

The  optic  tract  may  be  invaded  or  compressed  by  tumors  springing 
from  the  inner  part  of  the  temporosphenoidal  lobe,  by  softening  after  throm- 
bosis of  the  internal  carotid,  or  by  disseminated  sclerosis.  Primary  soften- 
ing in  the  tract  is  rare,  as  is  also  hemorrhage. 

The  cortical  visual  centers  may  be  invaded  by  hemorrhage,  softening, 
tumors,  pressure  by  depressed  bone  in  fracture,  and  other  traumatic  causes.. 


OPTIC  NERVE  AND  TRACT.  995 

Symptoms    of    Lesions    of    the     Optic    Nerve,     Chiasm,    Tract,     and 
Cortex. — 

1.  Visual  Effects. —  (a)  Lesions  of  the  optic  nerve  cause  defects  of 
vision  on  the  same  side,  with  lessening  of  the  reflex  action  of  the  pupil 
proportionate  to  interference  with  vision.  The  impairment  of  vision  in- 
cludes extent  of  field  of  vision  as  well  as  degree.  There  may  be  concen- 
tric limitation  of  the  visual  field  because  the  peripheral  layer  of  nerve-fibers 
near  the  opfic  foramen  is  damaged  by  processes  external  to  it.  In  other 
.cases  there  is  irregular  defect,  and  in  others  still  the  loss  of  sight  is  total 
and  lasting. 

To  the  ophthalmoscope  there  may  be  at  first  no  change,  but  if  the 
lesion  is  considerable,  the  atrophic  condition  soon  makes  its  appearance 
"  secondary  "  to  changes  in  the  nerves,  as  distinguished  from  "  consecu- 
tive "  atrophy,  which  succeeds  papillitis.  There  may  be  slowly  super- 
vening atrophy  without  recognizable  papillitis.  Central  loss  of  vision,, 
due  to  axial  neuritis,  is  less  common,  but  occurs  sometimes  in  tobacco 
amblyopia. 

{b)  In  lesions  of  the  chiasm  the  characteristic  symptom  is  bitemporal 
hemianopsia,  or  loss  of  the  outer  half  of  each  field  of  vision ;  this  is  because 
the  lesions  mainly  afifect  the  chiasm  at  its  central  portion,  where  the  fibers, 
after  decussating,  pass  to  the  nasal  half  of  each  retina.  Usually,  however,. 
the  process,  be  it  tumor  or  inflammation,  which  causes  temporal  hemianopsia 
extends  laterally,  involving  the  non-decussating  fibers  of  one  side  of  the 
chiasm,  causing  total  blindness  of  the  corresponding  eye;  or,  if  extending 
to  both  sides,  blindness  of  both  eyes.  These  different  stages  may  often 
be  traced  in  a  single  case  as  the  disease  progresses.  The  term  "  oscillating 
bitemporal  hemianopsia  "  is  applied  to  a  rapid  and  frequent  variation  of  the 
dark  fields,  and  is  regarded  as  more  or  less  clearly  diagnostic  of  basal 
syphilis,  such  as  gumma  or  syphilitic  meningitis.  More  rarely  we  have  the 
binasal  hemianopsia  already  described.  Slight  variations  in  the  extent  of 
the  dark  fields  have  been  referred  to  as  the  result  of  peculiarities  in  decus- 
sation rather  than  of  lesion  or  seat  of  lesion. 

(c)  In  lesions  of  the  optic  tract  between  the  chiasm  and  the  external 
geniculate  body  there  is  bilateral  hemianopsia. 

(d)  Bilateral  hemianopsia  is  also  a  result  of  lesion  of  the  central  fibers 
of  the  nerve  between  the  primary  visual  centers  and  the  cerebral  cortex. 

(e)  Lesions  of  the  cuneus  cause  bilateral  hemianopsia.  A  lesion  in 
each  hemisphere,  affecting  the  visual  paths  back  of  the  chiasm,  will  cause  a 
double  hemianopsia,  with  total  loss  of  vision  in  both  eyes.  Such  a  result 
has  followed  successive  lesions  in  the  two  occipital  lobes. 

(f)  Hemianopsia  may  be  due  to  functional  disease.  Transient  hemian- 
opsia is  sometimes  a  symptom  of  migraine,  either  as  an  isolated  symptom 
apart  from  headache  and  gastric  disturbances  or  associated  with  them.  It 
may  affect  now  one  half  of  the  field  and  now  another. 

Hemianopsia  is  also  rarely  a  symptom  of  hysteria. 

2.  Other  Symptoms  Associated  with  Hemianopsia. — In  about  one-half 
the  cases  of  hemianopsia  there  is  transient  or  permanent  hemiplegia,  the 
result  of  the  same  lesion,  the  hemiplegia  being  on  the  side  of  the  loss  of 
vision,  so  that  the  patient  cannot  see  'the  paralyzed  side.  Hemianesthesia 
may  also  be  associated,  and  defects  in  speech  are  sometimes  found  when  the 
paralysis  is  on  the  right  side. 

Hemiachromatopsia  has  been  mentioned.     (See  p.  994.)     In  this  con- 


996  DISEASES  OF  THE  NERVOUS  SYSTEM. 

dition  there  is  no  change  in  the  field  for  ordinary  objects,  but  all  colors 
appear  gray  as  soon  as  ihe  vertical  line  is  passed.  The  symptom,  accord- 
ing to  Gowers,  probably  depends  on  disease  of  one  part  of  the  occipital 
lobe,  and  is  proof  of  a  separate  center  for  color  not  yet  precisely  located, 
perhaps  in  some  part  of  the  occipital  cortex  in  front  of  the  apical 
region. 

The  limitation  of  the  remaining  functionally  active  half  field  and  the 
isolated  loss  for  colors  are  the  only  known  differences  in  the  features  of 
hemianopsia  due  to  variations  in  the  seat  of  the  lesion  in  the  optic  path 
behind  the  chiasm,  the  limitation  of  the  active  half  field  indicating  a  lesion 
in  the  optic  radiation  near  the  thalamus,  the  isolated  loss  for  colors  pointing 
to  a  lesion  in  the  occipital  lobe. 

3.  Amblyopia. — Amblyopia  is  another  form  of  sight  defect  due  to  brain 
disease.  The  term  is  used  to  indicate  a  partial  loss  or  blurring  of  vision. 
There  is  concentric  limitation  of  the  visual  field,  varying  in  different  cases, 
and  along  with  it  the  color  fields  are  also  reduced. 

Similar  eye  defects,  associated  with  hemianesthesia,  occur  sometimes 
in  hysteria,  with  which  it  may  be  confounded.  Since  a  simple  functional 
loss  of  vision  may  rarely  result  as  a  reflex  from  irritation  of  the  fifth  nerve 
or  from  hysteria,  so  a  functional  amblyopia,  afifecjing  both  eyes,  may  also 
result  from  such  causes — indeed,  is  more  common  than  the  organic  form. 
A  carious  tooth  may  act  in  this  way.  Amblyopia  from  errors  of  refraction 
must  not  be  confounded  with  the  amblyopia  due  to  brain  disease. 

Diagnosis. — How  shall  we  interpret  these  phenomena  of  vision  con- 
cerned with  the  optic  nerve  and  tract?  Some  conclusions  are  easy;  others 
are  difficult,  by  reason  of  the  limitations  of  our  knowledge.  Accurate  inves- 
tigation of  fields  of  vision,  with  a  view  to  the  study  of  hemianopsia  and  other 
defects  in  the  visual  fields  variously  caused,  is  made  by  means  of  the  perim- 
eter, for  directions  concerning  the  use  of  which  instrument  the  student  is 
referred  to  works  on  ophthalmology.  Herman  Sahli  suggests  an  easy, 
rough  method,  quite  sufficient  for  recognizing  marked  difference  in  the  field 
of  vision,  performed  as  follows:  The  physician  seats  himself  opposite  the 
patient,  whose  right  eye — supposing  this  to  be  the  one  to  be  tested — is 
opposite  the  physician's  left,  the  other  eye  of  each  being  closed.  The  two 
open  eyes  being  thus  fixedly  opposed,  the  physician  passes  his  finger  to  and 
fro  across  the  field  of  vision  exactly  midway  between  the  two  eyes.  In  this 
way  he  can  compare  his  own  field  of  vision  with  that  of  the  patient,  noting 
at  what  moment  the  finger  is  seen  approaching  from  the  periphery  of  each. 
Care  must  be  taken  that  the,  finger  is  kept  exactly  midway  between  the 
physician  and  patient,  and  in  order  to  do  this,  the  examiner  must  from  time 
to  time  open  his  closed  eye.  Defective  sight  in  one  eye  with  diminished 
reflex  action  of  pupil  proportionate  to  the  defect,  the  function  of  the 
remaining  eye  being  intact,  usually  means  disease  of  one  optic  nerve.  In 
some  rare  cases  of  functional  disease  in  which  the  sight  of  one  eye  only  is 
involved,  the  perfect  responsiveness  of  the  pupil  distinguishes  it  from  organic 
disease  of  the  nerve.  Total  loss  of  sight  in  both  eyes  may  mean  chronic 
atrophy,  damage  to  the  chiasm,  or  disease  of  both  tracts  or  in  both  hemi- 
spheres. In  these  cases  the  symptoms  are  at  first  partial,  and  in  this  way  the 
diagnosis  is  aided. 

Central  scotoma  means  damage  to  nerve-fibers  in  the  center  of  the  trunk 
of  the  optic  nerve,  either  inflammatory  or  the  result  of  hemorrhage.  Periph- 
eral limitation  of  vision  means  damage  to  fibers  running  in  the  periphery  of 


OPTIC  NERVE  AND  TRACT.  997 

the  nerve.     Sectorial  blindness  in  one  eye  means  disease  of  the  nerve,  decided 
in  degree  but  limited  in  extent. 

Bitemporal  hemianopsia  means  disease  of  the  chiasm,  while  the  combina- 
tion of  complete  blindness  of  one  eye  with  temporal  hemianopsia  in  the 
other  means  disease  of  the  chiasm  which  has  extended  to  the  outer  fibers, 
and  even  to  the  optic  tract  or  optic  nerve,  on  the  side  on  which  blindness  is 
complete. 

Bilateral  hemianopsia  is  due  to  disease  back  of  the  chiasm,  and  the 
determination  of  the  spot  involved  in  the  tract  between  the  chiasm  and  the 
occipital  area  which  is  the  cortical  center  of  vision,  stimulates  diagnostic 
acumen.  The  most  that  can  be  attempted  is  the  setthng  of  the  question  as 
to  whether  the  disease  is  in  the  tract  between  the  chiasm  and  the 
external  geniculate  body  or  in  the  fibers  beyond  bounded  by  the  visual 
centers.  To  this  end  the  hemianospk  pupillary  reaction  of  Wernicke  is 
sought.  A  perfect  pupil  reflex  requires  the  integrity  of  the  retina,  of  the 
fibers  of  the  optic  nerve  and  tract,  of  the  center  and  fibers  of  the  third 
nerve,  and  of  the  iris.  When  the  light  is  thrown  on  the  blind  half 
of  the  retina  the  pupil  contracts  as  much  as  if  it  is  thrown  on  the  seeing  half, 
if  the  disease  is  in  the  hemispheres ;  but  if  the  disease  is  in  the  tract,  it  does 
not  contract  because  the  path  to  the  third  nucleus  below  the  corpora  quad- 
rigemina  is  interrupted.  The  employment  of  the  test  requires  much  care 
and  experience.  Seguin  directs  that  the  patient,  being  in  a  darkened  room 
with  a  light  behind  his  head  in  the  usual  position,  be  directed  to  look  to  the 
other  side  of  the  room,  so  as  to  eliminate  accommodation  movements. 
Then  a  faint  light  is  thrown  upon  the  eye  from  a  plane  or  large  concave  mir- 
ror, held  well  out  of  focus,  and  the  size  of  the  pupil  is  noted.  With  the 
other  hand  a  beam  of  light,  focused  by  an  ophthalmoscopic  mirror,  is  then 
thrown  directly  into  the  optical  center  of  the  eye,  then  laterally  in  various 
positions  and  from  above  and  below  the  equator  of  the  eye,  noting  the 
reaction  at  all  angles  of  incidence.  According  or  not  as  a  response  is 
obtained  in  the  pupil  the  inference  is  drawn. 

Amblyopia  with  concentric  reduction  of  the  field,  decided  in  one  eye 
and  slight  in  the  other,  may  be  due  to  atrophy  of  the  nerve,  to  disease  of 
the  higher  visual  center  in  one  hemisphere,  or  to  hysteria.  If  atrophy,  the 
ophthalmoscope  recognizes  the  lesion  and  the  responsiveness  of  the  pupil 
is  diminished.  If  disease  of  one  hemisphere,  the  nerve  is  normal  to  the 
ophthalmoscope,  the  pupil  contracts  perfectly  under  the  action  of  light, 
and  the  onset  is  sudden  or  accompanied  with  other  signs  of  organic  brain 
disease.  Mind-blindness,  described  on  page  975,  may  also  be  a  result  of 
lesion  in  this  locality.  In  hysteria  the  symptoms  are  the  same  as  in  dis- 
ease of  the  higher  visual  center,  and  the  diagnosis  depends  on  the  presence 
or  absence  of  signs  of  organic  or  functional  disease.  In  hysterical  blind- 
ness the  loss  of  sight  is  rarely  complete.  In  hysterical  and  neurotic  defects 
of  vision  there  may  be  a  derangement  of  the  natural  relation  in  color  fields. 
Thus,  while  normally  the  blue  field  is  most  conspicuous  in  the  last-named 
conditions,  it  is  often  overshadowed  by  other  colors. 


998  DISEASES  OF  THE  NERVOUS  SYSTEM. 


LESIONS   OF   THE   MOTOR   NERVES   OF   THE   EYEBALL. 

Anatomical. — The  third  cranial  nerve  (oculomotor)  supplies  the  leva- 
tor palpebrse  superioris,  the  superior  and  inferior  recti,  the  rectus  internus, 
the  obliquus  inferior,  the  sphincter  of  the  iris,  and  the  ciliary  muscle.  The 
fourth  cranial  nerve  (the  trochlear)  supplies  the  superior  oblique;  the 
sixth  cranial  nerve  (the  abducens),  the  rectus  externus.  The  functions  of 
the  muscles  to  which  these  nerves  are  distributed  are  sufficiently  indicated 
by  their  names. 

Third  Nerve. — Lesions  may  involve  the  nerve  at  it,s  nuclear  origin 
or  in  its  course.  Lesion  of  the  third  nerve  at  its  origin  involves  also  usually 
the  origin  of  the  other  motor  nerves  of  the  eye,  producing  general  ophthal- 
moplegia, as  a  result  of  which  the  eyeball  is  motionless,  and  an  object 
moved  about  in  front  of  it  can  be  followed  only  by  moving  the  entire  head. 
The  nerve  may  be  invaded  in  its  course  by  traumatic  causes,  meningitis, 
gummata,  aneurysm,  or  neuritis,  frequently  rheumatic,  and  may  also  be 
affected  in  diphtheria,  tabes  dorsalis,  and  diabetes  mellitus.  The  effect  may 
be  spasm  or  paralysis. 

The  results  of  spasm  of  the  muscles  supplied  by  the  third  nerve  are 
manifested  in  nystagmus.  This  consists  in  an  involuntary,  clonic,  rhyth- 
mical, oscillatory  movement  of  the  eyeball,  usually  horizontal,  but  some- 
times rotary,  more  rarely  vertical.  It  is  seen  in  congenital  or  acquired 
brain  lesions,  and  is  often  a  striking  feature  in  albinism.  In  meningitis 
and  hysteria  there  is  also  sometimes  spasm  of  the  muscles  supplied  by  the 
third  nerve,  especially  the  internal  rectus  and  the  levator  palpebrse,  the 
antagonist  of  the  orbicularis.* 

Paralysis  of  those  muscles  supplied  by  the  third  nerve,  which  include 
all  the  eye  muscles  except  the  external  rectus  and  the  superior  oblique, 
results  in  outward  squint ;  ptosis,  or  drooping  of  the  upper  eyelid ;  the 
absence  of  contracting  power  in  the  pupil,  which  remains  of  medium  size; 
loss  of  accommodation ;  the  double  vision,  or  diplopia.  Such  paralysis, 
involving  all  the  branches  of  the  nerve,  may  be  recurrent,  especially  in 
women,  often  at  the  menstrual  period,  or  at  wider  intervals. 

It  is  sometimes  associated  with  pain  in  the  head  and  at  other  times 
with  migraine.  The  individual  attack  lasts  a  few  days,  or  as  many  weeks. 
Partial  involvement  of  the  third  nerve  may  include  the  levator  palpebrse, 
the  superior  rectus,  the  ciliary  muscle,  and  the  iris,  while  the  external 
muscles — that  is,  the  internal  ^nd  inferior  recti  and  the  inferior  oblique — 
may  escape. 

Ptosis  only,  due  to  paralysis  of  the  levator  palpebrse,  complete  or  partial, 
may  occur  under  various  conditions.  It  may  be  congenital  and  incurable, 
or  due  to  cerebral  lesion ;  or  it  may  be  hysterical,  when  it  is  apt  to  affect 
both  eyes  and  is  associated  with  other  symptoms  of  hysteria.  It  may  be 
caused  by  disease  of  the  sympathetic  nerve  (pseudoptosis),  and  may  be 
associated  with  symptoms  of  vasomotor  palsy — viz.,  elevation  of  tempera- 
ture on  the  affected  side,  redness  or  edema  of  the  skin,  and  contraction  of 
the  pupil  on  the  same  side.  Finally,  it  is  seen  in  weak,  delicate  women  as 
a  transient  event,  especially  in  the  morning.     When  the  result  of  a  definite 

*  Blepharospasm  is  a  spasm  of  the  orbicularis  muscle,  which  is  supplied  by  the  facial  nerve.  It 
amounts  usually  only  to  twitching:  of  the  eyelids,  but  may  be  so  severe  as  to  close  them  completely, 
so  that  it  is  not  in  the  power  of  the  patient  to  open  them. 


LESIONS  OF  MOTOR  NERVES  OF  EYEBALL.  999 

.lesion  of  the  third  nerve,  at  its  nucleus  or  in  its  course,  it  may  also  be  asso- 
ciated with  a  paralysis  of  the  superior  rectus  alone,  or  of  the  internal  and 
inferior  recti  in  addition. 

Condition  of  the  Pupil. — The  condition  of  the  pupil  should  be  studied 
with  light  of  moderate  intensity,  and  in  doubtful  states  the  pupil  under 
examination  should  be  compared  with  that  of  the  eye  of  a  healt.hy  indi- 
vidual about  the  same  age. 

Miosis,  or  contraction  of  the  pupil,  is  found  physiologically  during 
sleep,  especially  in  elderly  persons ;  pathologically,  as  an  early  symptom  in 
tabes  dorsalis,  in  progressive  paralysis  of  the  insane,  and  as  an  effect  of 
eserin,  pilocarpin,  morphin,  and  in  complete  chloroform  narcosis. 

Mydriasis,  or  dilatation  of  the  pupil,  occurs  in  deep  unconsciousness, 
during  extreme  pain,  in  dyspnea,  in  peripheral  blindness,  especially  from 
optic  atrophy,  in  oculomotor  paralysis,  rarely  in  tabes  dorsalis  and  pro- 
gressive paralysis  of  the  insane.  It  is  also  an  effect  of  atropin,  duboisin, 
and  cocain,  and  of  the  early  stage  of  chloroform  narcosis. 

The  pupil  may  be  unduly  large  from  palsy  of  the  sphincter  (third  pair) 
fibers  or  from  spasm  of  the  radiating  (sympathetic)  fibers;  or  the  pupil  may 
be  abnormally  small  from  the  opposite  conditions. 

Other  limited  paralyses  due  to  third  nerve  disease  are  cycloplegia  and 
iridoplegia.  Cycloplegiu  is  paralysis  of  the  ciliary  muscle,  producing  loss 
of  the  power  of  accommodation.  In  this  state  of  affairs  distant  vision  is 
good,  but  near  objects  cannot  be  seen  distinctly.  It  may  occur  in  one  or 
t)oth  eyes,  being  in  the  latter  event  more  usually  due  to  disease  of  the 
nuclear  origin  of  the  third  nerve.  It  is  one  of  the  earliest  manifestations  of 
•diphtheritic  paralysis,  and  is  a  symptom  also  of  tabes  dorsalis.  It  may  be 
corrected  by  the  use  of  eye-glasses. 

Iridoplegia  is  paralysis  of  the  iris,  and  its  three  forms  are  thus  classified 
l>y  Gowers,  one  associated  and  twO'  reflex : 

1.  Accommodative  iridoplegia  is  a  form  in  which  the  pupil  does  not 
diminish  in  size  during  accommodation.  It  is  tested  by  having  the  patient 
look  at  a  distant  object  and  then  at  a  near  one  in  the  same  line  of  vision,  so  as 
to  avoid  any  change  in  the  amount  of  light  entering  the  eye.  It  is  usually 
associated  with  paralysis  of  accommodation,  but  the  ciliary  muscle  may  be 
efficient  and  yet  the  associated  action  of  the  iris  be  lost,  or  the  reverse.  This 
loss  is  less  common  than  that  of  reflex  action.  It  is  the  result  of  the  same 
cause  as  cycloplegia. 

2.  Re-flex  Iridoplegia,  or  Argyll  Robertson  Pupil. — The  path  for  the 
optic  reflex  is  along  the  optic  nerve  and  tract  to  the  nuclei  of  the  third  nerve ; 
thence  to  the  ciliary  ganglion,  and  through  the  ciliary  nerves  to  the  eye.  In 
testing  for  this  condition  each  eye  should  be  tried  separately,  the  other  being 
covered,  but  not  closed.  The  patient  is  asked  to  look  toward  a  dark  part  of 
the  room,  when  a  bright  light  is  thrown  suddenly  in  front  of  the  eye  at  a  dis- 
tance of  three  or  four  feet,  so  as  to  avoid  the  effect  of  accommodation.  If 
the  patient  looks  at  a  nearer  light,  he  will  accommodate  for  it,  and  the  pupil 
may  contract  when  there  is  no  action  to  light.  Such  absence  of  light  reflex 
without  loss  of  the  accommodation  contraction  was  first  pointed  out  by  Argyll 
Robertson. 

3.  Skin  Iridoplegia. — Loss  of  skin  reflex.  If  the  skin  of  the  neck  is 
pinched  or  pricked,  or  stimulated  by  an  electric  shock,  the  pupil  dilates 
reflexly.  Since  active  dilatation  of  the  pupil  is  through  the  sympathetic 
nerve,  the  motor  path  for  this  action  must  be  along  the  cervical  sympathetic, 


lOOO 


DISEASES  OF  THE  XERVOUS  SYSTEM. 


and  along  the  fibers  connecting  this  with  the  cord,  at  the  lowest  part  of  the 
cerv^ical  region. 

These  reactions  are  lost  when  the  path  is  interrupted  or  the  center  is 
damaged.  Thus,  the  light  reflex  is  lost  or  impaired  in  disease  of  the  optic 
nerve  including  the  retina,  or  in  disease  of  the  third  nerve.  Disease  of  one 
optic  tract  does  not  lessen  the  action  imless  the  light  falls  on  the  blind  half 
of  the  retina,  because,  as  already  stated,  the  fibers  from  the  central  and  most 
sensitive  region  of  each  retina  pass  through  both  optic  tracts,  whence  dis- 
ease of  one  does  not  abolish  the  reflex.  The  skin  reflex  is  lost  in  disease  of 
the  cervical  sympathetic  and  sometimes  of  the  cervical  spinal  cord,  especially 
when  there  is  associated  loss  of  sensibility.  Thus,  tumor  of  the  cord  some- 
times produces  this  symptom. 

When  the  eye  reflexes  are  lost  without  disease  of  the  sympathetic  or 
cervical  cord,  it  is  generally  due  to  degenerate  disease  of  the  centers.  Tabes 
dorsalis,  in  which  it  is  a  common  and  an  early  symptom,  is  a  conspicuous 
instance.     Less  frequent  is  general  paralysis  of  the  insane,  and  other  degen- 


Fig.  127. — Situation  of  the  Cranial  Nerves — {after  Edinger), 
Cranial  nerve  nuclei,  oblongata,  and  pons  represented  as  transparent.     Motor  nuclei, 

black;  sensitive  nuclei,  red. 

erative  processes  less  definite.  It  may  occur  also  without  other  nerve  symp- 
toms. In  most  of  the  cases  in  which  it  has  come  under  Gowers'  observation 
thus  isolated,  the  patient  had  suffered  from  constitutional  syphilis  for  years. 
The  two  palsies,  that  of  the  skirT  reflex  and  that  of  the  light  reflex,  are  com- 
m.only  associated,  but  not  always.  The  pupils  are  often  small,  reduced  to 
two  millimeters,  or  even  one  millimeter,  in  diameter. 

Inequality  of  pupils,  or  anisocoria,  is  also  a  symptom  of  progressive 
paresis  and  tabes  dorsalis,  but  occurs  also  in  healthy  persons. 


Fourth  Nerve. — The  fourth  cranial  nerve  (trochlear),  as  it  passes 
around  the  outer  surface  of  the  crus  into  the  orbit,  is  liable  to  be  compressed 
by  tumors,  by  aneurysm,  or  by  the  exudation  of  basal  meningitis.  Its 
nucleus  below  the  aqueduct  of  Sylvius  may  be  involved  in  tumors,  or  may 
undergo  degeneration  with  other  ocular  nuclei.  As  the  superior  oblique 
muscle,  supplied  by  it,  acts  in  such  a  way  as  to  direct  the  eyeball  downward 
and  rotate  it  slightly,  paralysis  causes  retardation  of  downward  and  inward 


LESIONS  OF  MOTOR  NERVES  OF  EYEBALL.  loor 

movement,  often  so  slight  as  not  to  be  noticeable.  The  head  is  inclined 
somewhat  forward  and  toward  the  sound  side,  and  there  is  double  vision 
when  the  patient  looks  down,  as  in  descending-  stairs.  Paralysis  of  this 
nerve  is  seldom  met  with  alone,  except  in  nuclear  disease. 

Sixth  Nerve. — The  sixth  nerve  (abducens),  emerging  at  the  junction 
of  the  pons  and  medulla  oblongata,  passing  forward  and  entering  the  orbit, 
is  liable  to  be  affected  by  meningitis  at  the  base,  or  by  tumors,  especially  gum- 
mata,  or  by  cold.  The  external  rectus  being  alone  supplied  by  it,  the  effect 
of  its  paralysis  is  to  produce  internal  squint,  and  the  eye  cannot  be  turned 
outward.  There  is  diplopia  when  looking  toward  the  paralyzed  side.  It  is 
a  frequent  ocular  palsy,  because  the  nerve  has  so  long  and  exposed  a 
course. 

If  the  nucleus  of  the  sixth  nerve  is  affected,  a  very  interesting  condition 
results,  which  was  first  studied  by  Beevor.  In  consequence  of  paralysis 
of  the  external  rectus  the  eye  of  that  side  is  turned  inward,  while  at  the  same 
time  the  internal  rectus  of  the  eye  of  the  opposite  side  has  lost  the  power  to 
turn  its  eye  inward.  Consequently,  both  eyes  are  turned  to  the  side  oppo- 
site and  away  from  that  of  the  injury.  Thus,  if  the  nucleus  of  the  right  sixth 
nerve  is  involved,  both  the  right  and  the  left  eye  are  turned  toward  the  left. 
Such  opposite  deviation  away  from  the  side  of  lesion  is  known  as  "  conjugate 
deviation."  It  is  due  to  the  fact  that  the  nucleus  of  the  third  nerve,  supply- 
ing the  internal  rectus,  is  connected  by  fibers  with  the  nucleus  of  the  sixth ; 
whence  in  lesion  of  the  nucleus  of  the  sixth  nerve  there  is  paralysis  of  the 
internal  rectus,  supplied  by  the  third  nerve,  in  associated  movements,  though 
the  nucleus  of  the  third  nerve  is  not  involved,  the  power  of  convergence  is 
not  affected. 

In  consequence  of  the  proximity  of  the  nucleus  of  the  sixth  nerve  to 
that  of  the  seventh  or  facial,  disease  of  the  former  is  apt  to  involve  the 
latter.  Whence,  say  if  there  is  lesion  of  the  left  nerve,  there  follows  con- 
jugate deviation  of  both  eyes  to  the  right,  with  a  complete  paralysis  of  the 
left  half  of  the  face. 

Diabetes  insipidus  is  sometimes  associated  wnth  paralysis  of  the  sixth 
nerve.  Such  a  case  I  saw  at  the  Philadelphia  Hospital  with  J.  Hendrie 
Lloyd.  The  paralysis  of  the  sixth  nerve  was  subsequently  substituted  by 
paralysis  of  the  third,  the  polyuria  remaining.  A  case  of  this  character 
may  be  caused  by  syphilitic  meningitis.  Basal  meningitis,  involving  the  vas- 
cular supply  to  the  floor  of  the  fourth  ventricle,  was  suspected.  Other  cases 
of  polyuria  associated  with  paralysis  of  the  sixth  nerve  are  reported,  notably 
Maguire's. 

Phenomena  in  General  of  Paralysis  of  Motor  Nerves  of  the  Eye. — 
These  include,  first,  limitation  of  movement  and  strabismus,  referred  to.  In 
addition  to  these  certain  derangements  of  vision,  known  "as  secondary  devia- 
tion, erroneous  projection,  double  vision,  occur. 

Secondary  deviations  are  thus  demonstrated :  After  covering  the  sound 
eye,  let  the  paretic  eye  fix  itself  upon  a  point  which  it  cannot  reach  at  all,  or 
can  reach  only  after  extreme  exertion.  Then  remove  the  covering  hand  from 
the  sound  eye,  and  it  will  be  found  that  the  latter  has  been  moved 
much  too  far  in  the  same  direction,  the  abnormal  attempt  at  innervation  of  the 
affected  eye  passing  over  to  the  associated  muscle  of  the  healthy  eye  and  caus- 
ing in  it  too  great  a  contraction. 

Erroneous  projection  furnishes  the  idea  that  an  object  at  which  we  are 


1002  DISEASES  OF  THE  NERVOUS  SYSTEM. 

looking  is  further  on  one  side  than  it  really  is,  or  that  the  movement  of  the 
eye  in  following  it,  when  moving,  is  greater  than  it  is.  Under  these  circum- 
stances, in  an  attempt  to  touch  the  object  with  the  fingers  the  latter  may  go 
beyond  it.  This  grows  out  of  the  fact  that  when  the  eyes  are  at  rest,  in  the 
mid  position,  an  object  at  which  we  are  looking  appears  directly  opposite  the 
face.  Turning  the  eye  to  one  side,  the  object  appears  to  the  side  of  its 
former  position;  and  if  the  object  moves,  we  estimate  the  extent  of  its 
motion  by  the  amount  of  movement  of  the  eyeball  following  it.  Now,  when 
one  muscle  is  weak,  the  increased  innervation  required  to  contr'act  it  gives 
the  impression  of  a  degree  of  movement  greater  than  actually  takes  place. 
This  is  erroneous  projection.  Now,  as  the  equilibrium  of  the  body  is  largely 
maintained  by  a  knowledge  of  the  relation  of  external  objects  to  it,  obtained 
by  the  action  of  the  eye  muscles,  the  erroneous  projection  due  to  paralysis 
disturbs  the  harmony  of  visual  impressions  and  may  produce  dizziness, 
known  as  ocular  vertigo. 

Double  z'ision  results  from  the  fact  that  if  one  eye  is  paralyzed  the  axes 
of  the  two  eyes  do  not  coincide,  nor  do  the  images  in  the  two  retinae.  The 
image  produced  in  the  sound  eye  is  called  the  true  image ;  that  in  the  affected 
eye,  the  false  image.  In  simple  or  homonymous  diplopia  the  false  image  is 
on  the  same  side  as  the  paralyzed  eye ;  in  crossed  diplopia  it  is  on  the  other 
side.  It  is  one  of  the  most  annoying  symptoms  'of  paralysis  of  the  eye 
muscles. 

Ophthalmoplegia. — Ophthalmoplegia,  or  nuclear  palsy,  is  a  term 
applied  to  a  chronic  progressive  paralysis  of  the  ocular  muscles,  due  to  dis- 
ease of  the  ocular  nuclei.  It  is  called  internal  when  the  internal  muscles  only 
are  involved — /'.  c,  the  iris  and  ciliary  muscles ;  external,  when  the  external 
muscles  are  affected  more  or  less  completely.  When  both  internal  and  ex- 
ternal muscles  are  involved,  it  is  known  as  total  ophthalmoplegia. 

Historical. — The  term  was  first  used  bj'  Brunner,  in  1850.  The  nature  of  the 
cases  was  pointed  out  by  v.  Graefe  in  1856,  and  in  1S68  compared  b}-  liim  with  bulbar 
palsy.  Forster  localized  the  lesion  in  1878  for  external  palsy,  including  all  the  mus- 
cles except  the  iris  and  ciliary  muscles.  Internal  ophthalmoplegia  was  described  by 
Hutchinson  in  the  same  year,  and  the  external  form,  with  postmortem  proof  of  its 
nature,  in  1879. 

Symptoms, — These  vary  according  to  the  position  and  character  of  the 
lesion,  which  may  be  degenerative,  hemorrhagic,  or  the  result  of  pressure  by 
tumors  or  the  product  of  basilar  meningitis.  They  are  bilateral,  except  in 
the  instance  of  the  sixth  nerve,  with  resulting  conjugate  paralysis.  Gowers 
describes  three  modes  of  onset-^chronic,  sudden,  and  acute. 

The  chronic  form  is  the  most  common,  due  to  nuclear  degeneration,  or 
more  rarely  to  tumor  and  embolic  obstruction,  and  still  more  rarely  to  hemor- 
rhage. In  this  form  there  is  a  great  variety  of  combination  and  degree. 
Thus,  there  may  be  internal  ophthalmoplegia  only,  or  external,  or  both.  In 
the  internal  form  there  may  be  loss  of  the  iris-reflex  only  or  of  the  ciliary 
muscle  action  only.  In  the  external  variety  the  levator  and  superior  recti 
are  commonly  first  involved,  the  other  muscles  gradually.  There  may  be 
loss  of  the  upward  and  downward  movement  of  the  eye,  ptosis,  and  conjugate 
lateral  palsy.  There  may  be  double  vision,  generally  of  short  duration.  In 
the  total  form  the  eye  is  fixed  and  immovable.  Each  variety  may  be  asso- 
ciated with  tabes  dorsalis,  general  paralysis  of  the  insane,  progressive  mus- 
cular atrophy,  and  bulbar  palsy,  often  with  syphilis.     It  is  more  common  in 


LESIONS  OF  MOTOR  NERVES  OF  EYEBALL.  1003 

jnales,  and  occurs  occasionally  in  the  young.  There  is  a  form  occurring  in 
children,  known  as  infantile  oculo-facial  palsy,  which  may  be  congenital  or 
acquired ;  rarely,  it  occurs  as  a  sequel  of  diphtheria,  late  and  permanent. 

The  disease  may  be  very  slow  in  developing,  and  may  require  years. 
Sometimes  one  eye  is  more  affected  than  the  other.  If  the  internal  muscles 
are  unaffected,  the  disease  is  quite  certain  to  be  nuclear  disease,  because  these 
muscles  can  scarcely  escape  bilateral  disease  of  the  nerve  trunks.  Indeed, 
V.  Graefe  thought  this  absence  of  involvement  of  the  internal  muscles  char- 
acteristic. Palsy  of  the  external  ocular  muscles  is  likely  to  be  accompanied 
by  facial  palsy. 

In  sudden  nuclear  palsy,  the  second  in  frequency,  the  onset  may  take 
but  a  few  minutes  or  an  hour  or  two.  The  causes  in  such  cases  are  com- 
monly obstruction  to  the  basilar  arterial  branches,  rarely  embolic  obstruction, 
and  still  more  rarely  hemorrhage.  The  obstruction  is  usually  bilateral.  The 
lesions  are  irregular,  and  the  symptoms  are  correspondingly  irregular  and 
unsymmetrical ;  the  tendency  is  to  recover.  In  these  respects  it  differs  from 
the  chronic  form  also  in  that  hemiplegia  is  a  frequent  accompaniment,  gen- 
erally on  the  side  opposite  the  greater  eye  palsy.  When  hemorrhage  is  a 
cause,  the  resulting  ocular  palsy  lasts  usually  but  a  few  hours,  provided  the 
hemorrhage  acts  on  the  ocular  centers  only  by  pressure,  while  the  other  phe- 
nomena of  presure  by  effused  blood,  which  is  apt  to  spread,  make  their 
appearance. 

Acute  nuclear  palsy  is  rare.  It  develops  in  a  few  days  or  weeks, 
and  is  possibly  of  inflammatory  or  toxic  origin,  whence  called  by  Wernicke 
poliomyelitis  superior;  but  toxic  cases  may  occur  without  inflammation. 
This  form,  according  to  Gowers,  may  be  due  to  peripheral  neuritis  and  not 
to  nuclear  disease.  Alcohol  may  be  a  toxic  cause.  The  eye  muscles  are 
invaded  irregularly,  and  it  is  common  for  the  internal  muscles  to  escape.  In 
fatal  cases  the  causal  influence  extends  to  the  centers  of  other  nerves  and 
possibly  to  the  cortex.  In  cases  that  survive  there  is  improvement,  various 
in  degree. 

Treatment  of  Ocular  Palsies. — The  cause  should  be  sought  and,  if 
found,  treated.  Although  syphilis  is  thought  to  be  one  cause  of  this  disease 
and  of  tabes  dorsalis,  with  which  it  is  so  frequently  associated,  disappoint- 
ment follows  the  syphilitic  treatment  in  the  majority  of  cases.  Yet  mercury 
perhaps  accomplishes  more  than  any  other  single  remedy.  Arsenic,  strych- 
nin, and  iron  are  sometimes  used,  strychnin  hypodermically. 

In  acute  cases,  when  there  is  pain,  hot  fomentations,  leeches,  and  coun- 
terirritation  may  be  used.  In  chronic  forms  electricity  has  been  extensively 
used,  galvanism  being  preferred.  Benedikt  recommended  placing  the  anode, 
or  positive  pole,  on  the  forehead,  and  the  cathode,  or  negative  pole,  on  the 
margin  of  the  orbit  near  the  affected  muscle.  If  the  faradic  current  is  used, 
the  orbital  pole  is  held  still ;  if  the  voltaic,  it  is  kept  moving  over  the  skin,  or 
the  current  is  broken  by  the  commutator.  To  overcome  the  ptosis,  electric 
stimulus  is  applied  to  the  third  nerve,  as  the  muscle  is  not  accessible. 

The  diplopia  is  removed  by  a  prism  not  strong  enough  to  fuse  the  two 
images  completely,  but  of  sufficient  force  to  approximate  them,  so  that  the 
fusion  may  be  completed  by  muscular  action.  Such  action  may  be  practiced 
for  an  hour  each  day.  The  dizziness  due  to  erroneous  projection  can  be 
removed  only  by  throwing  the  eye  out  of  use  by  an  opaque  glass.  Opera- 
tive treatment  is  not  recommended. 

Periodical  Oculomotor  Paralysis. — Up  to  June,  1890,  according  to  A. 


I004  DISEASES  OF  THE  XERVOUS  SYSTEM. 

Nieden,*  21  cases  of  periodical  oculomotor  paralysis  had  been  published. 
The  organic  lesion  at  the  bottom  of  these  paralyses  is  not  yet  settled  upon. 
Mobius.f  who  was  one  of  those  who  has  contributed  largely  to  the  subject, 
claimed  a  nuclear  degeneration  as  the  cause,  while  Mauthner  t  another  con- 
tributor, considers  that  the  majority  of  cases  have  a  basal  cause,  by  which  it 
is  presumed  he  means  a  basal  meningitis  or  other  cause  compressing  the 
trunk  of  the  nerve  at  the  base  of  the  cranium. 

In  the  paper  referred  to,  Nieden  reports  a  case  of  periodical  combined 
facial  and  abducens  paralysis  occurring  in  a  woman  thirty-six  years  of  age, 
who  had  seven  attacks  involving  the  sixth  and  seventh  nerves,  separately  or 
jointly,  at  intervals  of  from  a  few  days  to  several  months.  Between  these 
attacks  she  was  free  from  symptoms.  At  other  times  there  was  derange- 
ment of  other  cranial  nerves,  especially  of  the  auditory  on  the  same  side, 
manifested  by  tinnitus,  which  considerably  interfered  with  the  sense  of  hear- 
ing for  the  time.  Again,  in  the  fourth  attack  there  was  a  paralysis  of  the 
left  half  of  the  tongue,  which  made  speech  stammering  and  unintelligible. 
All  the  attacks  were  accompanied  by  severe  headache,  which  is  more  or  less 
characteristic  of  oculomotor  paralysis. 

Morbid  Anatomy. — From  these  conditions  Nieden  infers  an  involve- 
ment of  the  muscular  region  of  the  sixth  and  seventh  cranial  nerves  affect- 
ing first  the  nucleus  of  the  latter  on  the  left  side,  ^  and  after  a  short  inter- 
val the  former  of  the  same  side  and  a  part  also  of  the  nucleus  of  the  hypo- 
glossal. He  thinks  that  there  may  have  been  an  exudation  in  the  region  of 
the  floor  of  the  fourth  ventricle  deep  enough  to  involve  the  nuclei  of  these 
nerves  as  well  as  the  trunks  of  some  of  them. 

Treatment. — Because  of  syphilitic  origin,  in  many  of  these  cases  mer- 
curial treatment  proved  promptly  efficient,  while  at  times  the  symptoms  sub- 
sided spontaneously. 


LESIONS  OF   THE   TRIFACIAL   OR   FIFTH   NERVE 
(TRIGEMINUS). 

Anatomical. — This  important  mixed  nerve  of  the  face  supplies  by  its 
motor  trunk  the  muscles  of  mastication ;  by  its  sensory  portion,  the  skin  of 
the  face,  the  mucous  membrane  of  the  mouth  and  nasal  cavity,  the  conjunc- 
tiva, and  the  cornua :  also,  according  to  some  physiologists,  the  anterior  part 
of  the  tongue  with  gustatory  fibers.  The  gustatory  fibers  are  supposed  to 
reach  the  lingual  fibers  of  the  fifth  nerve  by  the  chorda  tympani  nerve. 
Recent  studies  of  Harvey  Gushing  make  this  doubtful. 

Lesions. — i.  There  may  be  lesions  of  the  pons,  especially  hemorrhage^ 
or  areas  of  sclerosis  invading  the  trigeminus  nucleus. 

2.  Injury  or  disease  at  the  base  of  the  skull,  especially  acute  and  chronic 
meningitis  and  caries  of  the  bone,  tumors,  syphilis,  new  formations  com- 
pressing the  trunk  or  the  Gasserian  ganglion.  Fracture  of  the  base  rarely 
afTects  this  nerve. 

3.  Tumors  or  aneurysms  pressing  on  the  first  division  (ophthalmic)  of 

*  "  Centralblatt  fiir  praktische  Aug-enheilkunde.'    1800,  p.  164. 

t  Mobius,  "  Ueber  periodische  wiederkehrende  Oculomotoriuslahmungr,"  "Berliner  klin. 
Wochenschr.,"  1884,  Nr.  ^o  u.  ^8,  S.  604  ;  and  "Arch.  f.  Psych.  11.  Nervenkrankh.,"  xiv.,  S.  844. 

t  Mauthner,  "Die  ursachlichen  Momente  der  Augenmuskellahmungen,"  "Vortrage,"  S.  415, 
Wiesbaden.  1885,  Bergmann. 


LESIONS  OF  THE  TRIFACIAL  OR  FIFTH  NERVE.      1005 

the  nerve  through  the  cavernous  sinus,  on  the  second  division  (superior 
maxillary)  and  on  the  third  division  (inferior  maxillary)  by  invasion  of  the 
sphenomaxillary  fossa. 

4.  There  may  be  inflammation  of  the  nerve,  which  is  rare. 

The  sensory  division  may  also  be  affected  in  hysteria.  The  gustatory 
fibers  of  the  trigeminus  may  be  influenced  by  peripheral  lesions  of  the  facial, 
whence  the  chorda  tympani  is  derived. 

Symptoms. — Paralysis  of  the  Sensory  Portion. — The  distribution  of 
the  anesthesia  varies  according  as  the  whole  trigeminus  or  only  a  part  is 
involved.  In  total  anesthesia  there  is  loss  of  sensation  in  half  the  corre- 
sponding side  of  the  head,  including  the  conjunctiva  and  cornea,  mucosa  of 
the  lips,  tongue,  hard  palate,  and  nose  of  the  same  side.  Hence  on  the 
tongue  or  mucous  membrane  there  are  often  ulcers  which  come  from  uncom- 
scious  lacerations  by  the  teeth.  There  is,  according  to  the  views  of  many, 
loss  of  the  senses  of  taste  and  smell.  The  loss  of  the  sense  of  smell  is  prob- 
ably due  to  drying  of  the  mucous  membrane,  as  it  is  not  probable  that  the 
fifth  nerve  contains  olfactory  fibers.  The  so-called  trophic  phenomena  are 
also  observed,  and  among  them  the  much-discussed  neuroparalytic  oph- 
thalmia^  an  ulcerative  keratitis,  beginning,  also,  always  in  the  lower  segment 
of  the  cornea,  and  passing  over  into  purulent  inflammation  of  the  whole  eye- 
ball. It  seems,  on  the  whole,  more  likely  that  the  inflammation  is  primarily 
due  to  the  action  of  irritants  which  in  health  are  excluded  by  the  proper 
closure  of  the  eyelids,  though  the  inflammatory  process  itself  may  be  trophic- 
ally  influenced.  The  salivary,  lacrymal,  and  buccal  secretions  may  be 
diminished  and  the  teeth  may  become  loose.  Herpes  is  a  trophic  result 
which  may  develop  in  the  course  of  the  nerve,  is  painful,  and  may  last  a  long 
time.  So,  too,  the  anesthesia  may  be  preceded  by  tingling.  The  skin  of  the 
face  is  sometimes  swollen. 

Paralysis  of  the  motor  portion,  which  supplies  especially  the  muscles  of 
mastication,  the  masseters,  temporals,  and  pterygoids,  is  not  common.  It 
is  most  frequent  in  diseases  of  the  base  of  the  skull,  compressing  this  branch. 
Difficulty  in  chewing  is  the  result.  If  on  one  side,  the  patient  can  chew  only 
on  the  other;  if  on  both  sides,  he  cannot  chew  at  all.  The  lower  jaw  hangs 
dow^n,  and  cannot  be  moved  from  side  to  side  because  of  the  paralysis  of  the 
pterygoids.  If  on  one  side,  the  external  pterygoid  cannot  push  the  jaw 
toward  the  sound  side,  and  when  depressed,  the  jaw  is  pushed  by  the  muscle 
of  the  sound  side  toward  the  paralyzed  side.  Cases  have  occurred  associated 
with  cortical  lesion :  from  one  such  Hirt  inferred  that  the  motor  center  for 
the  trigeminus  is  in  the  neighborhood  of  the  lower  third  of  the  ascending 
frontal  convolution. 

Spasm  of  muscles  of  mastication  is  found  in  connection  with  muscular 
cramp,  the  muscular  contraction  of  tetanus  (trismus),  sometimes  in  tetany 
and  meningitis,  and  reflexly  through  painful  affections  of  the  jaw  or  teeth, 
or  from  irritation  near  the  motor  nucleus.  It  is  also  sometimes  hysterical. 
Clonic  spasm  occurs  in  muscles  supplied  by  the  fifth  nerve,  constituting 
"  chattering  teeth."  It  occurs  generally  in  connection  with  general  condi- 
tions, such  as  chorea,  but  it  may  happen  as  a  local  symptom  in  women  late 
in  life. 

Diagnosis. — This  is  not  difficult.  Sensibility  is  tested  in  the  ordinan- 
way.  The  preliminary  pain  must  not  be  mistaken  for  neuralgia.  Gustatory 
sense  is  tested  in  the  anterior  end  of  the  tongue  by  applying  weak  acid  or 
salt  solutions  and  comparing  the  eft'ect  on  the  two  halves.     The  motor  power 


ioo6  DISEASES  OF  THE  XERVOUS  SYSTEM. 

is  tested  by  biting  on  a  piece  of  wood  or  cork  or  by  moving  the  jaws  against 
resistance. 

Treatment. — This  must  depend  upon  the  cause,  which  should  be  care- 
fully sought.  Syphilitic  new  formations  are  the  lesions  most  commonly 
amenable  to  treatment.  In  the  absence  of  such  causes  the  treatment  must 
be  symptomatic.  Stimulating  liniments  and  faradization  through  the  elec- 
tric brush  are  often  useful.  Galvanism  may  also  be  used,  brushing  the  part 
with  the  cathode.  The  anesthetic  part  should  be  carefully  protected  against 
irritants. 

In  the  absence  of  tangible  cause,  systemic  treatment  is  not  indicated, 
except  to  build  up  the  general  health  of  the  patient. 


LESIONS  OF  THE  FACIAL  XERVE,  OR  SEVENTH  PAIR. 

The  seventh  pair  (  portio  dura  of  the  seventh,  old  classification)  is  the 
motor  nerve  of  the  face,  and  is  subject  to  paralysis  of  motion  and  to  spasm. 

Paralysis  of  the  Facial  Nerve. 
Synonyms. — Mimetic  Facial  Paralysis;  Bell's  Palsy;  Monoplegia  facialis. 

Monoplegia  facialis  may  be  caused  by  lesions  in  the  cortical  center  of 
the  nerve,  in  the  brain  between  the  cortex  and  the  nucleus,  in  the  nucleus 
itself,  and  in  the  nenr  trunk. 

Supranuclear  Paralysis. — The  cortical  center  resides  in  the  foot  of  the 
central  convolution,  probably  the  anterior  central,  from  which  pass  out  fibers 
along  with  the  pyramidal  fibers  through  the  internal  capsule  to  the  facial 
nucleus  in  the  tegmentum  of  the  pons  on  the  opposite  side.  Accordingly, 
the  nen-e  is  commonly  involved  in  hemiplegias — in  fact,  facial  paralysis 
forms  a  part  of  most  hemiplegias.  Such  a  paralysis,  due  to  lesion  above 
the  facial  nucleus,  is  known  as  supranuclear. 

In  such  a  palsy  the  voluntar}-  muscles  of  the  lower  half  of  the  face 
are  paralyzed,  while  the  secretory  and  gustatory  functions  of  the  facial  are 
not  affected :  nor  are  the  orbicularis  and  forehead  muscles,  except  in  some 
cases  in  the  beginning  of  the  hemiplegia,  these  being  innervated  by  the 
upper  branch  of  the  facial.  These  features,  together  with  the  normal  elec- 
trical excitability  of  both  nerve  and  muscle,  the  intact  reflexes  and  taste 
sense,  all  point  to  a  central  facial  paralysis  as  distinguished  from  a  per- 
ipheral. The  limitation  of  the  ^paralysis  to  the  lower  half  of  the  face  is 
due  to  the  fact  that  the  lower  portion  only  of  the  face  receives  more  ex- 
clusively crossed  innervation,  while  the  upper  part,  like  the  ocular  muscles 
and  the  motor  trigeminus,  is  innervated  more  from  both  hemispheres,  so 
that  a  lesion  in  one  be  overbalanced  by  the  other.  This  will  be  understood 
by  an  examination  of  the  schematic  drawing  (Fig.  128),  from  which  it  is 
plain  that  a  one-sided  brain  lesion  at  a  paralyzes  only  the  inferior  and  not 
the  upper  facial.  Recent  investigations  show  that  the  upper  and  lower 
branches  of  the  facial  nerve  have  not  separate  nuclei.  That  they  are  func- 
iionally  distinct  is  further  shown  by  the  fact  that  in  bulbar  paralysis,  also 
a  disease  of  the  nerve  nuclei  of  the  medulla  oblongata,  only  the  inferior 
facial  is  involved.  That  the  upper  face  muscles  are  totally  uninvolved  in 
central  facial  paralysis  is  not  quite  true,  for  careful  examination  will  show 


LESIONS  OF  THE  FACIAL  NERVE. 


1007 


that  the  function  is  not  quite  so  perfect  as  in  health;  the  patient  cannot 
close  the  eye  of  the  paralyzed  side  by  itself,  as  in  the  normal  state ;  whence 
it  follows  that  the  upper  half  of  the  face  is  innervated  from  both  hemi- 
sphers,  as  is  also  shown  in  Figure  128.  The  crossed  influence  is,  however,, 
the  larger. 

Cortical  facial  paralysis,  monoplegia  facialis,  has  been  found  associated 
with  lesions  in  the  center  for  face  muscles  in  the  lower  Rolandic  region,  but 
isolated  facial  paralysis  due  to  involvement  of  the  nerve-fibers  in  their  path 
from  the  cortex  to  the  nucleus  is  extremely  rare.  Cortical  or  capsular 
facial  paralysis,  as  already  explained,  is  on  the  same  side  as  that  of  the  arm 
and  leg. 

Nuclear  Paralysis. — Paralysis  may  also  be  caused  by  lesions  of  the 
nucleus,  but  is  not  common.     There  may  be  tumors,  chronic  softening,  and 


Portion  of  the  facial  Nucleus  for 
the   Upper  Facial  Distribution 


!Pe?'^?iercd'J'hu:ictZ' 


Portion  of  the  Facial  Nu- 
cleus for  the  Upper  Faciar 
Distribution . 


Portion  of  the 
Nucleus  for  the 
Lower  Facial 
Distribution. 


Fig.  128. — Schema  for  Central  Innervation  of  the  Facial  Nerve — {after  Sahlt). 
The  nucleus  of  the  upper  branch  is  innervated  from  both  hemispheres,  though  mostly- 
from  the  opposite  side,  while  the  nucleus  of  the  lower  branch  is  innervated  almost 
totally  from  the  opposite  side. 


hemorrhage,  while  rarely  anterior  poliomyelitis  may  involve  the  facial 
nucleus  or  it  may  be  attacked  by  the  diphtheritic  poison.  The  symptoms 
are  essentially  the  same  as  those  of  paralysis  of  the  trunk  of  the  nerve,  or 
peripheral  facial  palsy. 

Intranuclear  Paralysis,  or  Peripheral  Facial  Paralysis. — This  includes 
all  cases  due  to  involvement  of  the  nerve  trunk.  The  distinctive  features  of 
this,  as  compared  with  cortical  paralysis,  have  already  been  stated.  It  still 
remains,  however,  to  determine  the  precise  segment  of  the  nerve  involved, 
to  be  again  referred  to  when  treating  of  diagnosis. 

Etiology. — Cortical  paralyses  are  usually  due  to  compression  or  de- 


ioo8  DISEASES  OF  THE  NERVOUS  SYSTEM. 

struclion  of  the  cortical  center,  as  by  traumatism,  hemorrhage,  tumor,  men- 
ingitis, or  emboHsm.  Nuclear  paralysis  may  be  caused  by  tumors,  chronic 
softening,  hemorrhage,  or  the  diphtheritic  toxin,  while  rarely  anterior  polio- 
myelitis may  involve  the  facial  nucleus. 

The  most  frequent  cause  of  peripheral  paralysis  is  exposure  to  cold,  as 
to  a  cold  wind  or  draft  from  an  open  window.  Such  cases  include  so-called 
rheumatic  paralysis,  and  may  be  due  to  neuritis.  Disease  of  the  middle  ear 
and  caries  of  the  petrous  portion  of  the  temporal  bone  are  relatively  fre- 
quent causes,  which  have  evident  explanation  in  the  course  of  the  facial 
through  the  Fallopian  canal  adjacent  to  the  tympanic  cavity,  whence  it  may 
be  invaded.  At  the  base  of  the  brain,  tumors,  syphilitic  new  formations  and 
inflammatory  processes  also  involve  the  facial.  Rarely  swelling  of  the  par- 
otid gland  is  a  cause  of  pressure.  Finally,  the  facial  is  frequently  impli- 
cated in  disease  of  the  brain  and  medulla  oblongata. 

Symptoms. — The  symptoms  vary  with  the  exact  seat  at  which  the 
nerve  is  invaded.  Paralysis  of  the  facial  muscles  of  expression  produces 
the  most  striking  change  of  physiognomy.  The  homely  description,  under- 
stood by  everyone,  is  that  the  face  is  drawn  to  one  side ;  and  so  it  is — to 
the  sound  side,  except  in  old  cases  after  contracture  has  occurred.  Exami- 
nation discloses  that  on  the  opposite  and  paralyzed  side  there  is  a  remark- 
able smoothness  of  face,  the  wrinkles  have  disappeared  from  the  forehead, 
the  labionasal  fold  is  gone,  and  this  half  of  the  face  is  quite  expressionless. 
The  corner  of  the  mouth  is  lowered,  while  saliva  frequently  flows  from  it ; 
the  eye  is  wider  open  than  natural,  and  can  be  only  partly  closed,  even  dur- 
ing sleep, — lagophthahnos, — and  the  eye  waters.  These  symptoms  are  ren- 
dered still  more  striking  on  effort  at  smiling,  talking,  or  whistling,  at  turn- 
ing up  the  nose,  wrinkling  the  forehead,  inflating  the  cheeks,  or  closing 
the  eyes.  On  attempting  the  latter  the  upper  lid  drops  as  though  heavy, 
the  eye  is  turned  upward,  the  pupil  covered,  but  quite  a  space  remains  "  un- 
covered. The  so-called  "  corneal "  and  "  optical "  reflexes,  by  which, 
through  closure  of  the  lid,  the  eye  protects  itself  from  the  entrance  of 
foreign  bodies  seen  approaching,  are  lost,  and  a  tendency  to  conjunctivitis 
results. 

In  complete  facial  paralysis  winking  is  impossible.  Whistling  is  also 
impossible,  and  speech  may  be  interfered  with,  ov/ing  to  the  difficulty  in 
forming  labial  sounds.  The  proper  muscles  of  manifestation  are  not  para- 
lyzed, but,  owing  to  paralysis  of  the  buccinator  muscle,  food  collects  between 
the  teeth  and  cheek  on  the  paralyzed  side,  and  an  attempt  to  snifT  reveals 
j>aralysis  of  the  nasal  muscles.  The  upper  teeth  cannot  be  uncovered,  and 
an  attempt  to  drink  is  only  partly  successful,  because  the  lips  cannot  be  kept 
close  to  the  glass.  The  tongue  is  sometimes  described  as  protruding  toward 
the  paralyzed  side,  but  this  appears  to  have  been  an  error.  The  organ  is 
really  central,  when  examined  in  its  relation  to  the  incisors,  and  the  erroneous 
impression  arises  from  the  fact  that  the  lips  are  drawn  to  the  sound  side. 
Many  authorities  speak  of  a  paralysis  of  the  soft  palate  on  the  affected 
side,  since  facial  fibers  pass  through  the  superficial  petrosal  nerve  to  the 
sphenopalatine  ganglion.  It  is  described  as  drooping,  while  effort  at  pho- 
nation  raises  the  soft  palate  obliquely  to  the  sound  side.  Both  Gowers  and 
Hughlings  Jackson,  however,  deny  this  symptom  in  most  cases,  and  are 
sustained  by  the  discovery  of  Horsley,  and  Beevor,  that  the  soft  palate  is 
innervated  by  the  spinal  accessory  nerve.  The  innervation  of  the  soft  palate 
is  not  definitely  known. 


LESIONS  OF  THE  FACIAL  NERVE. 


1009 


Derangement  of  taste  also"  occurs  in  the  anterior  two-thirds  of  the 
tongue  on  the  paralyzed  side  in  cases  where  the  facial  is  involved  in  that  part 
■of  its  course  in  which  it  contains  the  chorda  tympani  nerve — that  is,  in  the 
Fallopian  canal  between  the  genu  and  the  union  of  the  chorda  tympani  with 
the  facial.  When  the  nerve  is  affected  outside  of  the  skull,  the  sense  of  taste 
is  intact.  Tactile  sense  in  the  tongue  is  also  sometimes  lessened;  salivary 
secretion  is  diminished,  producing  dryness  of  the  mouth.  Hearing  may  be 
more  acute,  especially  for  low  notes,  because  of  paralysis  of  the  stapedius 
jnuscle,  antagonized  by  the  tensor  tympani,  which  is  innervated  from  the 


,^     ^ 


^     vi)    ,to 


fji 


r^P 


Fig,  129. — Simplified  Drawing  of  the  Peripheral  Distribution  of  the  Facial  Nerve — 

{a/fe?-  Sahli). 


trigeminus.  Hence  results  a  greater  sensitiveness  of  the  membrana  tympani. 
Other  disturbances  of  hearing  are  also  present,  but  they  are  generallv  due 
to  associated  aural  trouble.  Herpes  is  also  an  occasional  symptom,  and 
is  ascribed  to  the  presence  of  trigeminal  filaments  among  those  of  the 
facial. 

Facial  paralysis  usually  sets  in  suddenly,  rarely  gradually.  Sometimes 
there  are  prodromata,  consisting  in  abnormal  sensations  of  taste,  pain  in  the 
ear  and  face,  and  ringing  in  the  former,  all  from  inflammation  of  the  nerve. 
With  this  exception,  pain  is  not  common. 

64 


10 lo  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Diagnosis. — The  recognition  of  the  presence  of  paralyses  of  the  facial 
is  for  the  most  part  easy.  More  difificuh,  and  proportionately  important,  is 
it  to  ascertain  in  what  part  of  its  course  the  function  of  the  nerve  is  cut  off. 
This  is  rendered  easy  by  the  appended  schematic  drawing  of  the  distribution 
of  the  facial  nerve,  after  Sahli.      (See  Fig.  129.) 

The  phenomena  vary  in  accordance  with  the  following: 

(a)  Lesion  at  A,  trunk  of  the  facial,  affecting  only  the  mimetic 
branches.  Paralysis  of  all  the  facial  muscles;  taste,  secretion  of  saliva, 
hearing,  and  palate  normal. 

(b)  Lesion  at  5,  within  the  styloid  foramen.  Paralysis  of  facial  mus- 
cles, and  occipital  muscles  innervated  by  the  posterior  auricular  nerve.* 
Taste,  secretion  of  saliva,  hearing,  and  soft  palate  normal. 

(c)  Lesion  at  C.  Paralysis  of  the  facial  muscles,  derangement  of  taste, 
diminished  secretion  of  saliva ;  hearing  and  soft  palate  normal. 

(d)  Lesion  at  D.  Paralysis  of  the  facial  muscles,  derangement  of 
taste,  diminished  secretion  of  saliva,  abnormal  acuteness  of  hearing,  and 
paresis  of  soft  palate. 

(e)  Lesion  at  E,  above  geniculate  ganglion.  Paralysis  of  the  facial 
muscles,  diminished  secretion  of  saliva,  abnormal  acuteness  of  hearing, 
paresis  of  soft  palate,  but  no  disturbance  of  taste. 

(/)  Lesions  at  F,  in  Fallopian  canal,  often  associated  with  a  lesion  of 
the  auditory  nerve  in  consequence  of  its  proximity  to  it.  Paralysis  of  facial, 
diminished  secretion  of  saliva ;  hearing  may  be  influenced  by  common  lesions 
to  auditory ;  palate  normal,  taste  normal. 

The  student  is  referred  to  what  has  previously  been  said  as  to  the 
modification  rendered  necessary  by  the  observations  of  Gowers  and  others 
on  the  non-involvement  of  the  soft  palate  in  facial  palsy. 

We  are  aided  also  in  recognizing  precise  forms  by  the  causes,  if  known, 
like  the  presence  of  ear  disease,  or  a  history  of  exposure  to  cold  or  of  trau- 
matism. Coexisting  symptoms  of  brain  or  bulbar  disease  must  also  be 
considered.  Reaction  of  degeneration  cannot  occur  in  true  cerebral  facial 
palsy,  only  in  peripheral  palsy  or  in  such  bulbar  paralysis  as  affects  the 
facial  below  the  nucleus  itself.  In  cortical  facial  paralysis  the  frontal  dis- 
tribution of  the  facial  nerve  and  the  ocular  muscles  are  not  seriously  affected 
except  in  the  early  stages ;  in  the  peripheral  paralysis  they  are. 

The  existence  of  bilateral  facial  paralysis — diplegia  facialis — points 
almost  invariably  to  a  central  lesion,  and  more  especially  to  a  bulbar  affec- 
tion, since  it  must  be  a  rare  event  to  have  a  simultaneous  involvement  of 
both  nerves  in  their  peripheral  distribution,  though  its  possibility  cannot  be 
denied. 

Prognosis  and  Course. — The  prognosis  varies  with  the  etiology  and 
with  the  degree  of  severity.  Some  cases  get  well  rapidly;  others  partly 
recover ;  many  are  permanent.  The  following  division  of  forms  with  their 
probabilities,  according  to  Erb,  will  be  helpful : 

1.  The  Mild  Form  of  Facial  Paralysis. — To  this  many  rheumatic  cases 
belong.  The  affection  is  usually  one  of  facial  muscles  only.  Electrical  ex- 
citability in  the  paralyzed  muscles  remains  normal,  and  there  are  no  severe 
and  deep-seated  changes  in  nerves  or  muscles.  Recovery  is  rapid,  usually 
taking  place  in  two  or  three  weeks. 

2.  Middle  Form.     There  is   partial   reaction   of  degeneration,   the  ex- 

*  Since  the  occipital  muscle  is  in  most  men  not  under  control  of  the  will,  its  paralysis  can  be  ascer- 
tained only  by  the  electrical  test  (.reaction  of  degeneration). 


LESIONS  OF  THE  FACIAL  NERVE.  loii 

citability  of  nerve  being  diminished  but  not  lost ;  in  the  muscles,  however, 
in  two  or  three  weeks,  there  is  decided  increase  of  galvanic  excitability  to 
direct  excitement,  the  anodal  closure  contraction  being  greater  than  the 
cathodal  while  contractions  are  slow.  Recovery  may  still  be  quite  rapid, 
usually  in  from  four  to  six  weeks. 

3.  Severe  Form. — Complete  reaction  of  degeneration  in  nerve  and 
muscles — i.  e.,  loss  of  faradic  and  galvanic  excitability  of  nerve,  loss  of 
faradic  excitability  of  muscle,  and  quantitative  and  qualitative  changes  in 
galvanic  excitability  of  muscle.  In  this  form  there  is  always  degeneration 
of  nerve  and  muscle,  so  that,  if  recovery  takes  place  at  all,  it  is  only  after 
two  or  six  months,  or  longer. 

In  these  cases  there  often  intervene  symptoms  of  motor  irritation, 
consisting : 

1.  In  a  marked  tonic  contraction  of  the  paralyzed  muscles,  sometimes 
very  striking. 

2.  Single  spasmodic  contraction  of  muscles. 

3.  Special  associated  movements.  Thus,  if  the  patient  closes  his  eyes 
or  winks,  there  always  follows  a  marked  distortion  of  the  corner  of  the 
mouth,  which  cannot  be  restrained. 

4.  An  increased  reflex  irritability,  as  the  result  of  which,  on  pricking 
or  blowing  on  the  skin,  vigorous  muscular  contractions  follow. 

These  symptoms  last  for  a  long  time — for  years  in  incurable  or  imper- 
fectly cured  cases. 

Further  points  bearing  on  prognosis  have  reference  to  the  nature  of 
the  primary  disease.  Paralysis  caused  by  tumors  of  the  base  of  the  brain 
and  caries  of  the  petrous  bone  is  almost  always  incurable.  If  the  paralysis 
is  due  to  middle-ear  disease,  the  prognosis  depends  on  the  curability  of  the 
ear  disease.  The  electrical  examination  affords  helpful  data.  If  at  the  end 
of  one  or  two  weeks  electrical  excitability  still  remains  normal,  a  rapidly 
favorable  termination  may  be  predicted.  If,  on  the  other  hand,  the  reaction 
of  degeneration  is  present,  a  much  longer  course  and  delayed  recovery,  if 
any,  may  be  expected.     Relapses  may  occur. 

Treatment. — The  treatment,  is,  of  course,  that  of  the  lesion  which 
Hes  at  the  bottom  of  the  paralysis.  If  it  is  a  syphilitic,  inflammatory  prod- 
uct, the  iodids  should  be  administered  in  the  usual  ascending  doses.  Middle- 
ear  disease  should  receive  the  promptest  and  closest  attention,  as  some  of  the 
most  unfortunate  cases  are  thus  caused.  Any  possible  cause  of  pressure 
should  be  sought  and  removed. 

When  cold  is  the  cause,  and  the  case  comes  early  under  observation, 
warmth,  either  dry  or  moist,  should  be  applied  to  the  distribution  of  the 
nerve  in  the  face,  while  mild  counterirritation  at  the  pes  anserinus  is  useful. 
Decided  blistering  is  of  questionable  utility,  but  it  is  harmless  and  may  do 
good. 

For  the  paralysis  remaining  after  the  removal  of  the  cause  electricity 
is  indicated,  and  more  especially  the  constant  current.  A  weak  current 
should  be  used  for  from  three  to  five  minutes  at  a  time,  interrrupting  from 
four  to  six  times  a  minute,  placing  first  the  anode  and  then  the  cathode  in 
the  auriculo-mastoid  fossa,  the  other  pole  in  front  of  the  ear.  Galvanism 
and  faradization  may  be  applied  to^the  muscles  themselves,  including  the 
orbicularis,  the  direct  effect  of  the  electricity  on  which  is  shown  by  an 
increased  power  to  close  the  eye  immediately  after  the  application  of  the 
current.     Massasre  of  the  muscles  mav  be  used. 


IOI2  DISEASES  OF  THE  XERFOUS  SYSTEM. 

Sulphate  of  strychnin  is  a  drug  which  has  some  reputation  in  facial 
paralysis,  although  it  is  difficult  to  trace  the  results  of  its  use.  Its  admin- 
istration by  subcutaneous  injection,  daily  or  on  alternate  days,  is  recom- 
mended.    The  salicylates  may  be  used  with  advantage  in  some  cases. 

Facial   Spasm. 
Syonyms. — Mimetic  Facial  Spasm;  Convulsive  Tic. 

Facial  spasm  is  manifested  in  a  variety  of  w"ays.  Mimetic  facial  spasm, 
or  convulsive  tic,  consists  in  a  clonic  contraction  of  the  muscles  supplied  by 
the  facial  nerve,  a  lew  or  all.  usually  unilateral,  sometimes  bilateral.  A 
similar  condition,  especially  frequent  in  children,  as  the  result  of  imitation 
or  of  habit  of  grimacing,  is  known  as  habit  spasm. 

Etiology. —  Xo  cause  can  be  found  for  most  cases.  Possible  causes 
are  exposure  to  cold,  lesions  at  the  base  of  the  skull,  or  irritation  of  the 
facial  center  in  the  cerebral  cortex.  Other  cases  may  be  explained  by 
reflex  causes,  such  as  irritation  by  carious  teeth,  intestinal  worms,  or  disease 
of  the  sexual  organs.  Others  have  been  ascribed  to  violent  mental  excite- 
ment. Predisposition  to  the  disease  is  heightened  by  a  hereditary  neuro- 
pathic habit. 

Symptoms. — These  consist  in  short  contractions  in  the  muscles  affected. 
Sometimes  the  contractions  are  of  longer  duration.  The  face  is  the  seat 
of  constantly  changing  grimaces  during  waking  hours.  Sometimes,  how- 
ever, there  are  mtervals  of  complete  rest.  The  contractions  are  commonly 
without  exciting  cause.  Sometimes  they  invade  adjacent  muscles,  as  those 
of  mastication,  the  tongue,  or  the  muscles  of  the  neck.  \'oluntary  motion 
is  unimpaired,  and  there  is  no  pain  or  anesthesia. 

Blepharospasm. — A  variety  of  the  partial  form  is  blepharospasm,  a  tonic 
or  clonic  spasm  of  the  orbicularis  muscle.  In  the  clonic  form  it  is  apt  to 
be  associated  with  spasm  of  the  lateral  facial  muscles,  and  there  is  constant 
twitching  of  the  side  of  the  face,  with  partial  closure  of  the  eye.  In  another 
clonic  variety  there  is  constant  contraction  of  the  eyelids  and  consequent 
winking. 

The  tonic  form  is  usually  reflex  in  origin,  bilateral,  and  may  last  for 
days  or  weeks,  with  occasional  interruptions.  The  reflex  cause  is  commonly 
some  affection  of  the  eye,  producing  photophobia,  or  it  may  reside  in  some 
other  point  in  the  distribution  of  the  trigeminus.  The  clonic  form  may  also 
sometim^es  be  traced  to  a  reflex  cause. 

\*ery  interesting  in  connection  with  blepharospasm  is  the  discovery  by 
V.  Graefe  of  certain  so-called  "-^pressure  points."  These  are  points  at  which 
pressure  causes  the  spasm  to  cease,  so  that  the  eyelids  "  fly  up  as  if  by  a 
spring."  These  are  commonly  found  at  points  of  exit  of  the  trigeminus,  but 
have  also  been  found  on  the  vertebral  column  and  elsewhere. 

For  other  forms  of  spasm  of  the  facial  nerve  see  Choreiform  Aft"ections, 
page  1097. 

Prognosis, — This  in  all  forms  is,  as  a  rule,  unfavorable.  There  are 
intervals  of  suspension,  somethnes  of  considerable  length,  but  the  spasm 
recurs,  and  the  disease  generally  remains  incurable. 

Treatment. — The  treatment  is  correspondingly  unsatisfactory,  but  a 
number  of  things  may  be  done.  Causes  of  reflex  irritation  should  be 
sought  and  removed,  such  as  carious  teeth  and  ophthalmia.  Paquelin's 
cautery  may  be  applied  to  the  trunk  of  the  nerve,  or  to  pressure  points,  if 


LESIOXS  OF  THE  AUDITORY  OR  EIGHTH  NERVE.     1013 

they  exist.  Nerve  section  of  the  supra-orbital  nerve  has  been  practiced  in 
blepharospasm.  Xerve  stretching  has  been  followed  by  relief,  at  least  as 
long  as  the  paralysis  continues,  which  is  commonly  a  welcome  substitute 
for  the  twitching.  The  constant  current  may  be  used,  seeking  also  for 
pressure  points,  to  which  the  anode  is  to  be  applied.  If  there  are  none, 
this  pole  should  be  applied  to  the  trunk  of  the  nerve  and  to  the  different 
branches  of  the  pes  anserinus.  In  cases  of  reflex  origin  Berger  reports 
that  satisfactory  results  were  obtained  by  applying  the  anode  to  the  occiput 
just  under  the  protuberance,  while  the  cathode  was  held  in  the  hand — an 
attempt  at  galvanization  of  the  medulla  oblongata.  The  single  sitting  should 
last  from  five  to  ten  minutes.  Weir  Mitchell  recommends  the  freezing 
of  the  cheek  every  day  or  every  other  day  with  the  rhigolene  spray;  at  least 
transient  relief  follows. 

As  to  medicines,  those  usual  in  nervous  affections  should  be  tried — 
bromid  of  potassium,  strychnin  by  hypodermic  injection,  arsenic,  iron,  oxid 
of  zine,  atropin,   curare. 

The  treatment  of  convulsive  tic  is  that  of  hysteria. 

LESIONS    OF    THE    AUDITORY    OR    EIGHTH    NERVE. 

The  eighth  pair  (portio  mollis  of  the  seventh  in  the  older  classification 
of  Willis)  may  be  affected  anywhere  in  its  course  from  its  cortical  center 
in  the  upper  part  of  the  first  temporo-sphenoidal  convolution,  thence  in  the 
internal  capsule  across  to  its  nucleus  at  the  junction  of  the  pons  with  the 
medulla  oblongata,  or  at  the  base  of  the  brain  after  it  passes  out  of  the 
pons  into  the  internal  auditory  meatus  to  its  distribution  in  the  cochlea  and 
vestibule.  The  proximity  of  this  nerve  to  the  facial  at  the  base  of  the 
brain  and  in  the  internal  auditory  meatus  is  to  be  remembered.  As  indi- 
cated by  its  name,  it  is  softer  and  more  vulnerable  than  the  facial,  so  that 
equally  acting  causes  may  affect  it  and  leave  the  facial  intact. 

The  auditory  nerv^e  should  be  regarded  as  two  nerves — the  cochlear 
and  the  vestibular ;  the  former  having  to  do  with  hearing  and  the  latter  with 
co-ordination. 

Symptoms. — Directly  due  to  disease  of  the  auditory  nerve  are  limited 
to  some  derangement  of  hearing,  and  it  is  their  association  with  others  which 
widens  their  significance  in  the  study  of  nervous  diseases.  The  derange- 
ments of  hearing  resulting  from  such  lesion  are  six: 

1.  Loss  of  hearing,  or  deafness. 

2.  Increased  sensitiveness,  auditory  hyperesthesia,  or  hyperacusis. 

3.  S3'mptoms  of  irritation,  causing  subjective  aural  sensations — tinnitus 
aurium  and  allied  symptoms. 

4.  Disturbances  of  equilibrum  or  sensation  of  such,  due  to  irritation  of 
the  fibers  in  teh  semicircular  canals — ^Meniere's  disease. 

5.  Certain  rare  instances  of  involuntary  movements,  due  to  disease  of 
the  nerve  within  the  ear,  as  oscillaton.-  motions  of  the  head. 

6.  Purely  functional  derangements  of  hearing,  occurring  especially  in 
connection  with  hysteria  and  with  anemia  following  large  hemorrhage. 

I.  Loss   OF   FuxcTidx ;  Nervous  Deafxess. 

Etiology. — Deafness  may  be  congenital  when  it  is  due  to  labyrinthine 
defect.     According  to  Cowers,  80  per  cent,  of  deaf  mutes  are  congenitally 


10I4  DISEASES  OF  THE  XERVOUS  SYSTEM. 

deaf.  The  remaining  20  per  cent,  become  so  from  disease  in  early  life.  Of 
congenital  cases  it  is  said  that  the  intermarriage  of  relations  having  similar 
defects  is  responsible  for  some,  while  such  intermarriage,  even  where  there 
is  no  such  defect,  is  held  responsible  for  a  smaller  number.  Partial  as  well 
as  total  deafness  may  be  congenital. 

Of  the  cases  of  acquired  nervous  deafness,  disease  of  the  labyrinth, 
either  primary  or  secondary  to  that  of  the  middle  ear,  causes  most.  The 
labyrinth  is  subject  to  inflammation,  acute  or  chronic,  to  syphilitic  disease,  to 
degeneration,  and  to  hemorrhage.  It  may  be  invaded  b}'  meningitis,  cere- 
brospinal or  tuberculous.  Its  membrane  may  undergo  degeneration,  due  to 
gout  or  simply  to  old  age.  The  product  of  all  these  may  be  fibrous  or  cal- 
careous new  formation.  The  deafness  caused  by  certain  drugs,  as  quinin, 
has  been  ascribed  to  congestion  of  the  internal  ear,  and  that  by  loud  noise, 
as  the  explosion  of  artillery,  to  hemorrhage. 

Lesions  of  the  nerv-e  trunks  are  less  common  causes.  They  may  be  of 
the  same  character  as  those  of  the  labyrinth,  except  primary  inflanmiation, 
although  even  this  is  said  to  be  a  cause.  Primar}-  degeneration  may  occur 
in  tabes  dorsalis.  The  nerve  may  be  compressed  by  thickening  of  the  cranial 
bones,  calcareous  nodules,  tumors,  or  extravasated  blood. 

The  nuclei  within  the  pons  may  be  damaged  by  hemorrhagic  extrava- 
sations and  tumors.  Above  the  nuclei  there  may  be  a  lesion  encroaching  on 
the  superficial  layer  of  the  tegmentum,  a  lesion  in  the  internal  capsule,  or  in 
the  cortical  center. 

Symptoms. — Since,  as  already  stated,  derangement  of  hearing  consti- 
tutes the  only  essential  symptom  of  nervous  deafness,  any  enlargement  of  the 
subject  can  be  made  only  by  considering  the  miodifications  and  conditions  of 
this  symptom,  and  by  reviewing  such  methods  of  determining  the  precise  seat 
of  the  lesion  as  exist. 

The  ability  to  hear  through  the  bone  while  the  air  conduction  is  impaired 
implies  that  the  function  of  the  labyrinth  is  intact,  and  that  deafness  is  due 
to  obstruction  of  the  meatus  or  to  disease  of  the  middle  ear  and  not  to  nerve 
deafness.  This  is  further  confirmed  if  the  bone  conduction  is  intensified  by 
closing  the  meatus,  since  in  this  way  the  vibrations,  which  ordinarily  pass 
out  by  the  meatus,  are  retained.  On  the  other  hand,  if  there  is  diminished 
bone  conduction,  it  does  not  necessarily  follow  that  the  labyrinth  is  diseased, 
because  there  may  be  ankylosis  of  the  stapes,  which  will  diminish  bone  con- 
duction, although  no  amount  of  disease  of  the  middle  ear  will  extinguish  it  if 
the  labyrinth  be  intact.  Further,  in  health  air  conduction  is  heard  after  bone 
conduction  ceases.  This  is  the  basis  of  Rinne's  test,  in  which  the  vibrating 
tuning-fork  is  first  placed  upon  the  mastoid  process  and  allowed  to  remain 
until  the  sound  dies  away  to  the  patient,  when  the  fork  is  suddenly  trans- 
ferred to  the  external  auditory  meatus  of  the  same  ear.  If  the  air-conducting 
apparatus  is  normal,  the  vibration  of  the  fork  should  again  be  heard.  Again, 
there  may  be  a  moderate  impairment  of  hearing  and  maintenance  of  the  rela- 
tive delicacy  of  the  air  conduction.  Absence  of  bone  conduction  is,  however, 
the  characteristic  symptom  of  nervous  deafness.  So,  to  a  less  degree,  is 
deafness  to  short  and  high-pitched  sounds,  whence  the  high-pitched,  short 
sounds  of  the  ticking  of  a  w^atch  is  a  delicate  test  of  the  ability  to  hear 
through  the  bone.  Simple  senile  labyrinthine  degeneration  may  be  respons- 
ible for  inability  to  hear  the  ticking  through  bone  in  persons  sixty  years  old 
or  more. 

Can   we   distino-uish   between   labvrinthine   disease  and   disease  of  the 


LESIOXS  OF  THE  AUDITORY  OR  EIGHTH  XERJ'E.     1015 

nerve  before  its  terminal  distribution?  Given  the  absence  of  bone  conduc- 
tion, if  the  facial  nerve  is  paralyzed,  and  there  is  no  disease  of  the  middle 
ear  or  of  the  bone,  we  may  conclude  that  the  ner^^es  (facial  and  auditory) 
are  affected  at  the  base  of  the  brain  or  in  the  internal  meatus.  1+  there  is  dis- 
ease of  the  middle  ear  along  with  deafness  and  paralysis  of  the  facial,  it 
is  probable  that  the  facial  nerve  and  labyrinth  are  affected  by  extension  of 
the  disease  from  the  tympanum,  but  this  is  not  certain.  An  involvement  of 
the  trunk  of  the  nerve  at  the  base  is  also  probable  if  some  other  nerve  near 
it,  as  the  sixth,  is  involved.  The  fact  that  the  auditory  nerve  is  more  sensi- 
tive to  pressure  than  the  facial  has  already  been  mentioned,  whence  an 
agency,  such  as  an  inflammatory  product,  pressing  on  both  nerves  may  affect 
the  auditory  and  leave  the  facial  intact. 

No  distinctive  symptoms  have  been  found  associated  with  lesion  of  the 
auditory  nuclei  in  the  medulla  oblongata.  Such  lesion  is  very  rare,  but  has 
been  found  associated  with  deafness  on  the  same  side,  while  it  has  also  been 
found  when  the  hearing  has  been  unaffected.  Sudden  deafness,  associated 
with  other  symptoms  of  a  lesion  of  the  pons  or  medulla  oblongata,  should 
excite  suspicion  of  nuclear  lesion,  especially  if  paresis  of  limbs  on  the  opposite 
side  be  one  of  those  symptoms. 

The  auditor}- .  fibers  between  the  cortex  and  the  auditory  nucleus  in  the 
pons,  in  their  passage  through  the  tegmentum,  may  also  be  affected  and  may 
produce  deafness.     Such  a  lesion  is  a  tumor  of  the  corpora  quadrigemina. 

Lesions  of  the  cortical  center  are  very  rare,  though  they  have  been  suffi- 
ciently frequent  to  confirm  the  results  of  experiment  on  the  monkey,  which 
go  to  show  that  the  first  temporo-sphenoidal  gyrus  represents  the  center  for 
liearing,  since  the  destruction  of  this  gyrus  on  the  left  side  in  man  has  been 
attended  by  word-deafness.  It  is  possible  that  the  first  temporal  gyrus  in 
each  hemisphere  in  man  must  be  damaged  in  order  to  produce  cortical  deaf- 
ness for  sound.  Hemorrhages,  softening,  and  pressure  by  fractures  or 
tumors  may  be  causative  lesions  in  this  situation. 

Treatment. — This  is  for  the  most  part  unsatisfactory,  at  least  from  the 
physician's  standpoint.  Careful  otoscopic  examination  should  be  made  with 
a  view  to  discovering  the  existence  of  disease  of  the  external  and  middle  ear, 
and  the  aural  surgeon  should  invariably  be  consulted  in  derangements  of 
hearing  of  more  than  brief  duration,  with  a  view  to  obtaining  certainty  of 
diagnosis  between  nerve  deafness  and  disease  of  the  middle  or  external  ear. 
Suspected  syphilitic  tumors  should  be  treated  by  iodids.  A  blister  in  front 
of  or  behind  the  ear  may  be  useful,  especially  in  acute  cases ;  but  deep  blister- 
ing should  be  avoided  in  front  lest  it  cause  facial  neuritis.  Electricity  has 
been  employed  with  partly  satisfactory  results. 

2.  Auditory  Hyperesthesia. 

True  hyperesthesia,  or  hyperacusis,  is  a  condition  in  which  ordinary 
sounds  are  heard  with  more  than  normal  acuteness,  and  in  which  sounds 
inaudible  become  audible.  In  dysesthesia,  or  dvsacusis,  ordinar}-  sounds, 
although  not  intensified,  produce  discomfort.  There  is  generally  present 
some  pre-existing  symptom,  as  a  headache,  during  which  sounds  usually 
without  effect  intensify  the  headache.  Both  these  conditions  occur  in  func- 
tional as  well  as  in  organic  brain  disease.  0£  the  former,  hysteria  is  an 
instance  ;  of  the  latter,  meningitis. 

Treatment. — The  treatm.ent,  outside  of  the  removal  of  the  cause,  is  by 
nerve  sedatives,  as  the  bromids,  preparations  of  valerian,  and  asafetida. 


ioi6  DISEASES  OF  THE  XERVOUS  SYSTEM. 


3.  Irritation  of    the  Auditory  Xerve — Tinnitus  Aurium. 

The  term  tinnitus  includes  almost  every  conceivable  form  of  auditory 
subjective  sensation,  of  which  the  most  common  is  ringing,  roaring,  or  hiss- 
ing. The  tinnitus  may  include  humming,  ticking,  the  sound  of  rushing 
steam,  the  roaring  of  machiner\-  and  the  like,  the  sound  of  a  bell,  and  even 
articulate  speech,  music,  or  the  sound  of  voices.  It  may  be  persistent  or 
intermittent,  with  rhythmical  intermissions — these  commonly  correspond- 
ing with  the  beating  of  the  pulse.  The  sounds  may  be  so  slight  as  to  be  for- 
gotten when  the  attention  is  directed  to  something  else,  or  they  may  be  heard 
through  everything,  causing  the  sorest  distress  and  misery.  In  fact,  their 
victims  have  even  been  impelled  to  self-destruction.  The  clicking  symp- 
tom, sometimes  audible  to  those  standing  near,  is  often  very  annoying,  and 
may  be  due  to  clonic  spasm  of  the  muscles  connected  with  the  Eustachian 
tube  or  levator  palati.  The  so-called  premonitory  "  aura "  of  epileptic 
seizures  may  be  a  variety  of  tinnitus. 

Etiology. — Beyond  what  is  conveyed  by  the  word  "  irritation,"  it  is 
exceedingly  difficult  to  discover  the  cause  of  tinnitus.  Changes  in  the 
labyrinth  appear  to  be  the  most  common,  and  Cowers  tells  us  that  "  evi- 
dence of  nervous  deafness,  mostly  due  to  changes  in  the  internal  ear,  is  dis- 
tinct in  four-fifths  of  the  cases  which  come  under  the  physician's  notice. 
Disease  of  the  middle  and  external  ear,  including  inflammation  and  wax 
accumulation,  is  also  a  fruitful  cause,  while  in  a  few  cases  the  process  may 
be  wholly  in  the  auditory  centers,  in  the  nucleus  of  the  nerve,  or  in  the  cor- 
tical area.  Blood  movement,  not  usually  audible,  may  become  so.  Internal 
aneurysm  is  a  possible  cause.  Tinnitus  is  a  very  frequent  symptom  in  gouty 
cases,  in  my  experience,  especially  when  associated  with  the  nen'ous  tempera- 
ment. So  it  is  in  anemia  and  neurasthenia.  An  epileptic  aura  is  often  a 
tinnitus.  A  systolic  brain  murmur  is  sometimes  heard  over  the  ear  in  chil- 
dren, and  even  in  adults. 

Treatment. — This  is  generally  most  unsatisfactory.  The  ear  should 
be  explored  and  its  surgical  diseases  treated. 

The  gouty  diathesis  must  be  treated  by  the  administration  of  the  salicy- 
lates, colchicum,  and  purgatives,  and  by  regulation  of  the  diet;  anemia  and 
neurasthenia  by  iron,  arsenic,  nutritious  food,  and  rest.  Large  doses  of 
salicylic  acid  and  quinin,  it  is  known,  produce  ringing  in  the  ears — a  fact  to 
be  remembered  always. 

The  bromids  are  sometimes  beneficial,  and  a  few  drops  of  tincture  of  bel- 
ladonna are  sometimes  added.  ^  Xitro-glycerin  has  been  highly  commended. 
Beginning  with  doses  of  i-ioo  grain  ( 0.00066  gm.),  they  should  be  rapidly 
increased  until  the  physiological  effect  is  produced.  ]\Iy  experience  with 
nitro-glycerin  is  that  the  physiological  eft'ect  is  often  not  attained  in  adults 
even  by  doses  of  i-ioo  grain  (0.00066  gm.). 

Counterirritation  is  undoubtedly  useful  at  times.  It  should  be  applied 
behind  the  ear,  and  actual  vesication  is  the  most  efficient  form.  The  tempo- 
rary effect  is  sometimes  striking,  while  permanent  results  may  be  produced 
by  repeated  blistering. 


LESIONS  OF  THE  AUDITORY  OR  EIGHTH  NERVE.     1017 


4.  Disturbance  of   Equilibrium   Associated   with   Defect   of   Hear- 
ing— Labyrinthine  Vertigo.     Meniere's   Disease. 

Definition. —  The  term  Meniere's  disease  is  applied  to  a  vertigo,  usually 
sudden,  associated  with  deafness  and  noises  in  the  ear. 

Pathology  and  Etiology. — In  1861  Meniere  described  some  cases  in 
which  vertigo  was  produced  by  a  sudden  lesion  of  the  labyrinth.  Since  then 
the  term  Meniere's  disease  has  come  to  be  applied  to  all  cases  of  sudden  ver- 
tigo associated  with  labyrinthine  disease.  Gowers  says  that  "  in  nine  cases 
out  of  ten  in  which  there  is  definite  giddiness,  not  epileptic  in  nature  or 
obviously  due  to  organic  brain  disease,  it  is  due  to  a  morbid  state  of  the  laby- 
rinth or  auditory  nerve  endings."  Thus  the  vertigo  becomes  the  result  of 
the  irritation  of  the  nerve. 

In  addition  to  clinical  sources  for  the  confirmation  of  this  view  there  is 
the  fact  that  experimentally  induced  lesions  in  the  semicircular  canals  of 
animals  result  in  vertiginous  movements.  In  point  of  fact,  aural  vertigo 
results  from  almost  any  one  of  the  morbid  processes  possible  to  the  labyrinth 
and  the  nerve  endings  it  contains,  but  not  from  disease  of  the  middle  ear. 
The  precise  nature  of  the  morbid  change  can  only  be  conjectured.  It  is  twice 
as  frequent  in  men  as  in  women,  and  four-fifths  of  all  cases  occur  between 
the  ages  of  thirty  and  sixty.  Cold,  gout,  and  syphilis  have  been  followed  by 
it,  probably  through  inflammation,  and  possibly  resulting  hemorrhage.  The 
slower  forms  may  be  due  to  degenerative  processes,  like  those  of  tabes  or 
such  as  are  due  to  age.  Vasomotor  neuroses  of  the  vessels  of  the  labyrinth 
have  been  held  responsible. 

Symptoms. — The  vertigo  is  usually  sudden  and  paroxysmal,  though 
there  may  be  slight  continuous  dizziness  between  paroxysms,  which  occur  at 
intervals  of  from  a  few  days  to  as  many  weeks.  Occasionally  they  occur 
daily.  They  may  be  spontaneous  or  an  exciting  cause  of  trifling  character 
may  bring  them  on,  such  as  turning,  coughing,  or  sneezing.  Gastric  dis- 
turbances may  excite  them — a  fact  to  be  remembered  in  the  differential  diag- 
nosis from  gastric  vertigo.  There  may  be  brief  unconsciousness.  The 
attacks  generally  pass  off  in  a  few  minutes,  leaving  the  patient  pale,  faint, 
and  nauseated,  often  in  a  cold,  clam.my  sweat.  Vertigo  may  or  may  not  be 
accompanied  by  a  tendency  to  fall  forward,  backward,  or  to  one  side,  and  the 
victim  may  have  to  grasp  something  to  save  himself  from  falling.  External 
objects  may  appear  to  circle  about  him.  The  seeming  movements  of  person 
and  external  objects  are  usually  in  the  same  direction. 

The  auditory  symptoms — deafness  and  tinnitus — may  be  in  one  or  both 
ears,  and  more  marked  in  one  side  than  in  the  other.  In  the  latter  case  the 
sense  of  movement  may  be  toward  or  from  the  ear  most  affected ;  but  when 
the  subjective  and  objective  movements  coincide  in  direction,  they  are  more 
often  toward  the  affected  side. 

The  deafness  is  nervous  and  always  partial.  The  tinnitus  is  usually 
roaring  or  throbbing.  There  may  be  ocular  symptoms ;  these  are  secondary, 
and  include  nystagmus  and  diplopia.  Pressure  on  the  drum  or  on  the 
meatus  may  bring  on  the  nystagmus,  and  sometimes  an  apparent  jerky  move- 
ment of  objects.  Diplopia,  nystagmus,  and  jerky  movements  may  occur 
together. 

Diagnosis. — The  essential  symptoms  of  Meniere's  disease  are  dizziness, 
tinnitus,  and  deafness.     Gastric  disturbance  is  not  peculiar  to  it.     The  deaf- 


1018  DISEASES  OF  THE  NERVOUS  SYSTEM. 

-ness  must  be  proved  to  be  nervous  and  not  the  result  of  defective  air  con- 
duction. True  gastric  vertigo  is  not  associated  with  deafness,  while  other 
symptoms  of  dyspepsia  are  present  with  it. 

While  the  aura  of  epilepsy  is  sometimes  accompanied  by  giddiness,  there 
is  no  impairment  of  hearing.  Moreover,  in  Meniere's  disease  slight  vertigo 
is  more  or  less  constant,  the  tinnitus  is  persistent,  and  loss  of  consciousness, 
if  present,  is  very  brief.  It  is  the  petit  mal,  with  its  brief  unconsciousness, 
with  which  the  confusion  may  occur. 

The  vertigo  of  cardiuc  valvular  disease,  especially  aortic  insufficiency, 
■of  arteriocapillary  fibrosis,  and  of  chronic  interstitial  nephritis  is  unaccom- 
panied by  any  of  the  other  distinctive  signs  of  Aleniere's  disease.  Gelicr's 
vertigo,  characterized  by  attacks  of  paretic  weakness  of  the  extremities, 
ptosis,  and  profound  depression,  but  without  loss  of  consciousness,  occur- 
ring especially  among  laborers  in  the  canton  of  Geneva,  should  be  mentioned 
as  a  source  of  possible  error. 

Prognosis. — This  depends  upon  the  durability  of  the  lesion  causing  the 
malady.  In  cases  resulting  from  remedial  causes — such  as  gout  and  even 
syphilis — recovery  is  possible,  while  palliation  is  not  infrequently  attained. 
Other  cases  are  obstinate  and  incurable.  Relief,  however,  comes  to  the 
dizziness  when  the  deafness  becomes  total. 

Treatment. — When  traceable  to  gout  and  syphilis,  the  remedies  appro- 
priate to  these  diseases  should  be  prescribed.  The  salicylates  and  iodids  are 
most  frequently  useful,  but  the  lithium  salts  and  colchicum  are  to  be  remem- 
bered. The  salicylates  should  be  given  in  moderate  doses  rather  than  large 
ones,  which  produce,  the  ringing  in  the  ears.  In  the  absence  of  knowledge 
of  a  definite  cause  the  bromids  are  the  remedies  to  be  most  relied  upon. 
From  twenty  to  thirty  grains  (1.3  to  2  gm.)  should  be  given  at  a  dose,  and 
Gowers  recommends  the  addition  of  a  few  minims  of  the  tincture  of  bella- 
donna. Nitro-glycerin  has  been  recommended.  The  general  health  should 
be  looked  after. 

Counterirritation  by  blistering  behind  the  ear  is  som.etimes  promptly 
followed  by  favorable  results. 


LESIONS   OF  THE   NINTH   OR   GLOSSOPHARYNGEAL 

NERVE. 

Anatomical. — This  triply  mixed  nerve  supplies  sensibility  to  the  soft 
palate,  the  tonsils,  the  upper  part  of  the  pharynx,  the  Eustachian  tube,  and 
the  tympanic  cavity ;  motor  impulses  to  the  stylopharyngeus  and  to  the 
middle  constrictor  of  the  pharynx :  and  the  sense  of  taste  to  the  posterior 
third  of  the  tongue  and  to  the  palate. 

The  study  of  the  precise  pathology  of  this  nerve  is  rendered  difTficult  by 
its  numerous  communications  with  other  nerves,  notably  with  the  fifth,  the 
facial,  and  the  pneumogastric,  and  by  the  fact  that  it  is  rarely  involved  alone. 
Experimental  inquiry  with  it  is  also  difficult. 

The  nerve  may  be  invaded  by  meningitis,  tumors,  or  degenerations. 

Symptoms. — Symptoms  of  such  lesion  would  be  diiUcult  deglutition 
and  perversion  of  the  sense  of  taste — parageusia — or  complete  gustatory 
anesthesia. 

Modifications  of  the  sense  of  taste  are  tested  bv  means  of  sapid  sub- 
stances in  solution,  applied  to  the  anterior  and  posterior  parts  of  the  tongue 


LESIONS  OF  THE  PNEUMOGASTRIC  NERVE.  1019 

by  a  glass  rod  or  a  brush,  suitable  substances  being  used  for  each  taste. 
Thus,  for  bitter  a  solution  of  quinin  may  be  used ;  for  sweet,  a  solution  of 
sugar ;  dilute  acetic  acid  or  vinegar  for  acid,  and  common  salt  for  the  saline 
taste. 

Ageusia  may  result  not  only  from  lesions  of  the  glossopharyngeal  nerve, 
but  also  from  those  of  the  gustatory  or  lingual  branch  of  the  fifth,  and  of  the 
fifth  itself  within  the  cranial  cavity ;  from  affections  of  the  chorda  tympani 
in  disease  of  the  middle  ear,  of  the  facial  between  the  entrance  of  the  chorda 
tympani  and  the  geniculate  ganglion,  and  in  lesions  of  the  peripheral  organs 
of  the  nerves  of  taste.  Disturbance  of  taste  may  possibly  result  from  cere- 
bral lesions,  but  the  cortical  area  for  taste  is  not  known. 

Perversion  of  the  sense  of  taste  is  known  as  "  parageusia."  It  is  a  rare 
phenomenon,  found  in  patients  with  facial  palsy,  in  the  hysterical,  and  in  the 
insane,  in  whom,  also,  subjective  sensations  of  taste  may  be  present.  The 
latter  also  occurs  as  an  aura  in  epilepsy.  Hyperesthesia  of  taste  is  even 
more  rare,  and  is  purely  a  hysterical  symptom. 


LESIONS    OF    THE    PNEUMOGASTRIC    OR    VAGUS    NERVE— 

THE  TENTH  PAIR. 

Anatomical. — This  nerve  has  by  far  the  widest  distribution  of  any  of 
the  cranial  set,  supplying  the  pharynx,  larynx,  lungs,  heart,  esophagus,  and 
stomach,  and  in  part  also  the  intestines  and  spleen.  The  symptoms  of  its 
involvement  are,  therefore,  numerous  and  varied. 

It  is  a  mixed  nerve  of  motion  and  sensation,  some  of  its  most  important 
motor  functions  being  derived  from  the  spinal  accessory  nerve.  It  is  the 
chief  sensory  nerve  for  the  respiratory  center  in  the  medulla  oblongata,  but 
contains,  also,  accelerating  and  inhibitory  fibers  for  this  center.  The  former 
office  preponderates,  so  that  section  of  the  nerve  renders  respirations  less  fre- 
quent, 'though  deeper,  while  stimulation  of  the  divided  central  end  accelerates 
them,  and  acceleration  may  proceed  to  tetanic  arrest.  The  inhibitory  fibers 
are  contained  chiefly  in  the  superior  laryngeal  nerve,  stimulation  of  which 
arrests  breathing  with  the  muscles  in  a  state  of  relaxation. 

It  is  also  the  inhibitory  nerve  of  the  heart,  slight  stimulation  increasing 
the  length  of  diastole,  while  stronger  stimulation  arrests  its  action.  On 
dividing  the  nerve  cardiac  contractions  become  more  frequent.  It  is  also 
inhibitory  for  the  vasomotor  center,  and  its  stimulation  produces  relaxation 
of  the  arteries  throughout  the  body.  It  is  the  motor  and  sensory  nerve  for 
the  esophagus,  sensory  nerve  for  the  stomach,  and  partly  the  motor  nerve 
for  the  stomach  and  intestines. 

Lesions  Involving  the  Nucleus  and  Trunk  of  the  Pneumogastric 

AND   Branches. 

The  nucleus  in  the  medulla  oblongata  may  be  involved  in  softening, 
bemorrhage,  or  slow  degeneration,  but  adjacent  nuclei  are  also  afifected  at 
the  same  time,  whence  resulting  effects  are  associated  and  are  especially  seen 
in  bulbar  palsy.  , 

The  trunk  of  the  nerve  near  its  origin  may  be  compressed  by  thick- 
ened meninges,  tumors,  or  aneurysm  of  the  vertebral  artery.  In  its  course 
it  has  been  implicated  in  incised  wounds,  and  tied  in  ligation  of  the  carotid. 


I020  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Neuritis  and  neuromata  are  possible.  The  results  of  such  lesion  are  com- 
monly paralytic,  rarely  irritative.  The  former,  if  total,  are  diminished 
breathing-rate,  "  suffocation,"  frequent  pulse-rate,  and  death.  According 
to  Traumann  and  others  unilateral  division  of  the  vagus  in  experiments  on 
animals  caused  few  pulmonary  symptoms.  One  vagus  seems  to  be  sufficient 
for  the  function  of  both  lungs.  The  results  of  partial  paralysis  are  better 
considered  in  connection  with  lesions  of  the  separate  branches  of  the  pneu- 
mogastric,  some  of  which  are  also  invaded  separately. 

Lesions  of  the  Pharyngeal  Branches. — These  branches  of  the  pneu- 
mogastric,  together  with  branches  of  the  glossopharyngeal,  form  the 
pharyngeal  plexus,  from  which  the  muscles  and  mucous  membrane  of  the 
pharynx  are  innervated. 

Etiology. — Nuclear  disease  is  a  most  common  cause  of  paralysis  of 
the  pharynx.  It  shares  with  disease  involving  adjacent  nuclei,  constituting 
bulbar  palsy,  already  considered ;  but  it  may  also  be  caused  by  meningitis 
or  bone  disease  at  the  base  of  the  skull,  or  it  may  form  part  of  the  lesion  of 
diphtheritic  paralysis. 

Symptoms. — The  results  are  mainly  paralytic,  occasionally  irritative, 
producing  spasm.  The  symptoms  of  paralysis  are  difficulty  in  swallowing, 
food  lodging  in  instead  of  descending  into  the  esophagus.  A  most  frequent 
consequence  is  the  entrance  of  food  into  the  larynx,  causing  spasm  and  even 
choking.  Pulpy  food  is  better  swallowed  than  liquids,  the  latter  passing 
easily  into  the  posterior  nares  when  there  is  paralysis  of  the  soft  palate,  and 
even  when  the  paralysis  is  limited  to  the  superior  constrictor  of  the  pharynx 
owing  to  contraction  of  the  middle  constrictor.  When  the  nerves  on  one 
side  only  are  involved,  the  difficulty  is  much  diminished.  Should  there  be 
a  doubt  in  diagnosis  between  paralysis  of  the  pharynx  and  obstruction  or 
morbid  growth,  the  passage  of  a  bougie  will  clear  it  up. 

Spasm  of  the  pharynx  is  always  functional  in  origin,  chiefly  hysterical. 
The  so-called  "  globus  hystericus,"  or  sensation  as  of  a  ball  in  the  throat 
which  has  to  be  swallowed  but  immediately  rises  again,  is  one  of  its  mani- 
festations ;  so  is  eminently  the  spasm  in  hydrophobia.  Extreme  degrees 
are  those  in  which  persons  cannot  swallow  their  food  in  the  presence  of 
others. 

Lesions  of  the  Laryngeal  Branches. — The  laryngeal  branches  are 
two,  the  superior  and  inferior,  or  recurrent  laryngeal.  The  former  supplies 
the  mucous  membrane  above  the  vocal  cords,  the  cricothyroid,  and  the 
depressors  of  the  epiglottis.  The  inferior  or  recurrent  laryngeal  on  the  left 
side  winds  around  the  arch  ol  the  aorta;  on  the  right,  around  the  subcla- 
vian. The  nerves  then  pass  up  to  the  larynx  between  the  trachea  and  the 
esophagus,  supplying  all  the  laryngeal  muscles  except  the  cricothyroid  and 
epiglottic,  and  the  mucous  membrane  below  the  cords ;  also  that  of  the 
trachea.  It  has  been  supposed  that  the  motor  fibers  in  these  nerves  come 
from  the  spinal  accessory  nerve,  but  this  is  now  doubted.  The  sensory 
filaments  of  the  laryngeal  branches  pass  to  the  medulla  oblongata  in  the  roots 
of  the  pneumogastric. 

In  order  to  appreciate  the  phenomena  of  paralysis  of  the  larynx  it 
should  be  remembered  that  the  glottis  is  opened  or  closed  only  by  the 
movement  of  the  posterior  extremity  of  the  cords,  the  anterior  remaining 
fixed,  and  that  this  movement  is  effected  chiefly  by  the  arytenoid  cartilages 
attached  to  the  cricoid  cartilage  by  an  articulation  which  permits  free  move- 


LESIONS  OF  THE  PNEUMOGASTRIC  NERVE.  1021 

ment.  Each  arytenoid  is  shaped  like  an  irregular  pyramid  prolonged  at 
the  base  into  two  processes — an  anterior  or  vocal,  from  which  the  cord 
passes  to  the  thyroid  cartilage,  and  an  external  or  muscular,  to  which  the 
muscles  are  attached.  When  the  latter,  which  is  at  right  angles  to  the 
vocal  process,  is  moved  back,  this  process  moves  outward  from  its  fellow, 
the  cord  is  abducted,  and  the  glottis  opened.  If  the  muscular  process  is 
moved  forward,  the  vocal  process  is  moved  inward  toward  its  fellow,  the 
cord  adducted,  and  the  glottis  closed.  These  movements  are  further  aided 
by  movements  of  the  arytenoids  away  from  or  toward  each  other. 

Symptoms. — These  are  phonic  and  respirators,  together  with  altered 
position  of  the  cords,  as  recognized  by  the  laryngeal  mirror.  The  voice 
may  be  changed  or  lost,  the  entrance  of  air  in  breathing  impeded,  while 
the  closure  of  the  glottis,  necessary  to  coughing,  is  usually  imperfect.  The 
voice  and  respiratory  functions  of  the  larynx  are  regulated  by  the  same 
muscles  and  nerves,  but  by  centers  that  differ  in  anatomical  connection,  if 
not  in  position. 

In  breathing  the  cords  are  abducted  or  separated  during  inspiration, 
the  extent  being  proportionate  to  the  force  of  inspiration.  During  expira- 
tion they  are  a  little  nearer  than  in  inspiration.  In  phonation  they  are  made 
tense  and  brought  together,  the  degree  of  adduction  and  tension  varying 
with  the  note  produced.  After  death  the  vocal  cords  assume  a  position  of 
slight  abduction  from  the  middle  line,  a  little  nearer  than  during  ordinary 
breathing,  known  as  the  cadaveric  position.  The  position  is  one  of  partial 
relaxation,  complete  relaxation  being  never  fully  attained  during  life. 

The  symptoms  of  deranged  function  of  the  laryngeal  nerves  admit  of 
classification   into  those   of  paralysis  and  spasm. 

1.  Total  Paralysis  of  Both  Cords  or  of  One. — In  what  is  known  as 
complete  paralysis  of  the  lar}'ngeal  muscles — which  does  not,  however, 
usually  include  the  cricothyroid — the  vocal  cords  assume  the  cadaveric  posi- 
tion previously  mentioned,  from  which  they  cannot  be  moved.  Hence 
vocal  sounds  cannot  be  produced.  In  deep  inspiration  the  current  of  air  may 
bring  them  a  little  closer,  and  there  may  slight  stridor,  and  instead  of  the 
natural  explosive  cough,  there  is  only  a  sudden  rush  of  air  through  the 
glottis.  If  one  cord  is  paralyzed,  it  alone  is  motionless  in  the  cadaveric 
position.  Phonation  may  still  be  possible,  because  the  unaffected  cord  may 
be  overadducted  beyond  the  middle  line,  but  the  voice  is  low-pitched  and 
often  hoarse.  During  inspiration  the  abduction  of  the  healthy  cord  pre- 
vents stridor,  while  an  explosive  cough  is  impossible  because  the  glottis  is 
not  closed  w'ith  sufficient  firmness  to  produce  it,  unless  the  paralysis  is  very 
slight. 

The  causes  of  complete  paralysis  are  central  disease  and  disease  of  the 
trunk  of  the  vagus  or  of  the  recurrent  laryngeal. 

2.  Bilateral  Abductor  Paralysis. — In  abductor  paralysis  involving  the 
posterior  crico-arytenoids  the  cords  are  near  together — in  the  position  of 
phonation — and  cannot  be  abducted  even  as  far  as  the  cadaveric  position. 
They  can,  however,  be  brought  together  in  phonation  and  in  coughing,  at 
the  cessation  of  which  they  recede  a  little,  but  the  normal  wide  abduction 
of  inspiration  does  not  take  place.  This  slight  recession  is  due  to  the  elas- 
ticity of  the  attachment  of  the  cords..  The  adductors,  unopposed,  undergo 
secondary  contracture,  so  that  if  the  paralysis  is  of  long  duration,  the  chink 
of  the  glottis  becomes  permanently  narrower.  The  tensors  are  still  active, 
as  well  as  the  adductors,  hence  the  voice  is  little  affected.     The  chief  diffi- 


I022  DISEASES  OF  THE  NERVOUS  SYSTEM. 

culty  is  in  breathing,  since  the  normal  recession  of  the  cords  essential  to 
inspiration  does  not  take  place,  while  they  are  even  brought  closer  together 
by  the  pressure  of  the  entering  air.  Hence  inspiration  is  accomplished  with 
stridor,  and  the  obstruction  to  the  entrance  of  air  brings  into  play  the  extra- 
ordinary muscles  of  respiration,  the  effect  of  which  is  to  prolong  the  inspi- 
ratory act.  Expiration  is  unimpeded,  the  current  of  outward  air  tending 
to  open  the  cords.  The  absence  of  voice  involvement  and  of  cough  may 
cause  the  obstruction  to  be  referred  to  the  trachea,  but  the  absence  of 
expiratory  stridor  excludes  this,  while  the  movement  of  the  larynx  up  and 
down  during  breathing  is  greater  than  in  tracheal  stenosis.  The  added 
urgent  dyspnea,  the  loud  inspiratory  stridor,  livid  features,  and  cold  ex- 
tremities finish  an  unmistakable  picture ;  so  that  a  laryngoscopic  examination 
is  therefore  not  necessary  to  complete  the  diagnosis.  In  bilateral  palsy  there 
is  even  great  danger,  as  a  slight  catarrhal  swelling  may  close  the  larynx  and 
tracheotomy  may  be  necessary  to  save  life. 

The  causes  of  abductor  paralysis  are  central  disease  and  local  influence 
such  as  laryngeal  catarrh  and  degeneration  of  the  posterior  cricothyroids, 
possibly  of  toxic  origin.  Disease  of  the  recurrent  laryngeal  has  produced 
such  paralysis,  although  this  nerve  supplies  fibers  to  the  adductors  as  well 
as  abductors.  On  the  other  hand,  the  abductors  have  been  found  degen- 
erated when  the  other  muscles  were  found  normal".  Paralysis  of  both  cords 
is  generally  due  to  disease  of  both  nerves,  and  may  be  produced  by  pressure 
on  both  vagi  and  both  recurrent  laryngeal  nerves.  Central  causes  are  tabes 
dorsalis  and  bulbar  palsy.  Abductor  paralysis  is  also  a  rare  symptom  in 
hysteria,  when  it  is  bilateral,  with  characteristic  symptoms,  and  has  caused 
death. 

3.  Unilateral  Abductor  Paralysis. — In  this  the  afifected  cord  is  near  the 
middle  line,  and  it  does  not  move  in  inspiration.  There  are  hoarseness  and 
roughness  of  voice  and  sometimes  dyspnea,  but  the  mobility  of  the  other  cord 
permits  the  function  of  the  larynx  to  be  carried  on  with  tolerable  comfort. 
If  the  adductors  become  involved,  as  is  sometimes  the  case,  phonation  is  still 
more  impaired. 

The  most  frequent  cause  is  aneurysm,  and  the  left  icord  is  most  fre- 
quently involved, — though  other  tumors  may  cause  it, — and  on  the  right  side 
the  nerve  may  be  involved  in  a  thickened  pleura. 

4.  Adductor  Paralysis  {Phonic  Paralysis;  Hysterical  Paralysis). — In 
adductor  paralysis  due  to  involvement  of  the  lateral  crico-arytenoid  and  the 
arytenoid  muscles  the  cords  are  apart  and  cannot  be  approximated.  In  true 
adductor  paralysis  there  is  still  the  power  of  separating  the  cords  on  deep 
inspiration,  but  no  power  to"" bring  the  cords  nearer  than  in  the  cadaveric 
position. 

The  causes  of  adductor  paralysis  are  rarely  organic  diseases  of  the 
nerves  or  centers.  It  is  the  condition  causing  the  oft-quoted  hysterical 
aphonia,  and  may  be  brought  on  by  overuse  of  the  voice  and  catarrhal  laryn- 
gitis. The  patient  with  hysterical  aphonia  can  sometimes  sing,  though  she 
can  talk  only  in  a  whisper.  It  is  most  common  as  a  partial  paralysis.  While 
the  cords  cannot  be  approximated  for  phonation,  they  can  be  in  coughing. 
Hence  it  was  called  by  Tiirck  "  phonic  paralysis."  Another  partial  adductor 
paralysis  is  due  to  the  loss  of  power  in  the  arytenoid  muscle,  resulting  in 
defective  closure  of  the  posterior  part  of  the  glottis  and  hoarseness  or  loss  of 
voice. 

5.  Tensor  Paralysis. — Little  is  known  of  this  except  that  palsy  of  the 


LESIOXS  OF  THE  PNEUMOGASTRIC  NERVE. 


1023, 


internal  fibers  of  the  thyro-arytencideus  causes  the  edge  of  the  cord  to  be 
concave. 

Diagnosis. — The  laryngoscope  is  necessary  to  a  proper  diagnosis  of 
laryngeal  palsies,  but  symptoms  are  also  useful.  The  inability  to  produce 
explosive  cough  is  of  great  value  in  pointing  to  palsy  of  organic  origin,  if 
there  is  no  local  lesion  to  prevent  it. 

(a)  Absence  of  cough  with  entire  loss  of  voice  points  to  bilateral  palsy 
of  organic  origin. 

(&)  No  cough,  voice  low-pitched  and  hoarse,  paralysis  of  one  cord. 

(c)  Loud  inspiratory  stridor  without  loss  of  voice,  total  abductor 
paralysis. 

(rf)  Little  change  of  voice  or  cough,  unilateral  abductor  paralysis. 

{e)   Perfect  cough,  no  voice,  no  stridor,  unimportant  adductor  palsy. 

The  following  table  from  Gowers  contains  in  separate  columns  the 
symptoms,  laryngoscopic  picture,  and  lesions : 


Symptoms. 


Signs. 


Lesion. 


Total  bilateral  palsy. 


(a)  No  voice  ;     no    coiig-h  ;     stridor  Both  cords   moderately  abducted  and 
only   on   deep    inspiration.  j     motionless. 

(d)  Voice  low-pitched  and    hoarse  ;  One    cord    moderately    abducted    and  Total  unilateral  palsy. 
no  cough ;  stridor  absent  or  slighti    motionless,  the  other  moving  freely 
on  breathing.  and  even  beyond  the  middle  line  in 

phonation. 


ic)  Voice  little  changed  ;  cough  Both  cords  near  together,  and  during 
normal  ;  inspiration  difficult  and  inspiration  not  separated,  but  even 
long,   with  loud  stridor.  j    drawn  nearer  together. 

(d)  Symptoms    inconclusive ;   little  One  cord    near    the  middle    line,    not 
~  affection  of  the  voice  or  cough.     ,    moving  during  inspiration;  the  other 

1    normal. 


\e)  No  voice ;    perfect    cough 
Stridor  or  dyspnea. 


no  Cord  normal  in  position  and  moving 
normally  in  respiration,  but  not 
brought  together  on  an  a..cempt  at 
phonation. 


Total  abductor  pals}'. 


Unilateral    abductor 
palsy. 

Adductor  palsy. 


Spasm  of  the  Larynx. — In  spasm  of  the  larynx  the  adductors  are  alone 
concerned.  The  closers  of  the  glottis  are  stronger  than  the  openers,  while 
reflex  mechanism  is  connected  chiefly  with  those  muscles  because  of  the  im- 
portance in  guarding  against  the  entrance  of  foreign  bodies  into  the  larynx. 
Spasm  is  quite  common  in  children,  especially  in  the  rickety,  and  is  not  rare 
in  adults  under  the  name  of  laryngismus  stridulus.  It  is  generally  reflex, 
although  the  reflex  cause  is  not  always  discoverable.  The  patient  commonly 
wakes  up  at  night  in  an  attack  of  intense  dyspnea ;  but  it  may  occur  at  any 
time.     The  symptoms  are  like  those  of  ordinary  croup. 

The  paroxysm  differs  from  that  of  abductor  paralysis  in  that  the  stridor 
accompanies  expiration  as  well  as  inspiration.  The  attacks  occur  in  the 
so-called  laryngeal  crises  of  tabes  dorsalis,  in  tetany,  in  the  paroxysms  of 
hydrophobia,  sometimes  in  alternation  with  attacks  of  migraine,  and  in 
hysteria. 

Spasm  is  also  sometimes  excited  by  attempts  to  speak,  when  aphonia 
results.  The  condition  is  the  reverse  of  phonic  paralysis,  in  which  the  cords 
cannot  be  brought  together  in  speaking,  while  in  spastic  aphonia  they  come 
together  too  forcibh'. 

Disturbances  of  the  sensory  innervation  of  the  larynx  are  chiefly  con- 
fined to  the  irritation  which  causes  cough  and  spasm. 


I024  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Lesions  of  Cardiac  Branches. — The  cardiac  plexus  is  made  up  of 
fibers  derived  in  part  from  the  pneumogastric  and  in  part  from  the  sympa- 
thetic.    The  vagus  fibers  are  motor,  sensory,  and  probably  trophic. 

The  motor  fibers  include  those  which  inhibit,  control,  and  regulate  the 
cardiac  action.  Their  irritation  inhibits  the  heart's  action  and  causes  slow- 
ness oi  the  pulse,  or  bradycardia.  In  complete  paralysis  of  the  vagi  the 
inhibitory  action  is  abolished  and  the  accelerator  influence  is  unhampered, 
producing  rapid  pulse,  or  tachycardia.  Yet  it  sometimes  happens  that  com- 
plete paralysis  of  the  vagus  is  followed  by  no  cardiac  symptoms. 

The  causes  of  these  effects  are,  unfortunately,  not  always  discoverable. 
Pressure  of  a  tumor,  accidental  ligation  of  one  vagus,  irritation  of  its 
nuclei,  anginal  attacks,  in  one  instance  associated  with  a  small  tumor  of  the 
vagus,  have  all  been  followed  by  bradycardia.  Toxic  blood  states  are  also 
held  responsible  for  it.  Some  persons  are  able  to  control  the  action  of  their 
own  hearts,  notably  a  Colonel  Townsend,  who  could  control  the  action  of  his 
heart  at  will.  The  heart  may  sometimes  be  slowed  by  pressure  against  the 
pneumogastric  in  the  neck. 

The  opposite  condition,  tachycardia,  has  been  produced  by  diphtheritic 
neuritis,  tumors  of  the  vagus,  or  accidental  removal  of  the  vagus. 

Sensory  phenomena  in  connection  with  parts  supplied  by  the  cardiac 
branches  of  the  pneumogastric  are  unusual,  but  a^ny  uncomfortable  sensa- 
tions arising  from  palpitation  or  irregularity  are  conveyed  by  branches  of 
the  pneumogastric. 

Trophic  influence  in  the  pneumogastric  is  inferred  from  the  fact  that 
the  heart  has  been  found  in  a  state  of  fatty  degeneration  after  injury  to  the 
nerve. 

Lesions  of  Gastric  and  Esophageal  Branches. — Among  phenomena 
ascribed  to  effect  on  these  branches  are  spasm  of  the  esophagus  and  diffi- 
culty in  swallowing.  The  vagus  is  also  the  sensory  nerve  of  the  stomach, 
and  pain  in  this  organ  is  felt  through  this  nerve.  The  severe  gastric  crises 
which  occur  in  tabes  dorsalis  are  due  to  central  irritation  of  the  vagus  nuclei. 
The  senses  of  hunger  and  thirst  are  also  believed  to  be  conveyed  through  it, 
and  have  been  lost  in  disease  involving  the  root,  but  appetite  is  not  always 
lost  after  section  of  the  nerve,  while  in  some  cases  of  disease  of  the  nerve 
there  has  been  excessive  appetite.  On  the  other  hand,  loss  of  appetite  is  due 
to  so  many  causes  that  it  cannot  be  ascribed  to  pneumogastric  lesion  without 
careful  investigation. 

The  pneumogastric  is  also  the  motor  nerve  of  the  stomach,  though 
motion  of  the  organ  is  not  entirely  arrested  after  its  section.  Vomiting  is 
probably  produced  through  its  agency,  and  is  excited  by  central  and  reflex 
irritation.  Meningitis,  which  so  frequently  excites  vomiting,  does  so 
through  it ;  the  pressure  of  a  tumor  on  the  nerve  has  had  a  similar  effect, 
also  direct  pressure  on  an  exposed  nerve. 

Lesions  of  Pulmonary  Branches. — While  the  vagus  sends  branches 
to  the  lungs,  little  is  known  of  their  office.  They  are  supposed  to  go  to  the 
bronchial  muscles,  and  it  is  held  that  asthma  is  a  neurosis  of  these  fibers. 
Irritation  of  the  afferent  pulmonary  fibers  certainly  produces  spasm.  Stimu- 
lation of  the  respiratory  center  also  causes  energetic  respiratory  movements, 
while  rapid  congestion  and  even  hemorrhage  have  been  noticed  after  section, 


LESIOXS  OF  THE  PXEUMOGASTRIC  XERVE.  1025 

though  these  effects  may  possibly  be  of  reflex  origin  excited  through  the 
sympathetic,  since  the  vasomotor  fibers  in  the  vessels  of  the  lungs  are  derived 
from  the  sympathetic.  After  section  of  the  vagus  animals  die  of  broncho- 
pneumonia. This  has  not  been  considered  the  result  of  trophic  influence, 
but  because  of  the  entrance  of  foreign  particles  into  the  bronchi  in  conse- 
quence of  paralysis  of  the  larynx  and  esophagus ;  this  was  shown  by  Traube 
as  far  back  as  1871,  and  confirmed  by  Frey  by  numerous  experiments  in  1877. 
Such  broncho-pneumonia  has  also  been  ascribed  to  paralysis  of  the  bronchial 
musculature  and  of  the  vaso-constrictor  fibers  which  causes  neuroparalytic 
hyperemia  of  the  pulmonary  tissue.  Spiller's  case,  recently  reported,*  has 
some  bearing  on  the  subject.  This  patient  suffered  an  injury  of  the  left 
glossophar\-ngeus  and  vagus  by  a  fracture  of  the  base  of  the  skull.  He  died  46 
days  after  the  accident  and  at  necropsy  numerous  areas  of  bronchopneumonia 
were  found.  It  seemed  improbable  that  the  pulmonary  condition  was  caused 
by  the  entrance  of  foreign  bodies  into  the  lungs  in  this  case,  because  the 
patient  was  unable  to  swallow.  Saliva,  however,  doubtless  passed  into  the 
trachea  and  carried  with  it  muco-organisms.  The  patient  was  tested  with 
a  glass  of  water  and  his  choking  was  so  alarming  that  the  attempt  was  not 
repeated.  He  was  nourished  by  rectal  enemas  and  the  stomach  tube  was 
passed  only  on  the  day  before  his  death.  The  choking  was  probably  the 
result  of  impaired  function  of  the  epiglottis.  Spiller  thinks  it  reasonable  to 
attribute  the  pulmonary  condition  to  the  paralysis  of  the  vagus  nerve, 
although  the  pulmonary  lesions  were  not  recognized  until  the  necropsy  was 
made. 

The  phenomena  of  hiccough  may  be  the  result  of  disease  of  this  nerve, 
as  they  are  also  the  result  of  disease  of  the  respiratory  center. 

Prognosis  in  Pneumogastric  Lesions. — This  varies  greatly.  In  cen- 
tral and  nuclear  disease  it  is  unfavorable :  it  is  unfavorable  also  when  it  is 
the  result  of  pressure  from  intrathoracic  tumors,  especially  aneurysm.  In 
hysterical  and  purely  local  aft'ections  the  prognosis  is  more  favorable. 

Treatment. — This  is,  of  course,  that  of  the  causal  lesion,  if  it  can  be 
discovered.  Syphilis  is  the  more  curable  of  the  central  causes.  Other 
causes  of  central  disease  are  not  removable. 

Of  diseases  of  the  trunk,  neuritis  of  the  vagus  is  as  amenable  to  treat- 
ment as  the  polyneuritis  of  which  it  is  a  part.  The  laryngeal  symptoms  due 
to  involvement  of  the  recurrent  laryngeal  are  as  remediable  as  the  causes 
which  produce  them.  If  they  are  caused  by  aneurysm  of  the  aorta  or  cancer, 
treatment  is  useless :  if  caused  by  syphilitic  and  scrofulous  growths,  the  prog- 
nosis is  more  hopeful. 

In  the  paralyses  of  more  purely  local  origin,  especially  the  hj^sterical, 
phonic,  and  diphtheritic  forms,  electricity  oft"ers  the  most  promising  results. 
The  method  of  its  employment  will  be  found  detailed  under  diseases  of  the 
larynx.  Either  form  of  electricity  may  be  used.  Strychnin  is  a  useful 
remedy,  used  locally  as  mentioned.  The  method  preferred  is  by  hypoder- 
mic injection,  the  nitrate  being  employed  in  doses  of  from  1-60  to  1-30  grain 
(o.ooii  to  0.0022  gm.)  daily. 

In  addition  to  stn-chnin,  other  tonics  should  be  used  to  restore  the 
general  health  of  the  patient.  Lar}-ngeal  gymnastics  have  been  recom- 
mended and  used  with  some  success.  ,They  consist  in  pressing  firmly  with 
the  thumb  and  forefinger  on  each  side  of  the  upper  and  hinder  part  of  the 


*  "Univ.  of  Fenn.  !Med.  Bull,"  March,  1903 
65 


I026  DISEASES  OF  THE  NERVOUS  SYSTEM. 

thyroid  cartilage,  the  patient  being  requested  to  make  a  simple  sound  dur- 
ing the  compression. 

The  treatment  of  laryngeal  spasm  demands  also  the  removal  of  the 
cause  if  possible,  in  addition  to  which  sedatives,  local  and  general,  especially 
the  bromids  and  cocain,  may  be  used.  Chloral,  chloroform,  and  nitrite  of 
amyl  by  inhalation  may  be  necessary  to  break  up  the  spasm. 


LESIONS   OF   THE   ELEVENTH    PAIR   OR   SPINAL 
ACCESSORY   NERVE. 

Anatomical. — This  nerve,  purely  motor  in  its  function,  has  two  por- 
tions— an  internal,  which  passes  to  the  pneumogastric  and  innervates  the 
laryngeal  muscles,  and  an  external  or  spinal  portion.  The  former  has  been 
considered.  It  should  be  regarded  as  probably  a  part  of  the  vagus,  and  the 
eleventh  nerve  is  called  by  some  the  vago-accessory  nerve.  The  latter,  i.  e., 
the  spinal  portion,  is  essentially  a  set  of  motor  fibers  from  the  cervical  spinal 
cord,  which  ascends  into  the  cranial  cavity  and  passes  out  again  with  one  of 
the  cranial  nerves  to  be  distributed  to  the  sternocleidomastoid  and  trapezius 
muscles,  whose  innervation  they  share  with  the  spinal  nerves.  The  purpose 
of  the  trapezius  is  chiefly  to  raise  the  shoulder ;  that  of  the  sternocleido- 
mastoid is  to  assist  in  turning  the  head  to  the  opposite  side,  the  chin  being 
at  the  same  time  raised.  This  is  accomplished  by  drawing  the  occiput 
toward  the  side  of  the  muscle  acting. 

Lesions. — The  nuclear  origin  of  the  nerve  may  be  involved  and  con- 
tribute to  the  phenomena  of  bulbar  palsy,  or  it  may  shafe  in  progressive 
central  degeneration,  causing  wasting  in  the  muscles  supplied,  which  may  be 
a  part  of  a  more  general  muscular  atrophy.  The  trunks  of  the  nerve  or 
both  nerves  may  be  compressed  in  the  foramen  magnum  by  meningitis  or 
tumor'.  Outside  the  skull  there  may  be  wounds,  tumors,  caries  of  the  ver- 
tebrae, and  resulting  abscesses,  and  sometimes  abscesses  springing  from 
the  cervical  glands.  Rarely  the  spina!  accessory  may  be  invaded  by  rheu- 
matic neuritis. 

The  resulting  conditions  are  paralysis  and  spaswk  Those  of  the  in- 
ternal or  accessory  portion  have  been  described  under  lesions  of  the  pneumo- 
gastric.    It  remains  to  consider  only  those  of  the  external  branch. 

Symptoms  of  Paralysis  o£  the  External  Branch  of  the  Spinal  Acces- 
sory Nerve. — The  seats  of  the  paralysis  are  the  sternomastoid  and  trapezius 
muscles.  When  one  sternomastoid  is  involved,  the  head  may  still  be  moved 
to  the  opposite  side,  and  there  is  no  wry-neck,  or'  torticollis,  though  in  some 
cases  the  head  is  held  obliquely.  The  trapezius  is  not  so  much  involved 
because  it  is  well  supplied  with  cervical  and  thoracic  nerves,  but  the  portion 
which  passes  from  the  acromion  to  the  occipital  bone  is  motionless.  The 
middle  portion  of  the  muscle  is  also  weakened,  the  shoulder  droops  down- 
ward and  forward,  and  the  inferior  angle  of  the  scapula  is  rotated  inward 
bv  the  action  of  the  rhomboids  and  the  levator  anguli  scapulae.  Elevation 
of  the  arm  is  also  partial,  because  the  trapezius  does  not  fix  the  scapula  at  a 
point  whence  the  deltoid  can  work.  The  paralysis  is  well  seen  when  the 
patient  takes  a  deep  breath  or  tries  to  shrug  his  shoulders.  Wasting  almost 
always  accompanies  the  loss  of  power,  and  there  is  usually  reaction  of 
degeneration. 


LESIOXS  OF  THE  SPIXAL  ACCESSORY  NERVE.        1027 

In  bilateral  paralysis  the  power  of  holding  the  head  in  the  upright  posi- 
tion is  impaired.  If  both  sternocleidomastoids  are  affected,  the  head  tends 
to  fall  backward ;  if  both  trapezii,  it  falls  forward  so  that  the  chin  rests  on 
the  sternum.  The  latter  is  the  characteristic  position  of  the  head  in  pro- 
gressive spinal  muscular  atrophy,  and  in  children  who  have  chronic  menin- 
gitis about  the  foramen  magnum,  pressing  on  both  nerve-trunks,  and  in  cer- 
vical meningitis  the  result  of  caries.  A  peculiar '  drooping  of  the  head  is 
sometimes  seen  during  the  first  year  of  life  in  children,  which  Gowers  says 
may  be  due  to  injury  to  the  spinal  accessory  nerves  in  difficult  labor.  In 
recent  cases  the  nerves  may  give  characteristic  reaction  of  degeneration.  In 
central  disease  the  reaction  varies,  as  it  does  in  progressive  spinal  muscular 
atrophy. 

Treatment.— This  must  have  for  its  object,  first,  the  removal  of  the 
cause,  or  the  morbid  process  which  produces  it.  After  this  the  weak 
muscles  are  to  be  treated  by  massage  and  electricity.  Faradization  is,  per- 
haps, most  efficient  for  this  purpose,  and  either  form  of  current  will  answer. 

Symptoms  of  Accessory  Spasm  (Torticollis;  Wry-neck). — Though 
the  muscles  supplied  by  the  spinal  accessory  are  not  the  sole  ones  responsible 
for  these  conditions,  they  are  the  ones  chiefly  concerned.  The  terms  are 
applied  to  unnatural  positions  of  the  head  resulting  from  contraction  of 
these  muscles.     There  are  two  principal  varieties : 

1.  Fixed  wry-neck,  or  congenital  torticolhs. 

2.  Spasmodic  wry-neck. 

These  two  may  be  regarded  as  true  torticollis,  and  are  to  be  distin- 
guished from  two  somewhat  similar  states  which  may  be  called  false  torti- 
collis. The  first  of  these  is  the  ordinary  "  stiff-neck,"  which  is  really  a  rheu- 
matic condition  due  to  exposure  to  cold,  and  characterized  by  pain  and  ten- 
derness, for  the  relief  of  which  the  position  is  assumed,  and  should  not  be 
called  wry-neck.  The  second  is  a  twist-neck,  not  due  to  muscles,  but  to 
some  other  cause,  most  frequently  disease  of  the  cervical  vertebrae.  This 
deviation  puts  the  sternocleidomastoid  muscle  on  the  stretch,  and  thus  may 
give  rise  to  the  impression  that  it  is  responsible. 

I.  CoxGEXiTAL  Torticollis,  or  Fixed  Wry-xeck. — This  depends  on 
the  shortening  of  some  muscle,  commonly  the  sternocleidomastoid,  which  is 
also  often  atrophied,  hard,  and  firm.  It  is  met  most  frequently  in  children, 
and  is  thought  to  be  due,  in  some  cases  at  least,  to  injury  of  the  muscle  pro- 
duced by  traction  during  birth.  In  others  it  is  ascribed  to  developmental 
shortening  of  the  muscle,  due  to  the  inclined  position  of  the  child's  head  in 
the  pelvis.  It  is  not  always  noticed  immediately  after  birth  because  of  the 
natural  shortness  of  the  child's  neck.  A  similar  condition  may  result  from 
injur}-  to  the  muscle  during  life,  producing  inflammation  and  cicatricial  con- 
traction. It  aft'ects  the  right  side  almost  exclusively.  It  is  more  or  less 
constantly  associated  with  facial  asymmetry,  first  noticed  by  George  Wilks 
and  further  studied  by  Golding  Bird,  who  suggested  that  the  two  conditions 
are  parts  of  one  affection  which  has  a  central  origin.  In  fixed  wn--neck  the 
head  is  turned  toward  the  side  opposite  to  that  of  the  contracted  muscle, 
which  stands  out  conspicuously,  and  cannot  be  turned  toward  the  latter. 
While  the  sternocleidomastoid  is  the  , muscle  almost  invariably  responsible 
in  these  cases,  the  trapezius  is  occasionally  the  seat  of  similar  atrophy. 

Treatm.ent. — The  treatment  is  by  section  of  the  contracted  muscle. 
Somie  appliance  may  be  necessary  for  a  time  to  keep  the  head  in  proper 


1028  DISEASES  OF  THE  NERVOUS  SYSTEM. 

position,  especially  when  secondary  changes  in  the  articulation  have  taken 
place.  In  simple  rheumatic  wry-neck  I  have  used  an  appliance  consisting 
of  webbing  or  "  saddle  girth  "  about  three  inches  wide,  stretched  from  side 
to  side  of  the  bed  and  raised  a  few  inches  above  the  mattress, — the  distance 
to  be  regulated  by  circumstances, — on  which  the  patient  lay  at  night,  instead 
of  on  a  pillow  on  the  side  to  which  the  head  is  drawn.  This  expedient  may 
be  used  after  operation.  The  facial  asymmetry  is  apt  to  remain  after  the 
wry-neck  is  cured,  and  may  even  become  more  conspicuous. 

2.  Spasmodic  Wry-neck. — This  is  a  condition  analogous  to  the  facial 
spasm,  occurring  as  a  symptom  of  disease  of  the  facial  nerve.  There  are 
two  forms,  the  tonic  and  the  clonic,  which  may  alternate  in  the  same  case  or, 
as  is  most  usual,  occur  separately  and  remain  so. 

Etiology. —  It  is  for  the  most  part  an  affection  of  adults,  and,  accord- 
ing to  Gowers,  is  more  common  in  females — that  is,  in  twenty-two  out  of 
thirty-two  cases.  While  this  must  be  true  of  England,  the  opposite  seems 
to  be  the  case  in  this  country,  since  of  eight  or  ten  cases  observed  by  Osier 
in  Philadelphia  and  Montreal,  all  were  men.  It  is  more  common  in  middle 
life,  two-thirds  of  all  cases  occur'ring  between  the  ages  of  thirty  and  fifty. 
In  women  under  thirty  it  is  apt  to  be  of  a  hysterical  origin ;  rarely  it  is 
ascribable  to  the  same  cause  in  boys.  It  is  prone  to  occur  in  neurotic  fami- 
lies. Very  rarely  it  occurs  in  the  first  year  of  infantile  life,  ceasing  after  a 
few  months.     Cold  has  been  assigned  as  a  cause ;  also  traumatism. 

In  the  tonic  form,  when  the  sternocleidomastoid  is  responsible,  the  head 
is  continually  turned  to  the  opposite  side,  the  chin  is  raised,  and  the  occiput 
is  drawn  down  toward  the  afifected  side — the  caput  obstipuin  spasticuiiK 
When  the  trapezius  is  involved,  the  head  is  still  more  depressed  toward  the 
same  side.  In  combined  and  bilateral  spasm  of  these  muscles  the  head  is 
drawn  backward,  producing  the  retrocoUic  spasm.  In  prolonged  cases  the 
muscles  involved  are  prominent  and  rigid,  and  there  may  be  spinal  curvature 
with  the  convexity  toward  the  sound  side. 

In  the  clonic  for'm  there  are  paroxysmal  twitchings  of  the  head,  which 
may  be  very  severe  and  correspondingly  distressing.  When  there  is  pre- 
dominating unilateral  spasm  of  the  sternocleidomastoid,  the  head  is  turned 
to  the  opposite  side  and  the  chin  is  raised  with  every  contraction  of  the 
muscle.  In  unilateral  spasm  of  the  trapezius  the  head  is  drawn  more  back- 
ward with  each  contraction  and  toward  the  shoulder  of  the  affected  side.  In 
bilateral  and  combined  spasm  there  is  clonic  retrocollic  spasm,  with  shaking 
and  nodding  movements — the  so-called  "  salaam  convulsions  "  sometimes 
seen  in  children.  They  may^be  produced  also  by  contractions  of  the  other 
muscles  of  the  neck.  Tonic  and  clonic  spasm  of  the  splenius  may  occur 
either  alone  or  in  combination  with  that  of  the  trapezius  and  sternocleido- 
mastoid. In  splenius  spasm  the  head  is  also  drawn  backward  and  toward 
the  afifected  side,  and  ther'e  will  be  noticed  muscular  swelling  to  the  outside 
of  the  cervical  portion  of  the  trapezius.  The  splenius  is,  according  to 
Gowers,  associated  with  the  sternomastoid  about  half  as  often  as  the  trape- 
zius. The  retrocollic  spasm  is  commonly  associated  with  a  wrinkling  of  the 
forehead  in  both  the  tonic  and  clonic  form. 

In  the  clonic  form  the  contractions  may  come  on  suddenly  or  be  pre- 
ceded by  stififness  and  irregular  pain.  The  movements  occur  every  few 
minutes,  and  the  head  cannot  be  kept  still,  although  the  movements  cease 
during    sleep.     They    are    increased    by    emotion,    excitement,    or    fatigue. 


LESIONS  OF  THE  SPINAL  ACCESSORY  NERVE.        1029 

Sometimes  there  is  pain,  but  at  other  times  there  is  merely  a  sense  of  fatigue. 
The  muscles  in  time  may  become  hypertrophied,  but  never  waste. 

Pathology. — This  is  very  obscure.  Reasoning,  rather  than  demonstra- 
tion, leads  to  the  conclusion  that  the  muscular  contractions  probably  depend 
on  the  overaction  of  nerve-cells,  and  not  on  irritation  of  nerve-fibers ;  the 
movement  usually  involves  the  deep  rotators  on  one  side  of  the  neck  and  the 
sternocleidomastoid  muscle  on  the  opposite  side.  It  is  therefore  a  movement 
of  associated  muscles,  and  this  suggests  a  cortical  origin,  at  least  in  many 
cases. 

Diagnosis. — The  distinction  lies  between  true  and  false  torticollis,  in 
which  there  is  deviation  of  the  head  from  some  other  cause  than  muscular 
contraction,  and  it  is  only  the  form  of  tr'ue  torticollis  due  to  shortening  of 
one  sternocleidomastoid  which  is  likely  to  be  confounded  with  the  false.  In 
the  spurious  form  the  sternomastoid  is  tense  on  the  side  toward  which  the 
face  is  turned,  and  in  the  true  form  the  tension  is  on  the  side  opposite.  In 
retrocollic  spasm  the  invariable  association  of  contraction  of  the  frontalis 
muscles,  producing  the  peculiar  wrinkling  of  the  forehead,  distinguishes  it 
from  simple  tremor.  The  hysterical  form  occurs  in  women  under  thirty, 
and  this  fact  is  presumptive  evidence  of  its  presence,  while  hysterical  spasm 
is  also  apt  to  spread  from  the  neck  to  the  trunk ;  in  the  true  form  of  torticollis 
it  is  limited  to  the  neck. 

Prognosis. — The  prognosis  is  always  grave,  and  the  more  severe  and 
extensive  the  spasm,  the  more  unfavorable.  Relief  is  more  possible  in  the 
first  half  of  life  than  in  the  second.  Cases  do,  however,  occasionally  get 
well,  and  temporary  relief  is  more  frequent. 

Treatment. — If  the  cause  can  be  found  v/hich  is  responsible,  it  ought  to 
be  removed.  If  discovered  in  an  acute  stage,  absolute  rest  in  bed  and  fomen- 
tations or  dry  heat  are  indicated.  Electricity  has,  perhaps,  more  reputation 
than  any  other  remedy.  The  far'adic  brush  may  be  applied  over  the  skin  of 
the  affected  muscles  and  to  the  swelling.  Gradually  increasing  faradic  cur- 
rents may  be  used.  If  the  galvanic  current  is  used,  a  weak  one  is  preferred, 
and  the  anode,  or  positive  pole,  is  placed  below  the  occiput  or  highest  acces- 
sible part  of  the  nerve,  and  the  negative  on  each  contracting  muscle,  for  ten 
minutes  at  a  time. 

Sedatives  and  narcotics  have  also  some  reputation.  Among  these  the 
bromids  and  cannabis  indica  are  included  in  large  doses.  Five-minim 
(0.3  c.  c.)  doses  of  the  fluid  extract  of  cannabis  indica  may  be  given,  rapidly 
increased.  The  drug  is  proverbially  unreliable.  The  hypodermic  use  of 
morphin  is  of  tmdoubted  value  in  r'elaxing  the  spasm,  but  the  dangers  of  its 
protracted  use  almost  preclude  it.  It  would  be  unfair  to  the  drug,  however, 
to  omit  the  statement  of  Gowers  that,  "  continued  for  several  months  in  doses 
increased  gradually  to  half  a  grain  or  a  grain  a  day,  it  has  entirely  removed 
the  spasm."  Naturally  such  persons  are  weaned  from  the  drug  with  dififi- 
culty.  The  hypodermic  use  of  atropin  in  the  affected  muscles  has  also  been 
recommended. 

-Mechanical  supports  for  fixing  the  head  are  recommended,  but  are  not 
well  borne.  Surgical  measures  have  been  employed — such  as  section,  exsec- 
tion,  stretching  of  the  nerve,  and  section  of  the  muscle — with,  at  best,  but 
temporary  results.  Mention  should  be  made,  however,  of  the  deep-seated 
operation  of  W.  W.  Keen  and  Noble  Smith,  which  consists  in  dividing  the 
spinal  accessory  nerve  and  the  posterior  branches  of  two  or  three  cervical 
nerves  which  also  supply  the  splenius  and  complexus.     This   reduces  the 


I030  DISEASES  OF  THE  XERVOUS  SYSTEM. 

spasms  that  reside  in  these  muscles  to  a  slight  degree,  while  the  otherwise 
paralyzing  effect  of  the  division  cf  branches  of  the  spinal  nerves  is  compara- 
tively unimportant. 


LESIONS   OF   THE   TWELFTH   PAIR  OR  HYPOGLOSSAL 

XERVE. 

Anatomical. — This  is  the  motor  nerve  of  the  tongue,  ana  supplies 
also  the  depressors  of  the  hyoid  bone  and  the  hyoglossus  and  geniohyoid  of 
the  elevators.  It  arises  from  the  medulla  oblongata  beside  the  olivary  body. 
Its  cortical  center  is  probably  the  lower  part  of  the  ascending  frontal  gyrus 
or  the  posterior  part  of  the  third  frontal  convolution.  It  is  subject  to 
paralysis  and  spasm. 

Etiology. —  I.  Cortical  disease  is  frequently  responsible  for  paralysis 
of  the  tongue  on  the  opposite  side,  as  is  seen  in  the  numerous  cases  of  hemi- 
plegia associated  with  this  condition.  The  same  accident  occurs  when  the 
fibers  between  the  cortex  and  the  nucleus  in  the  medulla  oblongata  are  in- 
vaded, and  probably  this  is  the  most  frequent  cause  of  paralysis  of  the 
tongue.  Apoplexies  and  other  causes  of  compression,  softening,  throm- 
bosis, and  embolism,  are  agencies  operating  to  this  "end. 

2.  Nuclear  disease  is  another  cause.  It  is  usually  degeneration,  rarely 
sudden  softening:  the  former  as  a  part  of  bulbar  palsy  and  tabes  dorsalis, 
and  the  latter  from  vascular  obstruction.  The  effect  is  almost  always 
bilateral,  the  nuclei  being  so  close  together  that  it  is  scarcely  possible  to  in- 
volve one  only,  although  such  isolated  result  has  occurred  in  sudden  cases 
and,  rarely,  in  slow  ones,  as  in  tabes  dorsalis  and  general  paralysis. 

3.  Infrannclear  disease  may  operate  at  various  sites — 

(a)  Within  the  medulla  oblongata  the  root  fibers  may  be  invaded  by 
a  tumor  or  by  softening. 

(&)  Outside  the  medulla  oblongata  the  fibers  may  be  damaged  by  the 
products  of  meningitis,  simple  or  syphilitic,  and  by  new  fortnations.  The 
nerve  may  be  compressed  in  its  foramen  by  outgrowth  of  bone.  Outside  the 
skull  the  nerve  is  compressed  by  tumors,  by  inflammatory  products,  or  in- 
jured by  disease  communicated  from  caries  of  the  upper  cervical  vertebrae 
and  by  penetrating  wounds.  Hence  the  spinal  accessory  and  vagus  nerves 
are  often  implicated  coincidently  and  there  is  paralysis  of  the  palate,  occa- 
sionally of  the  vocal  cords,  with  or  without  wasting  of  the  trapezius  and  ster- 
nomastoid.     The  hypoglossal  may  be  the  seat  of  neuritis. 

Symptoms. — i.  Of  Hypoglossal  Paralysis. — These  are  motor  only. 
When  there  is  supranuclear  disease  in  addition  to  the  palsy  of  the  tongue, 
there  is  hemiplegia,  but  no  wasting  of  the  tongue,  which  is  protruded  toward 
the  affected  side,  nor  change  in  electrical  reaction.  In  nuclear  disease  the 
lesion  is  apt  to  be  bilateral  palsy.  The  tongue  lies  motionless  in  the  floor  of 
the  mouth,  and  speech  and  deglutition  are  seriously  impaired.  ^Mastication 
is  interfered  with  mainly  because  the  tongue  cannot  regulate  the  position  of 
the  food,  the  proper  muscles  of  mastication  being  intact.  There  are  atrophy 
and  reaction  of  degeneration.  The  mucous  membrane  is  thrown  into  folds. 
The  condition  is  likely  to  be  a  part  of  a  bulbar  palsy.  In  infranuclear  disease 
only  one  nerve  is  aft'ected,  there  is  wasting  with  reaction  of  degeneration  and 
fibrillary  twitching.     Speech  is  not  much  impaired,  nor  is  swallowing. 

2.  Of  Spasm. — Spasm  of  the  tongue  as  an  isolated  event  is  very  rare= 


CERVICAL  PLEXUS.  103 1 

It  may  be  unilateral  or  bilateral.  It  commonly  occurs  as  a  part  of  some  other 
convulsive  affection,  as  epilepsy  or  chorea,  or  spasm  of  the  facial  muscles. 
It  may  also  occur  in  hysteria.  In  the  biting  of  the  tongue  in  epilepsy  the 
organ  is  thrust  between  the  teeth  by  spasmodic  contraction  of  the  genio- 
glossus  and  caught  by  the  jaws  through  ^  spasm  of  the  masseters.  Spasm 
of  the  tongue  occurs  in  some  forms  of  stuttering,  the  spasm  often  preceding 
the  explosive  utterance  of  words.  In  other  cases  there  are  various  protru- 
sions and  deviations  of  the  tongue,  produced  in  some  instances  by  irritation 
of  the  fifth  nerve,  variously  induced,  as  by  a  carious  tooth.  The  spasm 
may  be  clonic,  the  tongue  being  thrust  in  and  out  many  times  in  a  minute, 
at  others  more  slowly.  It  may  be  associated  with  facial  spasm.  It  may 
occur  during  sleep. 

Diagnosis. — This  is  generally  easy.  If  there  are  hemiplegia  and  palsy, 
t)ut  no  wasting  of  the  muscles  of  the  tongue,  no  reaction  of  degeneration, 
the  lesion  is  supranuclear.  If  there  is  paralysis  of  the  tongue  on  the  one 
side  and  of  the  limbs  on  the  opposite,  there  is  probably  a  unilateral  lesion  in 
the  medulla  oblongata,  involving  the  nucleus  or  the  fibers  arising  from  it. 
When  the  disease  is  on  the  surface  of  the  medulla  oblongata,  the  paralysis  is 
commonly  unilateral,  and  is  associated  with  paralysis  of  the  correspondmg 
half  of  the  palate  and  vocal  cord,  because  of  the  involvement  of  the  spinal 
accessory  nerve.     Spiller  believes  it  is  because  of  involvement  of  the  vagus. 

Prognosis. — The  prognosis  is  usually  unfavorable  because  the  lesion 
is  incurable. 

Treatment. — The  treatment  embraces  that  of  the  disease  producing 
it.  The  symptom  of  lingual  paralysis  may  be  treated  with  electricity — with 
an  electrode  in  the  shape  of  a  tongue  depressor. 

The  treatment  of  spasm  has  been  by  sedatives,  including  bromids,  by 
iodid,  and  by  electricity. 


DISEASES  OF   THE  SPINAL  NERVES   AND   BRANCHES. 

CERVICAL    PLEXUS. 

Affections  of  the  Phrenic  Nerve. — Paralysis  of  this  nerve  may  be 
the  result  of  a  lesion  in  the  anterior  horn  of  the  gray  matter  of  the  cord, 
at  the  level  of  the  third  and  fourth  cervical  nerves ;  of  a  lesion  to  these 
nerve-roots  in  disease  of  the  membranes  of  the  cord  or  of  the  vertebrae; 
or  by  compression  by  aneurysms  or  other  tumors.  Exposure  to  cold,  pro- 
ducing neuritis,  may  cause  it,  and  it  may  be  a  part  of  a  diphtheritic  palsy. 

Symptoms. — The  result  is  paralysis  of  the  diaphragin,  which  is  com- 
plete if  both  nerves  are  involved,  as  is  the  case  in  disease  of  the  cord  or  its 
membranes ;  partial  when  a  tumor  or  other  cause  affects  one  nerve.  Res- 
piration is  still  carried  on  by  the  intercostals,  and  when  the  victim  is  quiet, 
there  is  little  or  no  embarrassment,  but  examination  shows  the  abdomen  to 
be  retracted  in  inspiration  and  protruded  in  expiration.  In  other  cases,  in 
consequence  of  increased  movement^  of  the  thorax,  the  upper  abdominal 
walls  are  drawn  outward  with  inspiration — a  movement  not  to  be  mistaken 
for  movement  of  the  diaphragm.  On  exertion,  however,  there  is  dyspnea, 
which  is  also  observed  if  the  paralysis  is  sudden.     The  effect  of  paralysis 


1032  DISEASES  OF  THE  NERVOUS  SYSTEM. 

of  a  single  phrenic,  involving  one-half  of  the  diaphragm,  is  scarcely  notice- 
able. 

A  further  effect  is  to  aggravate  any  lung  affection,  as  bronchitis  or 
pneumonia.  There  is  difficulty  in  coughing  effectually,  and,  therefore,  of 
emptying  the  lungs  of  mucus,  accumulation  of  which  may  result  in  impair- 
ment of  resonance  at  the  base  of  the  lungs  in  bronchitis,  and  in  the  physical 
signs  of  edema. 

Diagnosis. — Xervous  breathing  resembles  the  breathing  of  paralysis 
of  the  diaphragm  in  that  this  muscle  is  used  very  little,  while  the  upper 
thorax  is  freely  used.  If,  however,  the  attention  of  persons  thus  breathing 
is  distracted,  or  they  are  watched  when  not  conscious  of  observation,  the 
diaphragmatic  breathing  will  at  once  become  apparent. 

The  diaphragm  does  not  move  when  it  is  inflamed  or  in  diaphragmatic 
pleurisy,  but  it  is  because  of  the  extreme  pain  which  its  motion  causes 
under  these  circumstances. 

The  diaphragmatic  palsy  from  diphtheritic  neuritis  is  only  a  part  of  the 
symptoms  due  to  such  neuritis.  In  diaphragmatic  paralysis  due  to  spinal 
disease  there  is  usually  atrophy  of  other  muscles,  together  with  other 
symptoms  of  that  disease. 

Prognosis. — This  depends  upon  that  of  the  disease  of  which  it  is  a 
part,  except  in  diphtheritic  neuritis,  in  which  it  is'the  direct  result  of  the 
disease,  and  where  the  prognosis  is  unfavorable. 

Treatment. — The  treatment  is  that  of  the  disease  of  which  it  is  the 
result.  If  there  is  neuritis,  effort  should  be  made  to  galvanize  the  nerve 
by  pressing  one  pole  outside  the  clavicular  portion  of  the  sternomastoid, 
and  the  other  pole  over  the  epigastrium  or  the  corresponding  half  of  the 
diaphragm.  Counterirritation  may  also  be  applied  in  the  triangle  of  the 
neck  outside  the  clavicular  portion  of  the  sternomastoid. 


BRACHIAL    PLEXUS. 

Of  the  Combined  Plexus. — This  may  be  affected  above  the  clavicle 
by  causes  producing  pressure  on  the  nerve-trunks — the  five  lower  cervical 
and  first  thoracic — after  they  leave  the  spine  and  before  they  unite  to  form 
the  plexus.  Such  causes  are  tumors  and  other  morbid  processes  in  the 
neck.  IMore  frequently,  causes  operate  below  the  clavicle,  of  which  the  most 
frequent  is  prolonged  luxation  of  the  humerus,  especially  under  the  coracoid 
process.  One  or  more  branches  may  be  thus  involved,  producing  a  corre- 
sponding degree  of  paralysis,  to  which  is  added  wasting  of  muscles,  with 
reaction  of  degeneration  and  trophic  changes  in  the  skin.  Fracture  of  the 
humerus  is  another  cause.  Blows  or  falls  on  the  shoulder  and  injuries  in 
the  neck  may  produce  the  same  results,  as  may  also  compression  during 
birth.  The  muscles  involved  may  be  the  deltoid,  supraspinatus,  infraspina- 
tus, biceps,  and  brachialis  anticus. 

X^euritis  of  the  brachial  plexus  also  occurs  rarely  as  a  primary  inflam- 
mation. The  result  ultimately  may  be  complete  loss  of  power  in  the  arm. 
A  still  rarer  disease  is  neuroma  of  the  plexus. 

Lesions  of  Individual  X^erves. — D/  the  Long  Thoracic  or  Posterior 
Thoracic  (Serratus  Palsy).  This  nerve  is  particularly  subject  to  pressure 
through  its  long  course  and  position,  especially  in  the  posterior  triangle  of 


BRACHIAL  PLEXUS.  1033 

the  neck.  Such  pressure  may  be  direct,  as  by  carrying  heavy  burdens  on 
the  shoulder,  or  as  the  result  of  severe  muscular  effort  in  carrying  or  wield- 
ing a  hammer,  or  long  exertion  with  the  arm  raised,  as  in  whitewashing  a 
ceiling.  The  result  may  be  a  neuritis.  Neuritis  may  also  be  caused  by  cold. 
The  same  nerve  may  be  involved  in  progressive  spinal  muscular  atrophy  or 
poliomyelitis  anterior.     From  natural  causes  it  is  more  common  in  men. 

The  result  is  a  dislocation  of  the  scapula  of  the  corresponding  side, 
which  presents  a  winged  appearance  in  consequence  of  projection  of  its 
angle  and  posterior  border,  rendered  especially  distinct  when  the  arm  is 
moved  forward,  since  the  scapula  is  no  longer  held  to  the  thorax  by  the 
serratus.  In  severe  cases  faradic  irritability  is  lost,  though  voltaic  excita- 
bility may  remain.     Severe  neuralgic  pain  may  precede  the  paralysis. 

The  course  of  serratus  palsy  is  slow,  and  the  paralysis  is  sometimes 
permanent. 

Treatment. — The  treatment  consists  in  maintaining  the  nutrition  of 
the  muscles  by  electrical  stimulation.  Counterirritation  may  be  applied 
over  the  scalenus  muscle,  because  it  is  in  it  that  the  nerve  is  most  frequently 
injured.  The  arm  should  be  kept  at  rest,  and  to  this  end  should  be  carried 
in  a  sling,  embracing  the  elbow  in  such  a  way  as  to  raise  the  shoulder. 

Nerves  of  the  Arm. — i.  Of  the  Circumiiex  Nerve. — This  rises  from 
the  posterior  cord  of  the  plexus  and  supplies  the  deltoid  and  teres  minor, 
and  the  skin  over  the  deltoid.  It  may  be  injured  by  dislocations,  blows, 
bruises,  pressure  by  a  crutch,  or  position  long  maintained,  as  during  illness. 
Neuritis  may  result  from  these  causes  and  from  cold,  or  by  extension  of 
inflammation  from  the  joint. 

There  is  loss  of  power  in  the  deltoid  and  the  arm  cannot  be  raised, 
also  a  loss  of  sensation  in  the  skin  over  the  lower  part  of  the  muscle.  The 
muscle  wastes  and  the  shoulder  becomes  flattened.  The  joint  may  relax 
and  a  space  arise  between  the  head  of  the  humerus  and  the  acromion.  On 
the  other  hand,  adhesions  may  form,  partly  trophic,  since  the  articulation 
is  supplied  by  the  sam^e  nerve.  Movement  may  be  further  impaired  by 
thickening  of  the  ligaments. 

Paralvsis  of  the  deltoid  is  to  be  distinguished  from  ankylosis,  in  which 
the  scapula  moves  with  the  arm,  which  it  does  not  do  in  palsy. 

2.  Suprascapular  Nerve. — This  nerve  rises  from  the  trunk  formed  by 
the  union  of  the  sixth,  fifth,  and  a  branch  of  the  fourth  cervical,  but  its 
own  fibers  are  derived  from  the  fifth  and  partly  from  the  fourth  cervical. 
It  is  occasionally  injured  alone  or  with  the  circumflex  in  dislocation  of  the 
humerus,  and  by  falls  on  the  shoulder,  or  by  carrying  heavy  weights.  The 
result  is  palsy  of  the  supraspinatus  and  infraspinatus  muscles.  The  first  is 
of  little  significance,  but  the  latter  causes  a  defect  of  rotation  outward  of 
the  humerus,  interfering  with  many  movements,  of  which  one  is  carrying 
the  hand  along  in  writing.  The  scapula  is  rotated  so  that  the  lower  angle 
is  rotated  upward  and  inward. 

3.  Mnsciilospiral  Paralysis. — The  musculospiral  nerve  arises  from  the 
posterior  cord  of  the  brachial  plexus,  and  apparently  derives  its  motor  fibers 
from  the  nerve-roots  forming  the  plexus  except  the  first  thoracic.  With 
the  branches  it  supplies  the  triceps,,  all  the  muscles  of  the  back  of  the 
forearm,  the  extensors  of  the  wrist  and  fingers,  both  the  supinators,  as  well 
as  the  skin  on  the  radial  side  of  the  back  of  the  hand,  back  of  the  thumb, 
index-finger,  and  half  of  the  middle  finger.     As  the  musculospiral  nerve  is 


1034  DISEASES  OF  THE  NERVOUS  SYSTEM. 

called  the  radial  by  the  Germans,  its  paralysis  is  described  in  German 
literature  as  radial  palsy. 

It  is  more  frequently  paralyzed  than  any  single  nerve,  because  of  its 
position — winding  around  the  head  of  the  humerus  after  it  leaves  the  plexus. 
It  is  often  bruised  by  crutches,  producing  the  so-called  "  crutch  palsy,"  by 
blows  and  fractures,  and  especially  by  pressure  when  sleeping  with  the  arm 
over  the  back  of  a  chair  or  with  the  arm  under  the  body.  Even  a  sudden 
and  violent  contraction  of  the  triceps,  as  in  pulling  on  a  tight  boot,  or  forcible 
extension  of  the  forearm  as  in  throwing  a  ball,  may  bruise  it.  More  rarely 
it  is  the  subject  of  a  neuritis  from  cold. 

In  a  lesion  of  the  nerve  high  up  all  the  muscles  previously  named  are 
involved ;  when  near  the  middle  of  the  humerus,  the  triceps  generally 
escapes.  The  supinator  longus  and  exterior  carpi  radialis  longior  usually 
are  involved,  but  escape  if  the  lesion  is  below  the  origin  of  the  branches 
supplying  them,  and  sometimes  in  partial  injury  of  the  nerve  higher  up.     A 


Fig.  130. — Wrist-drop  in  Musculospiral  Paralysis — {Leube). 

characteristic  symptom  of  extensor  palsy  is  the  "  wrist-drop,"  while  the 
inabilit}  to  supinate  is  also  striking.  Sensation  is  rarely  lost,  though  there 
may  be  tingling  without  loss  of  sensibility. 

Paralysis  of  the  musculospiral  is  to  be  distinguished  from  the  wrist- 
drop of  lead  palsy,  which  is,  however,  bilateral,  while  the  supinators  are 
unaffected  and  the  onset  is  gradual.  However,  in  lead  palsy  the  supinator 
longus  may  be  affected,  and  in  wrist-drop  from  pressure  this  muscle  may 
escape.  Bilateral  wrist-drop  is  common  in  other  forms  of  neuritis,  especially 
the  alcoholic,  but  the  gradual  mode  of  onset,  the  involvement  of  the  legs, 
and  the  sensory  symptoms  are  their  characteristics. 

The  prognosis  is  usually  favorable,  the  pressure  palsv  disappearing  in 
a  short  time,  while  recovery  is  the  rule  even  when  delayed. 

Erb's  rules  as  to  prognosis  apply  as  follows :  If  both  faradic  and 
galvanic  irritability  are  maintained,  recovery  may  be  expected  in  from  four- 
teen to  twenty  days ;  if  these  are  lessened  for  the  nerve  and  increased  for  the 
muscle,  while  An  C    >  Ca  C,  with  contraction  sluggish,  recovery  may  take 


BRACHIAL  PLEXUS.  1035 

place  in  from  four  to  six  weeks,  sometimes  in  from  eight  to  ten  weeks. 
When  there  is  evidence  of  degeneration  of  the  nerve,  the  prognosis  is  more 
unfavorable,  so  that  recovery  may  be  delayed  for  from  two  to  fifteen 
months. 

4.  Ulnar  Nerve. — This  comes  through  the  inner  cord  of  the  plexus 
from  the  last  cervical  and  first  thoracic.  It  is  the  first  of  all  the  brachial 
nerves  to  be  affected  by  disease  ascending  from  the  thoracic  to  the  cervical 
part  of  the  cord.  It  supplies  the  ulnar  flexor  of  the  wrist,  the  ulnar  half 
of  the  deep  flexor  of  the  fingers,  the  muscles  of  the  little  finger,  the 
interossei,  two  of  the  lumbricales,  the  adductor,  and  the  inner  head  of  the 
short  flexor  of  the  thumb.  Its  sensory  portion  supplies  the  ulnar  side  of 
the  hand,  back  and  front, — more  on  the  back, — two  fingers  and  a  half,  with 
one  finger  and  a  half  on  the  front,  although  the  distribution  is  not  in- 
variable. 

The  course  of  the  nerve,  superficial  behind  the  elbow  and  at  the  wrist, 
makes  it  vulnerable.  It  may  be  injured  in  wounds  of  the  forearm  and  about 
the  elbow,  in  dislocations  and  fractures  about  the  shoulder  and  elbow,  and 


Fig.  131. — Position  of  Wrist,  Hand,  and  Fingers  in  Ulnar  Paralysis — {Leube). 

continued  flexion  of  the  elbow.  Neuritis  is  a  possible  cause.  The  most 
common  cause  is  probably  a  blow  upon  the  arm. 

The  hand  moves  toward  the  radial  side  because  of  paralysis  of  the  ulnar 
flexor,  and  adduction  of  the  thumb  is  impossible,  the  first  phalanges  can- 
not be  extended,  and  in  long-standing  cases  the  "  claw-hand  "  may  be 
produced,  consisting  in  overextension  of  the  first  phalanges  and  flexion  of 
the  others.  There  may  be  wasting  of  the  muscles  supplied  by  the  nerve. 
There  is  loss  of  sensation  in  the  sensory  distribution. 

A  similar  condition  of  the  ulnar  nerve  may  be  produced  by  lesion  of 
the  lower  cervical  portion  of  the  cord. 

5.  Median  Nerve.— Its  motor  fibers  arise  from  all  the  cervical  roots 
that  enter  the  brachial  plexus.  They  supply  the  pronators,  the  radial  flexor 
of  the  wrist,  flexors  of  the  fingers, — except  the  ulnar  half  of  the  deep 
flexor, — the  muscles  that  abduct  and  flex  the  thumb,  and  two  radial  lumbri- 
cales. The  sensory  fibers  supply  thQ  radial  side  of  the  palm  and  the  front 
of  the  thumb,  the  first  two  fingers,  half  of  the  third  finger,  and  the  dorsal 
surface  of  the  same  fingers. 

Isolated  palsy  of  this  nerve  is  not  frequent,  but  it  may  be  caused  by 


1036  DISEASES  OF  THE  NERVOUS  SYSTEM. 

wounds  or  fractures  of  the  forearm,  rarely  from  injuries  of  the  upper  arm. 
There  may  be  neuritis  from  compression. 

The  wrist  can  only  be  flexed  toward  the  ulnar  side,  and  the  thumb  is 
in  a  state  of  persistent  extension  and  cannot  be  opposed  to  the  tips  of  the 
fingers.  Pronation  is  impossible  beyond  the  midposition  to  which  the 
supinator  can  bring  the  forearm ;  an  attempt  is  made  to  supplement  this  by 
rotating  the  humerus  inward  and  separating  the  elbow  from  the  side.  The 
second  phalanges  cannot  be  flexed  on  the  first,  nor  the  distal  phalanges  of 
the  first  and  second  fingers,  while  in  the  third  and  fourth  fingers  this  action 
can  be  performed  by  the  ulnar  half  of  the  deep  flexor.  There  is  conspicuous 
wasting  of  the  thumb  muscles,  which  gives  a  characteristic  appearance. 

There  may  be  complete  or  partial  loss  of  sensibility.  If  there  is  anes- 
thesia, it  is  more  marked  on  the  palmar  surface. 

Treatment  of  Lesions  of  Nerves  of  the  Arm. — The  first  principle 
of  treatment  is  the  removal  of  the  cause,  whatever  it  may  be,  as  determined 
from  the  etiology.  If  neuritis  is  present,  it  must  be  treated.  Rest  by  sup- 
ports or  splints  may  be  necessary,  on  the  one  hand,  and  electrical  stimula- 
tion and  massage  on  the  other. 


LUMBAR  AND  SACRAL  PLEXUSES. 

The  Lumbar  Plexus. — This  is  sometimes  damaged  by  growths  in 
the  abdomen,  especially  of  the  lymph  glands,  by  inflammatory  process,  by 
psoas  abscess,  and  by  diseases  of  the  bones  and  vertebrse  affecting  the 
nerve-roots.  The  obturator  nerve  may  be  injured  during  parturition;  the 
anterior  crural  nerve  by  the  same  cause,  by  wounds  of  the  groin  or  thigh, 
by  dislocation  of  the  hip,  and  sometimes  by  growths  about  the  spine. 

Symptoms. — In  paralysis  of  the  obturator,  adduction  of  the  thigh 
and  crossing  of  the  legs  are  impossible,  while  outward  rotation  is  also 
deranged. 

In  paralysis  of  the  anterior  crural  extension  of  the  knee  is  impossible ; 
there  is  wasting  of  muscles,  with  anesthesia  of  the  anterolateral  part  of 
the  thigh  and  of  the  inner  side  of  the  leg  and  big  toe.  There  may  be  pain 
in  the  area  of  distribution. 

Paralysis  of  the  superior  gluteal  nerve,  which  is  rare  in  the  isolated  form, 
causes  loss  of  the  power  of  abduction  and  circumduction  of  the  thigh  from 
paralysis  of  the  gluteus  medius  and  minimus. 

The  Sacral  Plexus. — This  suffers  from  compression  by  growths  in 
the  pelvis,  pelvic  inflammations,  and  compression  during  labor.  In  addi- 
tion to  spontaneous  neuritis,  there  may  also  be  a  neuritis  ascending  to  it 
from  the  sciatic  nerve.  The  sciatic  may  be  affected  by  wounds,  dislocation 
of  the  hip,  disease  of  the  bone,  and  morbid  growths.  It  is  also  occasion- 
ally the  seat  of  neuroma. 

The  result  of  lesions  of  the  sciatic  varies  with  its  seat.  If  near  the 
sciatic  notch,  there  is  paralysis  of  the  flexors  of  the  leg  and  all  the  muscles 
below  the  knee,  while  injury  below  the  middle  of  the  thigh  involves  only 
the  latter  muscles,  the  flexors  of  the  legs  escaping.  There  is  anesthesia 
of  the  outer  half  of  the  leg,  of  the  sole  and  greater  portion  of  the  dorsum 
of  the  foot,  but  the  leg  may  escape,  perhaps  through  the  intermediation  of 
other  nerves.  Frequently  there  is  wasting  of  the  muscles,  with  other 
trophic  symptoms.     In  lesion  of  one  sciatic  the  leg  is  fixed  in  extension  by 


LUMBAR  AND  SACRAL  PLEXUSES.  1037 

the  action  of  the  quadriceps  extensor,  and  the  patient  can  walk,  even  when 
all  the  muscles  below  the  knee  are  paralyzed,  the  foot  being  raised  by  over- 
flexion  of  the  hip. 

The  stnall  sciatic  is  implicated  only  when  the  pelvic  plexus  is  impinged 
upon,  and  it  rarely  suffers  alone.  The  effect  is  palsy  of  the  gluteus  maximus, 
with  difficulty  in  rising  from  the  sitting  poisture,  and  a  strip  of  anesthesia 
along  the  back  of  the  middle  third  of  the  thigh  and  upper  half  of  the  calf. 

Injury  to  the  external  popliteal  or  peroneal  nerve  results  in  paralysis  of 
the  tibialis  anticus,  long  extensor  of  the  toes,  peronei,  and  extensor  brevis 
digitorum.  There  results  inability  to  flex  the  ankles  or  extend  the  first 
phalanx  of  the  toes,  or  to  raise  the  foot  from  the  ground  in  walking — there 
is  foot-drop.  Talipes  equinus  ultimately  results,  and  may  be  attended  with 
persistent  flexion  of  the  first  or  proximate  phalanges  from  contraction  of  the 
unopposed  interossei.  In  walking  the  whole  leg  must  be  lifted,  and  there 
is  the  steppage-gait  of  neuritis.  In  old  cases  there  may  also  be  wasting  of 
the  anterior  tibial  and  peroneal  muscles.  There  is  also  anesthesia  in  the 
outer  half  of  the  front  of  the  leg  and  on  the  dorsum  of  the  foot. 

Lesion  of  the  internal  popliteal  produces  paralysis  of  the  popliteus,  calf 
muscles,  tibialis  posticus,  long  flexors  of  the  toes,  and  muscles  of  the  sole. 
The  symptoms  are  loss  of  plantar  flexion,  inability  to  extend  the  ankle-joint, 
and,  if  the  disease  is  high  enough  to  involve  the  branch  to  the  popliteus, 
loss  of  power  to  rotate  the  flexed  leg  internally ;  the  foot  cannot  be  adducted, 
nor  can  the  patient  rise  on  tiptoe.  Talipes  calcaneus  results,  and  the  toes 
may  assume  a  claw-like  position  from  secondary  contraction,  due  to  over- 
extension of  the  proximal  and  flexion  of  the  second  and  third  phalanges. 
There  is  also  loss  of  sensation  on  the  outer  lov/er  part  of  the  back  of  the  leg 
and  on  the  sole  of  the  foot. 

Treatment. — The  treatment  of  lesions  of  the  nerves  of  the  legs  is 
similar  to  that  of  lesions  of  nerves  of  the  arms.  Secondary  contractures  are 
to  be  guarded  against,  being  favored  by  position.  Fatigue  and  exposure  to 
cold  should  be  avoided,  as  they  favor  fresh  attacks  of  neuritis. 


I038  DISEASES  OF  THE  NERVOUS  SYSTEM. 


DISEASES  OF  THE    MEMBRANES  OF  THE  BRAIN. 

Although,  anatomically  considered,  the  brain  is  enveloped  by  three 
membranes, — ^the  tough  dura  mater,  the  delicate  arachnoid,  and  the  highly 
vascular  pia  mater, — the  diseases  of  the  membranes  are  practically  confined 
to  the  dura  on  the  one  hand,  and  the  arachnoid  and  pia  conjointly  on  the 
Other,  the  last  two  being  always  affected  together.  The  dura  is,  however, 
separable  into  two  layers — a  thin  internal  layer  with  its  endothelial  covering, 
and  a  looser  external  layer  which  serves  as  a  periosteum  to  the  bones;  these 
two  layers  may  be  affected  separately. 

The  term  pachymeningitis  is  applied  to  inflammation  of  the  dura  mater, 
and  leptomeningitis  to  that  of  the  pia  and  arachnoid ;  the  latter  is  commonly 
meant  when  the  word  meningitis  is  used  alone. 


PACHYMEXIXGITIS. 

Synonym. — Inflainination  of  the  Dura  Mater. 
External    Pachymeningitis. 

Etiology. — External  pachymeningitis  is  akuays  acute  and  is  commonly 
circumscribed.  It  usually  results  from  injuries  to  the  head,  especially 
fractures;  from  caries  of  the  petrous  portion  of  the  temporal  bone  itself,  the 
result  of  middle-ear  disease;  or  from  syphilitic  disease  of  the  bone  with  pus 
formation.  Sometimes  no  cause  is  discoverable.  Rarely  pus  infiltrates 
between  the  two  layers  of  the  dura  mater.  j\Iore  frequently  there  is  pus 
between  the  dura  and  the  bone.  This  may  occur  in  syphilis,  which,  too,  may 
cause  thickening  of  the  bone. 

Symptoms. — These  are  indefinite  and  are  often  obscured  by  those  of  its 
causal  disease.  They  are  pain,  delirium ;  sometimes,  but  not  always,  fever ; 
sometimes  convulsions,  and  signs  of  pressure.  Such  pressure  may  or  may 
not  be  sufficient  to  cause  paralysis  of  the  opposite  side. 

Treatm.ent. — The  treatment  is  that  of  the  causing  disease,  with  sur- 
gical interference  to  remove  pressure  and  give  vent  to  pus. 

Internal   Pachymeningitis. 

This  is  usually  chronic.  Three  forms  are  commonly  noticed — purulent, 
pseudomembranous,  and  hemorrhagic. 

Purulent  and  pseudomembranous  internal  pachymeningitis  are 
not  recognized  before  death.  The  former  may  follow  an  injury  primarilv, 
but  commonly  it  is  an  extension  from  inflammation  of  the  pia.  Pus  between 
the  dura  and  arachnoid  is  rare.  Pseudomembranous  internal  pachymenin- 
gitis may  occur  as  a  secondary  process  in  infectious  diseases. 

Internal  Hemorrhagic  Pachymeningitis. — Hemorrhagic  pachv- 
meningitis,  or  hematoma  of  the  dura  mater,  is  a  rare,  but  well-recognized 
condition ;  it  is  much  more  common  in  infirmaries  and  hospitals  connected 
with  almshouses  and  asylums.     It  occasionallv  occurs  in  children. 


PACHYMENINGITIS.  1039 

Etiology. — It  is  probably  most  frequently  a  result  of  chronic  alcoholism, 
though  it  has  been  found  in  chronic  insanity  without  association  with  alco- 
holism, especially  in  general  paralysis  of  the  insane ;  also  in  acute  fevers, 
when  it  is  associated  with  profound  anemia.  Syphilis  is  a  possible  cause ; 
in  like  manner,  tuberculosis.  It  occurs  chiefly  in  males  over  fifty,  but  also 
in  those  between  thirty  and  forty.  In  mild  degree  it  is  sometimes  found  in 
chronic  cardiac,  renal,  or  pulmonary  diseases,  when  it  is  commonly  first 
recognized  at  necropsy. 

Pathology  and  Morbid  Anatomy. — The  original  dictum  of  Virchow 
continues  for  the  most  part  to  be  held — viz.,  that  it  begins  as  a  hyperemia  in 
the  area  of  the  middle  meningeal  artery,  extending  thence  forward,  back- 
ward, and  downward.  The  arteries  become  tortuous,  dilated,  and  sur- 
rounded by  thickened  adventitia,  while  the  capillaries,  being  overfilled,  pro- 
duce a  rose-colored  flush  on  the  under  surface  of  the  membrane.  To  this 
succeeds  a  delicate  weblike  tissue  containing  wnde,  thin-walled  capillaries 
three  or  four  times  the  natural  width,  between  which  is  a  delicate  reticulum 
of  spindle  cells  extending  over  the  greater  part  of  one  or  both  hemispheres. 
This  becomes  afterward  paler  and  firmer.  Upon  this  succeeds  another  deli- 
cate vascular  layer,  succeeded  by  another  and  even  another.  From  three  to 
seven  la^yers  are  thus  superposed  until  a  product  of  from  1-8  to  1-5  inch  (3 
to  5  mm.)  in  thickness  results.  The  delicately  walled  capillaries,  however, 
easily  give  way,  causing  hemorrhages  which  vary  in  extent  from,  mere  points 
to  large  collections  of  blood — the  smaller  being  interstitial  and  the  larger  be- 
tween the  youngest  vascular  layer  and  the  next  older.  The  proportion  of 
blood  and  organized  membrane  varies  greatly,  now  one  predominating  and 
now  another.  At  times  there  seems  to  be  blood  only.  The  hemorrhage  is 
believed  by  some  to  be  the  initial  event. 

Both  products  are  subject  to  degenerative  changes,  the  effused  blood 
being  disintegrated  and  partially  absorbed,  while  the  blood-vessels  become 
obliterated  and  substituted  by  lines  of  pigment  deposit  along  their  course. 
There  may  also  be  serous  infiltration,  cystic  degeneration,  and  even  diffuse 
suppuration. 

Symptoms. — The  symptoms  are  indefinite.  There  may  be  apoplecti- 
form seizures  coincident  with  fresh  hemorrhages,  drozvsiness,  or  coma. 
Muscular  zveakness  was  very  marked  in  a  case  under  my  own  observation. 
Headache  in  the  region  involved,  vomiting,  nystagmus,  convulsions,  gener- 
ally unilateral,  and  even  hemiplegia  may  be  present,  and,  toward  the  close, 
optic  neuritis;  extensive  disease  may,  on  the  other  hand,  exist  without  any 
symptoms  whatever. 

Diagnosis. — In  the  absence  of  distinctive  symptoms  the  possibility  of 
the  presence  of  hematoma  should  be  remembered  when  there  are  other  signs 
of  general  paralysis  or  chronic  alcoholism.  If  to  such  symptoms  great  mus- 
cular weakness  is  added,  further  suspicion  is  justified. 

Treatment. — With  a  prognosis  absolutely  unfavorable  as  to  recovery, 
it  remains  only  to  treat  symptoms  as  they  arise.  Indications  of  hemorrhage 
should  be  treated  by  rest  In  bed,  elevation  of  the  head,  and  an  ice-cap. 


1040  DISEASES  OF  THE  NERVOUS  SYSTEM. 


LEPTOMENINGITIS. 

Synonym. — Inflammation  of  the  Pia  Mater. 

Of  leptomeningitis  there  may  be  an  acute  and  a  chronic  variety.  In 
addition,  other  adjective  terms  are  used  to  indicate  its  seat  and  the  nature  of 
its  cause ;  such  as  basilar  meningitis,  meningitis  of  the  convexity,  tuberculous 
meningitis,  etc.     Epidemic  meningitis  has  received  separate  consideration. 

Acute   Leptomeningitis. 

Definition. —  An  acute  inflammation  of  the  pia  and  arachnoid  mem- 
branes, attended  by  exudation  between  the  two  membranes. 

Etiology. — All  ages  are  subject  to  meningitis,  that  of  the  convexity 
being  possibly  more  frequent  in  adults  because  they  are  more  subject  to  trau- 
matic agencies  which  cause  it,  while  the  basilar  form  is  more  common  in 
children.  It  is  rather  more  frequent  in  males,  and  there  is  a  hereditary 
tendency  to  one  form — tuberculous  meningitis. 

Of  the  direct  causes — 

1.  An  eruption  of  miliary  tubercles  is  the  mast  frequent.  This  cause 
may  operate  at  all  ages,  but  is  most  active  in  children.  In  adults  it  gener- 
ally starts  from  a  recognized  tuberculosis  elsewhere ;  in  children  the  process 
is  almost  always  part  of  a  general  tuberculosis.  Tuberculous  meningitis 
takes  place  generally  at  the  base  of  the  brain,  constituting  the  chief  form  of 
basilar  meningitis.   • 

2.  Adjacent  disease,  which  may  be  outside  of  the  dura  mater,  such  as 
caries,  especially  in  the  petrous  portion  of  the  temporal  bone.  Even  disease 
outside  the  skull,  like  erysipelas  or  suppurative  disease  of  the  scalp,  may  be 
a  primary  focus.  In  these  cases  it  is  usually  unilateral,  and  may  be  accom- 
panied by  thrombosis  of  the  sinuses  and  abscess ;  or  the  disease  may  result  in 
abscess  within  the  brain. 

3.  The  bacterium  or  toxin  of  the  acute  infections  diseases — pneumonia, 
ulcerative  endocarditis,  measles,  scarlet  fever,  smallpox,  typhoid  fever,  acute 
rheumatism,  and  septicemia.  Care  must,  however,  be  taken  not  to  confound 
the  simple  intense  delirium  in  some  of  these  affections  with  meningitis, 
remembering,  too,  that  the  latter  complication  is,  under  any  circumstances, 
a  rare  one.  The  toxin  of  pneumonia  is  the  most  common  cause,  and  perhaps 
after  this  that  of  smallpox.  The  inflammation  thus  caused  is  chiefly  of  the 
convexity,  except  in  septicemia?>  when  it  is  general. 

4.  Chronic  Bright's  disease  and  other  cachectic  conditions.  In  these 
the  inflammation*  is  commonly  basilar. 

5.  Sunstroke. 

6.  Mental  excitement  and  brain  work — doubtful  cause. 

7.  Rarely  in  acute  inflammation,  syphilis,  whose  product  is  also  basal. 

8.  Finally,  unknown  causes  may  produce  meningitis  of  the  convexity 
or  of  the  base.  Possibly,  as  Gowers  suggests,  organisms  otherwise  power- 
less may  become  sufficient  causes  during  ill  health.  Thus  may  be  caused 
some  undoubted  though  rare  cases  of  non-tuberculous  basilar  meningitis  of 
children — leptomeningitis  infantum. 

In  tuberculous  meningitis,  which  is  chiefly  basilar,  the  eruption  of 
tubercles  precedes  the  inflammation.     There  may  even  be  tuberculosis  of  the 


LEPTOMEXIXGITIS.  1041 

pia  without  inflammation.  In  tubercular  meningitis  the  inflammation  is 
never  actually  purulent,  though  the  lymph  has  often  the  appearance  of  pus. 
The  tubercles  are  most  abundant  about  the  optic  chiasm,  over  the  pons,  and 
in  the  fissure  of  Sylvius,  but  the  cortex  is  often  affected.  xA.ccording  to  Dr. 
Spiller's  experience  the  brain  cortex  has  contained  more  tubercles  than  were 
found  at  the  base. 

Morbid  Anatomy. — The  early  results  of  leptomeningitis  are  the  same 
in  all  varieties.  They  consist,  first,  in  a  hyperemia  of  the  capillaries  produc- 
ing a  diffuse  pinkish  tinge.  The  next  visible  changes  are  a  turbidity  and  an 
opacity  of  the  arachnoid  which  extend  to  the  pia,  where  opacity  is  especially 
distinct  along  the  blood-vessels,  consisting,  in  fact,  in  an  infiltration  of  the 
lymph  spaces  and  h-mphatic  sheaths  with  leukocytes.  As  the  cellular 
accumulation  increases  the  exudate  beneath  the  arachnoid  assumes  a  yel- 
lowish-white, creamy  appearance.  The  subarachnoid  fluid  increases,  consti- 
tuting hydrocephalus  extenius.  In  suppurative  cases  it  becomes  pus,  which 
forms  a  greenish-yellow  layer  at  the  convexity  or  base,  or  both. 

Ventricular  effusion  is  present  in  the  majority  of  instances, — about  four 
out  of  five, — constituting  hydrocephalus  interuus,  generally  associated  with 
closure  of  the  opening  of  the  fourth  ventricle.  The  effusion  is  usually 
limited  to  a  few  ounces,  but  it  may  be  large  in  quantity,  distending  the  ven- 
tricles and  compressing  the  cortex.  The  walls  of  the  ventricles  and  the 
choroid  plexuses  may  be  inflamed,  and  the  ventricular  eft'usion  may  be  the 
result  of  such  inflammation. 

In  all  varieties  of  meningitis,  and  especially  in  the  tuberculous,  the  super- 
ficial layer  of  the  cortex  is  also  involved,  being  at  least  hyperemic,  and  some- 
times softened ;  it  may  also  be  the  seat  of  punctiform  hemorrhages,  consti- 
tuting red  softening.  This  is  especially  prone  to  occur  in  tuberculous  menin- 
gitis, because  of  the  extension  of  the  tuberculosis  along  the  blood-vessels 
which  dip  into  the  cortex.  In  pulling  off  the  pia  these  blood-vessels  are 
dragged  with  it,  leaving  a  ragged  appearance  of  the  cortex. 

Leptomeningitis  infantum  presents  an  appearance  similar  to  that  of 
tuberculous  m.eningitis.  It  involves  chiefly  the  posterior  part  of  the  m.en- 
inges  and  cerebellum,  closing  sometimes  the  foramen  of  ]\Iagendie,  whence 
the  term  occlusive  meningitis.  It  may  also  cause  an  acute,  sometimes  puru- 
lent, hydrocephalus. 

Symptoms. — These  are  varied  and  not  always  distinctive  of  the  dift'er- 
ent  forms.  First,  it  is  important  to  remember  that  all  except  those  which 
are  peculiar  to  inflammation  of  the  base  may  be  present  in  any  of  the  serious 
infectious  fevers  without  meningitis,  especially  pneumonia,  typhoid  fever, 
and  smallpox ;  but  in  some  cases  of  typhoid  fever  the  typhoid  bacillus  has 
been  found  in  the  cerebral  membranes.  "When  secondar}-  to  these  affections, 
they  are  accompanied  by  the  symptoms  of  the  disease  to  which  they  succeed. 

Meningitis  is  usually  ushered  in  by  premonitory  symptoms,  which, 
again,  are  not  distinctive,  being  those  usual  to  acute  disease.  Perhaps  irri- 
tabilitx  is  more  constant  than  in  other  acute  diseases.  In  case  of  children, 
vomiting  with  a  slight  cause,  or  without  discoverable  cause,  is  a  symptom  of 
more  suspicious  nature.  It  is  especially  frequent  in  basilar  meningitis,  of 
w^hich  it  is  more  or  less  characteristic.  It  has  this  peculiarity,  that  it  is  not 
usually  accompanied  by  nausea  and  retching.  Generally  there  are  high  fever, 
coated  tongue,  and  constipation,  although  fever  is  not  invariable.  The  usual 
temperature  is  from  103°  to  104°  F.  (39.5°  to  40°  C),  but  it  may  reach  from 
105°  to  106°  F.  (40=5°  to  41.1°  C),  and  toward  the  close  of  fatal  cases,  108*- 
66 


I042  DISEASES  OF  THE  NERVOUS  SYSTEM. 

F.  (42.2°  C.)-  It  is  especially  apt  to  be  mild  or  absent  in  the  meningitis  of 
Bright's  disease  or  of  debilitated  children.  The  pulse  is  increased  in  fre- 
quency at  first,  but  later  may  be  slow  and  irregular. 

Of  the  symptoms  the  direct  result  of  the  disease,  pain  in  the  head  is  the 
most  constant.  Commonly  frontal,  it  may  be  general.  Its  constancy  and 
severity  are  characteristic.  Yet  it  is  subject  to  such  exacerbations  as  may 
cause  the  patient  to  cry  out,  constituting  the  hydroecphalic  cry  of  children. 
The  headache  is  invariable,  followed  sooner  or  later  by  unconsciousness. 
Delirium  is  an  early  symptom  and  soon  follows  the  headache ;  at  first  wander- 
ing, it  soon  becomes  active,  and  may  alternate  with  drowsiness  or  stupor. 

General  convulsions  are  also  another  symptom,  occurring  in  all  forms 
and  at  all  ages,  but  more  frequently  in  the  tuberculous  meningitis  of  children. 
When  the  inflammation  is  at  the  base,  rigidity  of  the  neck  with  retraction  of 
the  head  is  very  marked,  especially  when  the  inflammation  extends  down  the 
membranes  of  the  spinal  cord.  Optic  neuritis  is  another  symptom,  iisually 
late  in  occurrence, — at  the  end  of  the  first  week, — and  possibly  due  to  involve- 
ment of  the  sheath  of  the  optic  nerve  within  the  skull.  Strabismus  is  also 
common.  There  may  be  weakness  of  the  eye  muscles  and  slight  ptosis.  The 
pupils  are  usually  contracted  in  the  early  disease  from  intolerance  of  light; 
later,  they  are  dilated.  Inequality  of  the  pupil  is  even  a  more  characteristic 
symptom,  though  transient  and  variable.  It  occurs  in  connection  with  in- 
flammation of  the  convexity  as  well  as  of  the  base. 

The  facial  nerve  may  be  involved  in  basilar  cases,  producing  slight 
paralysis,  as  may  also  be  the  iifth  nerve,  producing  anesthesia  and  trophic 
changes  in  the  cornea.  On  the  other  hand,  hyperesthesic  skin  is  often 
present ;  also  hyperesthesia  of  the  special  senses,  especially  hearing  and  sight. 

S}"mptoms  in  the  limbs  may  present  themselves,  such  as  muscular 
rigidity,  unilateral  convulsions,  and  even  hemiplegia,  but  the  last  is  rare. 
When  they  occur,  they  are  late  symptoms. 

Diagnosis. — The  diagnosis  is  not  always  easy,  because  so  many  symp- 
toms may  be  simulated  by  simple  congestion  due  to  the  poison  of  the  infec- 
tious diseases.  The  basilar  symptoms  are  the  most  distinctive,  and  it  is  a 
real  help  to  know  that  a  possible  cause  is  present,  either  predisposing  or 
exciting ;  such,  for  example,  as  the  tuberculous  taint,  or  tuberculous  disease, 
or  middle-ear  disease.  Retraction  of  the  head,  so  characteristic  of  this  form,, 
may  result  from  rheumatism  of  the  muscles  of  the  back  of  the  neck.  Sir 
\\'illiam  Jenner  pointed  out  a  difference  between  the  relation  of  headache 
and  delirium  in  general  disease  and  meningitis :  In  general  disease  the  head- 
ache ceases  when  the  delirium  begins ;  in  meningitis  the  headache  continues 
and  coexists  with  the  disease.  ^Convulsions,  too,  when  present,  occur  at  the 
beginning  of  a  general  disease,  particularly  in  scarlet  fever,  while  they  occur 
late  in  meningitis.  Optic  neuritis  and  other  eye  symptoms  are  common  in 
meningitis. 

A  rapidly  growing  intracranial  tumor  often  gives  rise  to  difficulty  in  the 
diagnosis  between  it  and  meningitis.  In  tumors  which  may  be  tuberculous 
or  gliomatous,  symptoms  in  the  extremities,  such  as  weakness,  hemiplegia, 
and  convulsions,  are  manifested  only  after  the  tumor  once  begins  to  interfere 
with  function,  which  it  may  not  do  at  first ;  the  loss  of  power,  moreover, 
comes  on  gradually,  while  in  meningitis  all  these  symptoms  are  rapidly  devel- 
oped. Higher  degrees  of  optic  neuritis,  as  observed  by  the  ophthalmoscope, 
are  found  in  connection  with  tumor  rather  than  with  meningitis.  The  dura- 
tion of  the  disease  will  settle  the  question  ultimately,  as  meningitis  is  of  short 


LEPTOMENINGITIS.  1043 

duration — from  two  or  three  days  to  as  many  weeks — while  tumors  last  for 
months. 

Meningitis,  especially  tuberculous,  is  sometimes  mistaken  for  hysteria, 
but  the  almost  invariable  presence  of  fever  in  meningitis  and  its  total  absence 
in  most  cases  of  hysteria  should  prevent  error.  In  children  the  symptoms 
even  of  tuberculous  meningitis  are  sometimes  closely  simulated  in  bad 
cachectic  states,  in  which  there  is  no  meningitis  whatever.  What  is  re- 
garded as  meningitis  after  sunstroke  is  a  prolonged  state  of  mental  hebe- 
tude with  symptoms  usually  aggravated  on  slight  exposure  to  the  sun. 

Prognosis. — The  prognosis  in  leptomeningitis  is  unfavorable,  although 
not  necessarily  hopeless.  In  meningitis  of  the  convexity  recovery  is  pos- 
sible ;  in  undoubted  tuberculous  meningitis  it  is  very  rare,  and  yet  it  may 
occur.  But  I  have  so  often  known  an  erroneous  diagnosis  of  tuberculous 
meningitis  with  corresponding  prognosis  followed  by  complete  recovery  in 
children,  that  I  have  grown  very  cautious  in  making  a  prognosis.  Espe- 
cially in  general  tuberculosis  should  we  avoid  too  unfavorable  a  prognosis, 
because  mistakes  here  are  quite  frequent.  In  meningitis  from  adjacent  bone 
disease  much  depends  on  the  accessibility  of  the  bone  lesion,  but  as  this  is 
generally  difficult  of  access,  the  prognosis  is  correspondingly  serious.  This 
is  especially  the  case  in  ear  disease.  In  syphilitic  meningitis  if  the  diagnosis 
is  made  early,  chances  of  recovery  or  improvement  are  better. 

Treatment. — ^The  treatment  of  adjacent  disease  which  may  cause  the 
meningitis  is  of  the  first  importance.  Surgical  interference  should  be 
promptly  resorted  to  in  middle-ear  disease.  In  the  absence  of  such  disease 
the  treatment  is  mainly  symptomatic.  The  utmost  quiet  and  the  avoidance 
of  all  causes  of  excitement  are  paramount.  It  is  the  one  disease,  outside 
of  ophthalmia,  in  which  the  darkening  of  the  room  may  be  justified.  The 
head  should  be  raised.  Leeching  is  a  most  valuable  measure  toward  cure, 
when  possible,  and  temporary  relief  when  cure  is  impossible.  Leeches 
should  be  applied  to  the  back  of  the  ear  and  to  the  temple.  Ice  should 
be  kept  applied  to  the  head.  C ounterirritation  by  blisters  to  the  back  of 
the  neck  is  also  very  useful,  and  not  so  painful  or  annoying  as  its  appear- 
ance suggests.  It  has  even  been  applied  to  the  whole  scalp  after  shaving 
the  head,  but  I  have  never  felt  justified  in  doing  this,  especially  when  the 
diagnosis  of  tuberculous  disease  is  quite  clear.  The  bowels  should  be 
kept  free. 

The  diet  should  be  liquid — milk  and  animal  broths  of  a  light  kind  are 
the  best  food.  Such  drugs  as  meet  the  symptoms  should  be  given.  Phen- 
acetin  to  relieve  pain  in  the  head  if  the  ice  and  abstraction  of  blood  do 
not  do  it.  The  temperature  is  kept  down  by  sponging  and  even  by  cool 
bathing.  Mercury  is  still  an  acknowledged  drug  in  meningitis  not  tuber- 
culous ;  and  as  chances  of  error  of  diagnosis  always  exist,  it  may  be  em- 
ployed in  any  case.  It  should  be  administered  to  the  production  of  slight 
salivation,  preferably  by  inunction  because  the  effect  is  more  rapidly  pro- 
duced.    The  mercurial  ointment  should  be  used. 

Chronic  Leptomeningitis. 

Etiology   and    Morbid  Anatomy. — This    comparatively   rare    disease 

affects  chiefly  the  convexity  of  the  brain,  and  is  the  result  of  alcoholism, 
syphilis,  or  tuberculosis. 

In  milder  degrees,  seen  in  alcoholics,  the  pia  arachnoid  is  opaque,  as 


1044  DISEASES  OF  THE  NERVOUS  SYSTEM. 

seen  over  the  sulci,  the  opacity  and  thickening  being  more  marked  along 
the  borders  of  the  blood-vessels.  In  syphilis  there  are  often  foci  or  thick- 
ened patches,  thickest  in  the  center  and  receding  toward  the  edges.  These 
may  reach  dimensions  to  justify  the  term  gummy  outgrov^^th  or  tumor. 
The  blood-vessels  are  the  seat  of  endarteritis.  In  the  tuberculous  forms 
in  children  the  base  of  the  brain  is  affected,  as  in  acute  tuberculous  menin- 
gitis. Internal  hydrocephalus  may  be  a  consequence  when  there  is  obstruc- 
tion to  the  orifice  of  the  fourth  ventricle. 

Symptoms. — These  are  those  of  the  acute  form  in  a  milder  and  more 
prolonged  manner — headache,  vomiting,  mental  symptoms,  sonjetimes  con- 
vulsions, rigidity,  retraction  of  the  head,  optic  neuritis,  more  rarely  strabis- 
mus, and  nystagmus.  They  may  last  from  a  month  to  a  year  or  more. 
Fever  is  more  frequently  absent  in  chronic  meningitis,  but  careful  observa- 
tion will  generally  find  some  elevation  of  temperature. 

Diagnosis. — It  is,  in  fact,  the  chronic  variety  of  leptomeningitis  which 
is  separated  from  tumor  with  the  greatest  difficulty.  Loss  of  motor  power 
is  more  characteristic  of  tumor.  Optic  neuritis  is  also  a  more  decided 
symptom  in  tumor,  and  goes  on  increasing,  while  it  seldom  reaches  an  ad- 
vanced stage  in  chronic  meningitis.  Other  eye  symptoms — strabismus, 
irregularity  of  pupil — are  more  distinctive  of  meningitis.  Strabismus 
occurs  in  hysteria,  but  it  is  always  convergent  and  there  is  total  absence  of 
fever,  as  shown  by  the  absence  of  elevation  of  temperature. 

Prognosis.— This  is  not  so  unfavorable  as  in  the  acute  variety.  The 
syphilitic  form  is  quite  amenable  to  treatment,  the  alcoholic  less  so ;  the 
tuberculous  is  almost  always  sooner  or  later  fatal.  Caution  in  prognosis 
is  demanded  by  occasional  error  in  diagnosis. 

Treatment. — ^The  cause  must  be  carefully  sought.  If  syphilitic,  iodids 
and  mercurials  must  be  used,  as  for  this  disease.  In  alcoholism  and  tuber- 
culosis the  symptoms  must  be  treated  by  measures  already  indicated. 


HYPEREMIA.  1045 

AFFECTIONS  OF  THE  BLOOD-VESSELS  OF  THE  BRAIN. 

HYPEREMIA. 

Synonyms. — Cerebral  Hyperemia;  Congestion  of  the  Brain. 

Definition. —  A  condition  of  tlie  brain  in  which  the  blood-vessels  are 
surcharged  with  blood.  The  congestion  is  active  as  the  result  of  increased 
flow  of  blood  to  the  brain,  as  in  alcoholic  hyperemia ;  passive  when  there  is 
obstruction  to  its  outward  movement,  as  in  constriction  of  the  vessels  in  the 
neck. 

Etiology. — The  causes  of  active  hyperemia  are  prolonged  mental 
activity,  excitement,  and  overw^ork,  pre-eminently  alcohol  and  the  causes  of 
the  acute  fevers ;  the  hypertrophy  and  overaction  of  the  heart  which  attend 
aortic  regurgitation  m.ay  be  causes.  The  causes  of  passive  congestion  are 
mainly  mechanical,  including  mitral  valvular  heart  disease,  emphysema, 
straining,  or  other  cause  obstructing  the  return  of  blood  from  the  brain, — 
such  as  tumors  pressing  on  the  vessels  of  the  neck,  or  tight  clothing. 

Morbid  Anatomy. — While,  from  the  standpoint  of  morbid  anatomy,  our 
ideas  may  be  very  definite  as  to  what  should  constitute  active  and  passive 
hyperemia,  it  cannot  be  said  that  a  definite  set  of  symptoms  is  associated 
with  either  in  the  case  of  the  brain.  In  the  first  place,  the  amount  of  blood 
in  the  brain  varies  greatly  within  the  limits  of  health,  and  while  it  might  be 
said  that  physiological  hyperemia  ends  where  abnormal  mental  phenomena 
present  themselves,  it  is  undoubtedly  true  also  that  an  overfullness  of  the 
vessels  of  the  brain  may  exist  for  some  time  without  the  symptomatic  expres- 
sion which  finally  appears.  With  the  appearance  of  such  symptoms  we  com- 
monly date  the  clinical  beginning  of  the  pathological  state  known  as  chronic 
hyperemia. 

The  dii^culties  are  increased  by  the  fact  that  in  acute  active  and  passive 
hyperemia,  at  least,  no  postmortem  evidences  of  it  remain,  the  congestion 
having  disappeared  with  death,  although  an  unusual  distinctness  of  the 
puncta  vasculosa  has  long  been  regarded  as  postmortem  evidence.  The 
difficulty  of  recognizing  such  condition  makes  this  sign  an  unreliable  one. 
In  chronic  hyperemia  there  result,  sometimes  at  least,  a  turbidity  and  even 
an  opacity  of  the  pia  mater,  wuth  slight  thickening,  together  with  elongation 
and  tortuosity  of  the  vessels,  which  are  regarded  as  characteristic. 

Symptoms. — These  are  not  very  distinctive.  Tlie  symptoms  of  active 
h3^peremia,  so  far  as  recognizable,  are  a  sense  of  fullness  or  pressure,  head- 
ache, mental  excitement,  irritability,  confusion  of  ideas,  insomnia,  vertigo, 
ringing  in  the  ears,  and.  in  extreme  cases,  hallucinations,  delirium,  and 
mania.  These  symptoms  are  increased  when  the  head  is  held  downward  or 
there  is  straining.  The  phenomena  of  so-called  "  rush  of  blood  to  the 
head  "  are  probably  the  result  of  active  hyperemia.  They  include  a  suffu- 
sion of  the  skin  of  the  face  and  head  and  a  feeling  of  warmth  in  these 
situations,  strong  beating  of  the  carotids,  headache,  tinnitus  aurium,  spots 
b-efore  the  eyes,  vertigo,  and  sometimes  actual  falling. 

It  is  not  easy  to  separate  the  phenomena  of  passive  hyperemia  from 
those  of  active  congestion.  They  are,  however,  less  pronounced  and  slower 
in  their  development. 


I046  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Treatment. — The  indications  for  treatment  are,  nevertheless,  plain. 
The  head  is  to  be  kept  raised.  Purgation  is  the  first  measure  to  be  thought 
of.  The  saline  and  hydragogue  cathartics  are  especially  indicated,  because 
of  their  depleting  effect.  The  ice-cap  should  be  used.  In  extreme  cases 
even  blood-letting  may  be  necessary,  the  efficiency  of  which  is  sometimes 
seen  in  the  relief  afforded  by  bleeding  of  the  nose.  Leeches  applied  behind 
the  ears  often  afford  magical  relief  to  the  symptoms  commonly  ascribed  to 
congestion  of  the  brain.  Wet  cups  may  be  placed  upon  the  back  of  the 
neck  for  the  same  purpose.  The  diet  should  be  spare  and  easily  assimilable, 
in  acute  cases  liquid  only. 

Of  medicines,  the  hromid  of  potassium  theoretically  fulfills  the  indica- 
tions, and  in  full  doses  of  from  fifteen  to  thirty  grains  (i  to  2  gm.)  every 
three  hours  to  adults  is  often  useful,  though  it  should  not  be  allowed  to  sub- 
stitute the  other  measures  mentioned.  Phenacetin-  and  phcnalgin  are  ad- 
mirable remedies  for  the  headache,  a  single  dose  of  ten  grains  (0.66  gm.) 
being  often  sufficient.  It  may  be  repeated  if  necessary,  or  smaller  doses  may 
be  given  more  frequently. 


ANEMIA  OF  THE  BRAIN. 

Definition. —  The  more  usual  application  of  the  term  anemia  of  the 
brain  is  to  conditions  in  which  the  quantity  of  blood  in  the  organ  is  dimin- 
ished, although  depraved  states  of  the  vital  fluid  without  loss  of  bulk  may 
also  produce  the  same  symptoms. 

Etiology. — The  causes  leading  to  this  condition  are  for  the  most  part 
those  which  withdraw  blood  from  the  brain,  but  they  include  also  such  as 
prevent  its  access.  Among  the  former  are  hemorrhages,  profuse  and  rapid ; 
bowel  fluxes,  such  as  those  of  cholera  in  adults  and  cholera  infantum  in  chil- 
dren ;  and  the  opening  of  vascular  areas  b}^  the  removal  of  pressure  caused 
by  large  tumors  or  ascitic  fluid.  Thus  is  explained  the  fainting  which  some- 
times succeeds  the  removal  of  a  large  abdominal  dropsy.  In  the  second  set 
of  causes  are  feeble  action  of  the  heart,  ligation  of  the  carotid  artery,  or  other 
obstruction  in  vessels  carrying  blood  to  the  brain.  Such  obstructions  are 
thrombi  and  emboli.  The  brain  substance  adjacent  to  the  dilated  ventricles 
in  hydrocephalus  interna  is  anemic  from  compression.  The  fainting  due  to 
sudden  emotion,  such  as  fright,  is  ascribed  to  a  withdrawal  of  blood  from  the 
brain. 

Morbid  Anatomy. — This  is  more  distinctive  than  in  hyperemia.  The 
membranes  are  pale,  the  bloctd  in  their  vessels,  except  the  larger  ones,  is 
scanty,  and  over  the  convolutions  the  vessels  are  quite  empty.  The  gray 
and  the  white  matter  are  both  pale  on  section,  and  the  puncta  vasculosa  are 
less  distinct  and  less  numerous.     The  cerebrospinal  fluid  is  increased. 

Symptoms. — Some  of  these  are  definite  and  the  direct  result  of  loss  of 
blood  to  the  brain.  Such  are  the  dizziness,  confusion  of  ideas,  flashings  of 
light,  roaring  in  the  ears,  nausea,  and  ultimate  loss  of  consciousness  and 
even  death  which  succeed  hemorrhages  or  emotion.  In  other  cases  the  skin 
is  cold  and  clammy,  and  a  cold  perspiration  starts  to  the  surface.  Other 
symptoms  are  less  distinctive.  They  are  ascribed  to  chronic  anemia,  but 
may  result  also  from  other  causes.  Such  are  mental  apathy,  disinclination 
to  work,  a  sleepy  feeling  during  the  day,  and  insomnia  at  night.  Nausea, 
headache,   tinnitus,   vertigo,   hallucinations,   and   delirium   are    also   conse- 


Anterior  communicating  a 
Antero-median  ganglionic  arteries 

Ophthalmic  a 
Internal  carotid  a 


Vertebral  a 
Posterior  spinal  a 

Anteriorspinal  a. 


Anterior  cerebral  a. 

Postero-median  ganglionic  arteries 


tero-lateral  ganglionic  arteries 
Middle  cerebral  a. 


Superior  cerebellar  a. 
nor  inferior  cerebellar  a. 


Posterior-inferior  cerebellar  a. 
Posterior  meningeal  a. 


Circle  of  Willis  and  Arteries  of  Brain. — (Deaver. 


EDEMA  OF  THE  BRAIN.  1047 

quences  more  particularly  of  lowered  composition  of  the  blood,  of  anemia, 
in  fact,  the  result  of  prolonged  illness,  like  pulmonary  consumption  and 
Bright's  disease.  The  convulsions  characteristic  of  the  latter  disease  have 
been  ascribed  to  anemia  and  also  to  edema  of  the  brain. 

The  hydrocephaloid  symptoms,  described  by  Marshall  Hall  as  the  direct 
result  of  prolonged  diarrhea  and  of  cholera  infantum  in  children,  are  re- 
garded as  results  of  anemia.  They  include  semistupor  with  eyes  unclosed, 
later,  dilated  pupils,  strabismus,  convulsions,  rigidity,  and  death. 

Treatment. — The  immediate  consequences  of  the  acute  form  of  anemia 
are  diminished  or  averted  by  placing  the  patient  on  the  flat  of  the  back  with 
the  head  low ;  by  diffusible  stimulants,  of  which  alcohol  and  ammonia  are  the 
types ;  also  cardiac  stimulants,  and  nourishing  and  easily  assimilable  foods. 
The  chronic  forms  of  brain  anemia  are  treated  by  nutritious,  easily  assimila- 
ble foods,  and  tonics,  especially  iron  and  arsenic.  In  the  hydrocephaloid  con- 
dition in  infants  alcohol  is  the  pre-eminent  remedy,  associated  with  warm 
baths  and  general  restorative  measures.    . 


EDEMA  OF  THE  BRAIN. 

Definition. — •  The  term  includes  two  conditions,  the  most  definite  and 
easily  recognizable  of  which  is  an  abnormal  accumulation  of  cerebrospinal 
fluid  within  the  pia  arachnoid.  In  the  second  condition  there  is  added  to  the 
first  an  abnormal  moistness  of  the  substance  of  the  brain. 

Etiology. — The  most  common  cause  is  mitral  stenosis,  although  any 
cause  obstructing  the  return  of  blood  from  the  brain  as  well  as  recurring 
irritative  hyperemias,  such  as  are  produced  by  alcoholism  and  the  psychoses, 
are  also  causes.  Bright's  disease  is  a  cause  of  edema  of  the  brain,  local  or 
general. 

Local  edemas  of  the  brain  are  also  caused  by  obstruction  of  single 
minuses  of  the  dura  mater,  or  compression  by  tubercular  or  other  tumors  of 
the  veins  of  the  velum  interpositum,  known  as  the  vence  Galeni. 

Morbid  Anatomy. — The  membranes  are  turbid,  their  vessels  are  dis- 
tended and  serpentine  in  their  course,  and  the  subarachnoid  space  is  filled 
with  clear  fluid.  The  substance  of  the  brain  is  anemic,  moist,  and  glisten- 
ing. In  extreme  cases  there  is  compression  of  the  cortex,  with  resulting 
flattening  of  the  convolutions  and  widening  of  the  sulci.  The  fluid  in  the 
lateral  ventricles  may  also  be  increased. 

Symptoms. — Tbese  are  ill  defined.  There  may  be  hallucinations  and 
•even  mania,  very  similar,  in  fact,  to  those  of  anemia.  Traube  and  Rosen- 
stein  ascribed  the  convulsions  of  Bright's  disease  to  edema  of  the  brain,  while 
certain  unilateral  convulsions  and  paralysis  in  connection  with  this  disease 
bave  been  assigned  to  the  same  cause.  Even  death  has  been  ascribed  to 
sudden  serous  effusions  of  this  kind,  constituting  acute  edema  of  the  pia 
mater,  or  apoplexia  serosa.  In  recent  years  much  has  been  written  on  cere- 
bral edema  under  the  name  of  meningitis  serosa. 

Treatment. — 'The  treatment  is  that  of  the  conditions  to  which  the  symp- 
toms are  secondary.  The  effects  of  cardiac  stenosis  must  be  overcome  by 
cardiac  stimulants;  Bright's  disease  ^ must  receive  appropriate  treatment. 
Thrombosis  of  the  sinuses  admits  of  no  treatment,  though  its  effects  may 
diminish  by  gradual  contraction  and  possible  liquefaction  and  removal  of  the 
thrombus.     The  psychoses  should  receive  treatment  appropriate  to  them. 


I04&  DISEASES  OF  THE  XERVOUS  SYSTEM. 


APOPLEXY. 

Definition. —  The  temi  apoplexy  is  applied  to  a  sr.dden  loss  of  con- 
sciousness and  motor  power  due  to  cerebral  hemorrhage,  or  the  sudden  plug- 
ging of  a  blood-vessel.  Laceration  of  the  brain  without  hemorrhage  pro- 
duces a  like  effect.  In  point  of  fact,  when  the  term  apoplexy  is  used,  cere- 
bral hemorrhage  is  commonly  intended. 

Unconsciousness  mav  also  be  produced  by  simple  congestion,  and  it  was 
formerly  thought  that  a  simple  serous  transudate  could  produce  similar 
symptoms  in  a  milder  form  and  of  shorter  duration;  w'hence  the  term 
'■  serous  apoplexy."  Concussion  of  the  brain,  however,  causes  similar 
symptoms. 

I.  Cerebral  Hemorrhage. 

Arterial  Distribution. — In  the  first  place  hemorrhage  is  meningeal 
or  central .  ^Meningeal  hemorrhage  may  be  outside  of  the  dura  mater,  be- 
tween it  and  the  bone,  or  between  the  dura  and  the  arachnoid,  or  within  the 
pia  arachnoid.  The  extradural  and  subdural  meningeal  hemorrhages  are 
both  traumatic,  one  variety  of  which  is  produced  during  birth,  but  those  in 
the  pia  arachnoid  are  due  to  the  causes  to  be  considered  below.  Central 
hemorrhages  may  also  burst  into  the  membranes  as  well  as  into  the  ventricles 
of  the  brain  and  in  some  instances  the  hemorrhage  is  almost  entirely  intra 
ventricular.  ^leningeal  hemorrhage  may  occur  in  the  infectious  fevers,  in 
leukemia,  and  in  anemia. 

It  is  a  rare  event  to  find  a  rupture  in  any  of  the  large  arteries  of  the 
circle  of  Willis,  although  white  patches  of  atheroma  are  often  seen  upon 
them  at  autopsy.  But  the  free  anastomosis  of  this  circle  scarcely  allows  of 
increase  of  intravascular  pressure  sufficient  to  cause  rupture.  Further,  it  is 
the  "  central "  rather  than  the  "  cortical "'  branches  of  this  circle  which  rup- 
ture, and  especially  the  central  branches  of  the  middle  cerebral,  which,  enter- 
ing the  brain  at  the  anterior  perforated  space,  pass  to  the  corpus  striatum 
and  internal  capsule.  One  of  these  is  the  so-called  artery  of  "  cerebral 
hemorrhage,"'  thus  named  by  Charcot  because  of  the  frequency  of  its  in- 
volvement. It  passes  to  the  internal  capsule  and  lenticular  nucleus,  where 
the  majority  of  the  massive  hemorrhages  of  the  brain  occur. 

Etiology. — Disease  of  the  artery  involved  is  responsible  for  the  vast 
majority  of  cerebral  hemorrhages.  Indeed,  except  in  the  case  of  traumatic 
hemorrhages  either  with  or  without  fracture  of  the  skull,  it  is  very  doubtful 
whether  hemorrhage  ever  occurs  without  such  disease.  The  simplest  form 
is  the  fatty  degeneration  and  "  erosion  "  of  the  intima,  characteristic  of  ad- 
vanced age.  Endarteritis,  however  produced,  is  perhaps  the  most  frequent 
cause.  Its  ultimate  result,  as  shown  by  Charcot  and  Bouchard  as  far  back 
as  1868,  is  the  miliary  ancnrysm  which  in  almost  every  instance  precedes  the 
rupture.  It  is  a  spindle-shaped,  rarely  lateral,  dilatation,  from  1-25  to  1-5 
inch  f  I  to  5  mm.)  in  diameter.  The  inflammatory  process  preceding  it  con- 
sists in  a  proliferation  and  degeneration  of  the  intima  cells,  followed  by 
atrophy,  which  extends  also  to  the  muscular  layer  and  the  scanty  adventitia. 
These,  yielding  to  the  intravascular  pressure  at  the  weak  points,  dilate  to 
form  the  little  aneurysm,  which  is  later  ruptured  by  some  further  increment 


APOPLEXY.  1049 

of  pressure.     Embolism  is  also  a  cause  of  endarteritis  which  may  result  in 
aneurysm. 

The  "  fatty  erosion  "  of  the  intima  which  is  the  next  most  frequent  cause 
of  vulnerability  is  favored  by  age,  by  chronic  interstitial  nephritis,  and  the 
overstrain  of  the  vessels  due  to  hypertrophy  of  the  left  ventricle,  so  often 
associated  with  that  disease  as  well  as  with  valvular  heart  disease. 

While  by  far  the  larger  majority  of  hemorrhages  are  preceded  by  miliary 
aneurysm  or  fatty  erosion, — fully  nine  out  of  ten, — there  still  remain  a  num- 
ber of  instances  in  which  careful  search  fails  to  find  anything  but  diffuse 
degeneration;  whence  the  miliary  aneurysm  and  fatty  erosion  cannot  be  re- 
garded as  indispensable  conditions.  The  infectious  fevers,  leukemia,  and 
anemia  are  also  causes  of  hemorrhage  which  is  independent  of  miliary 
aneurysm. 

Age  is  also  a  predisposing  factor,  most  ruptures  occurring  after  fifty,, 
although  apoplexy  has  occurred  under  ten ;  while  the  occupations  and  dis- 
sipations of  men  furnish  an  additional  predisposing  elements  which  accounts 
for  its  greater  frequency  in  the  male  sex.  Other  predisposing  causes  are 
those  usually  responsible  for  endarteritis — viz.,  gout,  alcohol,  syphilis, 
Bright's  disease,  the  apoplectic  habit,  as  seen  in  the  stout,  short-necked,  full- 
blooded  individual ;  and,  finally,  heredity,  Vv^hich  is,  strictly  speaking,  a 
hereditary  tendency  to  the  favoring  diseases. 

The  exciting  causes  are  such  as  temporarily  increase  intravascular 
pressure,  as  violent  exertion,  straining,  debauch  in  eating  and  drinking,  and 
mental  emotion. 

Morbid  Anatomy. — The  large  central  ganglia  in  the  neighborhood  of 
the  lateral  ventricles — /'.  e.,  the  optic  thalami,  the  caudate  and  lenticular 
nuclei,  and  the  adjacent  white  matter  of  the  internal  capsule  and  centrum 
ovale — are  the  favorite  seats  of  miliary  aneurysm  and  consequent  hemor- 
rhage. These  aneurysms  are  found  also,  but  much  more  rarely,  in  the 
smaller  branches  of  the  cortical  vessels,  in  the  pons,  cerehellum,  crura  cerebri, 
or  medulla  oblongata.  On  section  of  the  large  ganglia  these  may  be  seen 
as  small  dark  points,  as  large  as  a  pin's  head,  and  are  often  very  distinct  in 
arteries  drawn  out  of  the  substance  of  the  brain,  especially  the  anterior  per- 
forated space.  Coarser  aneurysms  are  also  found  on  the  branches  of  the 
circle  of  Willis. 

Given  a  massive  hemorrhage,  what  is  its  effect  on  the  brain  substance, 
and  what  are  the  changes  in  the  extravasated  blood?  The  former  varies 
somewhat  with  its  situation.  If  extradural,  the  dura  mater  is  torn  away 
from  the  bone  to  a  varying  extent.  If  subdural  or  beneath  the  pia  arach- 
noid, it  separates  these  membranes  from  the  brain  substance,  but  in  either 
event  the  convolutions  are  more  or  less  flattened  and  the  sulci  more  or  less 
obliterated. 

As  already  stated,  central  hemorrhage  most  frequently  occurs  in  the 
neighborhood  of  the  corpus  striatum,  through  which,  if  large,  the  blood  finds 
its  way  toward  the  outer  section  of  the  lenticular  nucleus,  pushing  inward 
the  optic  thalamus  and  bursting  into  the  lateral  ventricle  or  into  the  white 
matter  of  the  centrum  ovale.  The  pressure  exerted  is  often  such  as  to 
flatten  the  convolutions,  empty  the  parietal  veins,  and  press  the  falx  aside, 
sometimes  even  to  produce  a  sense  of  fliuctuation  over  the  membranes.  Hem.- 
orrhages  may  occur  in  the  crura  or  pons  or  fourth  ventricle,  and  also  in  the 
cerebellum,  not  infrequently  from  the  superior  cerebellar  artery.  Osier 
mentions  two  cases  of  death  in  women  of  twenty-five  from  cerebellar  hem- 


I050  DISEASES  OF  THE  NERVOUS  SYSTEM 

orrhage.  Very  rarely  hemorrhages  into  the  ventricle  may  start  in  the  cho- 
roid plexus  or  the  ventricular  walls.  Blood  in  large  quantities  may  be  poured 
out  at  the  base  of  the  brain,  and  it  may  flow  down  into  the  cord  from  a  rup- 
ture of  any  of  the  arteries  going  to  or  from  the  circle  of  Willis. 

If  the  patient  survives,  changes  take  place  in  the  extravasated  blood, 
which  promptly  coagulates  into  a  dark-red  mass.  This  almost  immedi- 
ately begins  to  contract,  permitting  often  the  return  of  a  certain  degree  of 
function  by  removing  pressure.  As  time  elapses  the  dark-red  mass  passes 
into  a  chocolate-brown  pulp,  composed  of  liquefying  blood-clot  and  disinte- 
grated nervous  matter.  The  microscope,  at  this  stage,  recognizes  numer- 
ous hematoidin  crystals  and  granular  fat-cells  which  are  probably  fatty 
by  imbibition  of  fat-granules.  The  adjacent  nervous  tissue  is  stained  yellow 
by  the  imbibed  hematoidin.  The  clot  itself  becomes  encapsulated  by  fibrin 
and  gradually  absorbed,  being  often  substituted  by  a  semitransparent  or 
completely  transparent  fluid,  forming  the  apoplectic  cyst.  If  smaller,  the 
walls  approach  and  unite,  leaving  only  a  linear  pigmented  scar.  Especially 
is  this  the  case  with  small  clots  on  the  surface  of  the  convolutions,  which  may 
leave  only  a  staining  of  the  membranes.  In  other  cases  of  abundant  cortical 
effusion,  especially  in  infants,  there  may  be  circumscribed  wasting  of  the 
convolutions  and  a  cyst  of  the  meninges  or  brain.  The  position  and  extent 
of  the  permanent  lesion  determine  the  presence  of  secondary  descending 
degeneration.  If  the  motor  cortex  or  motor  tract  is  involved,  there  may 
be  found,  in  persons  dying  some  years  after  a  stroke  of  apoplexy  with 
hemiplegia,  degeneration  in  the  pyramidal  fibers  of  the  pons  and  medulla 
oblongata,  in  the  direct  pyramidal  fibers  of  the  cord  of  the  same  side,  and  in 
the  crossed  pyramidal  fibers  of  the  opposite  side,  and  to  some  extent  in 
the  crossed  pyramidal  fibers  of  the  same  side. 

Symptoms. — Premonitory  signs  are  occasionally  present.  There  may 
be  a  feeling  of  fullness  in  the  head,  headache,  tinnitus,  vertigo,  or  numb- 
ness, tingling,  pains  in  the  limbs  on  one  side,  loss  of  memory  of  words  or 
choreiform  movements, — prehemiplegic  chorea, — possibly  due  to  miliary 
aneurysm  or  otherwise  diseased  vessels. 

With  the  bursting  of  a  vessel  of  sufficient  size  there  occurs  the  apoplec- 
tic "  stroke,"  or  apoplectic  shock.  Its  most  striking  feature  is  sudden  loss 
of  consciousness.  If  complete,  the  patient  falls  heavily  to  the  ground,  and 
there  may  be  slight  convulsive  movement,  but  it  soon  ceases.  More  rarely 
a  true  convulsion  ushers  in  the  attack.  The  patient  cannot  be  aroused,  the 
face  is  sufifused,  cyanotic — sometimes,  however,  pale;  the  breathing  is  slow, 
noisy,  stertorous,  often  attended  with  a  puffing  sound  during  expiration, 
corresponding  with  a  blowings  out  of  the  relaxed  cheek  on  the  paralyzed 
side ;  it  may  also  be  of  the  Cheyne-Stokes  type.  In  contrast  with  the 
foregoing,  the  development  of  unconsciousness  is  sometimes  much  more 
gradual,  requiring  several  hours  or  a  day,  corresponding  to  which  it  is  pre- 
sumed that  the  hemorrhage  is  slow,  constituting  the  "  ingravescent  form." 

The  second  major  symptom  of  apoplexy  is  motor  paralysis,  of  which 
bemiplegia  is  the  most  conspicuous  form.  In  most  cases  the  motor  pyr- 
amidal tract,  as  it  descends  in  the  internal  capsule,  is  either  directly  destroyed 
or  indirectly  affected.  Hence  most  patients  who  survive  the  primary  shock 
present  a  hemiplegia — paralysis  of  half  the  body  opposite  that  of  the  hem- 
orrhage, and  most  frequent  on  the  right  side.  It  is  most  noticeable  in  the 
arms  and  legs.  These  are  thoroughly  relaxed,  falling  limp  when  allowed  to 
drop,  as  the  limb  of  one  thoroughly  etherized.     More  rarely  there  is  early 


APOPLEXY.  1051 

rigidity,  especially  on  the  paralyzed  side.  This  symptom  is  possibly  more 
frequently  associated  with  hemorrhage  into  a  lateral  ventricle.  Reflex  ca- 
tion is  early  either  totally  suspended  or  only  brought  out  in  response  to  a 
deep  pin  thrust  or  severe  pinching. 

The  signs  of  hemiplegia  are  not  always  easily  elicited  at  first,  because 
a  certain  degree  of  consciousness  is  necessary  to  stimulate  attempt  at  motion, 
but  it  may  be  that  the  angle  of  the  mouth  hangs  down  lower  on  one  side, — 
the  paralyzed  side, — while  the  puffing  of  the  cheek  alluded  to  may  be 
present  on  the  same  side,  or  the  limbs  of  one  side  may  be  appreciably  more 
flaccid  than  those  of  the  other,  or  a  small  amount  of  reflex  response  may 
be  elicited  on  the  sound  side.  The  pulse  is  usually  slow,  full,  strong, 
and  tense.  The  temperature  may  be  subnormal  at  first,  rising  to  normal 
and  even  above,  and  in  basal  hemorrhage  may  be  higher.  In  a  rapidly 
fatal  case  it  remains  subnormal  to  the  end.  The  pupils  are  irregular — /.  e., 
sometimes  contracted,  at  others  dilated,  unequal.  They  respond  to  light 
either  slowly  or  not  at  all.  If  the  hem.orrhage  is  where  it  can  irritate  the 
nucleus  of  the  third  nerve,  the  pupils  are  contracted.  This  may  occur  with 
hemorrhage  into  the  pons  or  ventricles. 

In  cortical  lesions  quite  often  one  of  the  early  symptoms  in  hemiplegia 
is  conjugate  deviation  from  the  paralyzed  side  and  toward  the  side  of  lesion, 
from  which  we  have  the  expression  that  "  the  patient  looks  at  the  lesion  " ; 
that  is,  in  right  hemiplegia  the  head  and  eyes  look  toward  the  left  side. 
This  symptom  usually  passes  away,  but  sometimes  continues  for  weeks,  and, 
as  Gowers  suggests,  is  perhaps  occasionally  represented  by  nystagmus  or 
movement  in  the  direction  concerned.  Should,  however,  convulsion,  or 
spasm,  or  early  rigidity  develop,  the  head  and  eyes  are  rotated  toward  the 
paralyzed  side — l  e.,  away  from  the  side  of  lesion.  This  is  true  only  of 
cortical  lesions. 

In  lesions  of  the  pons,  on  the  other  hand,  where  the  conjugate  deviation 
may  also  occur,  the  phenomena  are  reversed, — the  patient  looks  away  from 
the  lesion,  in  the  absence  of  spasm, — but  if  the  convulsion  or  spasm  or 
rigidity  occur,  the  eyes  and  head  look  toward  the  lesion.  These  facts  are 
a  little  confusing  at  first  and  may  be  expressed  in  the  following . 

In  lesion  of  the  cortex — 

Without  spasm,  conjugate  deviation  is  toivard  the  side  of  lesion. 
With   spasm   or   convulsions   or   early   rigidity,   from   the   side   of 
lesion. 

In  lesion  of  the  pons — 

Without  spasm,  etc.,  from  lesion. 
With  spasm,  etc.,  toivard  lesion. 

This  may  be  due  to  the  fact  that  these  movements  in  health  are  inner- 
vated from  both  sides,  and  when  a  lesion  occurs  on  one  side  of  the  cere- 
brum, the  innervation  is  given  over  to  the  other  side  until  the  injured  one 
resumes  its  function,  or  until  irritation  in  it  causes  it  to  assert  or  exceed  its 
function.  In  pontile  lesions  the  destruction  occurs  possibly  below  the 
decussation  of  the  fibers  innervating  the  parts  affected  in  the  conjugate 
deviation  and  the  symptoms  are  reversed. 

The  feces  and  urine  are  passed  involuntarily,  and  the  latter  is  some- 
times slightly  albuminous.  , 

As  to  further  progress  in  a  few  cases  there  is  no  reaction  from  the  pre- 
viously described  condition.  The  symptoms  all  deepen,  the  breathing  be- 
comes rapid  and  rattling,  the  skin  cool,  the  pulse  weak  and  rapid,  and  the 


1052  DISEASES  OF  THE  NERVOUS  SYSTEM. 

patient  dies.  In  most  cases,  however,  there  is  a  certain  abatement  of  the 
symptoms,  even  if  the  patient  does  not  recover  more  fully.  Consciousness 
returns  partially  or  completely,  the  patient  can  be  aroused  by  a  loud  voice,  and 
one  can  recognize  which  side  is  paralyzed.  There  may,  at  this  time,  be  a 
febrile  movement,  due  to  cerebral  inflammation,  during  which  the  patient 
ma}-  die,  or  there  may  be  another  hemorrhage  which  carries  him  off. 

On  the  other  hand,  improvement  may  continue  to  a  further  degree. 
The  consciousness  and  intelligence  may  return  completely,  and  the  signs  of 
paralysis  may  gradually  grow  less,  more  rapidly  in  the  legs  than  in  the  arms. 
They,  however,  almost  never  disappear  completely,  the  patient  continuing 
lame  and  requiring  the  use  of  a  cane  for  the  rest  of  his  life.  In  severe  cases 
a  remnant  of  paralysis  of  the  face  can  almost  always  be  recognized,  while 
articulate  speech  may  also  continue  defective. 

Such  marked  improvement  is.  for  the  most  part,  reserved  for  the 
milder  attacks,  in  which  there  is  great  variety  as  to  degree.  In  such  the 
loss  of  consciousness  is  of  short  duration,  or  it  may  not  occur  at  all.  Such 
attacks  are  not  infrequently  ushered  in  by  nausea,  vomiting,  vertigo,  or 
sudden  headache.  The  paralytic  symptoms  may  still  be  marked,  and 
permit  a  study  rather  more  satisfactory  than  the  fulminating  cases.  In 
such  study  it  will  be  found  that  all  muscles  are  by  no  means  equally  para- 
lyzed. Thus  it  will  be  seen  that  the  lower  division  of  the  facial  nerve, 
which  supplies  the  muscles  of  the  cheek,  nose,  and  mouth,  is  plainly  para- 
lyzed ;  while  the  upper  division,  distributed  to  the  muscles  of  the  eyes  and 
forehead,  is  almost,  if  not  entirely,  intact.  The  forehead  may  be  wrinkled 
with  equal  ease  on  the  two  sides,  but  an  attempt  to  draw  up  the  nose  or 
purse  the  mouth  fails,  while  one  labionasal  fold  may  be  obliterated  and  one 
angle  of  the  mouth  lower  than  the  other.  The  natural  wrinkles  of  the 
forehead  are  commonly  less  distinct  on  the  paralyzed  side  than  on  the 
other.  This  event — the  comparative  freedom  from  paralysis  in  the  upper 
part  of  the  fall — may  be  explained  by  the  fact  that  while  both  sides 
of  the  face  receive  fibers  from  each  cerebral  hemisphere,  this  is  especially 
true  of  the  muscles  of  the  upper  part  of  the  face,  which  are  always  exercised 
bilaterally. 

The  tongue  may  not  be  paralyzed,  but  when  it  is,  if  protruded,  it  goes 
toward  the  paralyzed  side,  being  pushed  out  by  the  geniohyoglossal  muscle 
of  the  other  side,  the  innervation  being  by  the  hypoglossal  nerve.  Occa- 
sionally paralysis  of  the  tongue  contributes  to  difficulty  in  articulation. 
The  motor  branch  of  the  fifth  nerve  is  sometimes  involved  on  the  hemiplegia 
side,  and  there  is  paralysis  of  the  pterygoid,  temporal,  and  masseter  muscles. 

Of  the  trunk  muscles,  the^^trapezius  is  almost  solely  involved,  and  that 
but  slightly,  permitting  the  shoulder  to  drop  a  little,  and  the  paralyzed  side  of 
the  chest  may  expand  more  than  the  normal  side  in  ordinary  breathing,  while 
in  voluntary  deep  breathing  this  is  not  the  case.  The  reason  of  this  possibly 
may  be  found  in  the  exaggeration  of  the  reflexes  on  the  paralyzed  side; 
ordinary  breathing  being  a  reflex  action. 

Sensation  is  but  slightly  impaired  in  most  cases  of  hemiplegia  due  to 
cerebral  hemorrhage,  and  such  impairment  usually  grows  rapidly  less  as  time 
elapses.  It  is  hemianesthesia  when  anesthesia  exists,  and  it  is  on  the  side 
opposite  that  of  the  lesion.  There  may  also  be  trifling  paresthesia  at  first. 
Any  marked  disturbance  of  sensation  means  that  the  posterior  extremity  of 
the  internal  capsule  is  involved,  or,  according  to  some  authors,  it  indicates 
that  the  optic  thalamus  is  invaded.     Distinct  impairment  of  the  deep  sensi- 


APOPLEXY.  1053 

bility — the  so-called  muscular  sense  or  sense  of  position — may  indicate  a 
lesion  of  the  parietal  lobe.  There  is  sometimes  temporary  and  even  per- 
manent heniiaiiopsia,  which  implies  some  lesion  of  the  fibers  of  the  optic 
radiation  posterior  to  the  internal  capsule  or  the  posterior  tubercle  of  the 
optic  thalamus — the  pulvinar. 

The  tendon  reflexes  are  increased  in  nearly  all  cases  on  the  paralyzed 
side,  though  at  the  ver\-  beginning  of  a  severe  shock  they  may  be  abolished, 
and  if  this  abolition  of  the  reflexes  persists,  it  is  regarded  as  a  serious  sign. 
In  cases  of  any  duration  even  the  periosteal  reflexes  are  increased,  and  to  a 
less  degree  the  reflexes  of  the  sound  side  are  increased,  because  each  side 
of  the  body  is  innervated  from  both  sides  of  the  brain,  although  the  num- 
ber of  fibers  passing  to  the  same  side  of  the  body  is  considerably  less  than 
those  passing  to  the  opposite  side.  There  is  even,  at  times,  ankle  clonus, 
and,  more  rarely,  wrist  clonus.  These  events  are  explained  by  supposing  a 
suspension  of  the  inhibitory  reflex  cortical  centers,  due  to  the  cerebral  lesion. 
The  skin  reflexes,  on  the  other  hand,  are  diminished  on  the  paralyzed  side, 
remaining  normal  on  the  sound  side. 

The  rapid  improvement  mentioned  as  occurring  in  some  cases  is  usually 
confined  to  a  few  weeks  or  days,  after  which  improvement  goes  on  more 
slowly,  the  lower  extremities  recovering  more  completely  than  the  upper. 
The  gait  resulting  from  partial  recovery  is  peculiar.  Short  steps  are  taken 
by  the  affected  leg,  and  the  toe  is  dragged  more  or  less,  while  locomotion 
is  sometimes  accomplished  by  sweeping  the  leg  around  in  a  semicircle  by 
the  iliacus  and  psoas  and  the  vastus  externus,  while  it  is  held  stilt,  as  in  a 
splint,  by  the  quadriceps  extensor  muscle.  In  the  upper  limb  the  hand  mus- 
cles are  the  last  to  recover. 

Later  in  the  history  of  the  case  contractures  may  come  on  in  the  para- 
lyzed muscles,  shown  especially  in  flexures  of  the  fingers,  contracture  of  the 
forearm  in  a  position  of  pronation,  and  partial  flexion,  with  the  upper  arm 
adducted.  The  lower  extremity  is  usually  in  the  position  of  extension. 
This  contracture  is  explained  by  some,  and  notably  by  Striimpell.  as  a 
"  passive  contracture,"  the  position  assumed  being  the  natural  one  in  a  state 
of  rest.  On  the  other  hand.  Charcot  and  his  pupils  hold  that  the  contrac- 
tures are  due  to  secondary  degeneration  of  the  pyramidal  tract,  a  view  that 
is  probably  incorrect.  There  are  also  sometimes  associated  movements  of  the 
paralyzed  muscles,  to  which  Hitzig  has  called  attention.  In  these,  move- 
ments of  the  sound  side  excite  associated  movements  in  the  corresponding 
muscles  of  the  other  side,  and  attempts  to  move  the  aft'ected  side  result  in 
motion  of  corresponding  muscles  of  the  sound  side.  Sometimes,  also,  in- 
voluntary movements  of  the  lower  extremity  occur  when  the  patient  at- 
tempts to  move  the  corresponding  arm.  A  posthemiplegic  chorea,  first 
described  by  Weir  ]\Iitchell,  should  also  be  mentioned.  It  is  seen  not  so 
much  in  the  hemiplegia  resulting  from  cerebral  hemorrhage  as  from  focal 
disease  of  the  posterior  end  of  the  internal  capsule  and  optic  thalamus.  A 
form  of  hypertonia  has  recently  been  described  in  which  the  muscles  are  in 
a  state  of  exaggerated  tonicity  without  much  paralysis.  In  this  condition 
the  position  of  the  spastic  lim.bs  varies  from  time  to  time.  It  is  seen  in  some 
cases  in  which  a  cerebral  lesion  has  occurred  early  in  life. 

TropJiic  symptoms  may  appear  latcin  the  disease,  seen  at  first  in  elevation 
of  temperature,  increase  of  color  on  the  paralyzed  side  of  the  face,  swelling 
of  the  eyelids,  and  contraction  of  the  pupil ;  also  swelling  of  the  hands. 
It   is   to   be   remembered,   however,   that    slight   swelling   may   result    from 


1054  DISEASES  OF  THE  XERVOUS  SYSTEM. 

sluggish  circulation  of  blood  and  lymph,  contributed  to  by  diminished 
muscular  contraction  and  absence  of  use.  In  a  more  advanced  stage  the 
extremities  become  cooler  and  are  often  constantly  moist.  Among  these 
vasomotor  events  Charcot  has  placed  what  he  calls  acute  malignant 
decubitus — a  disposition  to  rapid  gangrene  of  the  tissues  over  the  sacrum. 
It  may  appear  in  a  few  days  after  the  shock,  beginning  with  a  circumscribed 
redness  and  formation  of  vesicles,  succeeded  by  deep-reaching  necrosis. 
While  this  is  probably,  as  Charcot  regards  it,  a  vasomotor  phenomenon,  it 
is  also  invited  by  the  usual  causes  of  gangrene  in  dorsal  decubitus,  such  as 
irritation  by  urine,  feces,  and  even  inequalities  in  the  bed-clothing.  Charcot 
also  considers  an  occasional  arthritis,  acute  or  chronic,  a  neuropathic  event. 

General  nutrition  is  well  maintained,  the  patient  even  gaining  in  flesh 
at  times.     ]\Iore  rarely  there  is  rapid  wasting. 

The  mental  condition  of  patients  who  recover  partially  from  the  eftects 
of  hemorrhage  is,  for  the  most  part,  good,  but  it  not  infrequently  happens 
that  after  a  time  mental  weakness  manifests  itself  in  loss  of  memory  and 
defective  intellection,  while  imbecility  sometimes  ultimately  supervenes. 

Diagnosis. —  The  greatest  difficulty  lies  in  the  differential  diagnosis 
between  cerebral  hemorrhage,  embolism,  and  thrombosis.  I  will,  however, 
defer  its  consideration  until  cerebral  embolism  and  thrombosis  are  treated. 

In  fulminating  cases  the  coma  is  sometimes  so  profound  that  it  is  diffi- 
cult or  impossible  to  ascertain  the  presence  of  hemiplegia.  The  symptoms 
which  aid  in  deterniining  this  have  been  mentioned  on  page  1050.  To  these 
may  be  added  the  increase  of  reflexes  on  the  affected  side,  not  present  in  an 
early  stage  of  the  paralysis,  conjugate  deviation  of  the  head  and  eyes,  and 
rigidity  of  limbs  on  one  side.  It  is  these  cases  that  are  sometimes  con- 
founded with  epilepsy,  opium  poisoning,  acute  alcoholism,  or  uremia.  In 
epilepsy  there  is  the  historv  of  previous  convulsions,  and  it  is  only  when 
this  has  been  overlooked  that  mistakes  occur.  In  opium  poisoning  the 
coma  is  slow  in  its  onset,  the  pupils  are  uniformly  contracted,  and  the  odor 
of  laudanum  is  often  on  the  breath.  But  here,  too,  the  victim  is  often  only 
discovered  after  coma  has  thoroughly  developed.  In  alcoholism  there  is 
the  odor  of  whisky,  but  many  an  innocent  person  has  been  treated  as  a 
drunkard  on  whose  brain  lay  a  clot  pressing  him  to  death.  The  young 
ambulance  or  police  surgeon  is  wise  who  defers  his  opinion.  Sometimes 
alcoholism  and  apoplexy  are  combined,  when  a  conservative  course  will  be 
no  less  astute.  The  coma  of  uremia  in  Bright's  disease  very  strongly 
simulates  that  of  apoplexy,  especially  in  the  rare  cases  of  the  latter  in 
which  there  are  convulsions.  ^The  presence  of  dropsy,  or,  in  its  absence, 
of  the  peculiar  anemia  of  Bright's  disease,  and  the  finding  of  albuminuria 
and  casts  should  suggest  this  disease,  but  albumin  may  be  found  in  hemi- 
plegia not  of  uremic  origin.  It  is  to  be  remembered,  too,  that  uremic  con- 
vulsion may  terminate  in  hemorrhage,  while  Bright's  disease  is  also  associated 
with  a  state  of  the  arteries  which  disposes  them  to  rupture.  Coma  in  a 
puerperal  woman,  associated  with  dropsy  and  albuminuria,  means  uremia. 

Prognosis. — To  have  had  a  stroke  of  paralysis  is  justly  regarded  as 
having  received  a  blow  which  marks  the  beginning  of  inevitable  decline 
in  health  and  usefulness,  though  cases  are  constantly  occurring  in  which  a 
"  slight  stroke "  is  followed  by  complete  recovery.  Some  of  these  are 
probablv  errors  of  diagnosis,  yet  all  are  not.  The  cortical  hemorrhages  are 
those  most  frequently  followed  by  recovery.  After  these  come  a  large 
number  of  cases   of  first  attack,  from  which  the  patient  recovers  quite  a 


APOPLEXY.  loss 

considerable  degree  of  health.     Second  attacks  are  prone  to  occur,  which  are 
more  severe,  and  few  survive  a  third  attack. 

The  unfavorable  cases  are  those  in  which  the  coma  is  profound  and 
lasting.  Such  are  hemorrhages  into  the  ventricles  and  co'-ona  radiata, 
which  are  rapidly  fatal.  Meningeal  hemorrhages  are  serious,  but  less  so 
when  traumatic  than  when  due  to  diseases  of  the  vessel.  Cases  attended 
by  early  and  persistent  fever  and  delirium  are  unfavorable,  as  are  also  cases 
complicating  renal  disease  and  alcoholism.  Hemorrhages  into  the  corpus 
striatum  and  internal  capsule  produce  persistent  hemiplegia,  followed  by 
contracture.  When  cases  survive  the  primary  stroke  and  improvement 
sets  in,  this  is  much  more  rapid  in  the  first  few  weeks  than  later.  In  ex- 
planation of  this  it  has  been  held  that  the  symptoms  thus  rapidly  removed 
are  indirect  focal  symptoms,  due  to  pressure  of  the  clot  on  adjacent  nervous 
tissue,  while  those  more  slow  to  yield  are  the  result  of  destructive  lesion. 

Treatment. — The  patient  should  be  promptly  placed  in  a  horizontal 
position  luith  the  head  raised.  This  is  of  the  greatest  importance,  as  it  con- 
stantly happens  that  a  patient  in  whom  consciousness  is  returning  imme- 
diately becomes  comatose  when  the  head  is  lowered.  He  should  then  he 
hied,  unless  the  pulse  be  small  and  feeble.  The  bleeding  should  be  accom- 
panied by  a  laxative,  which  should  be  given  alone  if  there  be  any  reason  why 
phlebotomy  should  not  be  practiced.  In  view  of  the  unconscious  state  of  the 
patient  the  best  laxatives  are  croton  oil  and  elaterium.  Two  drops  of  the 
former  should  be  mixed  in  a  little  glycerin  or  oil  and  carried  to  the  back 
part  of  the  throat,  or  1-4  grain  (0.0165  gm.)  of  elaterium,  dissolved  in  a 
small  quantity  of  water,  may  be  given  in  the  same  way.  The  rectum  should 
be  at  once  cleaned  out  by  an  enemia  of  warm  water.  An  ice-bag  should  be 
placed  on  the  top  of  the  head,  hot  water  and  mustard  to  the  feet,  while 
counterirritation  may  also  be  applied  to  the  back  of  the  neck,  but  it  is 
doubtful  whether  any  of  these  measures  will  accomplish  much. 

Conipression  of  the  carotid  artery,  formerly  recommended  and  practiced 
on  empirical  grounds,  has  recently  received  the  indorsement  of  Horsley  and 
Spencer,  these  experimenters  having  found  that  bleeding  from  the  lenticulo- 
striate  artery  ceases  when  the  carotid  is  compressed.  It  is  especially  in  the 
ingravescent  form  that  it  has  been  recommended.  F.  X.  Dercum  and  W.  W. 
Keen*  report  two  cases  of  ingravescent  hemorrhage  treated  by  ligation  of 
the  common  carotid,  of  which  one  recovered. 

If,  after  bleeding  and  purgation,  the  pulse  continues  bounding,  the 
tincture  of  aconite  or  zeratrum  viride  may  be  given  in  doses  of  a- minim g 
every  half-hour  tintiHhe  pulse  is  influenced.  lodid  of  potassium  can  hardly 
be  expected  to  promote  absorption  of  the  clot,  but  may  be  given  if  syphilis 
is  suspected.  It  may,  however,  facilitate  circulation  by  dilating  the  blood- 
vessels. 

The  foregoing  treatment  is  for  the  period  immediately  succeeding  hem- 
orrhage. The  remainder  of  treatment  consists  in  measures  to  protect 
the  patient  against  the  effect  of  decubitus  if  this  is  prolonged,  and  in  main- 
taining the  nutrition  of  muscles  and  protecting  against  contractures.  The 
former  is  accomplished  by  attending  to  the  secretions,  preventing  the  irri- 
tation of  the  body  by  putrid  urine  and  feces  or  foreign  substances  like 
bread-crumbs,  by  bathing  and  drying?  the  body  thoroughly,  by  frequent 
changes  of  posture.     The  latter  will  also  guard  against  pneumonia,  which 

*  "Jour,  of  Nervous  and  Mental  Disease,"  September,  1894. 


r-.  /(p 


1056  DISEASES  OF  THE  NERVOUS  SYSTEM. 

is  rather  prone  to  occur  on  the  paralyzed  side.  This  last  disease  may  also 
be  caused  by  the  inspiration  of  particles  cf  food,  liable  to  happen  if  there 
is  paralysis  of  the  muscles  of  deglutition.  The  second  indication  is  met  by 
massage,  faradization,  and  gymnastics^  but  they  should  be  deferred  for  two 
■or  three  weeks.  Warm  salt  baths  three  or  four  times  a  week  are  useful  to 
the  same  end.  Tonics  in  the  form  of  iron  in  small  doses,  quinin,  aiid 
strychnin  may  be  given,  but  alcohol  in  more  than  very  moderate  amounts  is 
contra-indicated. 

Operative  treatment  has  been  suggested  to  relieve  the  pressure  of  a 
clot  in  cerebral  hemorrhage,  and  when  it  is  certain  that  the  clot  is  menin- 
geal, especially  after  fracture,  satisfactory  results  show  that  it  is  justified. 
Careful  attention  should  be  paid  to  the  facts  mentioned  under  topical  diag- 
nosis with  a  view  to  determining  the  seat  of  hemorrhage  and  the  place  to 
trephine.     Deep  hemorrhage  is,  however,  beyond  reach. 


11.     Embolism  and  Thrombosis  of  the  Cerebral  Vessels. 

A. — Of  Cerebral  Arteries. 

Synonyms. — Cerebral  Softening;  Acute  Softening. 

Definition, — By  embolism  is  meant  the  plugging  of  an  artery  by  a  for- 
eign body  carried  into  the  circulation  from  some  point  in  the  vascular  sys- 
tem and  taken  by  the  blood  current  to  a  point  beyond  which  it  cannot  pass. 
By  thrombosis  is  meant  plugging  of  an  artery  or  vein  by  a  clot  formed  in 
situ. 

Etiology. — Nature  and  Source  of  Embolism. — The  embolus  is  most 
frequently  a  vegetation  from  a  diseased  valve  in  the  left  ventricle.  Less 
commonly  it  is  a  fragment  of  a  clot  in  the  same  ventricle  or  in  the  auricular 
appendage  or  in  an  aneurysm,  or  it  may  be  a  calcareous  particle  from  an 
atheromatous  vessel  or  a  piece  of  thrombus  from  the  same.  Even  the  terri- 
tory of  the  pulmonary  veins  may  contribute  an  embolus.  Embolism  is  very 
much  more  frequent  in  chronic  valvular  disease  than  in  primary  acute  endo- 
carditis. It  is  prone  to  occur  in  recurring  valvulitis,  and  especially  in 
mycotic  endocarditis.  Pregnancy  with  or  without  heart  disease,  the  infec- 
tious fevers,  and  blood  dyscrasise  may  be  predisposing  causes. 

The  embolus  commonly  enters  the  brain  by  the  carotid,  especially  the 
left, — which  furnishes  the  most  direct  course, — thence  through  the  internal 
carotid  to  the  left  middle  cerebral  in  the  fissure  of  Sylvius ;  more  rarely  by 
the  vertebral  and  its  posterior"  cerebral  branch. 

Thrombosis. — In  thrombosis  there  is  also  plugging  of  a  living  vessel, 
but  by  a  clot  formed  in  situ,  which  is  either  primary  at  the  point  plugged 
or  secondary  about  a  previous  embolus.  Some  favoring  cause  commonly 
exists.  This  is  most  frequently  roughening  due  to  endarteritis,  with  or 
without  atheroma.  Weak  heart  and  blood  dyscrasise  are  also  predisposing 
causes.  Ligation  of  the  carotid  artery  is  sometimes  followed  by  thrombosis 
of  cerebral  vessels. 

The  vessels  most  frequently  afTected  in  thrombosis  are  the  middle  cere- 
bral and  the  basilar,  but  the  vertebral,  the  posterior  cerebral,  and  the  branches 
of  the  circle  of  Willis  may  be  plugged,  and  the  basilar  at  its  bifurcation. 

Relative  Frequency  of  Thrombosis  and  Embolism. — Embolism  has  been 
thought  to  be  more  frequent  in  women,  but  of  79  cases  collected  by  Newton 


APOPLEXY.  1057 

Pitt  at  Guy's  Hospital,  44  were  in  men  and  35  in  women.  Thrombosis  is  con- 
sidered more  common  in  men.  Embolism  is  rare  in  children,  being  more 
frequent  at  from  twenty  to  fifty ;  thrombosis  in  older  persons,  at  from  fifty 
to  seventy. 

Morbid  Changes  Due  to  Thrombosis  and  Embolism. — Degeneration 
and  softening  of  the  brain  are  the  direct  result  of  obstruction  of  its  arteries, 
and  occur  sooner  or  later  when  the  shutting  off  of  the  blood  supply  is  suffi- 
ciently complete.  The  process  generally  begins  within  twenty-four  hours, 
and  the  minimum  time  required  to  complete  it  is  from  one  to  two  days. 
The  local  anatomical  product  of  embolism  is  much  less  distinctive  in  the 
brain  than  in  the  lungs  or  spleen.  Thus,  there  is  almost  never  a  dis- 
tinct hemorrhagic  infarct,  though  there  is  often  a  condition  resembling 
it,  the  area  cut  off  being  infiltrated  with  blood.  At  other  times  the  region 
is  paler  than  in  health  and  slightly  softer.  In  either  event  the  area  becomes 
gradually  infiltrated  with  serum  and  a  more  or  less  complete  liquefaction 
results,  presenting  a  reddish,  yellow,  or  white  color,  whence,  the  terms  red 
softening,  yellozu  softening,  or  zvhite  softening.  These  variations  are  not  the 
result  of  any  essential  difference  in  the  nature  of  the  process,  as  was  for- 
merly thought,  but  are  rather  accidental.  In  red  softening  the  softened  focus 
happens  to  contain  an  unusual  amount  of  extravasated  blood,  due  to  punc- 
tiform  hemorrhage  or  capillary  apoplexy.  This  blood  melts  away  and  stains 
the  softened  mass.  In  yellow  softening  the  proportion  of  fatty  degener- 
ated cells  is  larger,  and  it  is  found,  therefore,  chiefly  in  the  cortex,  where 
cells  prevail.  In  white  softening  there  are  few  or  no  cellular  elements, 
hence  the  white  softening  is  found  in  the  white  or  fibrous  nervous  matter. 
It  is  most  characteristically  seen  about  tumors  and  abscesses.  As  the  gray 
matter  of  the  cortex  is  also  the  most  vascular  part  of  the  brain,  it  is  here 
also  that  we  find  red  softening.  Certain  superficial  yellow  spots  known 
as  plaques  jaunes  are  found  at  times  on  the  surface  of  the  cortex  in  old  per- 
sons. They  are  sharply  circumscribed,  measure  from  2  to  4  centimeters 
(.8  to  1.6  inches),  are  niade  up  of  a  yellow,  turbid  material  sometimes 
crossed  by  trabeculae,  and  represent  fatty  degeneration  of  peripheral  corti- 
cal arteries. 

Minutelv  examined,  the  softened  areas  consist  of  fatty  granules  and  oil 
drops,  myelin  drops,  fragments  of  swollen  nerve-fibers,  fatty  granular  cells 
representing  fatty  neuroglia  and  nen-e-cells,  or  leukocytes  and  neuroglia 
cells,  and  perhaps  endothelial  cells  which  have  imbibed  the  oil  drops,  arising 
probablv  from  disintegrated  nervous  matter.  In  the  yellow  softening  these 
constitute  the  sum  of  altered  materials.  In  red  softening  there  are  added 
in  the  early  stages  blood-discs,  later  pigment  granules  or  hematoidin  crys- 
tals, or  there  is  general  staining  by  dissolved  hemoglobin.  In  the  white  sof- 
tening the  fragments  of  nerve-fibers  together  with  myelin  drops  make  up  the 
chief  bulk,  as  already  stated.  If  collateral  compensatory  circulation  is  set  up 
within  two  days,  the  destruction  may  not  go  so  far,  and  the  nervous  elements 
may  resume  their  function ;  or  if  this  does  not  occur  and  the  patient  lives,  the 
dead  and  disintegrated  tissue  may  be  gradually  absorbed  and  eventually  be 
replaced  by  a  cyst,  while  a  minute  focus  of  softening  may  be  replaced  by 
indurated  cicatricial  tissue.  If  the  embolus  is  derived  from  an  infective 
focus,  as  ulcerative  endocarditis,  an  abscess  may  result. 

Symptoms. — Xeither  thrombosis  nor  embolism  of  the  cerebral 
arteries  is  always  followed  by  recognizable  symptoms.  All  the  large  arteries 
of  the  base  and  the  smaller  arteries   of  the  surfac-e  anastomose  so  freely 

67 


I058  DISEASES  OF  THE  NERVOUS  SYSTEM. 

that  the  effects  of  obstruction  are  promptly  equaUzed.  Nay,  more ;  it  ia 
not  unusual  to  find  at  the  necropsies  of  elderly  persons  yellow  spots  of 
fattv  degeneration,  the  plaques  jauncs  referred  to,  scattered  over  the  convo- 
lutions where  nothing  was  suspected  before  death.  ^Moreover,  softening 
may  take  place  in  the  "  silent  regions  "  without  exciting  suspicion.  Very 
different  is  it  with  obstruction  of  the  middle  cerebral  artery — the  artery  of 
the  fissure  of  Sylvius. 

The  clinical  aspect  dift'ers,  however,  according  as  this  vessel  is  plugged 
at  its  origin  or  a  little  further  on  in  its  course.  Allusion  has  already  been 
made  (p.  1049)  to  the  two  separate  systems  wnrh  which  the  brain  is  supplied — 
the  "cortical  arteries''  (Duret),  passing  to  the  cortex,  and  the  "central" 
arteries,  passing  to  the  central  ganglia.  The  central  arteries  are  the  first 
given  off  bv  the  cerebral  branches  of  the  circle  of  Willis,  and  are  terminal 
arteries,  unprovided  with  anastomoses.  The  cortical  arteries  spring  from  a 
network  of  branches  of  the  cerebral  arteries  in  the  pia  mater,  in  which 
tolerably  free  communication  exists  between  the  tertiary  branches  of  the 
same  trunk,  and  even  between  the  branches  of  different  trunks.  These  two^ 
systems  of  cortex  and  center  are,  however,  altogether  independent  of  each 
other,  and  no  anastomosis  takes  place  between  them,  the  zone  at  which 
they  meet  within  the  cerebral  substance  being  situated  about  an  inch  and 
a  half  below  the  cerebral  convolutions.  In  the  case  of  the  middle  cerebral 
artery,  when  it  is  obliterated  beyond  the  point  at  which  its  "  central " 
branches  come  off,  the  superficial  parts  of  the  brain  are  alone  affected,  and 
since  its  branches  in  the  pia  mater  anastomose  with  those  of  the  anterior  and 
posterior  cerebrals,  there  may  be  no  softening  at  all,  and  but  a  temporary 
loss  of  function.  At  other  times  softening  does  occur,  the  exact  situation 
and  extent  of  which  vary  with  the  arteries  plugged.  The  blood  supply  of 
the  two  central,  the  three  frontal,  and  the  three  parietal  convolutions  being 
more  or  less  cut  off,  there  is  motor  paralysis  of  the  opposite  side  of  the 
body,  and  as  the  lesion  is  most  frequent  on  the  left  side,  there  are  right- 
sided  hemiplegia  and  aphasia ;  the  same  phenomena,  in  fact,  as  follow  hem- 
orrhage, and  which  may  be  peniianent  or  transient ;  or  the  lesion  may  be  still 
more  limited.  The  embolus  may  lodge  in  the  artery,  passing  to  the  third 
frontal  convolution,  or  in  that  of  the  ascending  frontal  or  ascending  parietal. 
It  may  lodge  in"  the  branch  passing  to  the  supramarginal  or  angular  gyrus,  or 
to  the  lo^\est  branch,  which  is  distributed  to  the  upper  convolution  of  the 
temporosphenoidal  lobe.  If,  on  the  other  hand,  the  seat  of  the  lesion  is  at 
the  point  where  the  Sylvian  artery  arises  from  the  internal  carotid,  the  cen- 
tral ganglia  are  involved,  and  there  is  almost  certain  to  be  softening  of  the 
corpus  striatum  and  optic  thalamus,  because  the  arteries  have  no  anasto- 
moses, while  the  cortex  escapes  entirely  because  its  vessels  are  distinct. 

Summary  of  the  Effects  of  Pluggitig  of  the  Cerebral  Vessels  : 

Internal  Carotid. — There  may  be  no  SA^mptoms  or  there  may  be  transient  hemi- 
plegia, or  permanent  hemiplegia  and  coma  ending  in  death  in  a  week  or  ten  daj'^s. 
In  the  first  alternative  the  circulation  is  maintained  by  the  communicating  vessels  of 
the  circle  of  Willis,  which  ordinarily  dilate  rapidly.  If  these  vessels  are  small  or 
absent,  permanent  hemiplegia  and  death  must  result,  as  a  small  part  of  the  hemi- 
sphere only  receives  blood  by  the  posterior  cerebral.  Thrombosis  is  verj-  apt  to  extend 
from  an  initial  focus  in  the  internal  carotid  to  its  branches,  and  maj^  extend  to  the 
ophthalmic  artery. 

Aiiterior  Cerebral — Because  of  the  right-angled  direction  at  which  this  vessel  is 
given  off  from  the  internal  carotid,  it  is  rarely  obstructed  b}^  embolus  unless  the 
parent  trunk  is  plugged  before  this  branch  is  given  off,  and  then  the  mischief  is  trifling" 
or  }iil.  since  branches  of  the  middle  cerebral  may  supply  much  of  the  same  territory. 

Middle  Cerebral. — This  is  the  most  frequently  plugged  of  all  cerebral  vessels.. 


APOPLEXY.  1059 

The  result  is  hemiplegia,  permanent  if  the  embolus  lodges  before  the  central  arteries 
are  given  off,  since  softening  of  the  internal  capsule  ensues  ;  if  beyond  this  point,  the 
hemiplegia  involving  the  arm  and  face  is  more  apt  to  be  transient.  If  on  the  left  side, 
there  is  aphasia,  and  there  may  also  be  impairment  of  sensibility  for  a  time.  The 
symptoms  vary  somewhat,  according  as  one  or  more  of  the  cortical  branches  are 
obstructed  by  a  plug  at  the  point  of  division  of  the  vessel  in  the  island  of  Reil.  Oc- 
clusion of  the  first  branch  may  produce  softening  of  the  third  frontal  convolution  and 
aphasia  if  on  the  left  side  ;  occlusion  of  the  second  and  third  branches,  softening  of 
the  ascending  frontal  or  ascending  parietal  convolution  and  hemiplegia,  partial  when 
the  softening  is  incomplete  ;  of  the  fourth  branch,  softening  about  the  posterior  limb 
of  the  fissure  of  Sylvius,  and  if  on  the  left  side,  sensory  aphasia — defective  perception 
of  words — with  corresponding  impairment  of  speech. 

Posterior  Cerebral. — Plugging  of  this  branch  distributed  to  the  occipital  and 
temporosphenoidal  lobes  is  a  rare  cause  of  softening.  So  far  as  ascertainable  the 
phenomena  are  mostly  sensory,  including  hemianesthesia  from  softening  of  the  teg- 
mentum of  the  crus,  or  of  the  internal  capsule,  or  hemianopsia  from  softening  of  the 
'cuneus,  though  the  same  symptoms  may  result  from  interruption  of  the  optic  tract 
when  the  cortex  is  intact.  Complete  but  temporary  less  of  sight  has  resulted  from 
plugging  of  one  posterior  cerebral  artery. 

Basilar  A rler_}'.— Total  occlusion  of  this  vessel  may  produce  bilateral  paralysis- 
from  involvement  of  both  motor  paths  in  the  pons,  with  other  symptoms  of  apoplex}'- 
of  this  center — viz.,  bulbar  palsies,  irregularity  of  heart  and  breathing,  spasm,  and. 
rarely  convulsions  ;  the  temperature  may  rise  rapidly  to  log^  F.  (42.6°  C.)  or  there- 
abouts after  an  initial  fall. 

Vertebral  Artery. — The  left  is  more  frequently  plugged,  rarely  alone,  commonly 
along  with  the  basilar.  The  nuclei  of  the  medulla  oblongata  are  affected,  and  we 
have  symptoms  of  acute  bulbar  pais}'. 

Cerebellar  Arteries. — Obstruction  of  the  isolated  cerebellar  arteries  is  rare  as 
compared  with  plugging  of  the  parent  trunk  in  the  basilar.  Even  then  the  area  of 
cerebral  softening  is  limited,  by  reason  of  collateral  anastomoses,  and  the  symptoms 
are  obscured  by  those  due  to  damage  to  the  pons  and  medulla  oblongata.  Inco-ordi- 
nation  of  movement  has  been  reported  in  one  or  two  cases  in  which  the  region  sup- 
plied by  the  posterior  cerebellar  was  cut  off. 

Diagnosis. — It  has  already  been  said  that  the  chief  difficulty  lies  in 
the  differential  diagnosis  between  cerebral  hemorrhage,  on  the  one  hand^ 
and  embolism  and  thrombosis  on  the  other.  Sometimes,  indeed,  at  first  it 
is  impossible.  Both  are  sudden.  In  embolism  the  patient  is  commonly 
younger,  but  not  always  so,  and  we  look  for  valvular  heart  disease.  Accord- 
ing to  Charles  L.  Dana,  even  in  patients  say  between  the  ages  of  thirty  and 
fifty,  when  there  is  no  heart  disease,  the  chances  are  six  to  one  in  favor  of 
hemorrhage.  An  apoplectic  seizure  after  parturition  is  apt  to  be  embolic.  In 
embolism,  too,  there  is  less  disturbance  of  temperature,  the  paralysis  is  more 
apt  to  precede  the  coma  and  convulsions  if  the  lattter  are  present ;  the  turgid 
face,  hard  pulse,  loud  breathing,  and  greater  general  disturbance  of  a  serious 
stroke  of  apoplexy  from  hemorrhage  are  wanting. 

In  thrombosis  the  difficulty  in  diagnosis  may  be  even  greater.  The 
symptoms  of  thrombosis  are  slower  in  their  development,  but  in  the 
"  ingravescent "  form  of  apoplexy,  in  which  the  hemorrhage  is  gradual, 
requiring  sometimes  a  day  or  two,  the  development  of  symptoms  is  corre- 
spondingly slow.  In  thrombosis  there  are  more  frequently  prodromata  in 
the  shape  of  slight  seizures,  quickly  recovered  from.  Such  events  occurring 
in  the  aged,  when  there  is  evident  atheroma  of  the  blood-vessels  and  weak 
heart,  point  to  thrombosis,  in  which,  too,  there  is  absence  of  stertorous 
breathing,  of  variations  in  temperature,  and  of  pupillary  disturbance.  Lesions 
in  the  pons  and  cerebellum  are  more  likely  to  be  hemorrhages. 

It  is  also  important  to  be  able  to  decide  whether  the  obstruction  is 
embolic  or  thrombotic.  In  the  former  the  onset  is  sudden,  without  pre- 
monitory symptoms ;  in  the  latter  it  is  gradual,  and  there  are  often  premon- 
itory symptoms.  In  the  former  there  may  be  convulsive  twitchings.  but 
hemiplegia  quickly  follows,  with  or  without  temporar}-  loss  of  consciousness. 
In  the  latter  the  patient  has  previously  complained  of  headache,  vertigo,  or 


io6o  DISEASES  OF  THE  NERVOUS  SYSTEM. 

tingling  in  the  fingers ;  then  paralysis  may  begin  in  one  hand  or  foot  and 
extend  slowly,  the  hemiplegia  often  remaining  partial.  Speech  may  have 
been  embarrassed  for  some  days  previous,  and  the  memory  defective.  In 
thrombosis  due  to  syphilis,  especially,  the  hemiplegia  may  come  on  gradually 
without  loss  of  consciousness.  The  same  is  true  of  the  so-called  senile 
softening,  which  is  generally  due  to  thrombosis  after  atheroma  of  the  cere- 
bral arteries.  In  a  few  cases  the  onset  is  more  sudden,  and  may  happen 
during  sleep.  The  temperature  usually  has  a  slight  initial  fall,  followed  by 
rise,  as  in  hemorrhage.  In  embolism  aphasia  is  quite  a  characteristic 
symptom,  as  it  seems  to  occur  more  frequently  on  the  left  side  than  on  the 
right. 

In  both  embolism  and  thrombosis  the  hemiplegia  tends  to  improve- 
rapidly  unless  the  vessel  obstructed  be  a  large  one  or  there  be  rupture  of  a 
collateral  branch.  It  is  true  that  acute  softening  may  terminate  fatally 
within  twenty-four  hours,  but  usually  the  patient  survives  the  onset,  and  at 
the  worst  dies  after  several  weeks,  the  phenomena  of  the  chronic  stage 
being  almost  identical  with  those  of  hemorrhage.  Spastic  symptoms  are 
also  likely  to  occur,  and  there  is  a  tendency  to  the  characteristic  mobile 
spasm. 

Prognosis. — A  patient  rarely  dies  of  a  first  attack  of  cerebral  embolism, 
unless  a  very  large  vessel  is  obstructed,  such  as  the  internal  carotid  or 
basilar,  whose  occlusion  is  fatal ;  next  in  seriousness  after  these  is  plugging 
of  the  middle  cerebral  and  vertebral,  while  obstruction  of  the  two  verte- 
brals  is  always  fatal.  Every  succeeding  attack  increases  the  danger.  Em- 
bolism is  less  serious  than  thrombosis ;  and  thrombosis  due  to  syphilitic 
disease  is  more  hopeful  than  senile  softening.  Sudden  severity  in  thrombosis 
is  serious,  and  deranged  breathing  is  an  unfavorable  symptom.  Convulsions 
may  be  a  result  of-  syphilitic  thrombosis.  When  the  embolism  is  due  to 
valvular  heart  disease,  it  is  apt  to  recur ;  when  due  to  other  causes,  not. 
Throimbosis  is  prone  to  occur,  especially  when  due  to  atheroma. 

Treatment. — Neither  thrombosis  nor  embolism  demands  blood-let- 
ting, as  does  hemorrhage.  Indeed,  it  is  strongly  contra-indicated.  Rest 
in  bed,  with  head  raised,  is  important.  If  syphilis  is  the  cause  of  throm- 
bosis, it  should  receive  the  usual  treatment — the  idodid  of  potassium  in 
ascending  doses  until  doses  of  a  dram  or  more  are  reached.  There 
is  no  treatment  for  atheroma.  Attention  should  be  paid  to  the  heart,  kid- 
neys, and  bowels.  The  heart  is  commonly  feeble,  and  digitalis  and  stro- 
phanthus  are  needed  to  keep  its  action  uniform  and  strong,  by  which  one 
condition  of  thrombosis  is  removed.  The  urine  is  scanty  and  highly  colored, 
but  the  treatment  for  the  heart  is  also  the  treatment  for  the  scanty  secretion, 
which  calls  also  for  diluents.  The  bowels  should  be  kept  freely  open  to  aid 
in  promoting  the  circulation.  The  latter  is  aided  by  nitroglycerin,  which 
may  be  given  in  doses  of  i-ioo  grain  (0.0066  gm.)  every  two  hours.  The 
iodid  of  potassium  is  useful  also  for  this  purpose.  Its  effects  are  more 
permanent  than  those  of  nitroglycerin.  From  five  to  fifteen  grains 
(0.33  to  0.99  gm.)  three  times  a  day  should  be  given. 

Moderate  stimulation  is  beneficial.  The  aromatic  spirit  of  ammonia 
and  alcohol  are  the  most  useful  for  this  purpose.  Mental  excitement  is  to 
be  especially  avoided  after  a  return  to  consciousness,  and  physical  rest 
should  be  continued.  Stimulants  are  then  best  discontinued,  or  continued 
in  great  moderation.  Care  should  be  taken  to  protect  against  the  effects  of 
decubitus. 


APOPLEXY.  y  1061 

Unfortunately  there  is  no  treatment  which  will  restore  softened  brain 
matter,  although  a  certain  amount  of  function  may  be  vicariously  assumed. 
The  same  measures  calculated  to  maintain  nutrition  and  muscular  integrity 
as  are  recommended  in  the  treatment  of  hemorrhage  should  be  taken. 

B.  Of  the  Cerebral  Sinuses  and  Veins. 

Description. — Thrombosis  chiefly  attacks  the  sinuses,  and  is  primary 
or  secondary.  Primary  thrombosis  is  the  result  of  a  state  of  the  blood  and 
circulation  ;  secondary,  a  consequence  of  disease  adjacent  to  the  sinuses.  The 
former  is  much  the  rarer,  occurring  half  as  often. 

Primary  thrombosis  is  met  in  the  longitudinal  sinus,  more  rarely  in  the 
lateral,  sometimes  in  the  cavernous.  It  is  found  associated  with  general 
malnutrition  and  prostration,  more  frequently  in  children  during  the  first 
six  months  of  life  as  the  result  of  exhausting  maladies,  especially  diarrhea. 
It  is  met  also  in  older  children.  Brayton  Ball  and  others  have  shown  its 
association  in  young  girls  with  chlorosis  and  anemia.  It  occurs  in  the  aged 
also  as  the  result  of  exhausting  disease,  like  pulmonary  tuberculosis  and 
cancer. 

Coagulation  is  favored  by  the  trabeculce  which  cross  the  cavity  of  the 
sinus,  and  by  irregularities  in  the  shape  and  lining  of  the  latter.  It  may  or 
may  not  be  associated  with  phlebitis. 

Very  little  is  known  of  thrombosis  of  the  cerebral  veins,  except  that  it 
may  occur  in  veins  of  the  convexity  as  the  result  of  meningitis,  and  from 
the  same  causes  that  produce  thrombosis  of  sinuses. 

Secondary  thrombosis  occurs  at  any  age,  and  is  the  result  of  disease 
adjacent  to  a  sinus,  commonly  caries  of  bone,  and  is  especially  frequent  as 
the  result  of  disease  of  the  internal  ear.  It  spreads  more  frequently  from 
the  posterior  wall  of  the  middle  ear,  but  also  from  the  mastoid  sinuses.  Frac- 
ture, suppurative  disease  outside  of  the  skull,  especially  erysipelas,  and 
tumor  compressing  the  sinus  may  produce  it. 

Symptoms. —  There  may  be  no  symptoms  in  prim.ary  thrombosis,  or 
there  may  be  nausea  and  vomiting,  headache,  and  hebetude  increasing  to 
coma.  Dilatation  of  the  pupils,  choked  discs,  and  paresis  have  been  re- 
ported. 

Secondary  thrombosis  is  a  septic  process.  It  is  commonly  announced 
by  a  chill,  followed  by  fever  and  occipital  pain,  succeeding  on  earache  with 
suppurative  otitis.  The  sinuses  occluded  are  those  near  the  ear,  but  the 
blood  escapes  by  other  channels,  and  the  brain  substance  is  not  seriously 
invaded.  The  symptoms  of  meningitis  are  soon  added.  They  are  head- 
ache, somnolence,  and  stupor,  or  there  may  be  active  delirium  and  convul- 
sions, rigidity,  or  optic  neuritis,  all  the  results  of  meningitis.  Death  is 
most  frequently  due  to  suppurative  pulmonary  pyemia,  as  was  the  case  in 
70  per  cent,  of  Newton  Pitt's  cases,  and  the  appearance  of  the  latter  disease 
under  the  circumstances  is  almost  conclusive  evidence  of  previous  sinus 
thrombosis. 

Prognosis. —  This  is  always  grave.  The  average  duration  of  the  sec- 
ondary' disease  is  about  three  weeks,  and  its  termination  is  almost  always 
fatal.  Pitt  reports  a  case  of  recovery'  in  a  boy  of  ten  who  had  otorrhea 
for  years,  after  removal  of  a  foul  clot  from  the  lateral  sinus  by  opera- 
tion. 

Treatment.— For   primar}'   thrombosis   there    is    no   treatment   except 


io62  DISEASES  OF  THE  NERVOUS  SYSTEM. 

that  for  its  cause.  For  secondary,  operative  treatment  is  indicated  by  tre- 
phining or  other  measures  to  give  exit  to  pus.  Quinin  and  restorative 
measures  are  indicated.  Gowers  lays  particular  stress  on  the  use  of  the 
tincture  of  the  chlorid  of  iron. 


INTRACRANIAL  ANEURYSM. 

Definition. —  Intracranial  aneurysms  are  of  two  kinds,  miliary  and  those 
of  larger  size.  The  former  have  been  considered  when  treating  of  hemor- 
rhage. 

Distribution. — Larger  aneurysms  affect  the  larger  arteries  at  the  base 
of  the  brain  in  the  following  order: 

1.  Middle  cerebral. 

2.  Basilar. 

3.  Internal  carotid. 

4.  Anterior  cerebral. 

The  anterior  or  posterior  communicating  and  vertebral  arteries  are  also 
occasional  seats ;  the  posterior  cerebral  and  inferior  cerebellar  rarely.  Wil- 
liam Osier  found  12  of  these  aneurysms  in  800  autopsies,  and  Newton 
Pitt  19  in  1900.  The  aneurysm  varies  in  size  from  that  of  a  pea  to  that  of 
a  walnut. 

Etiology. — Intracranial  aneurysms  are  found  rather  more  frequently 
in  the  male  sex,  and  most  frequently  between  the  ages  of  from  ten  to  sixty. 
Osier  and  Pitt  each  found  one  at  the  age  of  six.  Heredity  exercises  some 
influence.  Endarteritis  and  embolism,  both  of  which  weaken  the  vessels, 
are  the  chief  causes.  The  former  may  be  syphilitic  or  simple.  The  pres- 
ence of  endocarditis  should  especially  invite  examination  for  them  at  au- 
topsies. 

Symptoms. — Death  from,  apoplexy,  owing  to  rupture  of  the  aneurysm, 
may  be  the  first  intimation.  Not  only  are  there  often  no  symptoms,  but 
when  present  they  are  vague.  They  may  be  those  of  tumor  at  the  base  of 
the  brain,  including  optic  neuritis  and  paralysis  of  the  third  and  other  cra- 
nial nerves.  There  are  rarely  convulsions.  There  may  be  headache,  vertigo, 
nausea,  hebetude,  and  even  coma,  hemiplegia,  and  hemianopsia.  A  murmur 
may  be  heard  on  auscultating  the  skull,  while  occasionally  the  patient 
himself  is  conscious  of  a  murmur  or  recognizes  the  pulsations  in  his 
head. 

Diagnosis.— This  is  usually  impossible,  but  the  foregoing  symptoms, 
associated  with  endocarditis,  may  excite  suspicion.  Syphilitic  disease  being 
as  likely  to  produce  tumor,  the  history  of  its  presence  gives  no  assistance  in 
diagnosis. 

Treatment. — None  exists  which  can  be  specifically  directed  to  the  dis- 
ease. 

THE  CEREBRAL  PALSIES  OF  CHILDREN. 

Definition. — Referring  to  the  division  already  made  of  the  motor 
path  into  an  upper  cortico-spinal  segment,  extending  from  the  cells  of  the 
cortex  to  the  gray  matter  of  the  cord,  and  a  lower  spino-muscular,  extend- 
ing from  the  ganglia  of  the  anterior  horns  to  the  motorial  end-plates,  the 
diseases  now  to  be  considered  have  their  anatomical  seat  in  the  former,  and 


THE  CEREBRAL  PALSIES  OF  CHILDREN.  1063 

are  characterized  by  paralysis,  with  spasm  or  disordered  movements,  exag- 
g-erated  reflexes,  normal  electrical  reactions,  without  rapid  or  extreme  wast- 
ing. They  result  from  a  destructive  lesion  of  the  motor  centers,  or  of  the 
pyramidal  tract  in  the  hemisphere,  internal  capsule,  crus,  or  pons.  They 
are  hemiplegic,  diplegic,  or  paraplegic. 

Spastic  Infantile  Hemiplegia. 

Synonyms. — Hemiplegia  spastica  cerebralis  (Heine)  ;  Hemiplegia  spastica 
infantilis  (Bernhardt)  ;  Acute  Encephalitis  der  Kinder  (Striimpell)  ;  Die 
atrophische  Cerehrallahmung  (Henoch)  ;  Agcnese  cerebrale  (Cazau- 
vieilh)  ;  Sclerose  cerebrale  atrophic  partielle  cerebrale  (other  French 
writers). 

Historical. — In  1884  Striimpell,  in  a  paper,  "  Ueber  die  acute  Encephalitis  der 
Kinder,"  called  attention  to  the  possibility  of  encephalitis  in  children.  Numerous 
papers  on  infantile  hemiplegia  have  appeared  in  Germany,  France,  and  America, 
among  which  may  be  especially  mentioned  those  of  Gaudard,  Wallenberg,  Jules 
Simon,  Morse,  Ross,  Gowers,  Sarah  J.  McNutt,  Weir  Mitchell,  B.  Sachs,  Wharton 
■Sinkler,  H.  C.  Wood,  J.  Lewis  Smith,  and  William  Osier. 

Etiology. —  The  disease  is  somewhat  more  common  in  girls  than  in 
boys,  63  out  of  120  cases  studied  by  Osier  at  the  Nervous  Infirmary  in 
Philadelphia  being  of  this  sex.  Of  these  cases  15  were  congenital,  45  arose 
in  the  first  year,  22  in  the  second,  14  in  the  third,  i  in  the  fourth,  3  in  the 
fifty,  sixth,  and  seventh,  i  in  the  eighth,  ninth,  tenth,  and  older.  In  10 
the  age  of  onset  was  not  given.  The  hemiplegia'  was  right-sided  in  68  and 
left-sided  in  52  cases. 

Among  the  causes  may  be  mentioned  abnormal  conditions  of  the 
mother  during  pregnancy,  including  accidents,  possibly  disease,  especially 
syphilis,  in  a  few  cases  fright  or  distress,  the  effect  of  the  last  two  being 
doubtful.  Especially  frequent  causes  are  difficult  or  abnormal  labor,  in- 
jury with  forceps  producing  flexures  and  fractures  of  the  cranial  bones  dur- 
ing delivery.  After  birth  are  penetrating  wounds  of  the  head,  ligation  of 
the  common  carotid,  and  infectious  diseases,  including  whooping-cough, 
diphtheria,  scarlet-fever,  measles,  meningitis,  typhoid  fever,  vaccinia,  and 
mumps.  Previous  convulsions  may  cause  the  lesion  on  which  the  paralysis 
depends,  and  in  a  few  cases  embolism  may  be  responsible. 

Morbid  Anatomy. —  The  morbid  states  of  the  brain  found  at  autopsy 
are  mainly  sclerosis  and  porencephalia — defect  consisting  in  arrest  of  devel- 
opment of  the  brain  resulting  in  the  absence  of  convolutions  or  even  lobes, 
causing  irregular  subpial  cavities.  Em^bolism  and  thrombosis  of  vessels, 
especially  of  the  Sylvian  artery,  and  hemorrhage  into  the  ventricle  and  sub- 
stance of  the  brain,  are  found  in  a  few  cases.  The  sclerosis  involves  either 
groups  of  convolutions,  an  entire  lobe,  or  even  an  entire  hemisphere.  The 
skitrll  may  be  flattened  on  the  affected  side,  broad  and  prominent  above  the 
mastoid  processes,  sometimes  thickened.  The  dura  may  be  thickened  and 
adherent,  and  in  one  case  contained  extensive  osseous  plates.  The  arach- 
noid is  turbid  and  thickened  and  the  amount  of  cerebrospinal  fluid  is 
increased.  The  pia  mater  may  be  thickened  and  adherent,  and  drag  portions 
of  the  cortex  away  on  being  remove^,  leaving  a  roughened  surface,  while 
there  may  be  nodular  projections  of  sclerosed  tissue.  The  reduction  of 
weight  of  the  sclerosed  hemisphere  may  be  very  considerable ;  in  one  case, 
referred  to  by  Osier  in  his  monograph,  the  atrophied  hemisphere  weighed 


io64  DISEASES  OF  THE  NERVOUS  SYSTEM. 

5  1-2  ounces  ( 169  gm.)>  the  normal  being  20  ounces  (653  gm.).  The  lateral 
ventricle  may  be  greatly  dilated,  and  the  brain  tissue  over  it  very  thin,  while 
cysts  have  been  found  in  the  sclerosed  areas — the  remnants  of  old  hemor- 
rhages.    The  Rolandic  area  is  that  most  frequently  involved. 

In  90  cases  studied  by  Osier  the  lesions  in  50  were  atrophy  and 
sclerosis,  in  24  porcencephalia,  and  in  16  embolism,  thrombosis,  or  hemor- 
rhage. 

Symptoms. — The  symptoms  are  complex  and  varied,  but  may  be 
divided  into  three  classes :  those  of  the  onset,  those  pertaining  to  the  par- 
alysis, and  the  residual  symptoms. 

The  hemiplegia  is  usually  preceded  or  accompanied  by  convulsions  and 
coma,  although  the  disease  may  come  on  suddenly,  without  spasms  or  loss 
of  consciousness,  in  children  apparently  healthy.  In  the  majority  of  cases, 
however,  the  disease  begins  with  convulsions,  partial  or  general.  Loss  of 
consciousness  almost  always  accompanies  the  convulsions,  and  may  last 
from  a  few  hours  to  many  days.  Rarely  coma  occurs  without  convulsions. 
Among  other  symptoms  may  be  mentioned  fever,  transient  or  persistent ; 
according  to  Striimpell  and  Gaudard,  it  is  an  invariable  accompaniment  of 
the  convulsions.  Delirium  is  a  common  symptom,  as  is  also  soreness  of 
the  general  surface.     Vomiting  and  screaming  spells  are  also  noticed. 

The  hemiplegia,  which  is  noticed  as  soon  as^the  child  recovers  con- 
sciousness, is  usually  complete.  Less  commonly  there  is  first,  paresis,  which 
gradually  extends  to  complete  loss  of  power;  and  in  some  instances  a  total 
paralysis  is  established  after  repeated  convulsions.  The  face  is  not  always 
involved,  and,  as  a  rule,  in  facial  paralysis  of  cerebral  origin  the  superior 
muscles  are  intact,  and  the  child  can  close  the  eyes  and  elevate  the  brows. 
The  facial  palsy  usually  disappears  rapidly  and  completely. 

As  to  residual  symptoms  in  adults,  also,  the  residual  paralysis  is  most 
marked  in  the  arm,  which  is  subject  to  slow  wasting,  and  is  commonly  use- 
less for  the  ordinary  purposes  of  life.  The  atrophy  is  moderate,  but  there 
may  be  arrested  development,  leaving  a  wasted  and  withered  member.  In 
extreme  cases  the  arm  is  held  close  to  the  side,  the  forearm  strongly  flexed 
at  right  angles  and  in  a  semiprone  position,  the  hand  flexed  and  the  fingers 
contracted,  the  palm  usually  embracing  the  thumb.  Motion  may  be  almost 
lost  in  the  arm  and  completely  in  the  fingers,  though  in  most  cases  there  is 
considerable  power  of  movement,  the  patient  being  able  to  lift  the  arm  above 
the  head,  while  flexion  and  extension  can  be  made  at  the  elbow  and  wrist. 
The  finer  and  more  delicate  movements  of  the  hand  are  rarely  recovered.  The 
leg,  as  a  rule,  recovers  more  rapidly  and  completely  than  the  arm,  and  the 
palsy  may  disappear  entirely  in'^it,  while  it  rarely  does  in  the  upper  extrem- 
ity. In  the  leg  the  wasting  is  also  less  pronounced,  while  arrested  develop- 
ment is  also  less  frequent.  A  persistent  halt  is  apt  to  remain — indeed,  al- 
most always  does — as  evidence  of  impaired  power ;  this  may  consist  in  simply 
favoring  the  affected  side,  noticeable  only  on  rapid  walking.  A  decided 
dragging  of  the  limb  is,  however,  more  usual,  and  there  may  be  tremor  of  the 
leg  while  moving. 

The  frequency  with  which  rigidity  is  present  has  given  rise  to  one  of 
the  names  of  the  disease,  spastic  infantile  hemiplegia.  It  is  not,  however, 
an  invariable  symptom,  and  the  paralyzed  limbs  may  be  relaxed  a  long  time 
after  paralysis  sets  in.  When  rigidity  is  present,  it  is  lessened  during  sleep, 
and  is  increased  by  emotion  and  forcible  attempts  to  overcome  the  spasm. 
Contracture   may   ultimately   result,   after   which    relaxation   is   no    longer 


THE  CEREBRAL  PALSIES  OF  CHILDREN.  1065 

possible.  A  form  of  rigidity  without  much  paralysis  is  known  as  postapo- 
plectic hemi-hypcrtonia,  and  has  been  previously  referred  to. 

The  reflexes  are  almost  always  increased  in  the  affected  limbs,  ankle 
clonus  being  often  obtainable  in  addition  to  exaggerated  knee-jerk.  The 
reflexes  may  even  be  increased  on  the  sound  side.  Rectus  clonus  and 
clonus  of  the  flexors  of  the  Angers  are  rarely  present,  while  in  a  very  few 
cases  the  reflexes  are  absent. 

Sensation  is  rarely  affected,  but  vasomotor  derangements  are  sometimes 
present.     Electrical  reactions  are  normal^  as  a  rule. 

Posthemiplegic  chorea — hemiataxia — is  not  infrequent.  More  uncom- 
nion  are  mobile  spasm  and  athetosis  and  posthemiplegic  tremor.  These 
interesting  symptoms  were  first  described  by  S.  Weir  Mitchell  and  Hammond 
in  a  study  of  cases  of  cerebral  palsy. 

Aphasia  is  present  in  a  majority  of  cases  almost  invariably  transitory^ 
associated  most  commonly  with  right  hemiplegia,  very  rarely  with  left. 

Defects  of  intelligence  are  very  common,  the  degree  of  feeble-minded- 
ness  ranging  from  low-grade  imbecility  to  total  idiocy.  Psychoses  may 
occur  late  in  life,  even  when  there  have  been  no  defects  in  childhood. 

Epilepsy  is  very  frequent,  and  is  sometimes  confined  to  the  paralyzed 
side,  but  also  tends  to  become  general.  The  attacks  usually  begin  within 
two  or  three  years,  sometimes  within  a  few  weeks,  after  the  onset  of  the 
hemiplegia,  but  may  be  delayed  from  eight  to  ten  years,  or  even  longer. 
The  seizures  may  present  three  zvell-dcfined  degrees — the  first,  in  which  the 
child  is  simply  dazed  for  a  moment  or  two,  or  longer,  without  any  motor  in- 
volvement ;  second,  Jacksonian  epilepsy,  without  loss  of  consciousness,  in 
which  the  spasms  are  confined  to  the  affected  side,*  and  third,  general  con- 
vulsions, beginning  in  the  paralyzed  limbs,  and  usually  accompanied  by  loss 
of  consciousness.  The  Jacksonian  epilepsy  is  most  common,  but  all  forms 
may  occur  in  any  one  case. 

Diagnosis. — Infantile  spinal  paralysis,  anterior  poliomyelitis,  most  fre- 
quently must  be  excluded,  usually  without  difficulty.  The  history  of  the 
case,  including  the  presence  of  some  of  the  causes  named,  the  frequent  onset 
with  convulsions,  the  hemiplegia,  the  absence  of  rapid  wasting  of  the 
affected  muscles,  the  retained  electrical  reactions,  are  characteristic  of  in- 
fantile cerebral  hemiplegia  in  its  early  stage ;  while  rigidity  of  muscles,  in- 
creased reflexes,  the  peculiar  gait,  and  residual  palsy,  with  mental  imbecility 
and  epileptic  seizures,  distinguish  the  latter  stage. 

Tumor  of  the  brain  sometimes  produces  similar  symptoms.  Tubercu- 
losis and  glioma  are  the  forms  most  common  in  children.  Pressure  paral- 
ysis by  obstetrical  forceps  affects  the  face  and  upper  extremities,  but  other 
symptoms  are  wanting,  and  it  is  scarcely  likely  to  be  confounded  with  infan- 
tile hemiplegia. 

Prognosis  and  Treatment. — The  prognosis  is  favorable  so  far  as  life 
and  the  recovery  of  considerable  locomotive  power  are  concerned;  unfavor- 
able as  to  recovery  from  mental  defect  and  epilepsy.  An  institution  for 
feeble-minded  children,  in  which  the  subjects  have  the  benefit  of  training 
and  watching,  is  the  safest  permanent  home  for  them. 

*  Jacksonian  epilepsy  is  usually  without  loss  «if  consciousness,  unless  the  convulsions  are  very 
severe  or  involve  a  large  portion  of  the  body. 


io66  DISEASES  OF  THE  NERVOUS  SYSTEM. 


Bilateral  Infantile  Spastic  Hemiplegia. 

Synonyms. — Spastic  Rigidity  of  the  Nciv-born  (Little)  ;  Tonic  Contraction 
of  Extremities;  Essential  Contractions;  Permanentes  Kinder-Tetanus 
(Stromeyer)  ;  Spastic  Paralysis  of  Children  (Adams)  ;  Spastic  Dip- 
legia (Gee)  ;  Spasme  Muscnlaire  Idiopathique  (Delpech)  ;  Birth  Palsies 
(Gowers)  ;  Little's  Disease. 

Historical. — Delpech  was  probablj-  the  first  to  describe  the  disease  fairly  cor- 
rectl}'.  To  the  German  orthopedic  surgeon,  Heine,  belongs  the  credit  of  first  appre- 
ciating these  conditions  and  their  cerebral  origin  and  separating  them. from  common 
infantile  paralysis.  His  paper  was  written  in  iS6o.  Little's  paper,  published  two 
years  later  in  England,  so  attracted  attention  that  his  name  became  applied  to  the 
disease.     Stromeyer,  Adams,  and  Rupprecht  have  furnished  careful  accounts. 

Etiology. — 'Slost  cases  of  bilateral  hemiplegia  in  children  date  from 
birth,  and  are  the  result  of  injury  during  birth.  The  infectious  fevers  are 
responsible  for  a  certain  number,  and  a  few  are  direct  results  of  convulsions. 
In  a  word,  the  causes  are  those  of  infantile  hemiplegia. 

Morbid  Anatomy. — As  may  be  inferred  from  the  name,  the  lesions 
are  bilateral  and  involve  motor  areas  of  the  cortex  almost  solely.  They 
consist  in  sclerosis  or  porencephalous  defect,  of  which  the  most  frequent  pri- 
mary cause  is  compression  by  a  blood-clot  due  to  meningeal  hemorrhage 
from  the  veins  or  longitudinal  sinus.  A  meningo-encephalitis  may,  how- 
ever,   be  responsible  for  the  sclerosis. 

Descending  degeneration  of  the  pyramidal  tracts  or  imperfect  develop- 
ment of  these  tracts  has  been  found  in  a  few  cases. 

Symptoms. — These  are  to  be  distinguished  from  those  of  the  next 
form,  cerebral  spastic  paraplegia,  which  the  disease  closely  resembles  when 
the  arms  are  so  slightly  affected  that  the  palsy  is  scarcely  appreciable.  The 
cerebral  spastic  paraplegia  of  childhood  is  due  to  lesions  similar  to  those  of 
the  bilateral  spastic  hemiplegia.  In  the  diplegic  state  all  the  e.vtreuiitics 
must  be  more  or  less  spastic,  although  the  legs  almost  always  are  more  so 
than  the  arms.  These  cases  are  further  characterized,  as  are  those  of  spastic 
paraplegia,  by  their  occurrence  at  or  very  sooji  after  birth. 

There  may  be  convulsions  or  a  prolonged  succession  of  convulsions 
immediately  after  birth.  After  this  or  without  it  there  may  be  noticed  a 
linip)iess  or  flaccidity  of  uuiscles,  an  expression  of  paresis,  often  overlooked, 
because  present  at  a  time  when  the  muscular  development  of  the  child  is  so 
slight  that  little  is  expected  of  it.  Soon,  however,  the  inability  to  hold  up 
its  head  may  be  observed,  and  when  the  time  comes  for  it  to  walk,  it  is 
noticed  that  the  limbs  are  chimsily  used,  and  when  examined,  thev  are 
found  to  be  stiff.  As  the  child  grows  older  it  slowly  acquires  some  power 
so  as  to  be  able  to  sit,  but  the  legs  are  crossed  and  the  head  is  not  well  sup- 
ported by  the  neck  muscles.  If  it  is  held  up,  the  legs  are  extended  and 
strongly  adducted,  and  crossed  with  the  feet  in  the  pes  equinus  or  equino- 
varus  position.  Occasionally  the  legs  are  partially  fle.ved.  while  stiffness 
varies  greatly,  involving,  in  extreme  cases,  the  whole  body,  sometimes  one 
side  more  than  the  other.  It  is  sometim.es  constant,  at  other  times  not. 
It  may  be  greater  on  one  side  than  another.  The  arms  are  usually  stiff  in 
flexion. 

To  the  spastic  symptoms  described  are  added,  in  certain  cases,  spasm 
and  certain  movements  known  as  athefoid.  In  the  former,  in  an  attempt  at 
voluntarv  movement,  as  taking  hold  of  an  obiect.  the  fingers  are  thrown 


THE  CEREBRAL  PALSIES  OF  CHILDREN.  1067 

out  in  a  stiff,  spasmodic,  or  irregular  manner,  or  there  may  be  constant 
irregular  movements  of  arms  and  shoulders,  movements  which  are  usually 
characterized  as  choreic.  In  fact,  such  cases  have  been  named  chorea 
spastica,  being  differentiated  from  the  congenital  choreas  by  the  spastic 
feature.  Spasm  rarely  affects  the  muscles  of  the  face,  though  it  does  occa- 
sionally, causing  a  continual  grimacing,  which  does  not  always  disappear 
during  sleep. 

The  athetosis  is  double  or  bilateral,  resulting  in  the  most  grotesque  and 
distorted  movements.  They  consist  in  a  constant  flexion  and  extension 
of  muscles,  more  particularly  of  those  of  the  fingers  of  one  hand  and  fore- 
arm. Flexion  of  the  fingers  of  one  hand  may  take  place,  while  those  of 
the  other  may  be  extending,  and  the  same  may  be  true  of  different  fingers 
of  the  same  hand.  The  shoulder  and  trunk  m.uscles  may  be  also  affected, 
producing  a  rhythmical  and  orderly  twisting  and  bending  of  the  body;  or 
those  of  the  neck,  producing  a  turning  of  the  head  from  side  to  side.  These 
movements  are  all  increased  under  excitement  or  with  the  effort  to  do  any- 
thing. 

Mental  defect,  consisting  in  imbecility  and  various  grades  of  idiocy,  is 
more  or  less  characteristic  of  these  cases,  but  is  commonly  less  than  in  in- 
fantile hemiplegia. 

The  form  resulting  from  premature  birth  should  be  distinguished  from 
that  caused  by  injuries  at  birth,  or  by  lesions  acquired  later,  as  in  the  former 
convulsions  and  athetoid  movements  do  not  usually  occur,  mentality  may  not 
be  affected,  and  improvement  may  be  slowly  progressive  even  after  many 
years. 

Infantile  Spastic  Paraplegia. 

Synonyms. — Paraplegia  cercbralis  spastica  (Heine)  ;  Tetanoid  Pseudopara- 
plegia  (Seguin)  ;  Spastic  Spinal  Paralysis  (Erb)  ;  Tabes  dorsalis  spas- 
modique  ( Charcot ) . 

Definition. — Spastic  paralysis  of  the  legs  in  children. 

Historical. — A  common  affection  of  children,  though  only  recently  understood,  was 
fully  described  and  correctly  named  by  Heine  in  1849.  Delpech  and  Stromeyer  in 
Germany  and  Adams  and  Little  in  England  described  it.  Erb  and  Seeligmiiller  in 
Germany  and  Gee  in  England  brought  the  subject  to  the  notice  of  physicians,  and 
Erb  contrasted  it  with  the  spastic  paraplegia  of  adults.  Ross,  Hadden,  Gowers, 
d'Heilly,  Gilbert,  and  Osier  have  more  recently  treated  the  subject  as  one  of  the  cere- 
bral palsies  of  children.  It  must  be  distinguished  from  the  spastic  paralysis  occurring 
in  adults  and  found  in  a  very  few  cases  to  be  due  to  primary  degeneration  of  the 
pyramidal  tracts. 

Etiology. — The  causes  are  those  of  spastic  diplegia  and  infantile  hemi- 
plegia, and  also  premature  birth,  the  child  being  born  at  a  period  when  the 
central  motor  tracts  are  very  imperfectly  developed ;  premature  birth  causes 
an  arrest  in  the  development  of  these  tracts. 

Morbid  Anatomy. —  This  is  less  known  than  the  morbid  anatomy  of 
the  other  forms  of  cerebral  palsy.  It  may  be  due  to  cerebral  lesion  involv- 
ing especially  the  centers  for  the  lower  limbs,  to  imperfect  development  of 
the  motor  tracts,  or  to  other  causes.  A  few  cases  with  necropsy  are  re- 
corded, r 

Symptoms. — These  are  almost  identical  with  those  already  described 
as  belonging  to  the  spastic  paraplegia  of  adults,  with  which  the  earlier 
writer  classed  it.     Spastic  paralysis  of  the  lower  extremities,  dating  from 


io68  DISEASES  OF  THE  NERVOUS  SYSTEM. 

birth  or  appearing  within  the  first  few  years  of  life,  with  tahpes  equinus  or 
equinovarus,  adductor  spasm,  rigid  stiff  gait,  the  patient  walking  on  his  toes 
or  by  crossed-legged  progression, — all  without  wasting, — these  are,  in  a 
word,  the  symptoms.  The  order  of  sequence  of  events  is  very  similar  to  that 
described  under  spastic  diplegia.  In  attempting  to  walk  the  heels  are  everted 
and  knees  approximated,  because  of  spasm  of  the  adductors,  which  may  be 
so  strong  as  to  make  it  impossible  to  separate  the  thighs.  The  spastically 
extended  legs  may,  however,  be  gradually  forced  into  flexion  after  the 
manner  of  the  "  lead-pipe  "  contraction.  If,  however,  the  attempt  be  made 
to  extend  the  leg,  the  spasm  returns.  If  the  extension  be  gradually  insisted 
upon,  it  often  happens  that  when  the  extension  is  nearly  complete,  the  spasm 
suddenly  completes  it,  as  the  spring  acts  on  the  blade  of  a  pocket-knife, 
whence  the  name  "  clasp-knife  "  rigidity. 

Mental  imhecility  is  not  so  serious  as  in  spastic  diplegia  or  even  as  in 
infantile  hemiplegia,  and  may  be  entirely  absent,  especially  in  those  cases 
resulting  from  premature  birth. 

Diagnosis. — The  distinction  between  spastic  diplegia  and  paraplegia  is 
not  a  very  important  one.  The  two  conditions  are  probably  the  results  of 
different  degrees  of  similar  lesions  having  different  locations.  There  is  an 
affection  of  children  known  as  pseudoparalytic  rigidity,  idiopathic  contrac- 
tion with  rigidity,  or  tonic  contraction  of  the  extremities,  with  which  it  is 
sometimes  confounded,  but  the  following  table  of  differences  from  Osier's 
monograph  will  aid  in  separating  the  two  conditions. 


PSEUDOPARALYTJC    RiGIDITY. 


Spastic   Paralysis  ;   Diplegia  and  Para- 
plegia. 


Follows  a  prolonged  illness.     Is  often  as-  Usually    exists    from    birth.     Histor}^   of 
sociated    with    rickets,    laryngismus  difficult  labor  [or  of  premature  labor], 

stridulus,    and    the   so-called    hydro-  of  asphyxia  neonatorum,  or  of   con- 

cephaloid  state.  vulsions. 

Begins  in  hands  and  feet  as  carpopedal  Arms   rarely  involved   without  legs  and 
spasm  ;  often  confined  to  hands  and  not  in  so  marked  a  degree, 

arms. 

Spasms  painful  and  attempts  at  extension  Usually  painless, 
cause  pain. 

Intermittent  and  of  transient  duration.  Variable  in  intensit5^  but  continuous. 

The  spasm  in  the  pseudo  cases  is  altogether  more  severe  and  difficult  to 
overcome.  The  disease  is  associated  with  rickets  and  other  constitutional 
diseases. 

Tetany  is  characterized  by  a  different  history  and  causation.  Bilateral 
rigidity  may  also  be  produced  by  tumors  of  the  pons  and  cerebellum. 

Treatment. — The  treatment  varies  with  the  stage  existing  at  the  time 
the  physician  is  called.  If  in  the  stage  of  initial  convulsion,  there  is  no 
remedy  like  chloral,  which  should  be  given  in  doses  sufficient  to  control  the 
fits.  In  the  mild  degrees,  or  with  a  view  to  keeping  up  an  effect  first  obtained 
by  chloral,  the  bromids  may  be  used.  If  chloral  fails,  chloroform  may  be 
inhaled. 

In  established  paralysis  medicines  do  not  avail  much  and  recoveries  are 
rare.  Hygiene  and  good  food,  gymnastics,  manipulation,  massage,  passive 
motion,  and  surgical  appliances  may  be  used.  Baths  and  electricity  should 
not  be  forgotten. 

The  epileptic  convulsions  should  be  treated  as  when  occurring  under 
other  conditions,  though  the  cortical  lesions  occasioning  the  disease  preclude 
any  expectation  of  permanent  relief.     Operative  procedure  has  been  sug- 


SCLEROSIS  OF  THE  BRAIN  AND  SPINAL  CORD.      1069 

gested  in  certain  selected  cases  and  carried  out,  but  with  results  which  have 
been  disappointing. 

The  mental  deficiencies  are  best  treated  in  an  institution  for  feeble- 
minded children,  where  all  such  cases  should  be  taken,  whatever  the  circum- 
stances of  the  parents. 


SCLEROSIS  OF  THE  BRAIN  AND  SPINAL  CORD. 

IMuLTiPLE  Sclerosis  of  the  Brain  and  Spinal  Cord. 

Synonyms. — Insular  Sclerosis;  Disseminated  Nodular  Sclerosis;  Sclerose 

en  plaques. 

Definition. —  A  chronic  affection  of  the  brain  and  spinal  cord,  consisting 
in  the  presence  of  numerous  sclerotic  patches  scattered  through  the  nerve 
centers,  characterized  especially  by  intention  tremor,  scanning  speech,  and 
nystagmus. 

Etiology. — Its  precise  cause  is  unknown.  The  infectious  diseases, 
especially  scarlet  fever,  are  alleged  causes ;  so  are  cold,  exposure,  mental 
emotion,  and  syphilis,  but  without  definite  foundation.  Hereditars'  predis- 
position has  been  noticed.  The  disease  is  more  common  between  the  ages 
of  eighteen  and  thirty-five,  though  Striimpell  met  a  case  which  came  to 
autopsy  at  sixty.  Both  sexes  are  equally  subject.  Prichard  states  that  more 
than  fifty  cases  have  been  reported  in  children,  but  it  is  doubtful  whether  the 
diagnosis  was  invariably  correct.  It  has  been  thought  that  the  disease 
depends  on  anomalies  of  the  vessels,  but  this  view  is  not  held  by  all. 

Morbid  Anatomy. — The  sclerosed  patches  are  widely  scattered 
through  the  brain  and  cord,  rarely  in  the  cord  alone.  They  may  generally 
be  recognized  by  their  gray  color  and  unnatural  firmness.  On  section,  they 
appear  as  grayish-red  areas.  Histologically  they  consist  of  thickened  neu- 
rogHa  traversed  by  a  few  healthy  nerve-fibers.  In  the  vessels  there  is  an 
increase  of  the  nuclei  and,  later,  a  thickening  of  the  walls.  Fatty  granular 
cells  are  present  in  fresh  cases.  Many  of  the  axis-cylinders  are  preserved  in 
the  sclerotic  patches  for  quite  a  long  timie  after  destruction  of  the  medullar}- 
sheaths.  The  favorite  seats  of  the  plaques  in  the  brain  are  the  centrum  ovale, 
the  walls  of  the  lateral  ventricles,  the  corpus  callosum,  and  the  cerebellum ; 
while  they  are  quite  numerous  in  the  pons,  less  so  in  the  medulla  oblongata, 
but  numerous  in  the  cord,  especially  the  white  substance.  The  cortex  is  not 
often  invaded. 

Symptoms. — By  no  means  every  case  of  multiple  sclerosis  can  be  recog- 
nized, so  often  are  the  symptoms  united  with  those  of  other  lesions  whose 
effects  predominate,  while  the  slowness  of  the  onset  necessitates  delay  in  the 
recognition  of  even  typical  cases.  Typical  cases  do,  however,  occur,  and 
they  present  a  set  of  symptoms  whence  their  recognition  is  more  or  less 
easy. 

One  of  the  most  important  of  these  symptoms  is  tremor,  known  as 
"  intention  tremor,"  because  associated  w'ith  any  voluntary  effort  to  perform 
an  act,  as  picking  up  an  object,  raising  a  glass  of  water  to  the  lips,  or  appos- 
ing the  ends  of  the  fingers  of  the  two^hands.  This  does  not  prevent  the  ulti- 
mate attainment  of  purpose.  When  the  patient  is  quiet,  the  tremor  ceases, 
and  in  this  respect  it  can  be  differentiated  from  the  trembling  of  paralysis 
agitans.     It  is  not  confined  to  the  arms,  but  occurs  also  in  the  head  and  trunk, 


I070  DISEASES  OF  THE  NERVOUS  SYSTEM. 

so  that  the  head  trembles  when  it  is  raised  from  the  pillow.  It  is  increased 
by  excitement. 

Another  characteristic  symptom  is  what  is  known  as  scanning  speech, 
a  slow,  measured,  yet  indistinct  and  obscure  utterance,  depending  upon  dis- 
turbances in  the  innervation  of  the  tongue  and  larynx,  probably  due  to  the 
presence  of  sclerotic  patches  in  the  pons  and  medulla  oblongata.  There  may 
be  tremor  in  the  tongue  and  lips  when  speaking.  The  third  symptom  is 
nystagmus — oscillatory  or  lateral  movements  of  the  eyeball  when  the  eyes  are 
directed  to  an  object.  In  addition  there  may  be  spastic  symptoms  mani- 
fested chiefly  in  the  presence  of  increased  reflexes — including  periosteal  as 
well  as  tendon  reflexes — in  both  upper  and  lower  extremities,  but  the  skin 
reflexes  remain  normal.  There  is  ankle  clonus,  and  the  gait  is  often  spastic. 
Paresis,  at  first  absent,  ultimately  appears,  amounting  at  times  to  complete 
paralysis.  Indeed,  spastic  rigidity  and  paresis  may  be  among  the  earliest 
signs  of  the  disease.  The  sphincters  remain  intact,  at  least  until  toward  the 
close.  There  are  no  disturbances  of  sensibility  in  the  majority  of  cases. 
Optic  atrophy  is  sometimes  present,  less  commonly  than  in  tabes  dorsalis, 
and  associated  with  such  derangements  of  vision  as  amblyopia,  achroma- 
topsia, and  even  blindness.  Optic  neuritis  may  occur  with  subsequent 
atrophy,  especially  in  the  temporal  halves  of  the  optic  nerve.  There  may  be 
also  derangements  of  innervation  with  diplopia. 

Mental  iveakness  and  imbecility  are  sometimes  present,  more  rarely 
melancholia  or  exaltation.  Apoplectiform  attacks  also  occur,  following  pro- 
dromal symptoms,  such  as  vertigo  and  headache,  and  succeeded  by  hemi- 
plegia, which,  howev.er,  subsequently  disappears. 

Diagnosis. — This  is  not  difficult  in  typical  cases.  The  intention  tremor, 
the  scanning  speech,  and  nystagmus  are  characteristic,  and  when  associated 
with  spastic  weakness,  the  diagnosis  of  multiple  sclerosis  is  probably  correct. 
The  apoplectiform  seizures  and  mental  weakness  are  also  valuable  signs. 
When  the  symptoms  are  mixed  with  those  of  other  nervous  lesions,  diagnosis 
is  not  so  easy.  In  paralysis  agitans  tremor  occurs  during  rest  as  well  as 
motion ;  in  multiple  sclerosis  only  when  motion  is  attempted.  Striimpell 
says :  "  The  circumstance,  indeed,  that  the  anomalous  cases  will  not  properly 
fit  the  molds  of  any  other  form  of  disease  should  make  us  think  of  the  pos- 
sibility of  multiple  sclerosis." 

The  disease  known  as  pseiido  sclerose  en  plaques,  described  by  Westphal, 
seems  to  have  most  of  the  symptoms  of  multiple  sclerosis  except  nystagmus. 
The  tremor  movements  are  said  to  be  more  violent.  Striimpell  has  found 
slight  degneration  of  the  pyramidal  tracts  in  a  few  cases  of  this  kind. 

Prognosis. — This  is  unfavorable  after  a  long  and  tedious  course,  termi- 
nating in  the  bedridden  state. 

Treatment. — This  is  unavailing.  The  end  may  be  delayed  by  galvanism 
and  tepid  bathing. 


DEMENTIA   PARALYTICA. 

Synonyms. — Chronic    Diffuse    Meningo-encephalitis ;    Paretic    Dementia; 
General  Paresis;  Progressive  General  Paralysis  of  the  Insane. 

Definition. —  A  chronic  progressive  meningo-encephalitis,  or  meningo- 
rachitis,  with  resulting  mental  and  motor  derangements,  terminating  in 
dementia  and  paralysis. 


DEMENTIA  PARALYTICA.  1071 

Historical. — Boyle  in  1822  and  Calmeil  in  1826,  by  their  descriptions,  first  sepa- 
rated paralytic  dementia  from  other  diseases  which  run  a  like  course.  The  minute 
anatomical  changes  lying  at  the  bottom  of  the  symptoms  are  a  matter  of  compara- 
tively modern  study,  and  have  received  valuable  contributions  from  Bevan  Lewis 
and  others. 

Etiology. —  At  least  75  per  cent,  of  all  cases  are  caused  by  syphilitic 
infection,  and  observations  reported  by  Krafft-Ebing  seem  to  indicate  that 
the  proportion  is  much  greater.  Starting  out  with  this  assumption,  we  have 
at  once  an  explanation  of  its  greater  frequency  in  the  male  sex,  though  many 
women  have  it ;  while  it  is  rather  a  sad  commentary  on  the  fidelity  of  man 
that  it  is  much  more  frequent  among  married  men.  The  fact  that  it  occurs 
most  frequently  between  the  thirtieth  and  fiftieth  years,  that  it  is  a  disease 
of  the  better  classes, — especially  anny  officers  and  artists, — and  that  it  is 
pre-eminently  a  disease  of  the  cities,  should  be  added.  Although  other 
factors  apparently  enter  into  the  causation  of  general  paresis,  those  who  have 
most  closely  studied  the  subject  are  disposed  to  assign  to  them  a  predispos- 
ing role.  Such  influences  are  heredity  and  exhausting  mental  work,  such  as 
comes  of  public  political  life  and  ambitious  financial  ventures.  Intem- 
perance, chronic  lead  poisoning,  and  traumatism  are  included  among 
causes. 

Morbid  Anatomy. — An  atrophy  of  the  brain,  and  especially  of  the 
frontal  lobes,  may  be  set  down  as  the  m.ost  important  morbid  change.  The 
convolutions  are  wasted  and  pale  in  color,  the  fissures  are  wider,  and  the 
weight  of  this  portion  is  reduced  to  one-fourth  or  one-third  the  normal,  while 
the  consistence  is  finricr  and  more  resisting  to  section.  Other  macroscopic 
changes  are  a  thickening  of  the  dura  mater,  pachymeningitis  interna,  edema 
of  the  pia  with  thickening,  opacity,  and  adhesion  to  the  cortex.  Minute 
examination  of  the  cortex  recognizes  thickening  of  the  vessel-zvalls  and  cel- 
lular infiltration  of  the  adventitia  of  the  arterioles  and  lymphatic  sheaths — 
in  other  words,  the  effects  of  mild  inflammation.  To  these  are  added  demon- 
strable destruction  of  nerve  elements,  especially  of  the  fine  medullary  nerve 
fibrils  known  as  "  tangential  fibers  "  in  the  frontal  convolutions,  island  of 
Reil,  and  elsewhere ;  also  atrophy  of  the  ganglion  cells.  Associated  with  this 
are  neuroglia  or  proliferation  and  numerous  Deiters'  spider  cells.  Here 
enters  a  contested  question  as  to  whether  these  nerve  changes  are  primary 
or  secondary  to  an  interstitial  encephalitis.  Tuczek,  Wernicke,  and  Striim- 
pell  hold  to  the  former  view ;  while  Rindfleisch  and  Mendel  adopt  the  latter, 
making  the  destruction  of  nervous  tissue  secondary  to  the  overgrowth  of 
neuroglia. 

The  white  matter  is  also  involved,  the  central  ganglia  as  well.  Coin- 
cident changes  in  the  spinal  cord, — first  described  by  Westphal, — consisting 
in  fascicular  systemic  degeneration  of  the  lateral  columns  and  posterior 
columns,  either  alone  or  jointly,  are  quite  constantly  present.  To  these  is 
ascribed  a  large  part  of  the  ataxic  and  spastoparalytic  S)-mptoms.  From  this 
brief  statement  of  the  character  and  situation  of  the  morbid  changes  it  will 
be  seen  that  they  are  widespread  in  their  distribution  through  the  nervous 
system,  while  they  are  also  degenerative. 

Symptoms. — So  widely  scattered  a  distribution  of  morbid  phenomena 
naturally  brings  about  corresponding  differences  in  the  variety  and  degree 
of  the  symptoms.  As  further  characteristic,  no  absolute  constancv  is  ob- 
served in  the  order  of  their  development.  As  a  rule,  however,  the  first  stage 
is  characterized  by  abnormal  mental  processes,  and  these  are  at  first  what 
may  be  comprehended  under  the  single  expression  peculiarity  or  "  queer- 


I072  DISEASES  OF  THE  NERVOUS  SYSTEM. 

ncss  "  of  conduct.  The  patient  will  perform  acts  wholly  unnatural  to  him, 
and  will  surprise  his  friends  and  family  by  breaches  of  decorum  and  morality. 
An  apathy  and  loss  of  memory,  causing  the  omission  of  obligations,  are  also 
constant.  At  first  these  may  pass  unnoticed  as  temporary,  but  their  per- 
manence is  gradually  established.  In  lieu  of  this  may  be  present  an  irri- 
tability and  intense  restlessness,  so  that  the  patient  cannot  remain  in  one 
spot,  but  walks  constantly  to  and  fro.  Not  often  in  this  stage  is  there  much 
volubility,  but  rather  a  morose  silence  is  observed.  In  this  stage,  too,  the 
patient  may  make  rash  and  ruinous  financial  ventures,  and  lose  his  own 
money  and  that  of  his  friends,  or  he  may  become  very  generous,  ^giving  away 
freely  all  he  possesses,  and  more,  too.  The  power  of  arithmetical  calculation 
is  defective  or  gone.  He  may  be  self-satisfied  and  intensely  egotistical.  On 
the  other  hand,  he  may  be  conscious  of  these  ills  and  be  anxious  about  them, 
as  well  as  experience  a  discomfort  or  malaise,  for  which  he  may  consult  the 
physician. 

Nor  are  motor  disturbances  wholly  wanting  in  the  first  stage.  They  arc 
chiefly  derangements  of  speech  and  handwriting,  and  are  of  no  small  diag- 
nostic value.  The  speech  is  slow  and  hesitating,  yet  the  patient  stumbles 
over  syllables,  especially  when  the  word  is  complex  or  rather  difficult  to 
enunciate.  As  to  the  handwriting,  it  is  tremulous,  characterized  by  the 
omission  of  letters  and  substitution  of  wrong  ones,  as  well  as  erroneous  spell- 
ing— all  motor  defects. 

Other  symptoms  of  the  first  stage  are  inequality  of  the  pupils,  ocular 
paralysis,  and  absence  of  patellar  reflex,  in  tabetic  cases  often  reflex  immo- 
bility of  the  pupils,  and  in  spastic  cases  increase  of  reflexes.  There  may  be 
neuralgic  pain  and  attacks  of  migraine. 

The  second  stage  is  characterized  by  more  exalted  mental  symptoms  and 
excitement,  with  a  higher  degree  of  motor  disturbance.  The  former  consist 
in  exaggeration  of  all  previously  maintained  mental  symptoms,  amounting  to 
noisy,  boisterous,  and  maniacal  excitement,  and  even  uncontrollable  violence. 
In  this  stage  belong,  too,  those  extraordinary  delusions  of  grandeur — expan- 
sive delirium — in  which  the  patient  imagines  himself  or  herself  to  be  a  per- 
son of  great  consequence  and  unlimited  wealth.  This  is  not,  however,  in- 
variable, and  there  may  be  an  exaggerated  degree  of  the  opposite  condition 
of  melancholy  sometimes  present  in  the  first  stage,  or  the  two  conditions  of 
delirium  and  depression  may  alternate  or  may  be  absent.  Sleeplessness  may 
be  added  to  restlessness  and  mental  excitement,  causing  rapid  decline  of 
strength. 

Motor  disturbances  are  greatly  increased  in  this  stage,  but  a  uniform 
order  of  invasion  is  by  no  means  always  observed,  while  remissions  and  tem- 
porary improvement  are  often  noticed.  Speech  becomes  almost  impossible 
and  incomprehensible.  There  is  paraphasia — persistent  repetition  of  words 
— and  reading  and  writing  are  impossible.  The  voice  can  no  longer  be 
modulated,  and  is  weak  and  rough  from  imperfect  innervation  of  the  vocal 
cords. 

The  gait  becomes  defective,  and.  the  patient  often  trips  in  walking. 
There  may  be  ataxia  and  other  tabetic  symptoms ;  apoplectic  seizures  with 
paralysis;  or  epilepsy  with  grand  or  petit  mal  and  aura,  sometimes  one-sided 
and  followed  by  monoplegia  or  hemiplegia.  There  may  be  loss  of  sensihility, 
with  bladder  and  rectum  paralysis.  The  tendon  reflexes  may  be  lost  and  the 
pupil  be  immobile,  or  the  opposite  condition  of  spasm  with  increased  tendon 
reflexes  prevails.     The  paralytic  attacks  may  occur  in   the   earlier   stages. 


DEMENTIA  PARALYTICA.  1073 

though  in  mild  degree,  manifested  by  vertigo  or  obscuration  and  loss  of 
consciousness,  lasting  for  a  short  time  and  then  passing  away.  There  may 
be  local  twitching  in  the  face  and  extremities  and  even  typical  Jacksonian 
epilepsy.  Finally,  biilbar  symptoms  may  appear  with  invasion  of  the 
medulla  oblongata.  Ultimately,  the  patient  becomes  helpless,  bedridden,  and 
completely  demented,  dying  from  exhaustion  or  intercurrent  disease. 

In  a  few  cases  none  of  the  mental  symptoms  described  are  present,  but 
a  gradual  decline  of  mental  power  takes  place  until  complete  dementia  super- 
venes. An  acute  variety  is  also  sometimes  met,  properly  termed  "  gallop- 
ing," in  which  the  disease  runs  its  whole  course  in  a  few  months,  and  is 
especially  characterized  by  emaciation  and  rapid  loss  of  strength  due  to 
restlessness,  sleeplessness,  and  insufficient  food.  The  pulse  and  temper- 
ature are  essentially  normal,  or  at  least  there  are  not  characteristic  varia- 
tions. 

Diagnosis. — To  recognize  paretic  dementia  ab  initio  is  perhaps  impos- 
sible, but  to  watchful  observation  the  disease  commonly  reveals  itself  after 
the  symptoms  have  existed  for  a  short  time.  The  early  symptoms  resemble 
those  of  neurasthenia,  but  dififer  from  those  of  the  latter  disease  in  their 
steady  progression.  Other  affections  possibly  mistaken  for  it  are  cerebral 
syphilis,  tumors  of  the  brain,  and  multiple  sclerosis.  In  cerebral  syphilis 
the  onset  is  usually  more  sudden,  and  paralytic  symptoms  appear  earlier. 
Headache  is  more  frequent  and  severe,  and  there  may  be  convulsive  seizures, 
but  affections  of  the  tongue  and  speech  are  wanting,  while  the  train  of  men- 
tal symptoms  is  less  complete  and  characteristic,  and  expansive  delirium,  as 
a  rule,  does  not  occur.  The  epilepsy  is  more  commonly  Jacksonian.  It  is  to 
be  remembered  that  the  syphilitic  virus  produces  both,  and  it  is  not  unnatural 
that  the  two  should  sometimes  merge.  Tumors  of  the  brain  frequently,  but 
not  always,  produce  symptoms  more  localized,  and  often  also  optic  symptoms, 
including  choked  disc.  The  symptoms  of  insular  sclerosis,  which  include 
dementia,  are  often  identical  with  those  of  paralytic  dementia,  and  the  two 
diseases  cannot  then  be  differentiated.  Intention  tremor  is  more  character- 
istic of  sclerosis.  The  cerebral  symptoms  of  some  forms  of  plumbism,  it  is 
said,  also  sometimes  closely  resemble  those  of  paralytic  dementia. 

Prognosis. — The  prognosis  is  almost  always  unfavorable,  although  the 
course  of  the  disease  varies  somewhat.  The  most  rapid  cases  of  the  gallop- 
ing form  may  terminate  in  a  few  months,  but  two  or  three  years  is  the  more 
usual  duration ;  sometimes  much  longer,  it  may  be  ten  years  or  more.  Death 
ensues  from  exhaustion,  hastened  by  the  complications  and  secondary  condi- 
tions which  naturally  supervene  on  an  illness  so  prolonged  and  in  which 
nutrition  is  so  interfered  with ;  or  it  may  be  due  to  intercurrent  disease. 

Treatment.—  In  view  of  the  general  acknowledgment  of  the  syphilitic 
origin  of  chronic  diffuse  meningo-encephalitis  and  the  acknowledged  effi- 
ciency of  antisyphilitic  treatment  over  tertiary  manifestations  of  the  disease, 
it  is  rather  surprising  that  attempts  at  curative  treatment  are  so  futile.  The 
treatment  is  confined  mainly  to  iodids  and  mercurials.  Mercurials  are  best 
used  by  inunction,  and  the  iodids  in  ascending  doses.  These,  however,  do 
not  arrest  the  disease. 

As  to  the  rest,  treatment  m.ust  be  symptomatic.  The  bromids  and 
chloral,  with  quiet,  hygienic  svirroundings,  and  sometimes  enforced  retire- 
ment, are  measures  demanded  for  the  relief  of  the  nervous  excitement. 

For  the  opposite  condition  of  depression  and  melancholia  change  of 
scene  by   travel   and   residence   in   different    localities   should   be   enjoined. 

68 


10/4  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Further  than  this  the  use  of  a  proper  hygiene,  with  bathing,  frictions,  whole- 
some outdoor  hfe,  and  an  abundance  of  nourishing  and  easily  assimilable 
food  constitute  about  the  sum  of  the  means  we  can  bring  to  bear  against  the 
disease. 

TUMORS    OF  THE  BRAIN. 

Synonyms. — Ncoplasniafa  cerebri;  Intracranial  Tumors. 

Definition. — Cerebral  tumors,  clinically  considered,  include  not  only 
tumors  of  the  meninges  and  substances  of  the  brain,  but  also  all  intracranial 
and  even  such  extracranial  tumors  as  ultimately  invade  the  brain.  Among 
the  latter  are  tumors  of  the  orbit  or  nasal  cavity,  of  the  antrum,  and  of  the 
sphenopalatine  fossa. 

Varieties. —  The  principal  varieties  of  cerebral  tumor,  approximately 
in  the  order  of  frequency,  are : 

I.  Tyroma,  or  tubercular  tumor.  2.  Glioma.  3.  Sarcoma.  4.  Car- 
cinoma. 5.  Cystic,  including  parasitic  cysts  and  cysts  arising  in  sarcomata 
and  gliomata.  6.  Gumma.  7.  Histioid  tumors.  After  these  occur  in 
irregular  order,  cholesteatoma,  lipoma,  myxoma,  angioma,  fibroma,  psam- 
moma.  Even  dermoid  cysts,  as  well  as  parasitic  cysts — including  the 
echinococcus  or  hydatid  cyst — and  the  cysticercus  cellulosse,  are  met.  Of 
these  tumors,  psammoma  and  glioma  are  peculiar  to  the  brain.  According 
to  M.  Allen  Starr's  tables,  gliomata  and  gliosarcomata  practically  equal  in 
number  the  sarcomata,  but  the  term  gliosarcoma  is  regarded  by  many 
unfavorably. 

Etiology. — Except  sarcoma,  tumors  are  found  in  males  more  frequently 
than  in  females.  Tubercle  is  more  common  in  childhood ;  parasites,  glioma, 
sarcoma,  and  gumma  in  early  and  middle  life,  and  cancer  in  middle  and  late 
life,  but  is  rare  even  then.  Brain  tumors  of  any  kind  are  rare  after  sixty. 
Heredity  appears  to  have  slight,  if  any,  influence.  A  few  brain  tumors  are 
metastatic,  especially  carcinoma,  and  to  a  less  degree  sarcoma.  Eichhorst 
relates  several  remarkable  cases  in  which  trauma  seemed  to  be  the  exciting 
cause. 

Certain  tumors  seek  by  preference  special  localities.  Thus,  tuberculous 
tumors  are  most  numerous  in  the  cerebellum  and  about  the  base  of  the 
brain.  Glioma  starts  from  the  neuroglia  in  any  part  of  the  brain,  but  more 
frequently  the  cerebrum,  and  may  also  attain  a  large  size — larger  than  any 
other  brain  tumor ;  it  is  further  characterized  at  times  by  its  great  vascularity, 
leading  sometimes  to  rupture ^and  apoplectic  symptoms.  Glioma  may  also 
occur  in  the  eye.  Sarcoma  develops  also  most  frequently  in  the  membranes 
of  the  brain  and  sheaths  of  the  vessels ;  it  may  be  primary  or  secondary ;  it 
is  often  encapsulated.  Myxoma  and  fibroma  occur  in  the  same  localities. 
Carcinoma  is  usually  secondary,  but  may  be  primary ;  it  arises  more  fre- 
quently in  the  membranes,  but  may  be  found  in  the  substance  of  the  hemi- 
spheres ;  it  is  especially  secondary  to  primary  cancer  of  the  breast,  lungs,  or 
pleura.  Syphilorda  elects  the  hemispheres  or  the  pons  and  vicinity ;  it  is 
generally  superficial,  grows  from  the  meninges,  or  is  attached  to  arteries, 
attaining  sometimes  a  large  size.  It  may  be  multiple.  Parasitic  tumors  are 
found  in  the  membranes,  the  substance  of  the  brain,  and  the  ventricles.  The 
hydatid  cysts  developed  by  the  echinococcus  are  usually  on  the  surface  of  the 
brain;  the  cysticercus,  usually  multiple,  on  the  surface  or  in  the  ventricles. 


TUMORS  OF  THE  BRAIN.  1075 

Psammonia,  or  sand  tumor,  is  found  commonly  in  the  neighborhood  of  the 
pineal  gland. 

Symptoms. — The  symptoms  of  cerebral  tumor  are  in  no  way  special- 
ized by  the  kind  of  tumor  present,  and  depend  entirely  upo'H  the  effect 
exerted  on  the  surrounding  brain  substance,  chiefly  by  pressure.  They  do, 
however,  vary  somewhat  with  the  part  of  the  brain  involved.  It  occasion- 
ally happens  that  a  brain  tumor  may  produce  no  symptoms  whatever,  being 
thoroughly  latent,  and  disclosed  only  by  the  autopsy.  On  the  other  hand, 
apparently  insignificant  tumors  cause  very  decided  symptoms.  Such  differ- 
tnces  may  depend  in  part  on  the  location  of  the  tumor,  and  in  part  on  the 
rapidity  of  its  development. 

As  in  all  local  diseases  of  the  brain,  two  sets  of  symptoms  usually 
present  themselves:  (i)  Diffuse  and  (2)  Focal  symptoms. 

I.  Diifuse  or  General  Symptoms. — These  are  symptoms  which  may  be 
associated  with  various  forms  of  nervous  disease.  The  most  constant  of 
these  is  perhaps  headache,  which  varies  in  intensity  and  constancy.  Prob- 
ably the  severest  headaches  it  is  given  human  beings  to  suffer  are  caused  by 
brain  tumors,  exhibiting  every  variety  of  pain — sharp,  cutting,  shooting, 
boring,  or  dull  and  pressing.  At  times  it  is  moderate,  producing  a  sense  of 
discomfort  only.  It  may  be  intermittent  or  constant.  It  may  be  over  the 
entire  head,  or  half  of  it,  or  be  still  more  localized  in  the  forehead  or  back  of 
the  head,  extending  also  from  the  former  over  the  face  and  the  latter  down 
the  neck.  It  may  be  increased  by  mental  excitement  of  any  kind,  by  noise, 
or  by  alcoholic  drink  or  strong  light.  There  may  be  tenderness  on  pressure, 
or  pain  in  percussing  the  head.  The  seat  of  pain  is,  however,  for  the  most 
part,  no  indication  of  the  seat  of  the  tumor,  though  the  presence  of  pain 
limited  to  the  occiput  and  back  of  the  neck  suggests  a  tumor  in  the  posterior 
fossa  of  the  skull,  the  occiput,  or  the  cerebellum.  Localized  pain  on  tapping 
the  skull   is  a  more  reliable  index. 

Vomiting  is  another  characteristic  symptom  of  brain  tumor.  It  may 
occur  independent  of  headache,  but  is  often  associated  with  it.  It  is  further 
characterized  by  being  independent  of  food  ingestion,  may  be  without  nausea, 
and  is  apt  to  be  worse  in  tumors  of  the  cerebellum  and  pons. 

Dizziness  is  also  a  very  frequent  symptom,  and  often  an  early  one.  It 
is  at  times  intermittent,  at  others  constant,  and  it  may  be  so  severe  as  to 
make  it  impossible  for  the  patient  to  walk.  It  is  most  serious  in  tumors  of 
the  posterior  fossa  and  of  the  cerebellum.  Along  with  vertigo  may  be  slozv- 
ing  of  the  pulse. 

Mental  symptoms  may  be  present.  They  may  be  intermittent,  and  vari- 
ously manifested  in  peculiarities  of  temper,  such  as  sullenness,  indifference, 
absent-mindedness,  and  loss  of  memory;  or  the  opposite  condition  of 
maniacal  excitement  or  delirium ;  or  there  may  be  drowsiness  and  even  coma. 
Such  mental  states  may,  indeed,  be  the  only  manifestations  of  tumor. 

Speech. — The  patient  may  talk  slozdy,  and  the  facial  expression  is  some- 
times altered. 

Apoplectic  seizures  and  epileptiform  attacks,  especially  of  the  Jacksonian 
variety,  are  distinctive  symptoms.  The  former  may  be  due  to  hemorrhages 
in  the  tumor  or  around  it,  and  may  be  followed  by  transitory  paralysis  and 
paresis.  Epileptic  convulsions,  especiaUy  if  unilateral,  point,  though  not 
unmistakably,  to  tumors  in  the  hemispheres  impinging  on  the  cortex. 
Choreiform,  movements  are  sometimes  present. 

Choked  disc  or  papillitis  and  optic  neuritis  are  the  most  constant  and 


io;6  DISEASES  OF  THE  NERVOUS  SYSTEM, 

most  valuable  diagnostic  symptoms  of  brain  tumor.  Choked  disc  consists, 
in  brief,  in  a  swelling  of  the  optic  nerve,  with  overdistention  and  congestion 
of  the  retinal  veins,  and  narrowing  of  the  retinal  arteries.  It  is  usually 
bilateral,  rarely  unilateral.  There  is  still  much  difference  of  opinion  as  to 
the  mechanism  of  choked  disc,  but  it  is  thought  by  many  to  be  the  result  of 
intracranial  pressure  forcing  the  cerebrospinal  fluid  from  the  subarachnoid 
space  into  the  lymph  sheath  of  the  optic  nerve,  causing  compression  of  the 
nerve  and  the  vessels  within  it.  The  vision  is  not  necessarily  deranged  in 
choked  disc,  and  its  defects  are  not  uniform,  varying  from  slight  amblyopia 
to  total  blindness.  The  swelling  may  diminish  and  improvement  in  vision 
ensue,  but  retinitis  or  neuroretinitis  may  set  in  with  consequent  nerve  atrophy, 
producing  permanent  impairment  of  vision.  The  choked  disc  is  sometimes 
the  only  symptom,  of  brain  tumor,  and  its  subject  first  consults  the  oculist  for 
relief.  On  the  other  hand,  it  is  not  caused  by  brain  tumor  alone,  but  it  may 
result  from  meningitis  or  abscess,  in  fact  anything  which  produces  intra- 
cranial pressure.  Optic  neuritis  occurs  in  from  80  to  90  per  cent,  of  all  cases 
of  intracranial  tumor.  It  may  be  absent,  even  though  a  brain  tumor  of  con- 
siderable size  exists. 

The  senses  of  s:neil  and  hearing  may  be  impaired  by  tumors  impinging 
on  the  olfactory  or  auditory  nerves,  and  there  may  be  pruritus  and  other 
modifications  of  cutaneous  sensibility ;  also  neuralgic  pains.  If  the  tumor  is 
on  the  floor  of  the  fourth  ventricle,  there  may  be  polyuria  and  glycosuria. 
Finally,  sooner  or  later  the  appetite  may  fail  and  the  nutrition  suft'er, 
although  the  opposite  condition  of  large  appetite  and  good  nutrition  may 
obtain.  In  the  terminal  stage  there  may  be  irregularity  of  breathing 
(Cheyne-Stokes)  and  slowing  of  the  pulse,  while  the  final  issue  is  often  pre- 
ceded by  a  febrile  movement.  The  local  temperature  in  brain  tumor  is  usu- 
ally raised  from  92°  to  95°  F.    (33°  to  34.9°  C),  and  even  98°  F.  (36.7°  C). 

2.  Focal  Symptoms. — These  are  symptoms  peculiar  to  the  seat  of  irrita- 
tion or  destruction,  and  become,  therefore,  of  value  in  diagnosis.  They  are 
the  results  either  of  irritation  or  destruction  of  nervous  tissue,  irritation  caus- 
ing contraction  and  spasm,  while  destruction  causes  paresis  and  paralysis. 
For  convenience  in  localization  the  brain  may  be  divided,  as  in  Fig.  132, 
after  C.  L.  Dana,  into: 

1.  The  prefrontal  area,  including  all  anterior  to  a  line  starting  from  ihe 
upper  end  of  the  ascending  branch  of  the  fissure  of  Sylvius  at  right  angles 
to  another  drawn  between  the  frontal  and  occipital  ends  of  the  brain. 

2.  The  central  region,  bounded  in  front  by  the  line  just  named  and 
behind  by  a  line  limiting  the  posterior  central  convolution  prolonged  down- 
ward to  the  Sylvian  fissure.    ^ 

3.  The  parietal  lobe, 

4.  The  occipital  lobe. 

5.  The  temporal  or  temporosphenoidal  area. 

6.  The  pons  and  medulla  oblongata. 

7.  The  cerebellum. 

The  boundaries  of  these  territories  are  shown,  as  far  as  possible,  in  the 
accompanying  illustration. 

In  addition  there  are:  (8)  The  corpus  callosum;  (9)  the  great  basal 
ganglia  and  capsules ;  ( 10)  the  corpora  quadrigemina,  and  pineal  gland ; 
(11)  the  crura  cerebri ;  (12)  the  base  of  the  brain. 

I.  Tumors  of  the  prefrontal  area,  especially  on  the  right  side,  often  give 
no  localizing  symptoms  whatever,  motor  or  sensory,  w^hile  general  symptoms 


TUMORS  OF  THE  BRAIN. 


1077 


may  also  be  absent  and  the  tumor  truly  latent.  Then,  again,  general  symp- 
toms may  be  well  marked,  including  mental  torpor  and  imbecility,  childish- 
ness, irritability,  and  emotional  phenomena.  These  symptoms  are  the  same 
whichever  si-de  of  the  brain  is  affected.  If  the  tumor  extends  downward 
into  the  inferior  frontal  convolution,  it  may  cause  aphasia ;  or  if  backward,  it 
may  occasion  irritative  spasm  or  destructive  paralysis.  Involvement  of  the 
optic  tract  may  cause  hemianopsia  and  optic  neuritis ;  of  the  olfactory  system, 
anosmia ;  if  the  tumor  invades  the  orbit,  oculomotor  paralysis  and  protrusion 
of  the  eye.     Percussion  tenderness  may  aid  in  localizing  the  tumor. 

2.  Tumors  in  the  central  or  motor  region  may  cause  irritative  lesions, 
resulting  in  spasm.  If  the  tumor  is  in  the  upper  third  of  this  area,  the 
spasm  may  begin  in  the  toes,  in  the  ankles,  or  in  muscles  of  the  leg ;  if  in  the 
middle  third,  spasm  beginning  in  the  fingers,  in  the  thumb,  in  the  muscles 


2.  Localized  spasms  and  epilepsy,  with 
sensory  aurse;  local  palsies,  slight  an- 
esthesia, motor  aphasia,  agraphia. 


I.  No  symptoms 
or  mental  dull- 
ness, irritability, 
chiidishness, 
lack  of  power  of 
attention;  later, 
motor  spasms  or 
paralysis,  anos- 
mia, eye  symp- 
toms. Percus- 
sion tenderness. 


Ascending 
limb  of  fissure 
of  Sylvius. 


3.  No    symptoms  or    mus- 
cular   anesthesia,  aprax- 
oculomotor     ( third 
nerve)      symptoms, 
word     blindness. 
With    deep    lesions, 
anesthesia;    if    the 
lesion  penetrates 
sufficiently  deep, 
hemianopsia. 


4.  Hemian- 
opsia, word- 
blindness,  and 
mind-  blind- 
ness. 


7.     Cerebellar 

ataxia,    vertigo, 

vomiting,    forced 

movements,     occipi- 

,-  tal    headache ;    later, 

zontalL./bulbar  symptoms. 

=   F.of  S. 


6.  Crossed  paralysis; 
of  tongue  and  limbs 
bulbar   palsy. 

Fig.  132. — Showing  Focal  Symptoms  of  Brain  Tumor — {after  Dana). 


of  the  wrist  or  shoulder ;  if  in  the  lower  third,  in  the  muscles  of  the  face,  the 
angle  of  the  mouth,  or  tongue.  In  a  word,  the  phenomena  of  Jacksonian 
epilepsy  are  present.  All  of  these  may  be  preceded  or  associated  with  sen- 
sory disturbance,  such  as  numbness  and  tingling,  and  may  be  limited  to  one 
muscle  group  before  extending  to  another,  constituting  the  "  signal  symp- 
tom "  of  Seguin.  There  may  be  an  aura,  and  the  muscular  sense  is  also 
sometimes  affected. 

Destructive  lesions  cause  paralysis,  and  this  may  have  the  same  dis- 
tribution as  the  convulsions  which  sometimes  precede.  If  on  the  left  side  in 
right-handed  persons,  aphasia  and  agraphia  may  result. 

3.  Tumors  of  the  parietal  area  may  produce  no  symptoms  or  sensory 
and  motor  phenomena,  but  there  may  be  impairment  of  stereagnostic  percep- 
tion.    With  the  involvement  of  the  angular  gyrus  and  lower  parietal  lobule 


I078  DISEASES  OF  TEIE  NERVOUS  SYSTEM. 

may  come  word-blindness  and  mind-blindness.  If  the  tumor  is  upon  or  near 
the  central  area,  spasms  and  paralysis  of  the  various  muscular  groups 
described  under  2  may  develop.  Paralysis  of  the  third  nerve  has  occurred  in 
connection  with  tumors  in  the  neighborhood  of  the  angular  gyrus ;  no  satis- 
factory explanation  for  this  has  been  offered — possibly  it  is  due  to  pressure 
at  a  distance. 

4.  Tumors  of  the  occipital  lobe,  if  in  the  cuneus  or  neighboring  parts, 
may  produce  homonymous  hemianopsia ;  and  if  double,  total  blindness ;  if 
elsewhere  on  the  left  side,  there  may  be  mind-blindness ;  and  if  the  tumor 
extends  also  into  the  angular  gyrus,  word-blindness,  along  with  hemianopsia ; 
if  obtruding  further  forward  into  the  parietal  lobe,  hemianesthesia,  hemia- 
taxia,  and  perhaps  some  hemiplegia  from  involvement  of  the  internal  capsule 
may  occur. 

5.  Tumors  of  the  ternporosphenoidal  area  on  the  right  side  rarely  pro- 
duce symptoms ;  on  the  left  side,  in  the  posterior  part  of  the  first  and  upper 
posterior  part  of  the  second  gyrus,  they  cause  word-deafness.  Disturbances 
of  the  senses  of  smell  and  taste  may  result  from  involvement  of  the  hippo- 
campal  convolution. 

6.  Tumors  of  the  pus  and  medulla  oblongata  produce  two  sets  of 
phenomena : 

(a)  Irritation  or  destruction  of  fibers  in  the  pons  and  medulla  oblongata. 

(&)   Pressure  on  the  nerves  emerging  in  this  region. 

Either  may  occur  alone  or  both  jointly.  Lesions  here  are  especially  apt 
to  produce  alternate  paralysis :  that  is,  involvement  of  the  cranial  nerves  on 
one  side  and  the  limbs  on  the  opposite  side. 

If  the  tumor  is  in  the  cerebral  peduncle,  there  may  be  a  palsy  of  the 
third  nerve  on  the  same  side  and  a  hemiplegia  on  the  opposite  side ;  if  lower 
down  and  in  the  pons,  a  palsy  of  the  fifth  on  the  same  side  and  hemiplegia 
on  the  other ;  if  still  lower  down,  it  may  involve  the  sixth  nerve,  producing 
internal  strabismus,  the  seventh  producing  facial  paralysis,  and  the  eighth 
causing  deafness.  If  the  tumor  is  very  large,  it  may  produce  a  hemian- 
esthesia as  well,  and  there  may  be  forced  movements  of  the  body,  either 
toward  or  from  the  side  of  lesion.  Conjugate  deviation  of  the  eyes  away 
from  the  side  affected  may  also  occur.  This  is  in  direct  contrast  to  the 
conjugate  deviation  sometimes  noticed  in  cerebral  lesions,  in  which  the  head 
and  eyes  are  turned  toward  the  side  of  lesion. 

Tumors  of  the  medulla  oblongata  may  produce  hemiplegia  and  hemi- 
anesthesia, and,  if  the  tumor  is  large,  symptoms  of  bulbar  paralysis.  From 
irritation  of  nerves  on  the  same  side,  the  ninth,  tenth,  eleventh,  and  twelfth, 
■difficulty  in  swallowing,  irregular  action  of  the  heart,  irregular  breathing, 
and  vomiting  may  arise.  Sometimes  also  there  is  retraction  of  the  head,  or 
sensory  symptoms  including  numbness  and  tingling  and  finally  convulsion. 
If  the  cerebellum  is  impinged  upon,  there  may  be  unsteadiness  of  gait. 

7.  Tumors  of  the  cerebellum  produce  very  characteristic  symptoms, 
though  here,  too,  there  may  be  latency  if  the  growth  is  limited  to  the  hemi- 
spheres. If  the  middle  lobe  is  invaded,  vertigo,  vomiting,  headache,  optic 
neuritis,  and  choked  disc,  with  blindness  and  cerebellar  ataxia,  are  present. 
Optic  neuritis  is  more  common  in  cerebellar  than  in  cerebral  tumors.  The 
pressure  causing  choked  disc  is  not  directly  on  the  occipital  lobe  or  optic 
tract,  but  is  generally  on  the  cranial  contents,  and  possibly  interference  with 
the  circulation  of  fluid  in  the  ventricles  causes  pressure  on  the  optic  chiasm 
l»y  means  of  an  excess  of  fluid  in  the  third  ventricle.     More  rarely  nystag- 


TUMORS  OF  THE  BRAIN.  1079 

mus  and  neuralgic  pains  in  the  neck  and  occiput  occur.  The  irregular  and 
staggering  gait  of  cerebellar  ataxia  is  very  striking,  the  patient  reeling  like  a 
drunken  man,  or  he  may  be  thrown  sideways  or  forward,  rarely  backward, 
by  forced  motion. 

If  the  medulla  oblongata  is  compressed  by  the  tumor,  vomiting  from 
this  cause  may  ensue,  also  bulbar  symptoms  and  glycosuria. 

8.  Tumors  of  the  corpus  callosum  are  rare.  The  symptoms  are  similar 
to  those  of  tumors  in  the  third  and  lateral  ventricles  of  the  brain,  extending 
peripherally.  They  cause  general  symptoms  of  brain  tumor,  with  gradually 
developing  hemiplegia,  and  later  paraplegia.  With  this  there  are  mental 
dullness  and  drowsiness  and  indisposition  to  speak.  The  cranial  nerves  are 
not  involved. 

9.  Tumors  of  the  basal  ganglia  and  the  internal  capsule  produce  symp- 
toms similar  to  those  that  occur  in  the  corpus  callosum.  They  are  partly 
pressure  symptoms.  There  is  progressive  hemiplegia,  with  which  there  is 
apt  to  be  hemianesthesia.  Sometimes  there  are  choreic  and  athetoid  move- 
ments if  the  tumor  involves  the  optic  thalamus  and  adjacent  parts  of  the 
internal  capsule.  Tumors  of  the  caudate  nucleus  alone,  or  of  the  lenticular 
nucleus  alone,  are  generally  latent ;  so  are  those  of  the  anterior  three-fourths 
of  the  optic  thalamus,  except  that  choreic  and  athetoid  movements  referred 
to  may  be  noticed,  due  to  irritation  of  fibers  of  the  internal  capsule,  or,  as 
supposed  by  some,  to  irritation  of  the  anterior  cerebellar  peduncle.  Tumors 
in  these  areas  are  very  likely  to  give  pressure  symptoms.  A  large  tumor  of 
the  thalamus  may  involve  the  fibers  of  the  optic  radiation  and  cause  hemian- 
opsia or  sometimes  hemianesthesia.  This  may  be  differentiated  from 
hemianopsia  due  to  lesions  of  the  occipital  lobe  by  the  presence  of  the 
hemianopic  pupillary  reaction,  in  accordance  with  which  a  ray  of  light  thrown 
on  the  insensitive  part  of  the  retina  will  not  produce  a  reflex  contraction  of 
the  pupil.  Optic  neuritis  is  apt  to  be  an  early  symptom  of  tumors  in  this 
vicinity. 

10.  Tumors  of  the  corpora  quadrigemina  usually  involve  the  crura  as 
well.  They  are  characterized  by  inco-ordination,  forced  movements,  and 
oculomotor  palsies,  to  which  may  be  added  hemianopsia  or  blindness  due  to 
destruction  of  the  primary  optic  centers ;  the  pupillary  reflex  is  lost  and  there 
is  nystagmus. 

11.  Tumors  of  the  cms  from  involvement  of  the  third  nerve  are  espe- 
cially characterized  by  oculomotor  paralysis  on  one  (the  same)  side  and 
hemiplegia  on  the  other.     Tumors  of  the  crus  are,  however,  rare. 

12.  Tumors  of  the  base,  if  of  the  anterior  fossa,  produce  symptoms  much 
like  those  of  tumors  of  the  prefrontal  area,  adding,  however,  anosmia  from 
destruction  of  the  olfactory  lobe ;  while  there  may  be  also  involvement  of  the 
optic  and  oculomotor  nerves  and  of  the  orbital  contents.  Tumors  of  the 
middle  fossa  and  of  the  interpeduncular  space  produce  pressure  on  the  optic 
chiasm  with  consequent  neuritis  and  bitemporal  hemianopsia,  by  which  lesions 
of  this  area  are  distinguished  from  those  in  the  anterior  fossa. 

Diagnosis. — This  consists  first  in  the  recognition  of  the  presence  of 
tumor  from  the  general  symptoms,  and  then  the  determination  of  its  loca- 
tion in  either  hemisphere  from  the  focal  symptoms.  The  same  symptoms 
may  be  produced  by  any  agency  cafusing  pressure  on  these  structures. 
Choked  disc,  which  is  so  constant  a  symptom  of  tumor,  may  be  caused  by 
Bright' s  disease,  lead  encephalopathy,  and  anemia.  The  albuminuria,  hyper- 
trophy of  the  right  ventricle,  polyuria,  and  tube-casts  usually  help  to  recog- 


io8o  DISEASES  OF  THE  XERFOUS  SYSTEM. 

nize  the  first.  Other  symptoms  of  lead  poisoning  indicate  that  disease,  and 
the  usual  symptoms  of  anemia  point  to  it.  Meningeal  thickeni)ig,  hemor- 
rhage, aneurysm,  and  abscess  may  also  produce  pressure  symptoms. 

The  nature  of  the  tumor  may  be  determined  in  part  by  what  has  been 
said  of  the  preference  for  certain  localities  and  the  age  of  the  patient,  and 
in  part  by  the  history,  say  of  tuberculosis  or  syphilis  or  primary  growths 
elsewhere.  The  surface  temperature  is  of  uncertain  value  in  diagnosis. 
Death  may  be  sudden,  especially  from  growths  near  the  medulla  oblongata. 
It  is  usually  the  result  of  increasing  pressure.  The  X-ray  has  recently  been 
applied  to  the  diagnosis  of  brain  tumor  with  uncertain  results ;  a  change  in 
the  percussion  note  over  a  tumor  is  also  of  doubtful  value. 

Prognosis. — This  is  generally  unfavorable.  It  is  true  that  in  some  rare 
instances  the  brain  tumors  cease  to  grow  after  a  time.  \"arious  observers 
find  the  ratio  of  removable  tumors  from  5  to  10  per  cent.  Of  1121  cases 
collected  from  different  authors  by  M.  Allen  Starr  in  his  article  on  "  Tumor 
of  the  Brain  ""  in  Dercum's  "  Xervous  Diseases,"  80,  or  4.25  per  cent.,  were 
regarded  as  operable,  but  four-fifths  of  all  persons  operated  on  perish. 
\\'hen  due  to  syphilis,  they  may  in  some  cases  be  melted  away  by  mercurials 
and  iodids.  Calcification  is  a  rare,  but  happy,  temiination  of  tuberculous 
growths.  The  duration  of  tumor  averages  two  or  three  years ;  the  extremes 
average  from  a  month  to  many  years. 

Treatment. — This  is  medicinal,  hygienic,  and  operative.  The  first 
is  limited  in  its  purpose  to  the  cure  of  syphilitic  tumors  and,  perhaps,  in  a 
slight  degree,  to  tuberculous.  The  astonishing  effect  of  the  mercurial  and 
iodin  treatment  upon  syphilitic  new  formations  is  nowhere  so  well  shown  as 
upon  cerebral  gumma.  Unless  syphilis  can  be  excluded  with  absolute  cer- 
tainty, the  iodid  of  potassium  should  be  given  in  any  case  in  ascending  doses, 
limited  only  by  their  effects.  In  the  absence  of  syphilis  the  larger  doses  are 
not  well  borne.  In  addition,  mercury  should  be  used,  at  first  preferably  by 
inunction  until  the  specific  effect  is  produced,  after  which  it  may  be  discon- 
tinued, to  be  renewed  as  indicated.  Instead  of  inunction,  the  bichlorid  may 
be  given  internally  in  doses  of  1-12  grain  (0.005  gm.)  three  times  daily,  or 
until  the  physiological  effects  are  produced.  A\'hen  the  tumor  is  once  under 
control,  it  is  still  necessary  to  keep  up  the  treatment  in  such  doses  as  experi- 
ence may  determine  to  be  necessar}-.  Usually  the  iodid  of  potassium  is  suffi- 
cient for  this  purpose.  When,  however,  the  s}"mptoms  of  tumor  disappear 
and  remain  absent  many  years  under  iodids,  the  diagnosis  of  tumor  may  be 
doubtful.  On  the  other  hand,  I  have  a  patient  in  whom  for  thirty  years  the 
disease  has  been  kept  in  check^by  a  dose  of  sixty  grains  (4  gm.)  a  day,  which 
must  sometimes  be  doubled  for  a  time.  The  evidence  in  this  case  seems  as 
conclusive  as  possible,  since  following  acknowledged  infection  there  occurred 
secondary  symptoms  of  syphilis,  the  full  train  of  classic  symptoms  of  brain 
tumor,  including  ophthalmic  symptoms  studied  by  an  experienced  ophthal- 
mologist. If  mercury  is  necessary  in  this  stage,  the  hiniodid  may  also  be 
used  in  doses  of  from  1-24  to  1-12  grain  (0.0025  to  0.005  gm.),  as  required, 
though  I  have  not  the  confidence  in  it  that  I  have  in  the  separate  use  of  the 
iodid  of  potassium  and  the  bichlorid  of  mercury. 

In  tyroma  the  usual  constitutional  treatment  of  tuberculosis  by  cod-liver 
oil,  iron,  and  other  tonics,  with  nourishing  food  and  healthful  indoor  and 
outdoor  life,  is  to  be  carried  out. 

The  usual  remedies  indicated  to  relieve  pain  are  to  be  used,  bromids, 
if  necessary,  in  large  doses,  phenacetin,   antifebrin,  and  antipyrin.   and,   if 


SUPPURATIVE  ENCEPHALITIS.  1081 

necessary,  morphin.  The  ice-cap  may  be  used,  and,  above  all,  leeching  tried. 
The  most  magical  effect  is  sometimes  produced  by  free  leeching,  though  it  is 
unfortunately  temporary.  Other  symptoms  should  be  treated  by  appro- 
priate remedies. 

The  hygienic  treatment  is  of  the  greatest  importance.  Excesses  of  every 
kind  should  be  avoided,  alcohol  should  be  rigidly  excluded,  as  well  as  all 
sexual  excitement  and  mental  excitement  of  any  kind,  for  the  slightest  incre- 
ment of  blood  in  the  brain  may  bring  on  a  convulsion  and  cause  death. 

Exploratory  operation  being  much  less  dangerous  than  formerly,  with 
the  aseptic  precautions  of  the  present  day,  should  be  made  whenever  the 
tumor  can  be  localized  with  any  approach  to  accuracy.  Although  cerebral 
localization  has  been  developed  to  a  very  high  degree,  it  must  still  happen 
that  we  frequently  fail  to  locate  a  tumor  accurately. 


SUPPURATIVE  ENCEPHALITIS. 

Synonyms. — Suppurative  Iniiammation  of  the  Brain;  Cerehritis;  Abscess 

of  the  Brain. 

Definition. — By  encephalitis  is  meant  inflammation  of  the  substance  of 
the  brain  as  contrasted  with  inflammation  of  its  membranes.  What  is  spoken 
of  as  inflammation  of  the  brain  in  popular  parlance  is  really  inflammation 
of  the  membranes  of  the  brain,  or  meningitis.  A  literal  application  of  the 
term  is  here  intended. 

Etiology. — The  causes  of  cerebritis  are:  (i)  Traumatic;  (2)  an  adja- 
cent focus  of  inflammation  extending  to  the  brain  substance;  (3)  pyemia. 

Under  traumatic  causes  are  included  blows  upon  the  head  and  falls, 
more  commonly  those  attended  by  fracture  or  punctured  wound ;  although 
it  is  not  necessary  that  there  should  be  even  a  scratch  upon  the  skin. 

Under  adjacent  disease,  whence  extension  of  inflammation  is  especially 
frequent,  is  to  be  included  caries  of  the  petrous  portion  of  the  temporal 
bone  due  to  disease  of  the  middle  ear  or  labyrinth,  the  most  common  of  all 
causes  of  abscess  of  the  brain.  Disease  of  the  orbit  or  of  the  nasal  pas- 
sages is  another  focus  of  the  same  kind.  The  route  of  such  a  communica- 
tion may  be  through  either  the  sinuses  of  the  brain  or  the  lymph  paths. 

Pyemic  abscess  of  the  brain  is  rare.  Causal  foci  are  malignant  en- 
docarditis, gangrene  of  the  lung,  chronic  bronchitis  with  bronchiectasis,  bone 
disease,  suppuration  of  the  liver,  and  the  specific  fevers,  among  which  may  be 
included  la  grippe. 

Encephalitis  occurs  most  frequently  between  the  ages  of  ten  and  forty, 
and  about  three  times  as  often  in  the  male  sex  as  in  the  female. 

Morbid  Anatomy. — Abscesses  of  the  brain  are  usually  solitary, 
though  there  may  be  two  or  three,  or  even  more.  The  abscesses  may  be 
from  one-half  to  three  inches  (i  to  8  cm.)  in  diameter,  rarely  more,  though 
an  entire  lobe  has  been  involved.  The  abscess  itself  is  a  very  interesting 
product.  Unless  very  recent,  it  is  surrounded  by  a  distinct  wall  which  is 
composed  of  three  layers.  The  inner  is  smooth,  made  up  for  the  most  part 
of  granular  fatty  cells.  Outside  of  ^his  is  a  layer  of  germinal  tissue  con- 
taining spindle  cells  and  more  perfect  fibrillated  tissue.  Externally  again 
is  another  layer  of  fatty  cells.  The  pus  within  the  abscess  is  usually  green- 
ish-yellow in  color  and  acid  in  reaction,  while  its  corpuscles  are  distinctly 


io82  DISEASES  OF  THE  NERVOUS  SYSTEM. 

nucleated.  The  cone  outside  of  the  abscess  is  edematous,  the  cells  are  swol- 
len, sometimes  disintegrated,  with  blood  points  scattered  throughout,  becom- 
ing sparser  as  the  periphery  is  extended. 

The  locality  of  the  abscess  is  preceded  by  the  condition  known  as  red 
sojtening,  which  is  often  spoken  of  as  the  first  stage  of  the  inflammation,  but 
it  is  most  important  to  remember  that  red  softening  is  not  peculiar  to 
abscess.  It  consists  simply  of  brain  substance  broken  down  into  a  reddish, 
blood-stained  pulp.  In  this  substance  are  found  fragments  of  nerve-fibers, 
drops  of  myelin,  pus-corpuscles,  and  granular  fatty  cells.  The  termination 
of  cerebritis  is  not  always  in  abscess.  It  is  barely  possible,  before  the  stage  of 
abscess  is  reached,  for  a  condition  of  yellozi'  softening  to  supervene,  and  the 
so-called  apoplectic  cyst  may  be  the  final  result,  or  even  cicatricial  tissue 
may  develop. 

The  cerebrum  is  involved  four  times  as  often  as  the  ^cerebellum,  the  left 
hemisphere  more  frequently  than  the  right,  and  the  temporo-sphenoidal  lobe 
more  than  any  other.  The  cause  has  something  to  do  with  the  location : 
Ear  disease  places  the  abscess  in  the  temporal  lobe  or  cerebellum ;  if  in  the 
tympanum,  the  cerebrum  rather  than  the  cerebellum ;  if  the  mastoid  cells 
and  labyrinth,  the  cerebellum. 

Symptoms. — ^^"hile  inflammation  of  the  brain  is  spoken  of  as  acute 
and  chronic,  more  strictly  speaking  it  is  rather  primary  and  delayed,  the 
symptoms  of  the  so-called  chronic  form  being  essentially  the  same  as  those 
of  acute  cerebritis,  but  characterized  by  their  late  appearance  after  the  cause 
\vhich  precedes  them.  In  acute  cases  the  symptoms  develop  rapidly  and 
may  run  their  course  in  a  few  days,  while  in  the  forms  known  as  chronic 
the  symptoms  are  scarcely  less  rapid  after  they  once  set  in,  which  may  be 
weeks,  months,  and  even  longer,  after  the  operation  of  the  cause. 

These  symptoms  are  the  result  of  pressure, — direct  or  indirect, — 
of  destruction  of  the  brain  substance,  or  of  poisoning  due  to  absorption  of 
putrid  matter.  They  are  much  the  same  as  those  of  meningitis,  with  which, 
indeed,  abscess  is  often  associated,  especially  if  there  is  injury.  The  most 
striking  are  headache,  often  severe  and  persistent;  vomiting;  vertigo;  mental 
dullness,  succeeded  sometimes  by  delirium  and  sometimes  by  coma.  Con- 
vulsions  are  often  present,  and  are  epileptoid  in  character.  Optic  neuritis  is 
also  one  of  the  symptoms.  There  is  usually  fever,  as  shown  by  elevation 
of  temperature.  At  other  times  the  temperature  is  normal  or  subnormal. 
The  pulse  is  usually  slow — from  sixty  to  seventy.  The  symptoms  may  set 
in  with  a  chill  after  the  latent  period.  The  toxic  symptoms  are  those  usual 
to  toxic  states — viz.,  chill,  irregular  fever,  prostration,  emaciation,  exhaus- 
tion. Paralysis  in  the  form  of  hemiplegia  sometimes  occurs.  The  paralvsis, 
however,  is  not  always  hemiplegic,  and  may  be  limited  to  the  arm  and  face, 
especially  in  abscess  of  the  temporo-sphenoidal  lobe,  which  may  compress  the 
internal  capsule.  If  on  the  left  side,  there  may  be  aphasia.  Other  cranial 
nerves  beside  the  optic  are  sometimes  involved. 

When  the  abscess  is  in  the  parieto-occipital  region,  there  mav  be  hemi- 
anopsia. It  is  especially  in  abscess  of  the  cerebellum  that  vomiting  occurs, 
and  staggering  if  the  middle  lobe  is  affected. 

Of  the  chronic  form  it  has  already  been  said  that  the  symptoms,  though 
long  delayed,  are  the  same  as  those  of  the  acute  form.  Such  delay,  how- 
ever, does  not  always  cover  all  symptoms,  since  during  the  latent  stage  the 
patient  may  have  headache  or  vertigo  in  a  mild  degree,  and  especially  may 
he  be  irritable  and  depressed,  while  he  may  even  have  a  convulsive  seizure 


SUPPURATIVE  ENCEPHALITIS.  1083 

during  this  preliminary  period.  It  occasionally  happens  that  there  are  n6 
symptoms  at  all,  and  cases  have  occurred,  more  particularly  of  abscess  in 
the  frontal  lobe,  in  which  there  were  no  signs  or  symptoms  before  death. 
Phlebitis  of  the  superior  petrosal  and  lateral  sinuses  is  especially  com- 
mon when  the  abscess  is  caused  by  disease  of  the  ear,  since  the  former  re- 
ceives a  vein  from  the  internal  ear,  and  the  latter  receives  the  mastoid  veins. 
Edema  about  the  car  and  neck  and  hardness  of  the  jugular  veins  should  sug- 
gest phlebitis,  while  rigidity  of  the  neck  and  cranial  nerve  paralysis  even 
more  unerringly  point  to  meningitis. 

Diagnosis. — This  is  easy  in  acute  cases,  being  substantiated  by  the 
history  of  injury,  rigor,  and  fever,  followed  by  the  brain  symptoms  described. 
Almost  as  certain  is  the  diagnosis  when  such  symptoms  follow  chronic 
ear  disease  or  localized  putrid  lung  disease.  It  is  to  be  remembered,  how- 
ever, that  general  cerebral  symptoms  may  be  produced  by  pus  in  the  middle 
ear.  These  should  be  treated  by  puncture  of  the  tympanum,  and  should 
the  symptoms  persist,  after  puncture  abscess  may  be  suspected.  In 
like  manner  meningitis  and  abscess  may  be  confounded,  and  with  reason, 
because,  in  the  first  place,  meningitis  may  be  produced  by  the  causes  that 
produce  abscess ;  and,  second,  meningitis  may  be  caused  by  abscess,  and 
both  may  occur  together.  Meningitis,  however,  affects  the  cranial  nerves 
more  than  abscess,  unless  the  abscess  is  seated  in  the  pons,  and  usually  men- 
ingitis succeeds  more  promptly  upon  its  cause.  It  is  to  be  remembered  that 
tumor  of  the  brain  may  produce  symptoms  identical  with  those  described. 
The  chief  distinctive  symptom  in  abscess  is  the  presence  of  fever. 

Prognosis. — This,  unless  we  admit  a  curable  form  described  by  Striim- 
pell,  is  always  ultimately  fatal  unless  we  have  the  rare  good  fortune  to  reach 
it  with  the  trephine. 

Acute  cases  last  from  eight  to  fourteen  days,  rarely  thirty  days ;  the 
delayed  cases  may  not  show  their  first  symptoms  for  months.  In  the  curable 
form  referred  to,  Striimpell  says  pronounced  symptoms  of  focal  disease  exist 
for  a  time  and  suggest  a  tumor,  but  after  some  months  or  even  a  longer 
time  they  gradually  abate,  and  recovery  is  complete.  The  nature  of  the 
symptoms  is  such  as  to  suggest  a  seat  in  the  cortex,  for  there  is  usually 
paresis  of  some  part  of  the  body,  often  associated  with  symptoms  of  motor 
irritation  and  impairment  of  speech. 

Treatment. — A  certain  prophylaxis  may  be  exercised  in  the  proper 
treatment  of  disease  of  the  ear,  for  it  is  often  the  neglect  of  this  which  leads 
to  the  abscess.  Such  prophylaxis  includes  measures  which  secure  free  dis- 
charge and  antisepsis.  Beyond  this  the  only  treatment  for  abscess  which 
promises  anything  toward  a  favorable  result  is  operation,  on  which  account 
the  surgeon  should  be  promptly  associated  in  the  treatment  of  the  case. 
The  use  of  the  trephine  has  saved  a  few  cases.  For  the  details  of  the  oper- 
ation the  student  is  referred  to  text-books  on  surgery. 

Encephalitis  witout  Abscess. — When,  on  the  other  hand,  inflamma- 
tion of  the  surface  of  the  brain  accompanying  meningitis  is  eliminated,  and, 
on  the  other,  softening  of  the  brain,  formerly  thought  to  be  the  result  of  in- 
flammation, but  now  known  to  be  due  to  the  arrest  of  blood  supply,  a  number 
of  cases  of  encephalitis  without  abscess  remain,  in  some  of  which  a  necropsy 
was  obtained. 


io84  DISEASES  OF  THE  NERVOUS  SYSTEM. 


CHRONIC  HYDROCEPHALUS. 

Definition. — A  collection  of  serous  fluid  either  between  the  meninges 
or  in  the  ventricles  of  the  brain.  The  former  constitutes  intermeningeal 
hydrocephalus,  or  hydrocephalus  extenms,  or  hydrocephalus  ex  vacuo.  The 
latter  is  ventricular  hydrocephalus,  or  hydrocephalus  internus.  The  seat  of 
effusion  in  hydrocephalus  externus  may  be  either  in  the  subdural  space — 
i.  e.,  between  the  dura  mater  and  the  arachnoid — or  in  the  subarachnoid  space. 
The  first  was  formerly  regarded  as  the  most  frequent ;  later  its-  occurrence 
came  to  be  denied,  but  more  recently,  by  means  of  frozen  brain  sections,  it 
has  been  demonstrated.  Since  the  subarachnoid  space  communicates  with 
the  ventricles  of  the  brain,  the  two  forms  of  hydrocephalus  may  coexist. 
Both  external  and  internal  hydrocephalus  may  be  diffuse  or  circumscribed. 
When  circumscribed  there  result  in  the  case  of  the  former  cystic  spaces  in 
the  membranes,  and  in  the  latter  vesicular  distention  of  portions  of  the 
ventricles. 

External  Hydrocephalus  occurs  in  connection  with  atrophy  of  the 
brain,  and  is  not  of  much  clinical  importance. 

Internal  Hydrochephalus. 
This  is  divided  into  congenital  and  acquired. 

Congenital  Hydrocephalus. — This  pre-exists  before  birth,  and  may  be 
present  to  such  a  degree  as  to  retard  the  birth  of  the  head.  More  frequently 
it  is  not  recognized  until  some  time  after  birth. 

Etiology. — This  cannot  be  said  to  be  certainly  known.  Virchow  early 
ascribed  it  to  inflammation  of  the  ependyma;  Rindfleisch  rather  to  an  ob- 
struction to  the  circulation  in  the  choroid  plexus.  Drunkenness  and  syphilis 
in  parents,  and  accidents  in  pregnancy,  are  held  responsible ;  occasionally, 
also,  tumors  of  the  brain.  More  than  one  child  in  a  family  is  sometimes 
affected. 

Morbid  Anatomy. — The  head  is  characterized  externally  by  its 
spherical  shape  and  large  size,  its  smooth  eyebrows  and  protruding  eyes,. 
the  last  being  due  to  depression  of  the  orbital  plate  of  the  frontal  bone.  It 
is  often  so  great  that  the  eyelids  cannot  close  over  the  eyes.  The  size  of 
the  head  thus  obtained  is  often  enormous — from  eight  to  ten  inches  (20  to 
25  cm.)  in  diameter  in  a  child  of  three  or  four  years.  On  the  other  hand,  the 
face  appears  very  small.  On  closer  examination  the  cranial  bones  are  found 
separated  and  exceedingly  thin,  at  times  almost  as  thin  as  paper.  In  the 
membranous  interspaces  are  often  found  Wormian  boues.  The  veins  may  be 
seen  beneath  the  skin,  and  fluctuation  may  sometimes  be  obtained  through  the 
scalp.  On  incising  the  brain  a  variable  quantity  of  limpid  fluid  passes  out. 
The  quantity  is  sometimes  enormous,  reaching  twenty  pounds  (40  kilos)  or 
more.  The  cerebral  cortex  is  greatly  thinned,  the  thickness  on  the  convex- 
ity being  reduced  to  but  a  few  millimeters.  The  gyri  and  the  basal  ganglia 
are  compressed,  and  the  ventricles  are  dilated.  The  commissures  are  stretched 
and  even  torn.  The  foramen  of  Monro  is  a  wide  opening,  and  the  third  ven- 
tricle is  dilated  and  sometimes  also  the  fourth.  Tlie  ependyma  is  thickened,, 
the  choroid  plexuses  are  vascular,  sometimes  little  changed. 


CHRONIC  HYDROCEPHALUS.  1085 

Symptoms. — These  consist  largely  of  the  external  morbid  states  just 
described,  but  in  addition  there  is  slowness  of  physical  and  mental  develop- 
ment. The  child  learns  to  walk  late  and  is  very  feeble  and  apt  to  be  men- 
tally deficient,  although  it  is  sometimes  bright.  Convulsions  may  occur  and 
the  reflexes  be  increased. 

Diagnosis  and  Prognosis. — The  rachitic  head  may  be  mistaken  for 
the  hydrocephalic,  but  the  latter  has  not  the  broad  forehead  with  prominent 
frontal  eminences ;  it  is  rather  spherical  and  smooth.  The  congenital  case 
rarely  lives  to  be  more  than  four  or  five  years  old,  though  it  may  attain  adult 
life. 

Acquired  Hydrocephalus. — Etiology. — This  is  also  commonly  ascribed 
to  some  inflammatory  process,  although  it  is  said  to  be  sometimes  idiopathic. 
Especially  is  it  a  consequence  of  suppurative  and  tuberculous  meningitis, 
when  it  is  spoken  of  as  acute  acquired  hydrocephalus,  though  chronic  inflam- 
matory processes  may  also  cause  it.  Derangements  in  the  circulation  in  the 
choroid  plexus  a»d  in  the  ependyma  of  the  ventricles  may,  however,  be 
responsible.  Especially  may  a  tumor  in  the  third  ventricle,  at  the  base  of 
the  brain,  pressing  upon  the  venae  Galeni  or  on  the  straight  sinus  of  the 
dura  mater,  be  a  cause ;  or  closure  of  the  foramen  of  Monro,  by  which  the 
ventricles  communicate  with  the  membranous  spaces.  Even  lung  or  heart 
affections  and  growths  in  the  mediastinum  and  neck  may  produce  the  needed 
obstruction. 

Morbid  Anatomy. — In  cases  of  acquired  hydrocephalus,  even  though 
beginning  tolerably  early  in  life, — say  the  seventh  year, — as  well  as  in 
adults,  the  skull  does  not  necessarily  expand,  and  the  head  may  not  enlarge. 
Indeed,  the  head  may  even  be  smaller  than  natural,  as  in  cretins.  In  these 
instances  the  brain  substance  must  yield,  and  is  reduced  in  thickness,  at 
times  to  a  few  millimeters  only.  In  other  cases  the  skull  yields,  its  plates 
become  thin,  the  fontanels  grow  larger,  and  an  appearance  like  that  of  con- 
genital hydrocephalus  may  result. 

Symptoms. — The  symptoms  of  acute  acquired  hydrocephalus  are  never 
distinctive,  on  account  of  the  rapidity  in  the  course  of  the  disease  which  pro- 
duces and  obscures  it. 

Of  chronic  acquired  hydrocephalus  the  most  striking  symptom  is,  as  a 
rule,  the  marked  distortion  in  the  size  and  shape  of  the  head  already  described. 
The  weight  of  the  head  is  sometimes  so  great  that  it  inclines  to  fall  to  the  side 
or  backward  or  forward,  and  must  be  supported  by  the  hands  of  the  pa- 
tient. Other  symptoms  may,  at  times,  be  decidedly  delayed,  and  the  child 
may  make  some  progress  in  studies.  At  times  there  is  early  headache. 
Signs  of  mental  imbecility  sooner  or  later  make  their  appearance,  manifested 
first,  perhaps, — as  in  congenital  hydrocephalus, — by  absence  of  develop- 
ment, but  progressing  until  the  child  lives  an  almost  vegetative  existence, 
having  to  be  fed  and  cared  for  like  an  infant,  even  though  several  years  old. 
There  may  be  conznilsive  contractions,  tremors,  ataxic  gait,  paresis,  and  paral- 
ysis;  in  fact,  all  the  symptoms  which  succeed  on  irritative  and  destructive 
lesions  of  the  nervous  system.  The  symptoms  of  tumor  of  the  brain  may 
be  quite  closely  simulated,  especially  when  the  cranium  does  not  enlarge 
with  the  growing  distention  of  the  yentricles.  There  may  be  choked  disc, 
atrophy  of  the  optic  nerve,  and  total  blindness.  There  may  be  prolonged 
attacks  of  drowsiness,  or  coma,  with  slow  pulse,  while  sudden  death  is  not 
uncommon  during  epileptiform  convulsions  or  apoplexy. 


io86  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Spontaneous  evacuation  of  the  fluid  sometimes  takes  place  by  the  nose, 
mouth,  ear,  or  orbit. 

Diagnosis.— This  is  commonly  easy.  It  is  only  in  cases  in  which  the 
cranium  does  not  expand  that  the  symptoms  of  brain  tumor  may  lead  to  a 
diagnosis   of  the   latter   condition    instead  of   hydrocephalus. 

Prognosis. — This  is  usually  unfavorable.  Generally  the  child  lives 
from  two  to  five  years,  though  it  may  perish  in  a  few  months  or  live  for 
from  ten  to  fifteen  years,  or,  as  in  a  case  of  Bright's,  to  twenty-nine  years, 
or  even  longer.  It  has  happened  that  spontaneous  recovery  has  followed  the 
evacuation  of  fluid  previously  described.  The  absorption  of  small  amounts 
of  fluid  is  also  possible. 

Treatment. — This  consists  primarily  in  the  treatment  of  the  disease 
which  is  responsible  for  the  hydrocephalus  if  it  can  be  discovered ;  sec- 
ondly, in  the  treatment  of  the  symptoms  which  may  arise,  and  next,  in 
attempts  to  cure  the  malady.  Some  favorable  results  have  followed  the 
removal  of  the  fluid  by  puncture  of  the  ventricles,  although  there  has  been 
failure  in  the  majority  of  instances.  Measures  should  be  taken  to  make 
the  removal  gradual,  if  possible,  thus  attempting  to  imitate  the  spontaneous 
efforts  of  nature,  which  have  occasionally  been  followed  by  recovery.  To 
this  end  the  slow  removal  of  the  fluid — by  puncture  of  the  subarachnoid 
space  between  the  third  and  fourth  lumbar  vertebrse^ias  been  recommended 
and  practiced  by  Quincke.  At  this  point,  too-,  the  spinal  cord  is  not  very 
likely  to  be  injured.  It  is  more  particularly  in  congenital  hydrocephalus  that 
operation  is  indicated. 

If  operation  is  deemed  undesirable,  attempts  may  be  made  to  get  rid 
of  the  fluid  by  diuretics  and  purgatives,  although  with  little  prospect  of 
success.  lodid  of  potassium  may  be  tried,  with  the  faint  hope  that  the  hy- 
drocephalus is  due  to  a  syphilitic  tumor  which  might  thus  be  melted  away. 
Blisters  may  also  be  applied. 


ACUTE  DELIRIUM.  1087 


GENERAL   AND    FUNCTIONAL    DISEASES— NEUROSES. 

The  term  neuroses  is  applied  to  nervous  affections  in  which  there  are 
functional  disturbances  corresponding  to  which  there  is  no  known  anatomical 
lesion. 


ACUTE    DELIRIUM. 

Synonym. — Bell's  Mania. 

Definition. — An  acute  and  violent  febrile  delirium  of  unknown  cause 
and  undetermined  lesion,  running  a  course  of  from  two  to  three  weeks,  and 
usually  fatal. 

Historical. — The    disease  was  first  described  in    1849  by   Luther   Bell,    of  the 
McLean  Asylum. 

Symptoms. — These  set  in  suddenly  and  consist  in  violent,  active  deli- 
rium,  in  which  the  patient  talks  and  moves  incessantly,  with  a  speech  that  is 
incoherent  and  unintelligible  and  movements  which  are  aimless  and  irresist- 
ible or  rhythmical  as  though  with  a  purpose.  This  is  kept  up  for  hours 
and  hours,  notwithstanding  the  use  of  the  most  powerful  anodynes,  until 
the  patient  becomes  exhausted,  the  whole  presenting  a  picture  which  is  at 
once  revolting  and  pitiable.  At  times  sleep  is  obtained  for  an  hour  or  two, 
but  immediately  on  waking  the  active  movements  and  delirium  begin.  The 
rhythmical  movements  may  be  like  those  oi  the  salaam  convulsions,  up  and 
down,  as  of  one  chopping  wood  or  working  a  pump-handle.  Throughout 
there  is  high  fever,  the  temperature  ranging  from  102°  to  104°  F.  (38.9°  ta 
40°  C). 

The  tongue  is  dry,  the  pulse  rapid  and  feeble,  the  skin,  in  like  manner, 
dry  and  often  covered  with  petechial  spots  or  pustules  and  bullae  or  bruises, 
the  result  of  the  violent  acts  of  the  patient.  There  seems,  however,  no  pain, 
or  tenderness  other  than  is  due  to  these  causes. 

Morbid  Anatomy.— As  stated  in  the  definition,  there  is  nothing  defi- 
nite. There  may  be  venous  engorgement  of  the  meningeal  veins  and  of 
the  cerebral  cortex,  with  perivascular  exudation  and  cellular  infiltration  of 
the  lymph  sheaths  and  perivascular  spaces.  There  is  often  engorgement 
of  the  bases  of  the  lungs,  and  deglutition  pneumonia  has  been  found. 

Diagnosis. — At  first  the  disease  may  be  mistaken  for  any  of  the  acute 
fevers  which  sometimes  begin  with  violent  delirium,  especially  for  typhoid, 
but  the  course  of  the  temperature  and  absence  of  other  distinctive  symp- 
toms soon  eliminate  any  doubt. 

The  same  may  be  said  of  certain  fonns  of  puerperal  mania,  and  more 
rarely  pneumonia  of  the  meningeal  type  and  of  cerebral  meningitis  itself. 
The  incessant  violence  is,  however,  peculiar  to  Bell's  mania. 

Prognosis. — This  is  almost  always  fatal. 

Treatment. — This  must  consist  of  measures  to  control  the  mania,  of 
which  hypodermic  injections  of  morphin  are  almost  alone  efficient,  and 
these  often  only  feebly  so.  Chloroform  or  ether  must  sometimes  be  em- 
ployed, because' of  the  dangerous  doses  of  morphin  which  seem  necessar>^ 


io88  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Blood-letting  has  apparently  been  of  service  in  some  cases,  and  there  cer- 
tainly is  no  contra-indication  to  it  in  the  early  stage  of  most  cases,  the  patients 
being  commonly  very  strong  and  vigorous.  The  cold  bath  may  be  employed, 
but  is  not  an  easy  treatment  to  carry  out,  because  of  the  difficulty  in  con- 
trolling the  patient. 

PARALYSIS  AGITANS. 

Synonyms. — Chorea   scelotyrbe   she   festinans    (Sauvages)  ;    Chorea   pro- 
cur  siva  (Bernt)  ;  Shaking  Palsy;  Parkinson's  Disease. 

Definition. — A  chronic  nervous  disease  characterized  by  muscular 
weakness,  tremor,  or  shaking  in  the  extremities,  muscular  rigidity,  and  for- 
ward-bent gait. 

Historical. — The  disease  was  first  fully  described  by  Parkinson,  of  London,  in 
1817,  so  accurately  that  nothing  of  importance  has  since  been  added  to  his  description. 

Etiology. — Shaking  palsy  is  commonly  a  disease  of  the  second  half 
•of  life,  but  occasionally  occurs  between  thirty  and  forty,  and  has  been  ob- 
served as  early  as  the  twentieth  year.  It  is  a  little  less  frequent  among 
women  than  men — 11  to  14.  Among  the  causes  held  responsible  for  it  are 
exposure  to  cold  and  wet,  fright,  mental  excitement,  business  worry,  injury, 
— whether  to  nerves  or  other  parts  of  the  body, — alcoholism,  sexual  excesses, 
and  the  infectious  diseases,  including  malaria,  while  heredity  is  said  to  have 
a  certain  influence.  The  etiology  of  the  disease  is  largely  a  matter  of  con- 
jecture and  inference.  Perhaps  exposure  to  cold  is  the  best  determined 
■cause. 

Morbid  Anatomy. — This  is  unknown  so  far  as  essential  lesions  are 
concerned.  Various  lesions  have  been  described,  while  the  brain,  spinal 
cord,  and  peripheral  nerves  of  the  most  typical  cases  have  been  examined 
with  results  not  entirely  satisfactory. 

As  the  phenomena  are  similar  in  kind,  if  not  in  degree,  to  those  of 
senility,  it  is  held  by  Dubief,  Borgherini,  Roller,  Sass,  Jacobson,  Ketscher, 
and  Sanders  that  they  have  for  their  anatomical  basis  the  lesions  of  senility 
somewhat  intensified,  and  differs  from  true  senility  only  in  its  earlier 
onset.  Most  recent  studies  conclude  that  this  is  not  the  case,  and  that  paral- 
ysis agitans  is  a  disease  siii  generis,  although  there  are  many  changes  in  the 
spinal  cord,  brain,  and  nervous  system  which  are  common  to  the  two  affec- 
tions, consisting  essentially  in  increase  in  interstitial  tissue  and  proliferation 
of  neuroglia  in  the  spinal  cord,  medulla  oblongata,  pons,  and  the  motor  cor- 
tex in  a  less  degree.  Charles  L.  Dana*  says :  "  The  most  logical  conclusion 
one  can  reach  is  that  in  paralysis  agitans  there  is  early  a  functional  disturb- 
ance and  later  a  destruction  and  degeneration  of  the  dendrites  of  the  anterior 
horn  cells  which  interfere  with  the  even  flow  of  motor  impulses,  and  finally 
lead  to  motor  weakness  and  rigidity,  owing  to  the  cell  being  practically  cut 
off  from  the  brain."  Dana  continues :  "  The  difference  between  this  con- 
dition and  that  found  m  spastic  paraplegia  due  to  a  sclerosis  of  the  voluntary 
motor  tracts  is  manifest,  for  there  the  dendrites  of  the  anterior  horns  which 
subserve  reflex  purposes  are  normal,  while  in  paralysis  agitans  all  are  some- 
Avhat  affected.  The  rigidity  of  this  disease  is  much  like  that  found  late 
after  total  transverse  cord  lesions." 

*  "Paralysis  Agitans  and  Sarcoma,"  "  Am.  Jour,  of  the  Med.  Sci.,"  November,  1899. 


PARALYSIS  AGITANS.  1089 

H.  C.  Gordinier,*  on  the  other  hand,  says  the  primary  seat  of  the 
pathological  changes  is  in  the  blood-vessels,  starting  with  an  endarteritis 
and  peri-arteritis  and  consequent  proliferation  of  the  neuroglia  in  the  immedi- 
ate neighborhood,  with  the  production  of  patches  of  perivascular  sclerosis, 
which  are  characteristic  of  the  disease.  Also  that  "  the  alterations  which 
have  been  observed  in  the  nerve-cells  of  the  anterior  cornua  and  cranial 
nerve  nuclei,  together  with  the  shght  changes. in  the  cells  of  the  motor  cor- 
tex, are  secondary,  due,  in  all  probability,  to  a  gradual  diminution  of  nutri- 
tion dependent  on  the  vascular  changes."  The  truth  is,  the  pathology  of  this 
disease  is  unknown,  and  is  at  present  a  subject  for  speculation. 

Symptoms. — The  disease  is  not  a  very  rare  one  in  this  country,  and 
the  county  almshouses  almost  always  contain  one  or  more  cases — easily 
recognized  by  the  characteristic  shaking  or  tremulousness  of  the  hand. 
Though  commonly  gradual  in  onSet,  the  symptoms  may  come  on  quite 
suddenly,  and  at  first  only  after  exertion.  Indeed,  there  may  even  be  a 
prodrome  in  the  shape  of  neuralgic  pains,  paresthesia,  dizziness,  and  the  like. 
The  more  sudden  cases  follow  fright  or  trauma.  The  tremor  is  most  marked 
in  the  fingers  and  hands,  where  it  commonly  begins,  and  whence  it  extends 
to  the  arms  and  lower  extremities.  The  upper  arm  muscles  are  rarely  in- 
volved. It  most  frequently  passes  from  the  right  arm  to  the  right  leg,  thence 
into  the  left  arm,  and  thence  into  the  left  leg ;  or  the  course  may  be  crossed — 
that  is,  from  the  right  arm  to  the  left  leg.  It  may  remain  in  one  limb  to  the 
exclusion  of  the  others.  In  the  fingers  the  movement  between  the  thumb 
and  index-finger  is  frequently  that  of  rolling  pills,  but  the  movement  may 
not  always  be  characteristic.  At  the  wrist  that  of  pronation  and  supination. 
In  the  feet  it  is  most  marked  at  the  ankle-joint.  It  affects  the  writing,  mak- 
ing it  trembling,  as  in  the  aged,  and  ultimately  it  becomes  impossible  to 
write.  The  muscles  of  the  head  and  face  are  last  involved,  sometimes  not  at 
all,  and  when  present,  the  motion  is  vertical  and  quite  rhythmical,  usually 
about  five  times  in  a  second.  At  first  the  tremor  ceases  during  sleep,  but 
continues  during  the  waking  state  even  when  the  muscles  are  at  rest,  but 
tiltimately  it  continues  also  even  during  sleep — in  fact,  sleep  is  sometimes 
prevented  thereby.  It  frequently  is  partially  arrested  by  voluntary  motion 
and  is  increased  by  emotion.  Should  rigidity  become  excessive,  the  motion 
mav  cease. 

The  rate  of  tremor  varies  greatly,  being  at  first  slower,  and  increases 
in  rapidity  as  the  disease  advances.  Roughly,  it  may  be  put  down  at  from 
three  to  five  times  a  second.  There  may  be  intermissions  of  the  tremor  of 
days  and  even  weeks.  isiKq 

Muscular  weakness  is  a  less  striking  symptom,  but  may  be  estimated 
by  the  dynamometer,  arid  increases  with  the  duration  of  the  disease  and  the 
intensity  of  the  tremor.  It  is  most  striking  at  least  in  the  extensor  muscles, 
the  flexors  being  disposed  to  rigidity  and  spasm,  which  eatly  produce  a 
slowness  and  stiffness  of  motion  which  is  characteristic.  It  is  this  flexor 
spasm  which  brings  the  thumb  and  forefinger  into  the  writing  or  pill- 
rolling  position.  At  other  times,  hyperaction  of  the  interossei  muscles  over 
that  of  the  common  extensors  of  the  fingers  results  in  the  position  so  char- 
acteristic of  arthritis  deformans — that  is,  with  the  first  phalanx  bent,  the 
second  extended,  and  the  terminal  phalanx  also  bent.  Ultimately  extension 
is  impossible.     Occasionally  the  opposite  state  of  fixed  extension  exists^.  -'•"''• 

*  "  The  Pathology  of  Paralysis  Agitans,"  December,  1899. 
69 


I090  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  attitude  and  gait  ultimately  assumed  by  the  subject  of  shaking- 
palsy  are  also  the  result  of  rigidity,  which  sooner  or  later  affects  most  of  the 
muscles.  The  head  is  bent  forward,  the  back  is  bowed,  the  arms  are  held 
away  from  the  body  and  flexed  at  the  elbows,  and  the  knees  are  approxi- 
mated so  that  they  are  often  rubbed  in  walking;  while  the  general  appear- 
ance is  that  of  a  man  in  danger  of  falling  forward.  The  position  of  the  body 
due  to  flexion  also  gives  rise  to  a  "  propulsive  ''  gait,  caused  by  carrying  for- 
ward the  center  of  gravity,  so  that,  when  started,  the  patient  is  apt  to  "  get 
a-going  "  and  cannot  stop  until  he  comes  up  against  some  object.  On  the 
other  hand,  a  push  backward,  bringing  the  centers  of  gravity  behind  the 
point  of  support,  is  apt  to  make  the  patient  fall,  because  he  cannot  move  back 
fast  enough  to  save  himself  by  "  retropulsion."  Charcot  regards  both 
these  phenomena  as  "  forced  movements,"  but  Striampell  prefers  to  explain 
them  by  simple  physical  laws,  as  previously  described.  Sometimes  the 
characteristic  position  of  the  patient  exists  without  the  shaking,  and  for  this 
the  name  "paralysis  agitaris  sine  agitationc  "  has  been  employed. 

The  facial  expression  is  also  very  strikingly  altered.  The  face  is  indeed 
without  expression,  stiff  and  mask-like,  giving  rise  to  the  name  "  Parkin- 
son's mask."  There  is  often  a  dribbling  of  saliva  from  the  partially  closed 
mouth.  On  the  other  hand,  sometimes  the  mouth  is  kept  closed,  and  is 
found  full  of  saliva — a  condition  ascribed  to  delaye-d  deglutition  rather  than 
to  increased  secretion.  The  speech  is  slow,  hesitating,  and  monotonous,  and 
the  voice  may  be  piping  and  shrill.  On  the  other  hand,  if  the  lips  and  tongue 
share  in  the  tremor,  the  speech  is  stuttering,  as  though  the  patient  were  in 
a  hurry  to  speak — quite  different  from  the  scanning  speech  of  insular 
sclerosis. 

The  remaining  nervous  and  organic  functions  are  essentially  normal. 
Sensation  is  usually  unaltered,  and  the  bowels  and  bladder  are  unaffected,  as. 
is  also  the  temperature,  although  it  is  said  that  the  surface  temperature  is 
sometimes  elevated.  Charcot  has  noticed  an  alteration  of  the  temperature 
sense.     There  is  sometimes  a  tendency  to  unnatural  perspiration. 

Diagnosis. — This  is  usually  very  easy,  and  can  generally  be  made  at  a 
glance.  Multiple  sclerosis  resembles  it  in  some  respects.  Both  have 
tremor,  but  in  multiple  sclerosis  this  is  shown  more  particularly  when  the 
patient  attempts  to  do  something,  as  to  bring  a  glass  of  water  to  his  lips  or 
approximate  his  fingers.  The  speech  is  rhythmical,  "  scanning,"  instead  of 
stuttering,  as  in  shaking  palsy ;  there  is  nystagmus,  and  the  disease  begins 
almost  invariably  in  the  lower  extremities,  while  the  attitude  is  not  that  of 
paralysis  agitans.  Chorea  is  characterized  by  movements,  but  these  are  ir- 
regular and  more  intermittent.- 

Prognosis.— A  well-established  case  of  paralysis  agitans  is  not  curable 
by  medicines.  On  the  other  hand,  the  disease  lasts  indefinitely,  the  patient 
getting  slowly  worse,  with  perhaps  the  intermissions  alluded  to,  until  he  dies 
of  some  intercurrent  disease  or  from  the  effects  of  some  accident  growing" 
out  of  his  condition. 

Treatment. — Under  the  circumstances  this  must,  for  the  most  part, 
be  by  tonics  and  general  hygienic  measures.  As  the  disease  advances  the 
patient  should  be  guarded  against  accident;  and  especially  when  in  bed  his 
position  should  be  changed  for  him  if  he  cannot  change  it  himself,  as  is  often 
the  case. 

Cases  have  improved  under  the  use  of  the  iodid  of  potassium  and 
arsenic,  and  hyoscin  has  been  especially  recommended  by  Erb — hypoder- 


ACUTE  CHOREA.  1091 

mically,  in  doses  of  from  1-20  to  1-12  grain  (o.cx)3  to  0.005  gm.)  of  the 
muriate.  Good  results  have  also  been  reported  from  the  use  of  atropin,  of 
which  from  i-ioo  to  1-60  grain  (0.00066  to  o.ooii  gm.)  may  be  used  sub- 
cutaneously  or  by  the  mouth. 

Measures  calculated  to  improve  the  general  health  are  indicated,  such 
as  sea-bathing,  massage,  electricity,  fresh  air,  and  outdoor  life. 

Other  Forms  of  Tremor. 

Synonym. — Ballisuius. 

In  addition  to  the  tremor  in  paralysis  agitans,  a  similar  tremor  occurs 
under  other  circumstances,  sometimes  without  assignable  cause,  when  it  is 
known  as  simple  tremor,  or  it  may  be  induced  by  fright  or  overexertion. 
A  hereditary  tremor  has  been  described  by  C.  L.  Dana.  Senile  tremor  is 
the  well-known  form  of  tremor  which  comes  on  with  advancing  years,  at 
times  earlier  than  others,  but  usually  not  until  after  seventy  years.  The 
existence  of  a  tremor  due  to  senility  w^as  denied  by  Charcot,  but  is  accepted 
by  most  neurologists. 

Toxic  tremor  is  due  to  a  number  of  toxic  agents,  among  which  tobacco 
and  alcohol  are  the  most  frequent.  Lead  is  another  of  these  causes.  Finally, 
hysterical  tremor  occurs  as  a  part  of  hysterical  phenomena  in  women.  As- 
thenic tremor  is  due  to  simple  weakness,  and  is  especially  seen  in  exertion 
durinsf  convalescence  from  acute  disease. 


ACUTE   CHOREA. 

Synonyms. — Chorea  minor;  Mild  Chorea;  Sydenham's  Chorea;  St.  Vitus" 

Dance. 

Definition. —  A  disease  chiefly  of  the  young,  characterized  by  irregular, 
involuntary  muscular  contractions,  associated  at  times  with  psychical  dis- 
turbance, often  with  rheumatism  and  endocarditis.  The  term  chorea  is 
derived  from  the  Greek  x^P^^oc,  dancing. 

History. — The  term  chorea  Sancti  Viti  was  first  applied  by  Paracelsus  (1493- 
1541)  to  an  affection  of  a  totally  different  nature,  a  sort  of  hysterical  dancing  mania 
which  prevailed  in  epidemic  form  in  the  fourteenth,  fifteenth,  and  sixteenth  centuries 
in  Germany  and  the  Netherlands,  for  which  the  subjects  sought  relief  by  pilgrimages 
to  certain  shrines,  among  which  was  that  of  St.  Vitus,  in  Zabern,  whence  the  disease 
was  called  St.  Vitus'  dance.  From  other  shrines  it  received  other  names,  as  St. 
John's  and  St.  Anthony's  dance.  Chorea  minor  was  first  recognized  by  Sydenham  in 
the  sixteenth  century,  and  was  also  called  by  him  St.  Vitus'  dance,  though  a  widely 
different  affection  from  the  St.  Vitus'  dance  of  Paracelsus. 

Etiology. — The  disease,  though  not  confined  to  children,  occurs  far 
more  frequently  among  them,  notably  from  the  time  of  the  second  dentition 
— the  sixth  or  seventh  year — to  the  fifteenth  year.  More  than  three-fourths 
of  the  entire  number  of  cases  occur  during  this  period.  Among  adults  it  is 
relatively  more  frequent  from  the  fifteenth  to  the  twenty- fourth  year.  Occa- 
sionally it  occurs  in  old  age,  when  it  is  known  as  chorea  senilis.  Chorea  is 
about  twice  as  frequent  in  the  female  sex  as  in  the  male.  Heredity  has 
always  been  an  acknowledged  factor  in  its  causation,  but  is  probably  less  sig- 
nificant than  was  once  supposed.  It  has  even  been  claimed  that  the  disease 
is  sometimes  congenital  in  the  ofiispring  of  a  choreic  mother.     It  is  more 


1092  DISEASES  OF  THE  NERVOUS  SYSTEM. 

frequent  in  neurotic  families.  As  to  temperament,  it  is  well  known  that 
hig-h-strung,  excitable,  nervous  children,  as  contrasted  with  the  dull  and 
phlegmatic,  are  especially  liable  to  the  disease.  It  is  principally  in  these  that 
overstudy  is  seen  to  have  a  predisposing  effect.  Psychical  influences  are 
undoubtedly  potent ;  thus,  fright  causes  a  large  number  of  cases,  while  grief 
causes  many,  and  even  joy  some. 

The  so-called  Huntingdon's  chorea,  which  is  hereditary,  is  not  the  same 
as  Sydenham's  chorea,  although  Charcot  did  not  make  this  distinction. 
Sydenham's  chorea  affects  children  of  all  social  grades,  but  is  more  common 
among  artisans  and  the  lower  classes.  It  is  rare  in  the  ne^ro.  Wharton 
Sinkler,  who  has  especially  investigated  this  point,  has  seen  but  one  case  in 
a  full-blooded  negro,  while  William  Osier,  at  the  Johns  Hopkins  Hospital, 
out  of  175  cases  found  5  in  the  negro  race.  It  is  apparently  unknown  among 
Indians  in  their  natural  state. 

The  season  of  the  year  appears  to  have  an  undoubted  influence. 
Morris  J.  Lewis,  whose  studies  have  been  most  thorough  in  this  direction, 
finds  that  the  fewest  attacks  occur  in  October  and  November  and  the  greatest 
number  in  March  and  April.  Hermann  Eichhorst,  on  the  other  hand,  says 
that  the  greatest  number  of  cases  occur  in  the  autunin  and  winter  months. 
The  disease  prevails  more  generally  in  towns  than  in  the  country. 

Imitation,  commonly  regarded  as  an  exciting  cause,  has  been  shown  by 
modern  studies  to  play  a  less  important  role  than  was  thought,  many  cases 
described  as  thus  originating  being  .really  hysteria.  Trauma  precedes  a  cer- 
tain number  of  cases.  Reflex  irritation,  especially  digestive  disturbances, 
and  intestinal  worms  were  regarded  as  potent  causes  by  the  older  observers ; 
but  here  again  Osier's  studies  have  failed  to  find  any  causal  relationship. 
The  chorea  of  pregnant  women  has  been  referred  to  this  category.  The 
causal  relation  of  eye-strain  to  chorea  has  been  emphasized  by  Stevens,  but 
is  practically  denied  by  George  de  Schweinitz,  who  concludes,  from  an  exami- 
nation of  more  than  100  cases,  that,  while  ordinary  chorea  and  many  forms 
of  facial  spasm — habit  spasm,  etc. — are  materially  benefited  by  correcting 
refractive  errors  and  anomalies  of  the  ocular  muscles,  he  does  not  believe 
there  is  any  proof  to  show  that  eye-strain  is  of  itself  responsible  for  their 
origin,  with  perhaps  the  single  exception  of  habit  spasm  affecting  the  orbicu- 
laris and  adjacent  facial  area.  It  may  be  such  chorea  which  Howard  F. 
Hansell  cured  in  Da  Costa's  clinic  *  by  atropin,  paralyzing  the  ciliary  muscle 
and  preventing  the  effort  at  accommodation  until  the  habit  was  broken  up. 

The  association  of  arthritis  and  chorea  was  observed  by  the  earliest 
students  of  the  subject,  and  was  distinctly  recognized  in  England  as  early  as 
1802,  but  the  exact  causal  relation  of  the  two  diseases  has,  perhaps,  not  yet 
been  made  out.  That  they  are  frequently  associated  and  that  there  is  close 
connection  between  the  two  affections  is  admitted  by  English  and  French 
writers,  but  the  Germans  find  the  association  much  less  frequent.  Steiner, 
for  example,  found  only  four  cases  of  rheumatism  in  252  cases  of  chorea. 
English  observers  find  from  20  to  70  per  cent,  of  cases  of  associated  joint 
affection,  while  in  this  countr\',  where  rheumatism  is  apparently  less  frequent 
in  children,  the  range  of  percentage  found  by  various  observers  is  from  15.5 
to  54  per  cent.  That  the  arthritis  precedes  the  chorea  in  a  large  number  of 
cases  is  generally  conceded,  the  latter  disease  developing  with  the  subsidence 
of  the  former,  or  not  until  convalescence  has  been  well  established.     Hence 

*  Da  Costa's  "  Medical  Diagnosis,"  eighth  ed.,  1895,  p.  221. 


ACUTE  CHOREA.  1093 

that  the  rheumatism  is  the  cause  of  the  chorea  seemed  at  one  time  estab- 
Hshed,  but  recent  views  as  to  the  probable  infectiousness  of  rheumatism  and 
the  possible  infectiousness  of  chorea  changed  the  conditions.  As  the  nature 
of  the  virus  of  rheumatic  fever  is  unknown,  it  may  be  that  chorea  is  caused 
by  a  similar  poison.  This  theory  is  further  sustained  by  the  fact  that  the 
infectious  diseases  play  an  acknowledged  role  in  the  etiology  of  chorea. 
Scarlet  fever,  diphtheria,  measles,  typhoid  fever,  gonorrhea,  secondary 
syphilis,  puerperal  fever,  pyemia,  multiple  suppurative  polyarthritis,  have  all 
been  followed  by  chorea ;  but  with  the  exception  of  acute  rheumatic  poly- 
arthritis and  some  forms  of  septicemia,  the  number  of  cases  thus  associated 
is  not  large.  On  the  other  hand,  acute  exanthemata  developing  in  the  course 
of  chorea  usually  check  the  disease.  Anemia  has  been  held  to  be  a  cause, 
and  probably  is  a  predisposing  cause,  although  frequently  also  a  result.  In 
fact,  the  studies  of  Charles  W.  Burr  and  others  go  to  show  that  anemia  is  less 
frequently  associated  with  chorea  than  has  been  commonly  supposed.  The 
relation  of  hysteria  to  chorea  is  interesting  from  the  close  resemblance,  at 
times,  of  the  two  conditions.  It  has  already  been  said  that  the  cases  of 
so-called  imitation  chorea  are  often  hysteria,  and,  on  the  whole,  the  asso- 
ciation of  the  conditions  is  rather  coincidental  than  causal,  but  some  cases 
may  be  truly  imitation  in  children  not  hysterical.  Poisons  are  acknowl- 
edged causes  in  a  few  instances.  Carbon  dioxid  and  iodoform  are  among 
those  which  appear  to  have  caused  acute  attacks  of  chorea  of  short 
duration. 

Morbid  Anatomy. — There  is  no  definitely  ascertained  morbid  anatomy 
for  chorea,  and  the  lesions  which  have  been  found  are  the  result  of  the  compli- 
cations or  are  incidental.  The  most  constant  of  these  associated  lesions  are 
endocarditis,  in  85  per  cent,  of  Osier's  cases ;  pericarditis,  26  per  cent. ;  com- 
bined heart  lesions,  90.4  per  cent. ;  pneumonia,  12  per  cent. ;  less  numerous 
were  acute  pleurisy,  pyemia,  and  phlebitis,  also  noticed.  As  to  the  nervous 
system,  the  symptomatology  would  lead  us  to  expect  the  essential  lesions  in 
the  cortex  of  the  brain,  and  C.  L.  Dana  has  analyzed  the  recorded 
autopsies,  of  which  there  were  only  39  in  which  the  state  of  the  nervous 
system  was  accurately  described.  In  16  there  were  intense  cerebral 
hyperemia,  periarterial  exudation,  erosions,  softened  spots,  minute  hemor- 
rhages, and  occasional  emboli.  The  changes  were  most  marked  in  the 
deeper  parts  of  the  motor  tracts,  particularly  in  the  lenticular  nuclei  and  the 
thalami.  These  changes  are  the  same  as  those  described  by  W.  H.  Dickm- 
son  in  1876.  Essentially  similar  were  the  lesions  found  in  two  of  Osier's 
cases.  In  two  reported  by  Bevan  Lewis  there  was  apoplexy,  one  cerebellar 
and  one  cerebral  and  extraventricular.  The  so-called  chorea  corpuscles 
described  by  Ellischer  are  in  no  way  characteristic.  The  same  may  be  said 
of  the  swelling  and  turbidity  of  certain  of  the  large  pyramidal  cells  in  the 
deeper  layers  of  the  cortex  in  the  Rolandic  region  described  by  F.  C.  Turner, 
The  changes  in  the  ganglion  cells  of  the  spinal  cord  described  by  H.  C.  Wood 
in  canine  chorea  have  been  found  also  by  Triboulet,  but  he  agrees  with  others 
who  hold  that  canine  chorea  is  a  very  different  disease  from  human  chorea. 

Nature  of  Chorcct. — This,  it  must  be  admitted,  is  as  yet  unknown.  It 
has  been  intimated  that  the  symptoms  are  of  a  kind  which  would  naturally 
result  from  lesions  in  the  motor  cortical  area.  No  constancy  in  such  lesions 
is  demonstrable.  A  cerebral  seat  for  chorea  is  rendered  likely  by  the  exist- 
ence of  hemichorea,  the  association  of  chorea  with  mild  psychical  derange- 
ments, and  by  the  fact  that  choreiform  movements  are  sometimes  symptoms 


1094  DISEASES  OF  THE  NERVOUS  SYSTEM. 

of  undoubted  brain  lesions — posthemiplegic  hemichorea.  The  embolic 
theory  which  was  suggested  by  Senhouse  Kirkes,  and  supported  by  him, 
Hughlings  Jackson,  Broadbent,  Tuckwell,  and  others,  was  based  upon  rhe 
presence  of  foci  of  embolic  softening  found  in  a  few  instances  in  connection 
with  endocarditis,  but  has  gained  few  supporters. 

The  theory  which  is  at  the  present  day  naturally  attracting  most  atten- 
tion is  the  infectious  theory,  but  the  limits  of  a  text-book  do  not  permit  its 
developmental  consideration.  Suffice  it  to  say  that  Pianese,  of  Xaples,  has 
apparently  isolated  from  the  nervous  system  of  a  choreic  patient  a  bacillus 
which  he  was  able  to  cultivate  successfully,  and  the  cultures  from  which 
caused  death  in  animals ;  also  that  while  the  acuter  forms  present  many,  if 
not  all,  of  the  conditions  necessary  to  the  conception  of  an  infectious  disease, 
the  course  of  the  milder  forms,  their  etiology,  notably  their  negative  morbid 
anatomy,  seem  to  demand  that  the  disease  be  regarded  for  the  present  as  a 
neurosis — that  is,  a  disease  of  functional  derangement  without  known 
anatomical  basis. 

Symptoms. — Premonitory  symptoms,  both  motor  and  psychical,  usually 
precede  the  onset  of  chorea.  They  include  restlessness  and  inability  to  sit 
still,  and  an  altered  disposition,  manifested  by  irritability  and  perversity. 
These  symptoms,  often  misunderstood  by  parents,  are  sometimes  the  occa- 
sion of  reproof  and  even  severe  punishment  to  tlie  child — a  course  which 
accelerates  and  aggravates  the  disease. 

A  close  study  of  the  symptoms  permits  of  their  division  into  three 
separate  groups,  determined  chiefly  by  their  severity : 

1.  A  mild  form,  including  the  majority  of  cases  in  which  the  affection 
of  the  muscles  is  slight,  the  speech  scarcely  involved,  and  the  general  health 
slightly  disturbed. 

2.  The  severe,  in  which  the  choreic  movements  are  general,  power  of 
speech  is  lost,  and  the  patient  is  unable  to  go  about  and  help  himself. 

3.  The  maniacal,  or  chorea  insaniens,  characterized  by  intense  cerebral 
excitement. 

It  is,  however,  unnecessary  to  separate  the  symptoms  of  each  variety. 

The  motor  phenomena  are  those  first  observed.  They  consist  in 
peculiar  jerky  movements  which  begin  most  frequently  in  the  upper  extremi- 
ties, especially  in  the  right  hand,  rarely  in  the  legs.  Thev  may  even  be 
general  from  the  first,  though  the  earliest  symptoms  often  escape  notice. 
Speech  is  affected,  sooner  or  later,  in  one-fourth  of  the  cases.  The  extent 
varies  greatly  from  slight  hesitancy  to  incoherency — ^the  difficulty  being  in 
the  muscles  of  articulation  rather  than  in  phonation.  As  a  rule,  the  move- 
ments cease  during  sleep,  though  they  sometimes  persist  even  then.  It  is 
not  generally  believed  that  the  movements  extend  to  the  muscles  of  organic 
life,  though  associated  irregular  and  rapid  action  of  the  heart  has  been 
ascribed  to  choreic  spasm  of  the  papillary  muscles.  As  the  disease  con- 
tinues muscular  zveakness  becomes  manifest  in  a  general  want  of  strength 
rather  than  paralysis,  though  the  weakness  may  be  distributed  hemiplegic- 
ally  or  even  monoplegically.  It  may  even  precede  the  jerking  movements. 
Very  rarely  the  pulse  may  be  slow  in  the  feeble  state  that  follows  chorea. 

Sensory  symptoms  are  less  conspicuous  than  motor.  Pain  is  rare, 
though  its  presence  has  been  characteristic  enough  in  some  cases  to  obtain 
from  them  the  name  "  painful  chorea "  from  AA^eir  Mitchell.  Painful 
points  over  the  sites  of  emergence  of  spinal  nerves  have  been  pointed  out, 
though  they  must  be  rare.     Numbness,  tingling,  and  pricking  sensations  are 


ACUTE  CHOREA.  1095 

occasionally  met,  and  may  be  a  part  of  the  phenomena  of  multiple  neuritis 
sometimes  present.  Headache^  sometimes  very  severe  and  paroxysmal,  may 
occur,  while  epileptiform  seizures  are  also  a  rare  symptom,  and  when  they 
occur  are  probably  not  a  part  of  the  chorea.  The  reflexes  are  variously 
aftected,  the  knee-jerk  being  normal  in  about  half  the  cases,  in  the  remainder 
increased  or  absent.  Trophic  lesions  are  almost  unknown.  Mental  symp- 
toms, in  the  majority  of  cases,  are  not  very  conspicuous,  though  there  are 
in  some  severe  cases  extreme  manifestations,  including  melancholia,  hallu- 
cinations, and  even  mania,  which  have  their  climax  in  chorea  insaniens. 

Most  important  are  the  symptoms  of  cardiac  disease,  in  regard  to  which 
W  illiam  Osier  makes  the  startling  statement :  ''  There  is  no  disease  in 
which  endocarditis  is  so  constantly  found  postmortem  as  chorea.  It  is 
exceptional  to  find  the  heart  healthy."  The  symptoms  which  are,  therefore, 
to  be  ahvays  carefully  sought  include  a  systolic  apex  murmur,  palpitation, 
and  irregular  heart  action,  although  the  child  rarely  complains  of  the  latter 
or  of  pain  about  the  heart.  It  is  further  important  to  note  that  in  a 
majority  of  these  cases  the  endocarditis  is  independent  of  acute  arthritis, 
unless  we  hold  with  Bouillaud  that  in  young  subjects  the  heart  acts  as  a 
joint.  Organic  murmurs  at  the  base  are  very  much  more  uncommon,  most 
of  the  murmurs  here  being  functional.  They  are  heard  with  greatest  inten- 
sity in  the  area  of  the  pulmonary  artery,  but  are  audible  sometimes  in  the 
aortic  area  as  well.  In  a  large  proportion  of  all  cases  in  which  a  murmur  is 
heard  at  the  base  or  along  the  left  margin  of  the  sternum  in  the  second,  third, 
and  fourth  interspaces  it  is  functional,  but  a  soft  systolic  murmur  in  this 
area  with  systolic  pulsation  in  the  cervical  veins  may  be  caused  at  the  tri- 
cuspid orifice. 

On  the  other  hand,  endocarditis  sometimes  occurs  zvithoiit  symptoms  or 
physical  signs,  while  the  disappearance  of  physical  signs  does  not  prove 
that  endocarditis  was  not  present.  A  presystolic  murmur  is  also  at  times 
present,,  indicating  mitral  stenosis — in  19  per  cent,  of  Osier's  cases.  On  the 
other  hand,  the  comparative  rarity  of  simple  aortic  valve  involvement  is  con- 
spicuous, this  being  more  uncommon  than  combined  aortic  and  mitral  dis- 
ease, or  even  combined  mitral  and  tricuspid  disease.  The  tricuspid  valves 
may  alone  be  attacked. 

A  to-and-fro  murmur,  indicating  pericarditis,  may  be  present  in  from  8 
to  25  per  cent.,  and  in  more  than  half  of  these  it  is  associated  with  endocar- 
ditis. It  is  to  be  remembered  that  both  forms  of  organic  heart  disease,  and 
especially  endocarditis,  may  occur  in  chorea  without  rheumatism, — e.  g.,  in 
66  per  cent,  of  Osier's  cases, — also  that  such  endocarditis  may  lay  the 
foundation  of  permanent  organic  disease. 

Occasional  skin  affections  make  their  appearance  in  chorea,  the  larger 
proportion  being  due  to  the  prolonged  administration  of  arsenic,  so  much 
used  in  the  treatment  of  this  disease.  The  forms  for  which  the  arsenic 
treatment  is  more  or  less  responsible  are  erythematous  and  papillary 
eruptions,  herpes,  and  the  pigmentation  frequently  resulting  from  the 
prolonged  administration  of  this  drug.  Eruptions  also  occur  independent 
of  arsenic  administration.  They  are  usually  purpuric  and  associated  with 
arthritis,  similar  in  form  to  the  purpura  so  often  associated  with  rheuma- 
tism, and  include  some  of  the  forms  of- multiple  erythema — as  erythema  nodo- 
sum, purpuric  urticaria,  or  simple  purpura.     C.   H.   Brown*  has  reported 

*"  Journal  of  Mental  and  Nervous  Disease,"  August,  1893. 


1096  DISEASES  OF  THE  NERVOUS  SYSTEM. 

a  remarkable  case  of  subcutaneous  nodules  composed  of  young  granulating- 
tissue  in  a  case  of  chorea  in  a  boy  of  eleven. 

Fever  is  a  rare  symptom  in  chorea,  except  as  the  result  of  complica- 
tions, of  which  arthritis  is  the  most  common,  but  endocarditis  and  peri- 
carditis may  also  cause  fever.  The  rare  instances  are  cases  of  chorea  in- 
sanicns,  in  which  the  temperature  may  rise  to  105°  F.  (40.5°  C). 

Diagnosis.— This  is  usually  easy.  Simple  tremor,  athetosis,  paralysl<f 
agitans,  as  well  as  alcoholic,  senile,  saturnine,  and  mercurial  tremor,  are  not 
likely  to  be  confounded  with  the  movements  of  chorea.  The  symptomatic 
choreiform  movements  due  to  cortical  irritation  by  meningitis,  tubercle, 
hemorrhage,  softening,  tumor,  or  parasites,  are  attended  by  other  symptoms 
which  distinguish  them  from  chorea.  In  multiple  and  diffuse  cerebral 
sclerosis  the  so-called  chorea  spastica  movements  may  be  very  similar,  but 
the  early  onset, — usually  in  infancy, — impaired  intelligence,  increased  re- 
flexes, rigidity,  and  chronic  course  of  the  disease  characterize  it.  Fried- 
reich's ataxia  might  be  mistaken  for  chorea,  but  it  is  easily  recognized  by  the 
lost  knee-jerks,  the  slowness  and  inco-ordination  of  its  movements,  talipes, 
nystagrnus,  and  family  distribution.  Huntington's  chorea  is  characterized 
by  its  hereditation,  its  limitation  to  adult  life,  and  ultimate  gradually  de- 
veloping dementia. 

Prognosis.— Except  in  chorea  insaniens,  which  is  always  fatal,  recovery 
is  the  rule  in  from  eight  to  ten  weeks.  It  happens,  too,  sometimes  that  the 
severest  cases  of  the  ordinary  forms  are  intractable,  and  rarely  that  they  ter- 
minate fatally  after  a  few  days'  illness,  it  may  be  from  exhaustion  or  it  may  be 
from  the  complicating  heart  disease.  Chorea  of  the  pregnant  woman  is  more 
serious  than  the  chorea  of  children. 

The  duration  of  the  disease  may  be  from  eight  to  ten  weeks  for  the 
ordinary  cases  and  from  three  to  six  months  for  the  very  severe  ones. 
Remissions  occur,  and  relapses  as  well,  pointed  out  by  Sydenham.  A  dis- 
position to  vernal  recurrence  has  been  noticed. 

Treatment. — All  cases  should  be  carefully  examined  for  causes  of  re- 
flected irritation,  which  should  be  removed;  then  rest  is  essential.  It  is  not 
necessary  that  the  very  mildest  cases  be  put  to  bed,  but  they  should  be  with- 
drawn from  school  and  guarded  from  excitement  and  the  curious  gaze  of 
friends  and  strangers,  for  the  movements  almost  invariably  increase  when 
the  patient  is  under  observation.  More  serious  cases  should  be  put  to  bed — 
a  more  thorough  exclusion  as  well  as  rest  is  thus  secured.  Not  only 
is  recovery  thus  facilitated,  but  a  diminished  liability  to  heart  complication 
is  also  attained. 

Of  drugs,  arsenic  and  iron  hold  the  first  place.  The  former  is  given  in 
slowly  ascending  doses  of  Fowler's  solution  until  its  physiological  effect  is 
produced,  after  which  the  dose  should  be  gradually  diminished.  Some  one 
of  the  preparations  of  iron  should  be  given  continuously  in  moderate  doses. 
The  bromids  are  also  indicated,  especially  when  there  are  restlessness  and 
want  of  sleep,  when  chloral  may  also  be  added,  and  in  severe  cases  may  be 
given  continuously.  Opiates  should,  however,  never  be  employed.  An  old 
remedy  in  this  country  is  black  snakeroot  or  cimicifuga  racemosa,  first 
recommended  by  the  late  Dr.  Hiram  Corson,  who  wrote  me  that  he  had 
used  it  for  fifty  years  without  a  failure.  I  have  sometimes  used  it  in  the 
shape  of  the  infusion  in  mild  cases,  with  apparently  satisfactory  results,  in 
doses  of  one  or  two  fluid  ounces  (30  to  60  c.  c).  Modern  remedies  are  anti- 
pyrin  and  physostigma.     The  former  is  given  to  adults  in  doses  of  from 


CHOREIFORM  AFFECTIONS.  109/ 

seven  to  fifteen  grains  (0.5  to  i  gm.),  much  reduced  for  children.  Physo- 
stigma  has  been  given  in  doses  of  from  1-70  to  1-35  grain  (0.0094  to 
0.0188  gm.)  hypodermically.  Hyoscyamin  in  doses  of  i-ioo  grain  (0.00065 
gm.),  three  times  a  day,  has  apparently  been  followed  by  good  results.  The 
oxid  of  zinc,  valerianate  of  zinc,  nitrate  of  silver,  and  sulphate  of  copper, 
formerly  much  recommended,  have  fallen  into  disuse.  In  consequence  of  the 
close  relations  between  chorea  with  its  attending  arthritis  and  rheumatic 
arthritis  it  is  reasonable  to  expect  that  the  salicylates  might  be  useful,  but 
such  expectation  has  not,  as  yet,  been  realized. 


CHOREIFORM  AFFECTIONS. 

There  remain  to  be  considered  several  forms  of  convulsive  contractures 
included  under  the  term  "  habit  spasm  "  or  "'  habit  chorea,"  or  "  tic."  The 
term  tic,  as  usually  understood,  means  facial  spasm.  It  has,  however,  been 
extended  by  the  French  school  (whose  lead  in  these  affections  seems  at 
present  acknowledged)  to  include  "  an  habitual,  conscious,  convulsive  move- 
ment, resulting  in  the  contraction  of  one  or  more  muscles  of  the  body, 
reproducing,  most  frequently  in  an  abrupt  manner,  some  reflex  or  auto- 
matic action  of  common  life"  (Guinon).  It  is  characteristic  of  these  mo- 
tions that  they  are  more  or  less  under  the  control  of  the  will,  in  which  re- 
spect they  differ  from  the  contractions  of  chorea  minor. 


I.    Simple  Tic. 
Synonyms. — Habit  Spasm;  Habit  Chorea. 

Simple  tic  may  be  localized  or  general. 

Localised  tic  begins  usually  in  young  persons,  most  frequently  in  girls 
from  seven  to  fourteen  years  of  age,  and  may  persist  through  life.  The 
spasm  is  confined  to  a  single  muscle,  a  group  of  muscles,  or  a  group  of  asso- 
ciated muscles,  most  frequently  the  muscles  of  expression.  The  mild  formes 
are  looked  upon  as  simply  peculiarities  of  the  individual ;  but  the  more  severe 
forms,  in  which  nearly  all  the  muscles  of  the  face  are  affected  and  even  the 
depressors  of  the  jaw  and  the  tongue  are  often  thrown  into  action  while 
speaking,  are  manifestly  pathological.  It  differs  from  the  idiopathic  facial 
spasm  of  adults  in  that  the  latter  is  rarely  seen  until  after  the  fortieth  year, 
and  is  slower  than  is  the  habit  spasm  of  the  facial  muscles.  It  is  possible 
for  the  simplest  forms  to  be  a  perpetuated  childish  trick;  such  may  be  a 
blinking  of  the  eye  or  the  act  of  sniffing.  In  other  simple  forms  there  is  a 
drawing  aside  of  the  mouth  or  a  jerking  of  the  head  to  one  side,  or  a  sim- 
ple shaking  of  the  head,  while  the  eye  is  winked  at  the  same  time ;  or  there 
may  be  a  shrugging  of  one  shoulder.  More  rarely  the  contraction  occurs  in 
the  legs,  as  in  the  very  characteristic  "  string-halt  "  tic,  in  which  at  times 
the  leg  is  suddenly  drawn  up.  Localized  tic  miay  be  transient,  gradually  dis- 
appearing after  a  few  months. 

Generalised  Tic,  Electric  Chorea  (Henoch). — In  this  there  is  sudden 
electric-like  spasm  of  the  muscles  of  the  trunk  and  limbs,  but  especially 
of  the  neck  and  shoulders,  causing  an  instantaneous  start,  which  affects  the 
patient  for  an  instant  only,  when  it  passes  off  and  leaves  him  quiet  and 
motionless.     The  contraction  is  like  that  produced  bv  a  galvanic  shock.     It 


1098  DISEASES  OF  THE  NERVOUS  SYSTEM. 

may  be  associated  with  facial  spasm.  It  occurs  especially  in  children,  but 
also  in  adults,  particularly  in  wom.en,  and  may  persist  for  years. 

Paramyoclonus  Multiplex;  Myoclonia. — This  term  was  applied  by 
Friedreich  in  1882  to  a  disease  first  observed  by  him,  in  which  there  are 
clonic  convulsions  in  symmetrical  muscle  groups  in  the  arms  and  legs  without 
loss  of  consciousness.  It  occurs  usually  in  males,  and  follows  emotional  dis- 
turbances like  fright  or  straining.  In  addition  there  is  a  considerable  increase 
in  the  tendon  reflexes.  In  order  that  a  case  may  be  one  of  true  paramyo- 
clonus it  is  necessary  that  the  contractions  in  the  single  muscles  should  be 
sudden — lightning-like.  The  muscles  affected  are  commonly  those  of  the 
trunk  and  extremities.  The  contractions  are  usually  bilateral,  and  vary 
from  50  to  150  a  minute.  There  are  no  sensory  symptoms.  Between  the 
attacks  there  may  be  tremors.  These  cases  are  allied,  on  the  one  hand,  to 
the  electric  chorea  just  described,  and,  on  the  other,  to  the  different  forms 
of  convulsive  tic,  clonic  facial  cramp,  and  clonic  accessory  cramp.  Some 
cases  of  so-called  paramyoclonus  are  really  cases  of  hysteria.  This  view 
is  sustained  by  Arthur  Conklin  Brush,*  w^ho  reports  three  cases  and  reviews 
several. 

Duhini's  Disease. — The  term  electric  chorea  is  applied  to  an  acute 
infectious  disease  occurring  in  Lombardy,  and  known  as  Dubini's  disease, 
in  which  there  are  sudden  contractions,  first  usually  in  the  arm,  but  passing 
thence  into  all  the  extremities,  followed  in  several  weeks  or  months  by  paral- 
ysis and  muscular  atrophy,  occasionally  by  epileptiform  convulsions  and 
fever.     No  morbid  anatomy  has  been  determined. 

II.     Tic  with  Explosive  Utterances,  Corporalia,  Echolalia, 

Fixed  Ideas,  etc. 

Synonyms. — Maladie  de  la  tic  conviilsif;   Gilles  de  la  Tourette's  Disease. 

Definition. — In  addition  to  motor  spasm,  this  form  of  tic  is  charac- 
terized by  explosive  utterances  of  certain  words  and  sounds,  such  as  "  fire," 
"  murder,"  "  hah,"  "  bow-wow  " ;  or  profane  words,  such  as  "  God  damn," 
"  Jesus  Christ  " ;  or  filthy  and  obscene  w^ords,  when  it  is  known  as  coprolalia. 
There  may  also  be  mimicry  of  W'ords,  when  it  is  called  echolaUa;  or  mimicry 
of  action,  echokinesis;  or  the  patient  may  be  possessed  of  a  fixed  idea  of 
the  variety  known  as  arithniomania,  delire  dit  toucher,  onomatomania,  and 
folie  pourquoi.  In  arithmomania  almost  every  action  is  preceded  by  per- 
forming a  certain  number  of  acts,  as  in  a  patient  of  Osier's,  who  before 
she  went  to  bed  had  to  tap  her  heel  upon  the  bedstead  a  given  number  of 
times;  before  drinking  a  tumbler  of  water,  to  rotate  the  glass  nine  or  ten 
times,  and  the  same  thing  w^hen  setting  it  down;  before  opening  a  door  a 
certain  number  of  knocks  had  to  be  given,  and  the  greatest  difficulty  was 
experienced  in  getting  her  to  brush  her  hair,  as  it  took  so  long  to  count  be- 
fore she  began.  In  the  delire  du  toucher  there  is  the  constant  fear  of  con- 
tamination from  contact  with  objects ;  in  onomatommiia  to  repeat  over  and 
over  again  names  which  arise,  and  in  the  folie  pourquoi  to  demand  a  reason 
for  every  one  of  the  simplest  acts.  In  other  instances  the  patient  im- 
agines that  some  one  is  talking  to  her.  All  these  are  in  addition  to  the 
convulsive  acts. 

*  "  The   Nature  of    Paramyoclonus  Multiplex,"   "American  Jour,   of   the  Medical   Sciences," 
December,  1899. 


CHOREIFORM  AFFECTIONS.  1099 

The  involuntary  movements  themselves  vary  greatly  from  trifling  tic 
of  any  one  or  more  of  the  muscles  of  the  face  to  contractions  involving  all 
the  muscles  of  the  body.  This  condition,  which  is  neither  chorea  nor  habit 
spasm,  is  at  times  mistaken  for  both.  It  is  commonly  easy  of  recognition, 
and  although  of  uncertain  prognosis,  recoveries  take  place. 


III.     Complex  Co-ordinated  Tic. 

Definition. — This  includes  a  number  of  forms  of  habit  movement  dif- 
fering from  ordinary  tic  in  the  more  complex  nature  of  the  actions  per- 
formed. It  includes  tricks  and  habits,  such  as  those  of  one  who  in  writing 
stops  at  every  few  words  and  looks  intently  at  his  finger  tips ;  the  "  head 
nodding"  of  children  (not  to  be  confounded  with  the  epilepsia  niitmts  of 
children),  "thumb  sucking."  "rocking  in  bed,"  and  similar  actions.  Of 
the  same  nature  is  the  so-called  "  head-banging,"  in  which  the  child,  asleep 
or  awake,  while  in  bed,  will  turn  over  and  bang  the  head  violently  into  the 
pillow,  repeating  this  act  five  or  six  times  or  for  two  or  three  hours  at  a 
time;  or  the  child  may  strike  the  head  repeatedly  with  the  fist — krouomania; 
or  it  may  rotate  the  head  violently  from  side  to  side,  balancing  or  gyrating 
the  body  with  great  rapidity.  This  practice  is  sometimes  communicated 
from  one  child  to  another.  These  movements  are  met  especially  in  feeble- 
minded children,  in  whom  it  may  be  accompanied  by  nystagmus,  and  is 
sometimes  the  result  of  injury  after  birth.  When  these  phenomena  do  not 
occur  in  the  feeble-minded  or  after  injury  early  in  life,  the  prognosis  is  said 
hy  Gree  and  Haden,  who  have  especially  studied  the  subject,  to  be  favorable. 

IV.    Spasms  of  the  Muscles  of  Respiration  and  Deglutition. 

Definition. —  The  spasm  affects  the  muscles  of  respiration  and  pho- 
iiation,  the  muscular  contraction  being  accompanied  by  more  or  less  noise, 
as  a  "  sniffle "  or  "  hiccough  "  during  inspiration,  or  some  noisy  or  ex- 
plosive sound  during  expiration.  Such  spasms  are  sometimes  part  of  a 
hysterical  state.  Among  those  described  as  thus  occurring  is  a  sort  of 
rumbling  which  comes  from  low  down  in  the  abdomen,  passes  up  the 
stomach,  and  out  of  the  mouth  as  an  explosive  loud  noise — something  like 
belching,  but  louder.  In  another  instance  there  was  a  peculiar  clucking 
noise  in  the  throat  accompanying  motions,  particularly  those  of  swallowing", 
which  disappeared  only  during  sleep.  Again,  there  may  be  a  loud  inspi- 
ratory cry  preceded  by  three  or  four  deep  inspirations  and  followed  by  a  deep, 
hoarse,  expiratory  sound. 

V.  Chronic  Progressive  Chorea. 

Synonyms. — Huntington's  Chorea;   Chronic  Hereditary   Chorea. 

Definition. —  A  disease  of  adult  life,  commonly  hereditary,  characterized 
bv  irregular  movements,  deranged  speech,  and  ultimate  dementia  gradually 
developing.  r 

Historical. — The  affection  was  first  described  by  C.  O.  "Waters,  of  Franklin, 
N.  Y.,  in  Dunglison's  "Practice  of  Medicine,"  in  1842;  ag^ain  in  the  "American 
Medical  Times,"  1863,  by  Irving   W.  Lyon;  fully  in  1872  by  George  Huntington,  of 


iioo  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Ohio,  in  the  "  Medical  and  Surgical  Reporter,"  in  whose  paper  the  following  three 
marked  peculiarities  were  presented  and  dilated  upon: 

1.  Its  hereditar}'  nature. 

2.  A  tendency  to  insanity  and  suicide. 

3.  Its  manifesting  itself  as  a  grave  disease  only  in  adult  life. 

Subsequent  to  Huntington's  description  little  is  found  in  literature  until  1884, 
when  C.  A.  Ewald  reported  two  cases  m  Germany,  and  1S85,  when  Clarence  King, 
in  this  country,  reported  another  family.  Then  followed  numerous  reports;  and 
finally,  in  Paris,  in  1889,  the  monograph  of  Huet,  and  another  by  Osier,  in  1894,  in 
which  the  history  of  two  families  is  detailed.  Numerous  cases  were  reported  between 
1SS9  and  1894. 

Etiology. — Its  frequent  hereditary  origin  has  been  mentioned.  Indeed, 
heredity  is  one  of  its  most  striking  features,  25  per  cent,  of  certain  famiUes 
having  been  victims,  and  even  more  than  50  per  cent,  of  the  adults  in 
families.  It  is  especially  when  both  parents  were  affected,  and  seriously, 
that  one  or  more  of  the  offspring  almost  invariably  have  the  disease  if  they 
live  to  adult  age.  The  two  sexes  are  about  equally  afifected,  though  in  some 
families  males  are  oftener  affected.  It  is  further  characteristic  that  if  a 
generation  is  skipped,  the  disease  never  manifests  itself  again  in  that  family, 
and  that  it  rarely  presents  itself  before  thirty  years  of  age.  Huet  has,  how- 
ever, collected  seven  cases  of  earlier  onset.  It  is  said,  also,  that  it  is  not 
invariably  hereditary,  being  sometimes  due  to  emotional  causes.  In  all  the 
families  in  which  this  choreic  tendency  has  been  fouiid  the  nervous  tempera- 
ment prevails. 

Morbid  Anatomy, — This  is  somewhat  more  definite  than  that  of  chorea 
minor.  At  least,  there  has  been  found  at  necropsy  quite  frequently  a  con- 
dition of  pachymeningitis  and  hematoma  of  the  dura  mater  with  atrophy  of 
the  cortex,  and  less  frequently  a  disseminated  encephalitis,  evidenced  by  sub- 
cortical foci  of  round  cells.  Nothing  has,  however,  been  found  which  can 
in  any  way  be  regarded  as  peculiar  or  as  accounting  for  the  disease  occur- 
ring at  a  certain  age  or  for  its  affecting  certain  individuals,  though  the 
lesions  do  explain  the  motor  phenomena.  It  should  be  stated  that  Charcot 
and  his  pupil  Huet  do  not  separate  this  chronic  progressive  chorea  from 
chorea  minor,  but  all  other  writers  do. 

Symptoms. — The  onset  is  gradual  in  hereditary  cases,  although  it  may 
be  sudden  in  cases  arising  otherwise.  As  in  chorea  minor,  motor  symptoms 
are  the  first  to  appear :  first  usually  in  an  unsteadiness  of  the  gait  or  slightly 
irregular  movements  of  the  hands.  Occasionally  qnly  the  mental  symptoms 
are  the  first  to  appear,  not  usually  manifesting  themselves  until  the  motor 
are  well  established.  Motor  symptoms  include  also  spasm  of  the  muscles 
of  the  face.  The  movements  dififer  from  those  of  chorea  minor  in  being 
sloiver  and  in  absence  of  co-ordination,  strikingly  manifested  in  walking. 
The  station  may  be  good,  except  for  a  slight  swaying  of  the  trunk,  but  an 
attempt  to  walk  is  followed  by  an  unsteadiness  characterized  by  marked  lat- 
eral deviation  from  the  straight  line,  by  swaying  of  the  body,  and  sometimes 
by  precipitate  falling  movement  from  which  the  patient  may,  however,  re- 
cover himself — in  brief,  a  typical  drunkard's  gait.  This  unsteadiness  ulti- 
mately makes  locomotion  impossible,  and  the  patient  takes  to  his  bed.  Yet 
before  this  stage  is  reached,  although  ataxic,  he  may  be  able  to  walk  long  dis- 
tances. While  at  rest  the  movements  cease  altogether.  They  are  aggra- 
vated by  emotion  and  excitement,  while  in  the  beginning  they  may  to  a  de- 
gree be  Influenced  by  the  will.  Thus,  a  patient  said  to  me  lately :  "  If  I 
put  mv  mind  to  it,  I  can  stop  it." 

Speech  is  affected  in  most  instances,  being  at  first  slow  and  hesitating 


CHOREIFORM  AFFECTIONS.  iioi 

and  interrupted  by  interjections;  later  it  is  indistinct.  The  handwriting 
is  likewise  involved,  the  letters  being  irregular  and  badly  formed,  running 
into  one  another  and  off  the  line,  and  ultimately  writing  becomes  im- 
possible. Sensation  and  the  special  senses  remain  intact,  as  does  the  mus- 
cular sense,  until  the  disease  is  advanced.  The  reflexes  are  usually  in- 
creased. 

The  tendency  to  insanity  and  suicide  has  been  referred  to  as  an  acknowl- 
edged symptom.  Beginning  as  a  simple  irritability  or  moodiness  with  de- 
pression, it  passes  slowly  over  into  feeble-mindedness.  The  suicidal  impulse 
is  sometimes  carried  out. 

Diagnosis. —  This  is  easy  in  the  hereditary  cases  only.  Friedreich's 
ataxia  resembles  it  slightly,  but  begins  earlier.  Idiopathic  double  athetosis 
also  occurs  in  elderly  persons,  but  in  it  the  movements  are  associated  with 
rigidity  and  are  of  a  peculiar  character,  and  the  gait  is  also  spastic,  while 
neither  rigidity  nor  spastic  gait  plays  any  part  in  progressive  chorea. 

Prognosis  is  ultimately  fatal.  The  progress  of  the  disease  is  pro- 
gressively and  irresistibly  from  bad  to  worse. 

Treatment    is  of  no  avail. 


VI.    Chorea  Major. 

Synonyms. — Pandemic  Chorea;  Automatic  Chorea;  St.  Vitus'  Dance; 
Rhythmical  or  Hysterical  Chorea;  Lata;  Miryachit;  Jumpers;  Jerkers; 
Holy  Rollers. 

I  prefer  to  include  under  this  heading  all  the  different  varieties  of  sal- 
tatorial  spasm  of  which  the  historical  St.  Vitus'  dance  of  Paracelsus,  preva- 
lent in  the  fourteenth,  fifteenth,  and  sixteenth  centuries,  is  the  most  familiar 
ilVustration. 

All  are  varieties  of  tic,  in  which  strong  contractions  take  place  in  the 
leg  muscles  when  the  patient  attempts  to  stand,  causing  a  jumping  or  spring- 
ing action.  All  are  endemic  neuroses,  illustrated  by  the  "  jumping  French- 
men "  of  Maine  and  Canada,  the  subjects  of  which  are  liable,  on  any  sudden 
emotion,  to  jump  violently  and  utter  a  loud  cry  or  sound  and  obey  any  com- 
mand or  imitate  any  action  without  regard  to  its  nature.  The  jumping  pre- 
vails in  certain  families.  Similar  were  the  "  jerkers  "  who  appeared  during 
the  religious  re^dvals  in  Kentucky  in  the  early  part  of  the  present  century ; 
and  the  "  holy  rollers,"  in  New  Hampshire  and  Vermont.  The  disease 
known  as  lata  among  the  Malays,  and  miryachit  in  Russia  are  similar.  In 
the  true  St.  Vitus'  dance,  chorea  major,  or  chorea  Gcrnianorum,  the  par- 
oxysm arises  spontaneously ;  so,  also,  in  the  salaam  convulsions  of  children, 
in  which  the  muscles  of  the  abdomen  are  affected,  and  in  which  there  is  a 
bowing  forward  of  the  head  and  body  as  many  as  a  hundred  times  or  more. 
The  paroxysms  may  occur  several  times  a  day,  lasting  from  a  few  seconds 
to  as  many  minutes.  In  the  others,  as  the  American  jumpers,  etc.,  it  is  in 
response  to  some  external  impression.  During  the  paroxysm  the  affected 
person  sings,  dances,  jumps  from  the  ground,  rolls  from  side  to  side,  ham- 
mers with  his  hands,  stamps  with  his  feet,  or  whirls  madly  around  until  he 
falls  exhausted  to  the  ground.  , 


1 102  DISEASES  OF  THE  NERVOUS  SYSTEM. 

VII.       POSTCHOREAL  PARALYSIS  AND  POSTPARALYTIC  ChOREA. 

Synonym. — Posthemiplegic  Mobile  Spavin  (Gowers). 

Definition. —  By  this  are  meant  choreiform  movements  which  are  the 
result  of  cerebral  disease,  most  frequently  hemorrhage.  They  may  imme- 
diately precede  or  follow  the  stroke. 

History. — "Weir  ^Mitchell  *  first  called  attention  in  1874  to  certain  choreiform 
movements  which  sometimes  occur  in  partial!}-  paralyzed  limbs  after  an  attack  of 
hemiplegia.     Later,  Charcot  recognized  the  condition  and  described  it. 

Symptoms. — The  prehemiplegic  form  is  rarer  and  more  serious  in  sig- 
nificance. The  movements  vary  greatly,  and  the  milder  degrees  can  be 
recognized  only  on  close  examination.  In  this  form  the  symptoms  precede, 
usually  by  a  few  days,  the  apoplectic  stroke,  and  cease  as  soon  as  paralysis 
appears. 

Posthemiplegic  chorea,  on  the  other  hand,  ordinarily  appears  in  the 
limbs  previously  paralyzed,  at  the  time  when  they  again  begin  to  be  capable 
of  motion.  It  is  generally  sudden,  and  either  continues  throughout  life  or 
disappears  gradually.  Often  it  is  associated  with  contractures.  Not  infre- 
quently the  affected  side  of  the  body  is  anesthetic,  and  even  the  organs  of 
special  sense  may  take  part  in  the  hemianesthesia,  in  which  cases  it  is  prob- 
ably a  hysterical  hemianesthesia. 

The  movements  are  more  frequent  in  the  hand  than  in  the  leg,  though 
sometimes  they  occur  in  both,  most  marked  in  the  fingers  and  toes,  and 
diminish  toward  the  shoulders  and  hips.  They  are  really  more  athetoid 
than  choreic,  but  quicker,  consisting  mainly  in  inco-ordinate  gyrations  of 
the  fingers  and  thumbs,  flexion  and  extension  of  the  wrist  and  elbow, 
shrugging  and  other  movements  of  the  shoulder.  They  always  cease  dur- 
ing sleep.  Charcot  considers  posthemiplegic  chorea  as  identical  with  athe- 
tosis. 

The  lesion  causing  these  symptoms  is  regarded  as  cerebral,  and  in  that 
portion  of  the  cerebrum  within  the  internal  capsule  in  which  the  fibers  of  the 
pyramidal  tract  pass  between  the  lenticular  nucleus  and  the  optic  thalamus. 
Sometimes,  however,  similar  phenomena  are  associated  with  disease  else- 
where, as  in  the  pons  or  even  in  the  spinal  cord ;  but  under  any  circum- 
stances it  would  seem  to  be  necessary  that  there  should  be  irritation  of  the 
pyramidal  tracts  somewhere  in  their  course. 

EPILEPSY. 

Synonyms. — Morbus  cadncus  sive  sacer;  Morbus  divinus;  Falling  Fits, 

Definition. — Epilepsy  is  a  chronic  paroxysmal  disease,  characterized  in 
its  typical  form  by  sudden  loss  of  consciousness  and  by  violent  general 
convulsions  (grand  mal)  ;  but  both  unconsciousness  and  convulsions  may- 
be so  fleeting  as  to  be  barely  recognized  (petit  mal)  ;  while  convulsions 
may  be  localized  and  unattended  by  loss  of  consciousness  (Jacksonian  or 
cortical  epilepsy)  ;  finally,  seizures  may  be  substituted  bv  conditions  of 
uncontrollable  violence  or  somnambulistic  acts  (psychical  epilepsy). 

Epilepsy  is,   strictly  speaking,  a  syndrome  or  group  of  symptoms  of 

*  "  American  Jour,  of  the  Medical  Sciences,"  October,  1874,  p.  542. 


EPILEPSY.  1 103 

which  the  morbid  basis  is  not  always  the  same.  Formerly  it  was  considered- 
essential  to  the  diagnosis  of  epilepsy  that  the  convulsions  should  not  be 
toxic,  reflex,  traumatic,  the  result  of  previous  brain  disease,  or  heart  failure. 
At  the  present  day  toxic  convulsions,  which  are  essentially  covered  in  actual 
practice  by  uremic  convulsions,  are  not  regarded  as  epileptic,  nor  are  pure 
reflex  convulsions  which  are  due  to  such  causes  as  teething,  constipation, 
worms,  and  other  forms  of  peripheral  irritation.  On  the  other  hand,  cer- 
tain convulsions  due  to  cortical  brain  lesions,  which  will  be  further  consid- 
ered, are  acknowledged  to  be  epileptiform  in  addition  to  those  of  which  the 
anatomical  basis  is  still  unknown. 

Etiology. — From  one  to  six  persons  out  of  every  1000  have  epilepsy.- 
The  tendency  of  modern  studies  is  to  diminish  the  importance  of  heredity,, 
formerly  so  conspicuous  as  a  supposed  cause  of  epilepsy.  Gowers'  statistics, 
which  may  still  be  regarded  as  representing  the  older  pathology,  drawn 
largely  from  his  own  practice,  ascribe  to  heredity  a  percentage  of  35,  while 
the  range  in  the  older  statistics  is  from  9  to  40.  Osier's  observations,  on 
the  other  hand,  on  cases  at  the  Infirmary  for  Nervous  Diseases  in  Philadel- 
phia, and  in  the  Institution  for  Feeble-minded  Children  at  Elwyn,  Pa.,  give 
the  percentage  in  the  two  institutions  as  a  little  over  i  per  cent.,  and  in  five 
cases  out  of  435  in  which  the  epileptics  were  children  of  epileptic  parents 
it  was  traceable  to  the  mother  in  every  instance.  The  comparative  unim- 
portance of  heredity  as  a  cause  is  upheld  by  the  modern  French  school^ 
notably  by  Marie.  On  the  other  hand,  the  disease  is  of  frequent  occur- 
rence in  neurotic  families,  including  those  subject  to  insanity,  hysteria,  and 
neuralgia.  So,  too,  vices  of  constitution  and  habit  in  parents,  especially 
alcoholism  and  syphilis,  are  acknowledged  causes.  The  intermarriage  of 
relatives  is  also  an  element.  More  certainly  responsible  is  local  disease  of  the 
brain  cortex,  including  tumors  and  traumatic  disease,  svich  as  are  produced 
by  fractures,  and  the  conditions  described  as  causing  the  cerebral  palsies  in 
children. 

All  of  these  are  causes  which  may  be  both  essential  and  exciting. 
Among  the  more  purely  exciting  causes  are  fright,  irritation  by  worms  in 
the  intestinal  tract,  dentition,  constipation,  and  the  like,  all  of  which  may 
provoke  attacks  in  an  epileptic.  Some  would  regard  the  reflex  epileptiform 
attacks  excited  by  these  causes  as  true  epilepsy,  and  call  it  reflex  epilepsy. 
But  at  present  these  cases  should  not  be  called  epileptic,  since  they  do  not 
recur  after  the  exciting  cause  is  removed.  Such  were  the  two  striking  cases 
in  my  own  experience,  one  of  which  disappeared  entirely  after  the  removal 
of  a  tape- worm  in  a  girl  of  eighteen,  and  another  after  the  cure  of  consti- 
pation in  a  young  man  of  twenty.  These  are  very  dififerent  from  others  in 
which  attacks  are  brought  on  by  like  exciting  causes,  but  occur  also  inde- 
pendently of  these  causes. 

True  exciting  causes  are  infectious  diseases,  alcoholism,  and  syphilis. 
The  influence  of  infectious  diseases  is  thus  shown :  Given  an  epileptic  whO' 
is  subject  to  seizures  once  a  month,  who  acquires  typhoid  fever,  the  pro- 
dromal symptoms  are  almost  always  sure  to  include  frequently  recurring 
epileptic  seizures.  Masturbation  is  included  among  the  true  causes,  but  is 
probably  only  an  exciting  cause.  Ocular  and  aural  irritations  are  exciting 
causes.  Cardiac  epilepsy  is  a  variety  in  which  there  is  disturbance  of  the 
heart's  action,  either  palpitation  or  slowing,  prior  to  attacks ;  but  such  de- 
rangements are  cosymptoms  rather  than  causes,  or  they  may  be  a  mode 
of  manifestation  of  the  aura  to  be  presently  described. 


1 104  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Epilepsy  is  pre-eminently  a  disease  of  childhood  and  youth,  and  after 
twenty  it  is  most  unlikely  to  arise.  Most  cases  begin  between  the  ages  of 
ten  and  fifteen.  Yet  idiopathic  epilepsy  may  occur  after  sixty.  It  seems  to 
be  slightly  more  frequent  in  boys  than  girls,  although  all  statistics  do  not 
point  this  way,  whence  it  may  be  concluded  that  the  numbers  in  each  sex 
are  nearly  equal. 

Morbid  Anatomy.— The  cortical  lesions  described  as  causing  the  cere- 
bral palsies  of  children  and  some  resulting  from  trauma  are  found  in 
connection  with  most  cases  of  Jacksonian  or  focal  epilepsy.  Tumors,  espe- 
cially those  involving  the  motor  layer  of  the  cortex,  are  among  these 
causes ;  so  are  localized  syphilis,  pachymeningitis,  and  tyroma  or  tuberculous 
tumor,  and  sometimes  tuberculous  meningitis,  pointed  out  by  J.  Hendrie 
Lloyd.  Lloyd  would,  however,  exclude  the  gross  deformities,  such  as  po- 
rencephalia ;  and  diffuse  processes,  such  as  lobar  sclerosis,  which  manifest 
themselves  by  idiocy  and  arrest  development,  and  are  not  infrequently  pro- 
vocative of  epileptic  seizures. 

Sclerosis  of  different  parts  of  the  brain  and  medulla  oblongata  is  also 
found  in  cases  of  epilepsy,  especially  in  the  hippocampus  major,  this  being 
probably  a  conspicuous  local  focus  of  a  more  diffuse  lesion.  Similar  sclerosis 
is  sometimes  found  in  the  cerebellum.  A  nuclear  degeneration  and  vacuola- 
tion  of  the  cells  of  the  second  layer  of  the  cortex  h^s  been  claimed  by  Bevan 
Lewas  as  a  distinctive  lesion  of  epilepsy.  Many  cases  of  so-called  idiopathic 
epilepsy  are  still  without  a  demonstrable  morbid  anatomy. 

Mechanism  of  the  Convulsion. — The  epileptic  seizure  itself  is  regarded 
in  the  light  of  our  present  knowledge  as  an  explosion  or  discharge  of  nerve 
force,  the  seat  of  discharge,  in  the  severe  seizures,  at  least,  being  the  large 
motor  cells  in  the  deeper  layers  of  the  cortex,  the  function  of  which  is  to  store 
up  and  discharge  nerve  force.  The  same  mechanism  exists  in  sensory  and 
psychical  epilepsy.     The  explanation  is  not  entirely  satisfactory. 

Symptoms. — These  vary  in  the  four  varieties  known  as  grand  mal, 
petit  mal,  Jacksonian,  and  psychical  epilepsy. 

I.  Grand  Mai. — In  a  large  number  of  cases  the  epileptic  attack  is  pre- 
ceded by  what  is  known  as  the  aura,  a  peculiar  sensation  which  differs  greatly 
in  different  individuals.  Occasionally  it  is  like  what  the  word  literally 
means,  a  breath  of  air,  which  starts  from  a  particular  part  of  the  body,  as 
the  extremities  or  a  single  finger  or  toe  or  a  part  of  the"  surface  of  the  body, 
such  as  the  neighborhood  of  the  stomach  or  the  heart.  At  other  times  the 
aura  is  a  simple  epigastric  sensation,  a  sense  of  discomfort  or  uneasiness 
emanating  from  the  stomach  or  the  feeling  of  a  ball  arising  therefrom,  and 
this  is  not  a  very  uncommon ^orm.  It  may  be  a  flash  of  light,  which  may 
be  of  different  colors;  an  object,  as  a  face  or  faces,  and  even  a  cofiin — as  in 
one  of  M.  Allen  Starr's  cases.  Auditory  aurse  are  manifested  through  the 
sense  of  hearing,  and  may  be  subjective  sounds  of  any  kind,  including  musi- 
cal tones  or  even  voices.  Gustatory  and  olfactory  aurse  include  subjective 
tastes  and  smells,  mostly  of  an  unpleasant  character.  Aurse  are  represented 
also  by  tingling,  numbness,  or  simple  flushing  or  chilliness  anywhere  in  the 
body.  "  Intellectual  aur^,"  so  called  by  Hughlings  Jackson,  are  certain  men- 
tal conditions,  such  as  the  "  dreamy  state,"  and  the  consciousness  of  a  certain 
algebraic  formula,  which  always  presented  itself  to  a  patient  of  Starr's. 

In  other  cases  there  is  a  more  prolonged  prodrome.  For  several  hours 
or  for  a  day  the  patient  may  be  the  subject  of  sensations.  He  may  feel  gen- 
erally miserable,  dispirited,  timid,  irritable,  or  dizzy,  or  he  may  be  pale  or 


EPILEPSY.  1 105 

quiet,  and  wait  patiently  for  the  dreaded  event,  known  to  him  rather  by  its 
consequences  than  its  phenomena,  of  which  he  is  unconscious.  There  is 
j)athetic  sadness  often  in  this  patient  expectation.  The  aura  is  by  no  means 
always  present,  indeed,  perhaps  in  the  majority  of  cases  of  epilepsy  there 
occurs  no  warning  of  the  attack.  The  aura  may  be  substituted  by  certain 
movements,  such  as  running  rapidly  for  a  few  minutes  either  forward  or  in 
a  circle, — the  so-called  epilepsia  prociirsiva, — or  the  patient  may  stand  on 
his  toes  and  rotate  with  great  rapidity. 

Following  the  aura  or  independent  of  it  occurs  the  convulsion  or  "  fit," 
of  which  the  initial  event  is  often  the  epileptic  cry.  This  is  succeeded  by  the 
fall,  which  may  be  sudden,  as  if  the  patient  were  shot,  while  serious  injury 
may  be  a  consequence.  Following  this  the  phenomena  of  the  fit  may  be 
quite  sharply  divided  into  three  stages,  that  of  tonic  spasm,  of  clonic  spasm, 
.and  of  coma. 

(a)  The  Tonic  Spasm. — In  this  the  head  is  drawn  back  or  to  the  right 
and  the  jaws  are  fixed ;  the  arms  are  flexed  at  the  elbow,  the  hand  is  flexed  at 
the  wrist,  and  the  fingers  are  clinched  into  the  palm,  while  the  legs  and  feet 
are  extended.  The  muscles  of  the  chest  are  involved  and  respiration  is  sus- 
pended, and  the  face  becomes  dusky,  livid,  and  swollen,  contrasting  with  the 
initial  pallor.  The  muscles  of  the  two  sides  are  not  equally  affected,  so  that 
the  neck  is  twisted  and  the  spine  curved.  This  stage  lasts  but  a  few  seconds 
and  is  succeeded  by  clonic  spasm. 

(b)  The  Clonic  Spasm. — Now  the  muscular  contractions  become  inter- 
mittent. At  first  tremulous  and  vibratory,  they  soon  become  strong  and 
general,  until  the  arms  and  legs  are  thrown  about  in  the  most  violent  man- 
ner, sometimes  so  violently  as  to  produce  dislocation,  usually  of  the  shoulder. 
The  muscles  of  the  face  are  also  involved  in  distorting  contractions,  while 
the  eyes  roll  and  the  lids  open  and  close.  The  jaw  muscles  contract  violently, 
and  the  tongue  is  apt  to  be  caught  and  bitten.  A  frothy  saliva,  often  blood- 
stained, escapes,  and  the  patient  is  said  to  "  froth  at  the  mouth."  There  may 
be  involuntary  discharge  of  feces  and  urine.  The  lividity  supervening  in 
the  first  stage  diminishes  somewhat  during  this  stage.  The  temperature 
rises  1-2°  to  1°  F.  (0.28°  to  0.55°  C).  Very  soon  the  contractions  become 
less  violent,  finally  abate,  and  this  stage  terminates,  in  one  or  two  minutes, 
in  the  stage  of  coma. 

(c)  Coma. — In  this  the  limbs  are  relaxed  and  there  is  profound  uncon- 
sciousness, but  the  breathing  is  noisy  and  stertorous.  The  face  remains  con- 
gested, but  is  no  longer  cyanotic.  The  patient  may,  after  a  time,  be  aroused, 
but  if  left  alone,  commonly  sleeps  several  hours,  awaking  after  a  time  in  a 
remarkably  natural  state,  feeling  bruised  and  aching,  but  otherwise  quite 
himself;  or  there  may  be  some  mental  confusion  and  even  headache. 

These  are  the  phenomena  of  the  attack  in  the  vast  majority  of  cases  of 
grand  mal.  There  may  not  be  another  attack  for  several  days  or  a  month 
or  more.  In  severe  cases,  on  the  other  hand,  there  may  be  daily  recurrence, 
though  not  until  the  disease  has  lasted  for  several  years.  In  a  few  instances 
the  attacks  may  follow  one  another  in  rapid  succession  without  a  return  of 
consciousness,  lasting  from  twelve  hours  to  a  day  or  more,  producing  the 
status  epilepticus.  in  the  course  of  which  the  patient  may  die  from  exhaus- 
tion.    In  this  state  there  is  often  decided  fever. 

After  the  attack  the  reflexes  may  be  increased  and  ankle  clonus  may  he 
.obtained ;  at  other  times  the  reflexes  are  absent.     The  urine  i?  also  often 

70 


iio6  DISEASES  OF  THE  NERVOUS  SYSTEM. 

increased,  and  a  small  amount  of  albumin  is  quite  common  after  the  fit. 
There  is  also  sometimes  an  increase  in  the  amount  of  uric  acid  in  the  urine 
after  the  convulsion  in  grand  mal. 

Inequality  of  pupils  (anisocoria)  has  been  considered  a  symptom  of  epi- 
lepsy. This  symptom,*  however,  occurs  in  healthy  individuals,  and  too 
much  value  should  not  be  attached  to  it, 

2.  Petit  Mal. — The  symptoms  in  minor  attacks  vary  somewhat,  but 
commonly  the  patient  stops  in  the  midst  of  what  he  may  be  doing,  the  eyes 
become  staring  and  fixed,  the  pupils  dilated,  the  countenance  pale,  there  may 
be  some  twitching  of  the  facial  muscles  or  the  limbs,  and  consciousness  is 
lost,  but  there  is  no  convulsion.  Anything  that  is  in  the  band  may  be 
dropped,  but  in  a  minute  or  two  consciousness  returns  and  the  patient  re- 
sumes what  he  has  been  doing  as  though  nothing  had  happened.  Here,  too, 
though  rarely,  there  may  be  aurae  of  various  kinds  and  even  an  epileptic  cry ; 
also  forced  movements — procursive  epilepsy.  There  may  be  dizziness  with- 
out unconsciousness,  and  the  patient  may  fall.  An  increase  of  uric  acid  in 
the  urine  is  said  also  to  be  quite  frequently  associated  with  this  form  of 
epilepsy.  As  the  disease  continues  the  attacks  of  petit  mal  generally  become 
grand  mal,  or  the  two  forms  of  attack  may  alternate. 

3.  Jacksonian  or  Partial  or  Cortical  Epilepsy. — In  this,  consciovisncss 
is  retained,  though  it  is  thought  by  some  that  there  is  always  a  momentary 
period  of  unconsciousness  while  convulsions  occur,  though  circumscribed  to 
a  single  group  of  muscles  or  to  a  single  limb.  It  is  almost  always  symp- 
tomatic of  some  focal  lesion  in  the  cortical  motor  area,  which  may  be  a 
tumor,  an  injury  or  inflammatory  process  in  the  membranes  or  brain  sub- 
stance, softening,  hemorrhage,  abscess,  or  sclerosis.  It  is  especially  apt  to 
be  a  sign  of  a  growing  tumor.  Hence  it  is  also  called  symptomatic  epilepsy. 
Previous  to  the  twitching  there  may  be  a  numbness  or  tingling  in  the  part  to 
be  involved,  which  has  been  called  the  "  signal  symptom  "  by  Seguin,  because 
it  ushers  in  the  attack.  It  may  remain  during  the  attack,  and  is  of  value  in 
determining  the  seat  of  the  lesion,  and  therefore  the  place  for  operation.  Its 
seat  is  usually  the  same  in  the  same  patient  in  all  the  attacks. 

The  spasm  or  convulsion  begins  uniformly  in  one  part, — it  may  be  the 
face,  the  thumb,  the  toes, — thence  slowly  invades  an  entire  limb.  It  con- 
tinues sometimes  for  three  or  four  minutes  or  longer.  The  movement  is 
tonic  and  clonic,  extending  from  the  part  in  which  it  begins  to  other  parts  in 
a  definite  order  of  extension.  Thus,  if  it  begins  in  a  part  of  the  face,  it  ex- 
tends thence  to  the  whole  face,  then  to  the  shoulder,  arm,  forearm,  and  hand, 
and  possibly  the  leg  from  the  trunk  down  to  the  toes ;  or  it  may  start  in  the 
fingers  and  go  in  the  oppositcvdirection.  Jacksonian  epilepsy  also  occurs  in 
uremia  and  progressive  paralysis  of  the  insane,  and  it  has  already  been  spoken 
of  as  following  the  hemiplegia  of  children.  After  the  convulsion,  the  parts 
convulsed  and  especially  that  in  which  the  spasm  begins  may  be  partially 
paralyzed  and  awkward  in  movement,  and  quite  often  the  numbness  and 
palsy  continue  for  some  time,  with  a  moderate  degree  of  tactile  or  thermal 
anesthesia.  More  rarely  this  paresis  is  permanent,  when  it  is  evidence  of 
changes  in  the  cortex  such  as  may  be  caused  by  a  growing  tumor.  Rarely 
the  opposite  side  of  the  body  is  affected,  and  if  this  occurs,  consciousness 
may  be  finally  lost. 

4.  Psychical  Epilepsy. — This  occurs  either  as  a  later  symptom  follow- 

*See  a  paper  by  Wendell  Reber,  "  The  Pupil  in  Health  and  Epilepsy,"  "Med.  News,"   August 
24,  1895. 


EPILEPSY.  1 1 07 

ing  the  more  common  forms  of  grand  mal  and  especially  petit  nial,  or  as  an 
independent  state  or  as  what  is  known  as  a  "  psychical  epileptic  equivalent," 
where  the  usual  seizure  is  substituted  by  a  somnambulistic  state  in  which  the 
patient  performs  various  acts,  sometimes  of  great  complexity,  including 
driving,  walking,  and  the  like,  of  which  he  is  totally  oblivious  after  he  passes 
into  the  natural  condition.  Some  striking  instances  of  psychical  epileptic 
equivalent  are  related  by  M.  Allen  Starr  in  his  book  on  '"  Familiar  Forms  of 
Nervous  Disease."  Other  manifestations  of  psychical  epilepsy  are  repre- 
sented by  violent  maniacal  excitement  and  uncontrollable  violence,  in  which 
criminal  acts,  including  even  homicide,  are  committed. 

Relative  Frequency  and  Time  of  Attacks. — The  major  form  of  attack  is 
the  most  frequent,  after  this,  mixed  forms  of  major  and  minor,  and  then 
minor  and  Jacksonian ;  the  most  infrequent  are  the  psychical  forms. 

Two-thirds  of  the  attacks  occur  between  8  a.  m.  and  8  p.  m.  ;  many 
attacks  occur  early  in  the  morning  after  awaking,  some  between  3  and 
5  A.  M.,  and  others  in  the  night  at  unknown  hours — nocturnal  epilepsy.  In 
true  epilepsy  the  patient  generally  feels  perfectly  well  between  the  attacks — 
indeed,  he  not  infrequently  feels  better  for  a  time  after  the  spell. 

Diagnosis. — The  epileptic  fit  is  of  itself  in  no  way  characteristic  of  the 
disease.  The  uremic  convulsion  is  identical,  as  is  also  the  reflex  convulsion 
due  to  teething  and  other  causes.  Even  hysterical  convulsion  closely  re- 
sembles it,  but  there  are  points  of  difference.  Something  more,  therefore, 
than  the  convulsion  is  necessary  to  prove  the  presence  of  the  disease.  The 
aura  is  distinctive,  and  when  present,  is  almost  conclusive.  Scarcely  less  so 
is  the  epileptic  "  cry,"  although  it  is  less  constant  than  the  aura.  The  relaxa-- 
tion  of  the  sphincters  belongs  rather  to  the  epileptic  fit,  while  the  bitten 
tongue,  the  dilated  pupil,  and  sudden  unconsciousness  belong  to  uremia  as 
well ;  and  it  is  from  uremia  that  it  is  most  important  to  distinguish  epilepsy. 
The  occurrence  in  the  midst  of  apparent  health  of  a  convulsion  with  the 
features  described,  followed  by  prompt  recovery  without  albuminuria  or 
casts,  can  hardly  be  anything  but  epilepsy.  At  other  times,  when  other  signs 
of  Bright's  disease  are  absent,  it  may  be  necessary  to  defer  the  diagnosis  a 
little  longer  in  order  to  examine  the  urine.  Finally,  epileptics  may  have 
Bright's  disease,  when  errors  are  still  more  likely  and  sometimes  un- 
avoidable.* 

The  reflex  convulsion  in  children  is  apt  to  be  repeated  until  the  cause  is 
removed,  and  in  this  respect  the  condition  resembles  the  status  epilepticus, 
but  in  the  former  a  little  careful  searching  will  probably  discover  the  cause. 
The  isolated  reflex  convulsion  may  be  more  difficult  to  account  for  at  first, 
but  in  these  cases  immediate  decision  is  less  important,  and  we  may  await 
time  to  help  us.  The  very  short  duration  of  the  petit  mal  separates  it  sharply 
from  the  uremic  fit.  Nocturnal  convulsions,  occurring  as  they  do  often  with- 
out the  knowledge  of  the  patient,  are  usually  epileptic. 

The  hysterical  convulsion  sometimes  simulates  closely  the  epileptic. 
But  the  hvsterical  patient  rarely  loses  consciousness  completely,  the  fall  is 
not  so  sudden,  the  victim  rarely  if  ever  hurts  herself,  and  never  bites  her 
tongue ;  nor  is  there  anv  rise  of  temperature,  while  even  the  pulse  and  respi- 
rations commonly  remain  quite  normal.  There  is  rigidity,  but  it  is  unlike 
that  of  epilepsy — it  is  not  more  conspicuous  in  the  beginning  of  the  attack. 
Opisthotonos,  or  arching  of  the  back,  does  not  occur  in  the  epileptic  convul- 


*  See  two  interesting  cases  reported  by  me  in  the  "  Transactions  of  the  Association  of  American 
Physicians,"  vol.  vi.,  1891. 


iio8  DISEASES  OF  THE  NERJ'OUS  SYSTEAd. 

sion.  Finally,  the  hysterical  convulsion  is  of  longer  duration,  lasts  ten 
minutes  or  more,  while  the  duration  of  the  epileptic  fit  is  not  usually  more 
than  three  or  four  minutes. 

The  petit  iiial  is  most  frequently  mistaken  for  fainting,  but  after  two  or 
three  occurrences  it  should  be  recognized.  The  vertigo  of  Meniere's  disease 
and  of  attacks  of  indigestion  resembles  it,  but  in  the  former  there  is  deafness, 
while  in  neither  is  there  actual  unconsciousness,  as  is  always  the  case  in 
petit  )nal. 

Jacksonian  epilepsy  is  sni  generis  and  is  not  simulated  by  any  except  the 
rare  instances  of  circuniscrihed  ureniic  convulsions  and  similar  spasms  in 
general  paresis;  however,  it  has  been  described  as  occurring  in  liysteria.  A 
further  study  of  each  instance  must  quickly  dissipate  the  error.  While  the 
approximate  seat  of  the  lesion  may  be  inferred  in  many  cases  of  Jacksonian 
epilepsy,  the  precise  cause  cannot  generally  be  determined,  because  all  sorts 
of  lesions  produce  the  same  symptoms.  Recurring  epilepsy  in  persons  over 
thirty  is  probably  due  to  organic  causes,  and  in  nine  cases  out  of  ten,  accord- 
ing to  H.  C.  Wood  and  also  Fournier,  is  due  to  syphilis. 

The  highest  refinement  of  diagnosis  in  the  study  of  epilepsy  attempts 
to  determine  from  the  character  of  the  aura  the  seat  of  beginning  cortical 
irritation.  Thus,  a  visual  aura,  it  is  claimed,  might  indicate  that  the  ner- 
vous discharge  began  in  the  occipital  lobes ;  a  vertigo  might  indicate  that  it 
began  in  the  cerebellum ;  a  sense  of  numbness,  the  sensory  motor  area  of  the 
cortex.  The  "intellectual  aurse,"  as  they  are  called  by  Hughlings  Jackson, 
are  regarded  by  him  as  affording  evidence  of  a  nervous  discharge  from  the 
highest  cerebral  centers. 

Prognosis. — The  true  epileptic  rarely  gets  well.  I  believe  I  have  seen 
two  cases  of  recovery  in  my  experience.  In  such  statement  epileptiform 
attacks  due  to  peripheral  irritation  are  rigidly  excluded  as  not  being  true 
epilepsy.  These  invariably  get  w^ell  with  the  removal  of  the  irritation,  while 
true  epilepsy,  in  which  attacks  are  readily  excited  by  such  irritation,  is  bene- 
fited but  not  cured.  The  chances  of  recovery  are  said  to  be  greater  in  the 
young,  and  in  the  male  sex  than  in  the  female.  One  of  my  cases  of  apparent 
recovery  was  a  man  who  had  his  last  fit  after  forty ;  the  second  a  A\^man  who 
had  no  attack  after  fourteen.  Both  live.  C.  L.  Dana  places  the  recoveries 
at  from  5  to  10  per  cent.,  which  appears  to  me  large.  Even  cases  of  com- 
bined petit  mal  and  grand  mal,  of  which  the  prognosis  is  most  unfavorable, 
are  said  to  get  well.  The  prognosis  of  petit  mal  is  more  unfavorable  than 
that  of  grand  mal ;  of  the  mixed  forms  still  more  unfavorable,  and  post- 
hemiplegic epilepsy  most  unfavorable  of  all. 

On  the  other  hand,  an  epileptic  rarely  dies  of  his  disease.  He  may  fall 
in  the  water  during  an  attack  and  drown,  or  may  choke  to  death  if  attacked 
while  eating.  Death  sometimes  occurs  from  exhaustion  in  the  status  epi- 
leptiats,  but  this  is  not  frequent.  The  health  of  epileptics  usually  deterio- 
rates slowly,  and  life  is  shortened  accordingly,  few  surviving  the  age  of  forty 
or  fifty.  They  rather  frequently  die  of  tuberculous  phthisis.  Especially 
frequent  is  mental  deterioration ;  indeed,  it  may  be  said  to  be  the  rule  when 
the  patient  lives  long  enough,  and  about  10  per  cent,  become  demented  or 
insane.  Much  may  be  done  by  treatment  to  control  the  number  of  attacks, 
and  the  less  numerous  they  are,  the  less  serious  is  the  effect  upon  the  health. 
Many  epileptic  persons  earn  a  livine,  and  more  could  if  properly  helped. 

The  more  infrequent  the  attacks,  the  better  the  prognosis.  Pure  noc- 
turnal epilepsy  and  the  pure  diurnal  form  are  each  more  easily  cured  than  the 


EPILEPSY.  1 109 

mixed  forms.     Cases,  too,  which  arise  after  twenty  years  of  age  are  more 
likely  to  get  well. 

Treatment. — No  fact  in  therapeutics  is  better  established  than  that  the 
bromids  control  epilepsy  in  varying  degree — it  may  be  completely,  it  may  be 
simply  to  render  infrequent  the  seizures.  There  is  probably  no  important 
difference  in  the  efficiency  of  the  various  preparations,  but  the  bromid  of 
potassium  has  been  most  extensively  used.  The  bromid  of  sodium  is  pre- 
ferred on  account  of  its  greater  solubility.  Bromid  of  ammonium  is  slightly 
more  stimulating.  Alore  recently  bromid  of  strontium  has  been  highly 
recommended.  Causes  of  peripheral  irritation  should  first  be  sought,  and  if 
possible  eliminated.  Gastro-intestinal  irritation  should  be  removed. 
Phimosis  should  be  cured.  The  possible  practice  of  masturbation  should  be 
inquired  into.  These  eliminated,  the  bromid  treatment  may  be  commenced. 
The  doses  required  vary  greatly  and  must  be  determined  by  trial.  Scarcely 
less  than  fifteen  grains  (i  gm.)  four  times  a  day  are  required  for  adults,  and 
from  this  point  the  dose  may  be  increased  until  the  desired  effect  is  produced. 
The  massive  doses  sometimes  given,  amounting  to  ounces  in  a  day,  are  ulti- 
mately harmful,  but  doses  of  a  dram  (4  gm.)  are  sometimes  necessary  and 
well  borne.  It  is  sometimes  of  advantage  to  combine  the  various  bromids  of 
sodium,  potassium,  and  ammonium.  Greater  efficiency  is  secured  if  the  drug 
is  given  on  an  empty  stomach,  half  an  hour  before  meals  or  two  hours  after, 
and  smaller  doses  suffice  when  thus  administered,  and  the  omission  of  sodium 
chlorid  from  the  diet  is  believed  to  lessen  the  amount  of  bromid  necessary 
and  to  increase  its  efficiency.  Bromism,  shown  by  drowsiness,  mental  torpor, 
gastric  and  cardiac  distress  with  acne,  sometimes  results.  It  is  doubtful 
whether  it  can  be  obviated  in  any  way  except  by  omitting  the  drug.  The 
bromid  eruption  may  sometimes  be  averted  by  combining  arsenic,  but  this 
does  not  always  succeed,  and  on  this  account,  too,  the  drug  must  be  omitted. 
In  a  few  cases  the  bromids  are  absolutely  useless,  more  especially  in  cases 
in  which  they  produce  gastro-intestinal  derangement,  perhaps  in  about  five 
per  cent,  of  cases.  Chloral  adds  to  the  efficiency  of  the  bromids,  and  is  some- 
times necessary  to  produce  the  desired  effect.  It  may  be  given  in  doses  of 
from  ten  to  thirty  grains  (0.66  to  2  gm.). 

To  treatment  by  the  bromids  should,  of  course,  be  added  proper  hygienic 
measures.  Suitable  food,  especial  attention  to  the  bowels,  fresh  air,  and  out- 
door life  are  indispensable.  Bathing  is  important,  and  cold  baths — particu- 
larly douches  and  shower-baths,  cold  sponge-baths  or  wet  packs  should  be 
judiciously  used.     Vasomotor  tone  and  circulation  are  thus  strengthened. 

Food  should  be  simple  and  easily  assimilated,  overeating  should  be 
especially  avoided.  Stale  bread,  wheaten  grits,  and  similar  foods,  rice,  pota- 
toes, fresh  succulent  vegetables  like  string  beans,  peas,  and  tomatoes,  with 
an  abundance  of  milk,  are  suitable.  Water  should  be  freely  drunk  by  the 
patient,  and  a  glassful  is  advised  between  meals  and  at  bedtime. 

Of  other  remedies  recommended  may  be  mentioned  antifehrin  and  anti- 
pyrin.  A  trial  of  the  former  in  the  Vanderbilt  Clinic  in  New  York,  by  M. 
Allen  Starr,  w^as  unsatisfactory.  On  the  other  hand,  in  the  hands  of  Charles 
S.  Potts,  at  the  Dispensary  of  the  University  of  Pennsylvania,  it  was  appar- 
ently useful.  Especially  efficient  at  the  latter  proved  a  combination  of  anti- 
pyrin  and  bromid  of  ammonium,  suggested  by  H.  C.  Wood.  For  adults  a 
dose  of  six  grains  (0.39  gm.)  of  the  former  and  ten  grains  (0.66  gm.)  of  the 
latter,  three  times  a  day,  in  a  number  of  cases  averted  the  seizure  for  months. 
Continuous  exhibition  seems  necessary.     These  drugs  at  least  merit  a  trial 


mo  DISEASES  OF  THE  NERVOUS  SYSTEM. 

where  the  bromids  are  for  any  reason  unsatisfactory.  The  monobromated 
camphor  has  been  recommended  quite  recently  by  Hasle.  The  best  mode  of 
administration  appears  to  be  in  a  capsule  or  emulsion,  the  dose  being  two  to 
five  grains  (0.13  to  0.32  gm.j. 

Starr  has  also  used  the  tincture  of  simulo  {Cap  par  is  coriacea)  at  the 
Vanderbilt  Clinic  with  the  effect  of  reducing  the  number  of  attacks  in  grand 
mal.  but  to  no  purpose  in  petit  mal.  It  was  used  in  doses  as  large  as  1-2 
ounce  (13.5  c.  c.)  daily.  In  petit  mal  the  same  observer  found  nitro-glycerin 
the  only  remedy  of  any  service.  He  appears  to  have  used  it  in  doses  of  i-ioo 
grain  (o.(X)o65  gm.)  three  times  a  day.  In  my  experience  this  regulation 
dose  fails  in  a  large  number  of  cases  to  produce  the  physiological  effect,  and 
larger  doses — from  1-50  to  1-25  grain  (0.0013  to  0.0026  gm.) — may  be  given. 
It  is  to  be  remembered  that  epilepsy  is  one  of  the  diseases  which  are  nearly 
always  influenced  for  a  time  by  new  remedies.  The  preparations  of  valerian 
may  also  be  tried  in  the  event  of  failure  with  the  bromids.  Others  which 
have  been  used  are  borax,  iodid  of  zinc,  and  sulphonal. 

The  nitrite  of  amyl  has  been  employed  to  abort  the  attack  in  cases  where 
there  was  an  aura,  and  in  a  certain  number  of  cases — about  25  per  cent,  in 
Starr's  experience — has  proved  efficient. 

Operation,  usually  trephining,  is  increasingly  practiced,  and  many  suc- 
cessful cases  have  been  reported,  chiefly  of  Jacksonian  epilepsy.  When  a 
well-defined  lesion  can  be  located,  operation  should  promptly  be  done.  Even 
in  doubtful  cases  operation  may  be  justified,  as  with  modern  surgical  pre- 
cautions it  is  attended  with  much  less  risk.  It  should  be  remembered,  too, 
that  operation  per  se  has  proved  curative — that  is,  cases  have  apparently  re- 
covered after  trephining  where  no  lesion  was  found  after  removing  the 
disc. 

Asylum  Provision. — It  is  exceedingly  important  that  some  systematic 
provision  should  be  made  for  epileptics  either  by  the  State  or  by  private 
charity.  They  are,  as  a  rule,  unwelcome  inmates  of  hospitals  because  of 
their  incurability.  Doubtless  the  neglect  to  which  they  are  subjected  at  home 
aggravates  in  many  cases  their  condition,  while  it  makes  even  more  unhappy 
their  lot.  Provision  should  be  made  to  enable  them  to  pursue  some  vocation, 
the  tendency  of  which  has  been  shown  to  be  curative.  A  hospital  with  such 
provisions  has  recently  been  inaugurated  near  Philadelphia,  and  they  exist 
in  some  other  States.  The  mind  should  be  kept  occupied ;  nothing  is  more 
baneful  to  the  epileptic  than  idleness,  and  it  is  said  that  cures  have  been 
effected  by  giving  the  patient  something  to  do. 

Treatment  of  the  Conviilswn. — Of  no  small  importance  is  the  treatment 
of  the  eclamptic  attack.  The  first  measure  is  to  secure  protection  against 
biting  the  tongue.  Unfortunately,  this  is  often  the  initial  event  in  the  con- 
vulsion. The  end  of  a  towel  may  be  twisted  and  inserted  between  the  teeth, 
or  a  suitable  piece  of  wood  or  a  clothes-pin  may  be  similarly  used.  A  small 
object  like  a  cork  is  unsafe,  as  it  may  be  swallowed  or  drawn  into  the  larynx 
and  cause  death  by  suffocation.  Some  patients  carry  such  an  appliance  ready 
for  use.  The  patient  should  be  controlled  sufficiently  to  protect  him  from 
injury. 

Given  a  case  that  under  the  bromids  has  yielded  to  treatment,  what 
course  shall  be  pursued  as  to  its  interruption?  The  most  experienced  clini- 
cians urge  that  the  drug  should  be  continued  at  least  two  years  after  the  fits 
have  disappeared,  and  Seguin  even  advises  that  there  should  be  no  reduc- 
tion in  the  bromids  until  three  years  have  elapsed  without  symptoms.     My 


REFLEX  CONVULSIONS  OF  CHILDREN.  nil 

own  practice  has  been  to  continue  a  dose  of  from  fifteen  to  twenty  grains 
(i  to  1.32  gm.)  at  bedtime  for  an  indefinite  period  after  cessation  of  the  fits. 
The  friends  of  the  patient  should  be  impressed  with  the  importance  of  such 
a  course,  as  he  himself  is  almost  sure  to  grow  indifferent  after  the  long 
absence  of  attacks. 


REFLEX  CONVULSIONS  OF  CHILDREN. 

Synonyms. — Infantile  Convulsions ;  Eclampsia;  Epilepsia  acuta. 

Definition. — Convulsions  due  to  peripheral  irritation  in  children. 

Etiology. — There  is  some  confusion  in  the  use  of  the  word  eclampsia. 
Some  would  use  it  as  simply  synonymous  with  the  word  convulsion,  an  appli- 
cation, I  think,  altogether  the  best.  Others  apply  it  to  convulsions  due  to 
peripheral  irritation  only ;  others  seemingly  to  puerperal  convulsions  only ; 
others,  notably  Hermann  Eichhorst  and  C.  L.  Dana,  define  eclampsia  as 
acute  epilepsy.  Eichhorst  further  says :  •"  Epileptiform  convulsions,  which 
have  the  same  genesis  as  true  epileptic  attacks,  are  excited  by  irritation  of  the 
cortical  motor  brain  areas."  He  then  names,  among  the  causes  of  these, 
toxic  agencies,  including  uremia  and  lead  poisoning,  but  also  says  he  will 
treat  only  under  eclampsia  of  the  convulsions  of  infants  (five  to  twenty 
anonths),  among  the  causes  of  which  he  names  heredity;  psychical  causes, 
as  fright  or  anger ;  but  most  frequently  reflex  irritation,  as  of  the  skin  or 
gastro-intestinal  tract  (dentition,  intestinal  worms,  inflammation,  and  the 
like);  foreign  bodies;  fecal  accumulation;  stone  in  the  bladder,  etc.;  and 
finally,  the  infectious  fevers  and  rickets.  This  class  of  cases  I  have  taken 
great  pains  to  exclude  from  the  epilepsies,  and  prefer  to  include  at  present 
under  the  heading  of  Reflex  Convulsions  of  Children.  The  convulsions 
which  attend  diseases  of  the  brain  are  a  part  of  the  symptomatology  of  these 
affections,  and  do  not  require  separate  consideration. 

Debility  and  malnutrition  may  be  considered  as  predisposing  causes  of 
the  form  of  convulsion  under  consideration. 

Symptoms. — These  demand  no  detailed  consideration,  since  the  convul- 
sion is  epileptiform  and  has  been  described.  It  is  much  more  often  partial 
than  the  typical  fit  of  true  epilepsy,  but  it  has  the  same  stages  of  the  tonic 
and  clonic  spasm  followed  by  drowsiness.  It  is  most  frequently  single,  but 
the  fits  may  follow  one  another  in  rapid  succession,  and  though  rarely,  ter- 
minate fatally.  As  in  epilepsy,  the  temperature  rises  slightly  during  the  fit. 
It  may  come  on  suddenly  without  warning,  or  be  preceded  by  restlessness 
and  fever. 

Diagnosis. — This  is  usually  easy,  the  convulsion  coming  on  suddenly 
in  the  midst  of  health,  yet  traceable  to  some  such  event  as  the  ingestion  of 
some  indigestible  food,  to  teething,  or  to  some  other  source  of  peripheral 
irritation. 

The  convulsion  is  distinguished  from  that  of  infantile  hemiplegia  by  the 
absence  of  hemiplegia.  A  transient  paresis  does,  however,  sometimes  fol- 
low the  reflex  convulsion. 

These  convulsions  most  frequently  occur  between  the  fifth  and  twen- 
tieth months,  and  toward  the  end  of  the  second  year,  though  they  may  occur 
as  late  as  the  fifth  year.  Convulsions  occurring  after  this  period  are  more 
likely  to  be  true  epilepsy. 


1 1 12  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Prognosis. — Cases  of  infantile  convulsions  are  always  alarming,  yet 
most  get  well,  and  doubtless  many  cases  among  the  poor  recover  which  do 
not  come  under  the  notice  of  the  physician.  On  the  other  hand,  not  a  few 
deaths  are  caused  by  them — according  to  Morris  J.  Lewis,  8.5  per  cent,  of 
all  deaths  in  children  under  ten ;  and  according  to  West,  22.35  per  cent,  of 
all  who  die  under  one  year.  Cases  of  infectious  disease  ushered  in  by  con- 
vulsions are  almost  always  serious,  but  the  convulsions  themselves  are  rarely 
fatal.  Convulsions  due  to  gastric  derangement  are  generally  followed  by 
recovery. 

Treatment. — The  first  step  in  the  treatment  must  always  consist  in 
finding  and  removing  the  cause.  If  it  be  undigested  food,  an  emetic  and  an 
enema  are  indicated ;  if  dentition  is  at  fault,  the  lancet  should  be  promptly 
applied  to  the  gums.  The  next  step  is  immersion  in  a  zvarm  both,  say  at  95° 
F.  (35°  C),  increased  to  100°  F.  (38.8^^  C),  to  which  mustard  may  be  added. 
At  the  same  time  cold  should  be  applied  to  the  head  by  means  of  an  ice-bag 
or  cold  water.  To  control  the  convulsion,  chloral  is  the  remedy  par  excel- 
lence, but  while  waiting  for  its  effect,  it  may  be  necessary  to  permit  the  child 
to  inhale  a  few  drops  of  chloroform.  The  dose  of  chloral  should  be  suffi- 
cient— 2  1-2  to  five  grains  (0.165  to  0.33  gm.)  to  a  child  of  one  year,  fre- 
quently repeated  until  the  effect  is  produced.  It  may  be  given  in  enema  in 
double  this  dose,  the  buttocks  being  compressed  until  it  is  absorbed.  The 
bromids  may  be  given  in  combination  with  chloral,  but  they  are  altogether 
too  feeble  to  be  relied  upon  alone.  Should  these  measures  fail,  opium  may 
be  used  and  even  morphin,  hypodermically,  in  minute  doses ;  but  these  drugs 
should  be  used  only  as  a  last  resort.  Generally,  the  attack  is  relieved  the 
moment  the  peripheral  irritation  is  removed. 


MIGRAINE. 

Synonyms. — Sick   Headache;   Bilious   Headache;   Hemicrcmia;   Megrim; 
Migrdn;  Paroxysmal  Headache. 

Definition. — Migraine  is  an  intermittent,  sensory  neurosis,  of  which 
headache,  commonly  hemicranial,  is  the  most  invariable  symptom.  Al- 
most as  constant  are  aggravated  nausea  and  vomiting,  to  which  may  be 
added  other  sensory  symptoms,  especially  deranged  vision.  Opththal- 
moplegic  migraine  is  a  rare  form,  in  which  paralysis  of  ocular  muscles 
occurs.  .^ 

Etiology. — This  is  obscure.  The  disease  is  more  common  in  females 
— apparently  three  times  as  frequent  as  in  males.  It  begins  early  in  life, 
commonly  at  puberty,  and  even  earlier — as  early,  in  fact,  as  at  two  years. 
It  affects  vigorous  and  strong  as  well  as  nervous  and  anemic  subjects. 
Exciting  causes  are  fatigue,  mental  and  physical,  including  eye-strain, 
digestive  derangements,  and  menstrual  disorders.  What  is  known  as  the 
uric  acid  diathesis  plays  an  undoubted  role  in  certain  cases.  As  often  none 
is  discoverable. 

It  is  usual  to  speak  of  migraine  as  a  vasomotor  disturbance,  because 
there  are  symptoms  which  point  to  involvement  of  the  sympathetic  system, 
but  this  is  a  matter  of  inference  rather  than  demonstration.  The  attacks 
are  characteristically  paroxysmal.  It  appears  to  be  more  frequent  in  the 
winter  season  in  this  climate,  when  it  is  not  infrequently  associated  with  a 


MIGRAINE.  1 1 13 

gouty  or  rheumatic  attack.     Caries  of  the  teeth  and  nasal  troubles  are  a 
cause  in  children. 

Morbid  Anatomy. — No  lesions  other  than  those  described  as  causal 
are  found.  The  precise  seat  of  the  pain  is  not  known,  but  is  believed  to  be 
in  the  meninges  of  the  brain. 

Symptoms. — The  attack  is  often  ushered  in  without  any  warning, 
at  others  with  prodromal  symptoms  familiar  to  the  patient.  They  are 
various  and  not  distinctive  of  the  disease,  but  so  characteristic  for  each  case 
that  the  individual  foretells  the  attacks  on  their  approach.  They  include 
general  discomfort,  vertigo,  a  sense  of  pressure,  tinnitus,  spots  before  the 
eyes,  chilliness,  and  the  like.  Hemianopsia  and  scotoma  may  be  among 
them. 

Then  the  pain  starts  in  suddenly  and  is  continuous,  usually  in  one  side 
of  the  forehead,  but  it  may  also  be  in  the  occiput,  whence  it  extends  to  the 
half  or  whole  head.  It  is  extremely  severe,  sometimes  described  as  blind- 
ing, at  others  sharp  and  boring  or  shooting.  It  is  sometimes  attended  by 
flashes  of  light.  Light  and  noise  aggravate  it,  and  a  darkened  room  is 
always  sought.     Hemianopsia  is  not  infrequent. 

Along  with  pain  generally  is  absolute  want  of  appetite,  and  intense 
nausea  succeeded  by  vomiting.  The  vomited  matter  includes  first  the  con- 
tents of  the  stomach  (if  the  stomach  is  empty,  mucous  matter),  and  later 
yellow  and  bitter  bile,  whence  the  term  '*  bilious  headache."  '  If  the  stomach 
happens  to  be  full,  the  pain  may  be  relieved  by  the  vomiting. 

The  vasomotor  symptoms  are  conspicuous  in  some  cases,  and  are 
assigned  by  some  an  important  role  in  its  causation.  From  this  standpoint 
two  subdivisions  are  made,  angiospastic  heniicrania  and  a<ngio paralytic 
hemicrania.  In  the  first  form,  described  by  Dubois-Reymond  from  obser- 
vations on  himself, — some  of  the  best  descriptions  have  been  by  sufiferers, — 
the  forehead  and  ear  on  the  affected  side  are  pale,  the  skin  is  cool,  the  tem- 
poral arteries  are  contracted,  the  pupil  is  often  dilated,  and  the  secretion  of 
saliva  is  increased — in  a  word,  the  symptoms  of  irritation  of  the  sympa- 
thetic. In  hemicrania  angioparalytica,  described  by  MollendorfT,  also  from 
observations  on  himself,  the  face  is  reddened  on  the  affected  side,  it  feels 
warm,  the  temporal  arteries  are  dilated  and  pulsate  strongly,  there  is  some- 
times unilateral  sweating  of  the  face,  with  the  pupils  contracted — symptoms 
suggestive  of  paralysis  of  the  sympathetic.  By  no  means  all  cases  are 
capable  of  being  thus  classified,  and  mixed  forms  are  met. 

The  frequency  of  the  attacks  varies  greatly;  usually  they  do  not 
occur  oftener  than  once  in  two  weeks  or  once  a  month.  They  may,  how- 
ever, occur  every  ten  days  or  even  weekly. 

The  duration  of  the  attack  varies.  Very  often  the  patient  goes  to 
bed  at  night,  and  in  the  morning,  or  at  the  end  of  twelve  hours,  is  relieved ; 
or  the  attack  may  last  twenty-four  hours  or  even  two  or  three  days.  The 
attacks  continue  over  a  period  of  many  years,  sometimes  ceasing  in  w'omen 
after  the  climacteric  is  passed,  and  in  men  after  fifty. 

Further  speculation  as  to  its  true  nature  would  be  unprofitable  here, 
though  mention  should  be  made  that  the  arteries  on  the  affected  side  some- 
times becomes  the  seat  of  arteriocapillary  fibrosis,  a  condition  giving  some 
force  to  the  view  of  vasomotor  origiw. 

Diagnosis. — The  symptoms  of  brain  tumor  sometimes  closely  simu- 
late migraine.  One  case  of  supposed  migraine  under  my  observation  turned 
out  to  be  brain  tumor.     Ophthalmoscopic  examination  may  discover  choked 


1 1 14  DISEASES  OF  THE  NERVOUS  SYSTEM. 

disc  in  cases  of  brain  tumor  and  thus  settle  the  diagnosis.     Such  examina- 
tion should  always  be  made. 

Prognosis. — This  is  favorable  so  far  as  life  is  concerned,  but  it  is  not 
always  easy  to  prevent  the  attacks  or  diminish  the  frequency  of  their 
occurrence.     It  often  happens  that  they  cease  after  middle  life. 

Treatment, — Before  treatment  is  instituted  every  case  should  be 
thoroughly  investigated  with  a  view  to  discovering  causal  conditions. 
Should  such  search  be  successful,  their  elimination  may  result  in  a  cure. 
Such  accessible  causes  are  eye-strain,  affections  of  the  nose,  mental  and 
physical  fatigue,  and  indiscretions  in  diet. 

The  attack  itself  is  more  likely  to  be  warded  off  the  earlier  the  treatment 
for  it  is  instituted.  Sometimes  a  dose  of  salts,  taken  as  soon  as  the  first 
symptoms  appear,  wards  off  an  attack.  Phenacetin  in  from  ten  to  fifteen- 
grain  (0.66  to  I  gm.)  doses  relieves  some  attacks.  After  the  lirst  dose  it 
may  be  continued  in  smaller  doses.  Antipyrin  and  antifebrin  are  similarly 
successful,  and  I  am  informed  by  apothecaries  that  many  women  purchase 
these  drugs  regularly  to  relieve  their  attacks.  Such  practice  should,  how- 
ever, be  discouraged. 

Sometimes  a  hypodermic  injection  of  morphin,  even  so  small  a  dose  as 
1-8  grain  (o.oii  gm.),  acts  magically,  and  on  the  whole  it  is  the  most  reli- 
able remedy,  although  it  is  one  to  be  put  oft*  if  others  succeed.  Caifein  is  a 
less  efficient  remedy,  but  may  be  used  in  conjunction  wdth  morphin  or  im- 
mediately after  it  to  counteract  the  unpleasant  eft'ect  of  this  drug.  It  may 
be  given  in  three  to  five-grain  (0.2  to  0.33  gm.)  doses,  and  is  sometimes 
administered  hypodermically.  Salicylate  of  caifein  is  also  recommended  in 
like  doses.  Cannabis  indica  is  a  remedy  much  recommended,  but  is  unfor- 
tunately of  uncertain  strength.  We  may  begin  wdth  1-4  grain  (0.016  gm.) 
and  increase  rapidly.  Bromids  may  be  tried.  Guar  ana  is  more  efficient  in 
from  thirty-  to  sixty-grain  (2  to  4  gm.)  doses  of  the  powder  and  similar 
doses  of  the  fluid  extract. 

If  the  spastic  form  can  be  distinctly  recognized  as  present,  nitrite  of 
amyl  may  be  expected  to  be  serviceable — three  to  five  drops  by  inhalation. 
In  the  opposite  or  paralytic  form  ergot  has  been  advised,  and  may  be  given 
in  doses  of  from  fifteen  minims  to  one  dram  (i  to  4  gm.).  Nitro-glycerin 
in  doses  of  from  i-ioo  to  1-50  grain  (0.00066  to  0.0013  gm.),  and  nitrite 
of  sodium  in  doses  of  from  three  to  five  grains  (0.2  to  0.33  gm.),  may  be 
useful  in  the  class  of  cases  benefited  by  nitrite  of  amyl.  Cold  to  the  head  is 
sometimes  grateful,  and  when  there  is  nausea,  cracked  ice  or  cold  carbonated 
or  apollinaris  water  or  small  doses  of  iced  champagne  are  sometimes 
efficient. 

Electricity  is  said  to  have  been  useful  in  a  few  cases,  but  I  have  had  no 
experience  with  it.  It  is  recommended  that  in  the  spastic  form  the  anode 
should  be  applied  to  the  sympathetic,  and  in  the  paralytic  form  the  cathode, 
the  other  pole  being  applied  to  the  cervical  cord  as  high  as  possible  on  the 
occiput. 

Preventive  Treatment. — General  treatment  between  attacks  should  not 
be  neglected.  When  there  is  anemia,  the  judicious  use  of  iron  and  arsenic, 
continued  for  some  time,  has  occasionally  been  followed  by  a  disappearance 
of  the  tendency  to  the  disease. 

The  urine  should  be  carefully  examined,  and  if  concentrated  and  tend- 
ing to  deposit  uric  acid  or  oxalates,  diluents  and  the  alkaline  mineral  waters 
are  indicated.     In  a  few  instances  in  my  practice  the  daily  use  of  natural 


OCCUPATION  NEUROSES.  1115 

Vichy  water,  to  the  extent  of  a  bottle  a  day,  had  the  effect  of  diminishing, 
and  in  one  instance  of  ehminating,  the  attacks.  The  conditions  of  a  health- 
ful life,  bathing,  fresh  air,  and  simple  wholesome  food,  should  be  observed. 
Many  persons  are  totally  free  from  attacks  while  traveling.  A  course  at 
Contrexville,  Vichy,  or  Carlsbad  may  be  of  service  in  averting  attacks. 


OCCUPATION  NEUROSES. 

Synonyms. — Professional  Spasm;  Copodyscinesia. 

Definition. — A  term  applied  to  a  group  of  diseases  characterized  by 
symptoms  excited  by  an  effort  to  perform  some  oft-repeated  muscular  act, 
commonly  one  involved  in  the  occupation  of  the  patient.  The  most  usual 
symptom  is  cramp  or  spasm  in  the  muscles  concerned,  whence  this  word  is 
preceded  by  that  of  the  various  occupations,  to  indicate  its  special  variety. 
Thus  we  have  writer's  cramp  or  scrivener's  palsy,  telegrapher's  cramp, 
pianoforte-player's  cramp,  typewriter's  cramp,  seamstresses'  cramp,  milker's 
cramp,  etc. 

Writer's  Cramp. 

Synonyms. — Graphospasmus;    Cheirospasinus;    Mogigraphia;    Scrivener's 

Palsy. 

Definition. — The  professional  neurosis  of  clerks  and  scriveners.  It 
is  the  most  frequent  of  the  occupation  neuroses  and  may  serve  as  the  type 
for  all. 

Historical. — The  first  notice  of  writer's  cramp  appears  to  have  been  by  Bernhart 
Ramazini  in  1746.  It  was  first  fully  described  by  Sir  Charles  Bell  in  1830,  and  called 
scrivener's  palsy  by  Samuel  Solly,  who  published  three  admirable  clinical  lectures  in 
"The  Lancet"  in  1864-65.  Other  monographs  are  those  by  G.  V.  Poore,  in  "The 
Practitioner,"  in  1872-73  and  1878,  also  in  his  "  Text-book  of  Electricity,"  1876,  and 
"Med.-Chir.  Trans.,"  vol.  Ixi.,  1878;  W.  H.  Erb's  article  in  "  Ziemssen's  Cyclopedia," 
1876,  and  O.  Berger's  article,  "  Beschaftigungsneurosen,"  in  Eulenberg's  "  Real- 
Encyclopadie,"  first  edition,  1880,  third  edition,  1894. 

Etiology. — There  is  no  predisposition  to  sex,  the  disease  being  more 
frequent  in  men  in  occupations  where  more  men  are  employed,  and  more 
frequent  in  women  in  occupations  where  more  women  are  employed ;  and  it 
is  likely  that  since  an  increasing  number  of  women  have  become  telegraph 
operators,  more  cases  may  be  expected  among  them,  in  whom,  perhaps,  also, 
the  neuropathic  temperament  may  favor  it.  The  majority  of  all  cases  occur 
between  twenty  and  fifty — 154  out  of  177  cases  collected  by  Berger  from 
Gowers,  Poore,  and  himself.  Predisposition  is  caused  by  previous  injury 
and  a  neurotic  disposition,  while  even  heredity  is  said  to  predispose.  An 
especially  important  factor  is  a  faulty  method  of  writing,  while  cases  have 
occurred  which  were  apparently  independent  of  the  usual  exciting  cause. 
Steel  pens  are  said  to  be  responsible  for  an  increased  number  of  cases  since 
their  introduction.  The  disease  is  becoming  less  frequent  as  clerical  exac- 
tions grow  less. 

Morbid  Anatomy  and  Pathology. — No  distinctive  anatomical  changes 
have'  ever  been  discovered  in  writer's  cramp.  Three  theories  are  held  re- 
garding its  nature.  According  to  the  first,  it  is  essentially  a  local  disease: 
weakness   in    certain   muscles  permitting   overaction   on   the   part   of   their 


Iii6  DISEASES  OF  THE  NERVOUS  SYSTEM. 

antagonists,  an  overaction  which  increases  to  spasm.  According  to  a  second 
theory,  the  spasm  is  reflex  and  due  to  an  irritation  of  the  sensory  nerves, 
concerned  in  the  act  of  writing.  The  third,  and  usually  accepted  theory,, 
makes  the  affection  primarily  and  essentially  central,  due  to  deranged  func- 
tion in  the  centers  concerned  in  the  act  of  writing,  and  therefore  in  the  central 
nervous  system. 

The  only  discoverable  morbid  change  is  an  occasional  atrophy  of  muscles, 
concerned. 

Symptoms. — Spasm  is  almost  always  the  initial  disturbance,  commonly 
aft"ecting  the  forefinger  and  the  thumb;  but  the  onset  is  gradual,  and  the 
first  effect  is  an  awkwardness  in  which  the  pen  does  not  move  quite  as  m- 
tended.  It  is  irresistibly  grasped  too  tightly,  yet  the  forefinger  has  a  tend- 
ency to  slip  off,  the  pen  passing  between  it  and  the  middle  finger,  while  an 
attempt  to  mend  matters  by  taking  a  new  hold  only  increases  the  difficulty, 
and  the  hand  labors  as  if  tied  down.  It  feels  tired,  and  there  is  often  an  ach- 
ing pain  throughout,  extending  even  to  the  arm.  The  writing  is  irregular 
and  uneven.  These  symptoms  may  continue,  with  more  or  less  impairment 
of  the  power  of  writing,  for  weeks  or  months,  coming  earlier,  however,  after 
each  effort,  with  gradual  increasing  severity  until  the  intolerable  spasm  sets 
in.  This  may  be  so  violent  in  a  combined  movement  of  flexion  and  adduc- 
tion in  the  thumb  that  the  pen  may  be  wrested  from  the  grasp  and  thrown 
to  a  distance,  or  there  may  be  a  lock  spasm,  described  by  S.  Weir  Mitchell, 
in  which  the  pen  is  firmly  locked  between  the  fingers.  The  spasm  is  almost 
always  tonic  in  character,  although  it  may  now  and  then  be  varied  by  a 
slight  start  or  jerk.  It  is  sometimes  associated  with  tremor.  Rarely 
tremor  occurs  alone,  and  it  may  be  the  premonitory  symptom  of  atrophy. 
The  spasm  may  be  limited  to  the  act  of  writing,  while  other  actions  are 
well  performed ;  but  absolute  limitation  to  this  act  is  seldom  met  in  severe 
cases. 

Special  difficulty  attends  the  performance  of  acts  requiring  delicate- 
co-ordination  of  the  muscles.  Sometimes  a  patient  can  write  with  a  pencil, 
but  not  with  a  pen.  Paresis  and  paralysis  may  occur  with  spasm  or  alone. 
On  the  other  hand,  the  strength  of  the  hand  may  be  quite  unimpaired. 
Such  loss  of  power  varies  greatly,  being  sometimes  trifling,  at  other  times 
considerable. 

Sensory  symptoms  are  almost  always  present  in  various  degrees.  They 
may  even  exist  alone,  producing  a  sensory  form.  They  are  manifested  at 
first  by  the  distressing  fatigue  alluded  to,  or  by  dull  pain  often  referred  to 
the  bones  or  joints,  very  ofteji  to  the  metacarpal  bones  or  to  the  wrist, 
ceasing  with  cessation  of  writing.  Sometimes  there  is  local  tenderness  or  a 
tingling  sensation.  Again,  the  pain  is  more  severe,  neuralgic  in  character, 
and  distributed  along  the  course  of  the  nerve,  induced  at  first  by  the  act 
of  writing,  later  by  any  muscular  act  of  the  part.  There  may  also  be  ten- 
derness in  the  course  of  the  nerve. 

Vasomotor  disturbances  are  seen  in  severe  cases,  manifested  by  hyper- 
esthesia, a  glossy,  shining  skin,  or  a  cyanosed,  chilblain-like  appearance;  or 
the  hand  may  become  blue  and  hot  on  attempting  to  write. 

In  the  beginning  the  electrical  reactions  are  normal,  but  in  advanced 
cases  there  is  a  diminished  faradic  and  sometimes  increased  galvanic  irrita- 
bility of  the  motor  nerve  endings  distributed  to  the  muscles.  It  is  to  be 
remembered  that  the  radial,  ulnar,  and  median  nerves  all  supply  muscles: 
employed  in  writing. 


OCCUPATION  NEUROSES.  1117 

Diagnosis. — This  is  usually  easy,  the  initial  limitation  of  the  symp- 
toms to  the  act  of  writing  sufficiently  indicating  the  nature  of  the  case. 
More  frequently  other  paralytic  and  painful  affections  of  the  arm  and  hand 
are  mistaken  for  writer's  palsy.  Among  these  may  be  included  hemiplegia 
■of  gradual  onset,  commencing  insular  sclerosis,  early  tabes  dorsalis  affecting 
the  arms,  or  pressu-re  palsy  of  the  muscnlo-spiral  nerve. 

In  most  of  these  cases,  however,  other  symptoms  are  present  or  are 
soon  added.  More  frequently  nervous  persons  imagine  they  have  writer's 
palsy.     In  some  cases  the  condition  is  really  one  of  muscular  rheumatism. 

Prognosis. — A  well-established  case  of  scrivener's  palsy  rarely  gets 
well.  There  are,  however,  exceptions,  even  under  the  most  unfavorable 
conditions.  The  prognosis  is  more  favorable  when  sensory  symptoms  pre- 
dominate.    Relapses  are  prone  to  occur  when  the  patient  returns  to  work. 

Treatment. — Prevention,  as  usual,  is  much  more  eft"ectual  than  cura- 
tive treatment.  The  disease  is  confined  almost  exclusively  to  those  who 
write  in  a  cramped  manner,  and  is  said  to  be  unknown  in  those  who  write 
from  the  shoulder.  The  curative  treatment  consists  essentially  in  rest 
promptly  adopted — a  long  rest  being  often  sufficient  to  effect  a  cure,  while 
no  other  treatment  can  take  its  place.  Various  mechanical  devices  to  aid  in 
writing  while  the  cure  is  going  on  have  not  accomplished  much,  and  the 
patient  may  learn  to  write  with  the  left  hand,  although  the  disturbance 
may  occur  in  this  hand  also.  Typewriting  is,  as  a  rule,  as  easily  learned 
with  the  affected  hand  as  before  disability.  The  devices  referred  to  may  be 
such  as  a  very  thick  penholder  which  can  be  directed  by  the  whole  hand ; 
or  a  pen  attached  to  a  ring,  which  is  slipped  over  the  index  or  middle 
finger,  and  the  thumb  is  thus  permitted  to  rest.  The  typewriting  machine 
has,  however,  rendered  all  such  devices  of  less  consequence.  The  usual 
nerve  tonics,  such  as  strychnin,  may  be  given.  Hygiene  of  the  part,  includ- 
ing hydrotherapy,  frictions,  especially  massage,  and  sometimes  electricity, 
are  useful. 

The  important  position  assigned  by  all  neurologists  to  the  electrical 
treatment  of  writer's  cramp  demands  some  special  consideration,  especially 
as  the  methods  advised  are  by  no  means  uniform.  The  preference  given 
to  the  galvanic  current  over  the  faradic  is,  however,  almost  unanimous,  and 
unless  the  latter  is  especially  mentioned,  the  former  is  intended.  Berger 
recommends  a  stabile  current, — i.  e.,  a  current  in  which  the  electrodes  are  not 
moved  about, — with  the  positive  pole  in  the  neck  and  the  negative  partly  in 
the  fossa  supraclavicularis,  partly  on  the  aft'ected  nerves  and  muscles  of  the 
arm ;  the  length  of  sitting,  from  five  to  ten  minutes  daily,  or  every  other  day. 
Benedict  recommended  galvanization  along  the  spinal  column,  with 
especial  reference  to  sensitive  vertebrae,  but  also  localization  of  the  galvanic 
current,  as  recommended  by  Berger;  duration  of  sitting,  three  to  four  min- 
utes, current  strong  enough  to  be  easily  felt.  He  also  found  subsequent 
faradization  to  the  muscles  most  affected  useful.  Eulenberg  also  advised 
galvanization  of  the  muscles  affected  with  chronic  cramp  and  of  the  involved 
nerve-trunk  with  the  positive  pole.  In  cases  with  tremor  and  rapid  exhaus- 
tion the  negative  pole  is  to  be  applied  to  the  spinal  column  and  the  positive 
on  the  peripheral  nerve-trunks  and  muscles  affected.  Erb  advised  galvani- 
zation of  the  cervical  vertebral  column,  with  ascending  stabile  and  labile 
currents  combined  with  peripheric  galvanization.  In  several  cases  it 
appeared  to  him  that  transverse  and  longitudinal  currents  through  the  head 
were  followed  bv  favorable  results. 


iii8  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Oninnis  used  an  ascending  current  through  the  affected  arm,  with 
the  negative  pole  in  the  neck  and  the  positive  pole  upon  the  muscles  of  the 
forearm,  especially  the  ball  of  the  thumb,  in  addition  to  a  current  of  moder- 
ate strength  along  the  cervical  vertebrae.  M.  Meyer  employed  a  stabile  gal- 
vanic current  with  the  anode  to  the  tender  spots  on  the  vertebral  column 
when  these  were  present,  and  the  cathode  on  the  sternum.  Althouse  sought 
to  reach  the  cervical  cord  by  placing  the  anode  upon  the  cervical  spine  and 
the  cathode  on  the  depression  between  the  angle  of  the  jaw  and  the  ster- 
nocleidomastoid muscle — a  position  corresponding  to  the  superior  cervical 
ganglion  of  the  sympathetic.  The  current  should  be  mild,  uniform,  and  un- 
interrupted for  from  three  to  five  minutes  at  a  time.  The  methocl  should  not 
be  reversed.  In  cases  of  paresis  of  certain  muscles  it  is  sometimes  of  benefit 
to  have  the  patient  make  voluntary  movements  of  these  muscles  simultane- 
ously with  the  closing  of  the  galvanic  current  applied  to  the  nerve  inner- 
vating these  muscles. 

Testimony  is  united  to  the  effect  that  the  galvanic  treatment  must  be 
kept  up  for  a  long  time,  even  for  months  continuously,  with  a  current  of 
moderate  strength,  say  a  maximum  of  four  milliamperes,  and  section  elec- 
trode of  about  three  qcm. 

Faradization  is  recommended  only  in  cases  where  there  is  demonstrable 
paresis  and  anesthesia,  and  then  in  weak  currents.  '  In  anesthesia  the  brush 
may  be  used.  Erb  found  that  many  of  his  patients  were  benefited  by  wear- 
ing on  the  arms,  for  several  hours  daily,  a  simple  galvanic  element,  such  as 
a  zinc  and  copper  plate,  united  by  wire,  and  under  it  a  moist  piece  of  linen. 

Gowers  has  much  less  confidence  in  electricity,  especially  in  the  spas- 
modic fonn  of  the  disease,  and  is  probably  right  when  he  says  if  the  patient 
goes  on  writing  electricity  has  not  the  slightest  influence  on  the  disease. 
My  own  experience  with  electricity  has  not  been  very  encouraging. 

The  position  accorded  to  gymnastic  exercise  of  the  arm  and  hand 
muscles  is  scarcely  second  to  that  of  electricity — indeed,  it  is  preferred  by 
some.  Especially  efficient  appears  to  be  that  of  a  German  writing-master, 
Julius  Wolff.  The  gymnastics  are  of  two  kinds :  First,  active,  in  which  the 
patient  moves  the  fingers,  hands,  forearms,  and  arms  in  all  directions  pos- 
sible, each  muscle  being  made  to  contract  from  six  to  twelve  times  with 
considerable  force,  and  with  a  pause  after  each  movement,  the  whole  exer- 
cise not  exceeding  thirty  minutes;  and  repeated  two  or  three  times  daily. 
Second,  passive,  in  which  the  same  movements  are  made  as  in  the  former, 
except  that  each  one  is  arrested  by  another  person  in  a  steady  and  regular 
manner.  This  may  be  repeated  as  often  as  the  active  exercise.  Massage 
is  practiced  daily  for  about  twenty  minutes,  beginning  at  the  periphery; 
percussion  of  the  muscles  is  considered  an  essential  part  of  the  massage. 
Combined  with  this  are  peculiar  lessons  in  pen-prehension  and  writing. 
Priority  for  this  method  is  claimed  by  Roman  Vigoroux  and  Th.  Shott. 
The  testimony  of  some  of  the  best  authorities  in  Europe  is  given  in  behalf 
of  this  method.  Poore  secured  good  results  by  combining  gymnastic 
exercises  with  the  use  of  electricity.  Tenotomy  and  nerve-stretching  have 
been  attempted  and  abandoned  as  useless. 


TETANY.  1 1 19, 


ATHETOSIS. 

Synonym. — Hammond's  Disease. 

Definition. —  Athetosis  consists  in  a  peculiar  rhythmical  contraction  of 
the  fingers  and  toes. 

Historical  and  Nature.— It  was  first  thoroughly  studied  by  W.  A.  Hammond  in 
1871,  also  by  Charcot,  who  considered  it  identical  with  posthemiplegic  chorea  or  a 
modified  form  of  it.  This  may  be  regarded  as  correct  in  cases  where  there  has  been 
hemiplegia,  and  athetosis  occurs  in  the  muscles  of  the  side  which  was  hemiplegic.  It 
occurs  in  connection  with  hemiplegic  weakness  and  contraction  due  to  tumor  of  the 
brain.  Frequently  it  is  seen  as  a  sequel  of  infantile  pals}^  Epileptics,  idiots,  and 
alcoholics  also  exhibit  it  in  the  bilateral  form.  Rarely,  it  is  an  independent  affection,. 
said  to  be  the  result  of  cold  or  psychical  derangement,  and  is  even  held  to  be  con- 
genital. 

Symptoms  and  Diagnosis. — It  occurs  preferably  in  the  fingers  and 
toes.  In  the  fingers  it  is  seen  as  a  slow,  though  sometimes  rapid  flexion 
and  extension,  adduction  and  abduction,  with  the  appearance  as  though  the 
fingers  were  attempting  to  grasp  something.  The  thumb,  index-finger,  and 
little  finger  are  those  most  frequently  involved,  the  muscles  particularly  con- 
cerned being  the  external  and  internal  interossei.  The  wrist-joint  may  also 
share  in  the  motion,  and  not  infrequently  the  opposite  to  that  of  the  fingers. 
The  patient  may  resist  the  motion  but  for  a  short  time,  and  it  even  continues 
during  sleep,  though  in  a  less  marked  degree.  Excitement,  mental  and 
physical,  causes  an  increase  in  the  motion.  Subluxation  of  the  phalangeal 
articulations  may  take  place  in  long-standing  cases,  while  contractions  have 
been  known  to  occur  in  paretic  extremities.  Sometimes  there  has  been 
hypertrophy  of  the  front  of  the  arm  as  a  consequence  of  the  constant  mus- 
cular movements ;  in  other  cases  the  muscles  are  unaltered,  or  there  may  be 
atrophy.  The  electrical  condition  is  unaltered.  Similar  motions  occur  in 
the  toes  and  feet,  but  they  are  not,  as  a  rule,  so  active.  Even  the  muscles 
of  the  neck  and  face  and  tongue  may  share  in  the  process.  As  a  rule, 
athetosis  is  one-sided, — hemiathetosis, — but  bilateral  cases  have  been  de- 
scribed. 


TETANY. 

Synonyms. — Tetanilla,    Intermittent   Tetanus;   Contracture  des  nourrices. 

Definition. — A  disease  consisting  in  continuous  or  intermittent  tonic 
spasm  of  the  extremities,  usually  symmetrical,  but  occasionally  confined  to 
one  limb  or  rarely  even  becoming  general. 

Historical  — A  knowledge  of  the  symptom  complex  of  tetany  was  gradually 
acquired.  The  name  is  said  to  have  been  suggested  by  L.  Corvisart,  whose  book, 
published  in  1852,  was,  however,  preceded  by  one  by  Imbert  and  Gourbeyre  in  1844, 
and  another  by  Drepech  in  1846.  Dance  in  France  and  Steinheim  in  German}^  de- 
scribed It  about  the  same  time.  Trousseau  (i860)  first  discovered  the  effect  of  pressure 
on  the  large  vessels  and  nerves  of  the  arm  in  producing  the  contraction  in  the  hand 
muscles.  F.  Chvostek  (1S77)  described  the  markedly  increased  motor  excitability  of 
nerves  known  as  Erb's  symptom;  Chvostek  and  N.  Weiss  (1880)  discovered  the 
phenomena  of  facial  and  lip  muscle  c9ntraction,  elicited  by  tapping  the  facial 
nerve.  Hoffmann  (1887)  showed  that  in  tetany  even  sensory  nerves  are  over  excit- 
able, and  L.  von  Frankl-Hochwart  (1887)  that  only  galvanic  excitability  is  increased 
and  faradic  not.  Later  L.  von  Frankl-Hochwart  published  a  second  monograph  on 
the  disease  in  Nothnagel  System  of  Medicine. 


1 120  DISEASES  OF  THE  NERVOUS  SYSTEM. 

Etiology. — Tetany  occurs  in  children  and  in  adults,  and  when  present 
in  the  latter,  it  has  usually  made  its  appearance  in  comparatively  early  life. 
It  has  been  supposed  to  be  rare  in  North  America,  but  J.  P.  C.  Griffith,  in 
a  noteworthy  paper  read  before  the  Association  of  American  Physicians  in 
1894,  collected  ^2  cases  occurring  in  this  country.  Of  these,  five  happened 
in  his  own  experience.  It  is  rather  more  frequent  in  girls  than  boys. 
The  disease  is  more  common  in  \Tenna  and  Heidelberg  than  anywhere 
else,  especially  in  the  late  winter  and  early  spring. 

Among  possible  causes  may  be  mentioned  digestive  derangement,  in- 
cluding dentition,  dilatation  of  the  stomach,  hyperchlorhydria,  and  diar- 
rhea ;  rheumatism,  whence  this  form  is  sometimes  called  rheum'atic  tetany ; 
rickets;  open  wounds;  laceration.  Removal  of  the  thyroid  gland  (13  cases 
followed  37  operations  in  Billroth's  clinic,  and  removal  of  the  thyroid  in 
dogs)  has  been  followed  by  tetany.  Pregnancy,  acute  fevers,  and  diphthe- 
ria are  also  alleged  causes.  Trousseau  suggested  the  name  contracture  des 
nonrrices.  L.  von  Frankl-Hochwart  has  shown  that  it  occurs  quite  fre- 
quently among  the  shoemakers  and  tailors  of  Vienna. 

Symptoms. — The  characteristic  spasm  is  usually  limited  to  the  hands 
and  feet,  arms,  and  legs.  In  the  hands  the  thumbs  are  flexed  into  the  palms, 
the  fingers  firmly  bent  at  the  metacarpophalangeal  articulation,  but  straight 
elsewhere.  The  fingers  are  adducted,  the  ring  and  middle  fingers  some- 
times overlapping.  The  wrists  are  flexed,  the  elbows  bent,  and  the  arms 
folded  over  the  chest.  The  hand  is  described  as  the  obstetrical  hand,  from 
the  position  caused  by  the  cramp.  In  the  lower  limbs  the  knees  and  hips  are 
stiff  and  extended,  the  feet  extended,  and  the  toes  adducted.  Sometimes 
there  is  dorsal  flexion  of  the  foot  and  flexion  at  the  knee.  Contractions  may 
last  from  a  few  hours  to  several  days.  The  term  continuous  may  be 
applied  to  those  cases  in  which  the  contractions  have  lasted  uninterruptedly 
for  over  two  days,  and  intermittent  when  they  do  not  last  longer  than  two 
days  without  permanent  or  temporary  disappearance.  Following  this 
standard,  Griffith  found  38  cases  intermittent  and  25  continuous.  The 
spasm  is  always  associated  with  tenderness  or  pain,  the  latter  being  often 
extreme.  At  other  times  these  symptoms  are  present  only  in  the  beginning 
■of  the  attack  or  when  the  members  are  handled.  Rarely  the  muscles  of  the 
back,  neck,  and  face  are  involved ;  and  there  may  be  trismus,  the  angles  of 
the  mouth  being  drawn  out. 

Associated  symptoms  are  stridulous  respiration,  regarded  by  some  as 
an  essential  part  of  the  disease  or  as  a  manifestation  of  the  disease  in  the 
larynx.  Further  interesting  phenomena,  especially  studied  and  called  car- 
dinal symptoms,  are  contraction  caused  bv  tapping  the  muscles;  as,  for 
example,  the  pectoralis  or  the  facial  muscles,  known  as  Chvostek's  symptom. 
Another  is  Trousseau's  symptom — the  production  of  spasm  by  pressure  upon 
a  large  artery  or  nerve,  especially  in  the  arm ;  and  still  another  is  Erb's  symp- 
tom— increased  electrical  excitability.  Inability  to  urinate  may  be  present, 
and  anesthesia  has  been  recorded  among  symptoms.  There  may  be  slight 
elevation  of  temperature  and  frequent  pulse. 

Diagnosis. — The  rarity  of  this  disease  sometimes  causes  it  to  be  over- 
looked, while  differences  of  view  as  to  what  constitute  its  essential  symptoms 
also  cause  a  different  diagnosis.  Thus,  some  would  exclude  the  carpopedal 
spasm  of  children ;  while  Gowers,  Dana,  and  Griffith  include  these  cases 
tinder  tetany.  Many  cases  of  mild  spasm  succeeding  gastro-intesfinal  irrita- 
tion and  the  like  w^ould  be  regarded  by  some  as  tetany  and  by  others  not.     It 


HYSTERIA.  1 121 

possesses  nothing  in  common  with  tetanus,  whose  name  it  so  closely  re- 
sembles, but  whose  symptoms  are  totally  different. 

Prognosis. — This  is  usually  favorable,  recovery  taking  place  in  from  a 
few  days  to  months.  The  fatal  cases  are  those  associated  with  dilated 
stomach,  gastric  carcinoma,  and  thyroidectomy.  The  disease  has  a  marked 
tendency  to  return,  and  is  most  common  in  late  winter  and  early  spring. 

Treatment. — The  €mise  of  the  condition  should  be  sought  and,  if  pos- 
sible, eliminated.  After  this,  remedies  calculated  to  diminish  nervous  excite- 
ment should  be  administered;  also  wholesome  hygienic  measures  availed  of, 
including  massage,  passive  motion,  and  electricity.  Warm  baths  are  espe- 
cially recommended.  The  cases  attended  with  severe  pain  may  require 
the  hypodermic  use  of  morphin,  and  delayed  response  to  the  latter  may  even 
demand  chloroform  inhalation. 

Thyroid  extract  should  be  administered  in  those  cases  in  which  the  dis- 
ease follows  removal  of  the  thyroid  gland,  beginning  with  five  grains  three 
times  a  day.     A  portion  of  the  thyroid  may  be  transplanted. 


HYSTERIA. 

Definition. —  Hysteria  is  a  morbid  state  of  the  nervous  system  in  which 
may  be  manifested,  every  variety  of  nervous  symptom  due  to  deranged  func- 
tion of  the  cerebral,  basal,  and  spinal  centers,  associated  with  lowered  will- 
power and  exaggerated  emotional  tendencies. 

Etiology. — Hysteria  is  a  disease  of  civilization  and  of  certain  races.  It 
is  unknown  in  the  barbarian,  and  is  more  rare  in  Northern  races,  while  the 
volatile  Southern  temperament  favors  its  development.  Thus,  the  French 
and  Italians  of  the  Latin  race  furnish  many  subjects,  while  it  is  rarer  among 
Germans,  English  and  Americans.  The  disease  is  also  frequent  among 
Hebrews. 

The  sexual  organs  of  women  have  been  held  responsible  for  hysteria  in 
the  female,  and  the  name  hysteria  is  derived  from  vffTspa,  a.  womb;  but 
this  conception  is  erroneous.  In  males  the  disease  assumes  more  the  form 
of  hypochondriasis,  but  in  them  also  convulsions,  contractures,  and  paralysis 
occur.  It  is  found  in  boys  as  well  as  in  adult  males,  especially  in  alcoholic 
males.  About  half  of  all  cases  occur  in  the  second  decade,  especially  after 
puberty,  though  it  may  also  occur  earlier;  one-third  between  twenty  and 
thirty,  while  boy  subjects  are  commonly  under  the  age  of  puberty.  Mastur- 
bation and  adherent  prepuce  are  held  responsible  for  many  cases  in  boys. 
Heredity  plays  a  certain  part,  while  the  neurotic  constitution  especially  favors 
hysteria. 

Among  the  exciting  causes  are  included  diseases  of  the  generative 
organs  in  women,  but  their  influence  as  compared  with  other  illnesses  may 
simply  grow  out  of  their  'frequency.  Ovarian  disease  has  been  held  respon- 
sible, and  tenderness  in  the  ovarian  region  is  undoubtedly  a  frequently  asso- 
ciated symptom,  but  it  is  questionable  whether  this  tenderness  is  of  ovarian 
origin.  Association  with  others  similarly  affected  is  an  undoubted  factor, 
and  it  is  not  unusual  for  the  disease  to  spread  itself  from  one  to  a  number 
of  girls  living  under  the  same  roof.  Various  diseases  other  than  those  men- 
tioned also  predispose  to  hysteria.  Even  local  affections,  including  injuries, 
may  thus  operate,  and  hysterical  joint  affections  may  follow  trauma  of  a 
joint.     Striimpell   relates  an  instance  of  a  girl  who,   from  having  inhaled 

71 


1 122  DISEASES  OF  THE  XERVOUS  SYSTEM. 

smoke,  acquired  hysterical  paralysis  of  the  vocal  cords.  General  disease  of 
an  exhausting  kind,  such  as  fevers,  nervous  diseases,  functional  and  organic, 
predispose  to  hysteria.  Hysteria  is  common  in  prostitutes.  Cerebral 
tumors,  tuberculous  meningitis,  multiple  neuritis,  chorea,  infantile  hemi- 
plegia, often  cause  conspicuous  hysterical  phenomena.  Diphtheritic  paral- 
ysis may  pass  into  hysterical  palsy,  while  Gowers  has  known  hysterical  con- 
vulsions to  attend  the  onset  of  embolic  hemiplegia,  as  shown  by  autopsy. 
Among  psychical  nervous  causes  are  fright,  such  as  attends  a  runaway  or  a 
fire ;  an  angry  scene ;  the  constant  operation  of  trifling  mental  causes,  includ- 
ing worry  and  anxiety. 

Symptoms. — An  idea  of  the  number  and  variety  of  the  symptoms  of 
hysteria  has  probably  been  obtained  from  the  definition  given — a  variety 
which  belongs  to  no  other  disease,  and  which  may  include  almost  all  symp- 
toms excited  by  an)'  of  the  numerous  nervous  diseases.  The  hysterical 
patient  is,  however,  characterized  by  certain  general,  corporeal,  and  mental 
peculiarities  which  should  be  first  considered.  Such  persons  are  emotional, 
irritable,  capricious,  sensitive,  often  willful,  sometimes  because  of  indifferent 
early  home  training  and  overindulgence.  They  exaggerate  every  illness, 
and  demand  an  inordinate  amount  of  sympathy.  If  women,  they  are  at 
times  disagreeable  and  petulant  or  doggedly  silent,  while  at  others  they  are 
charming  and  fascinating.  They  are  often  intellectually  bright.  Hysteria 
does  occur,  however,  among  intellectual  degenerates.  Other  hysterical  cases 
present  no  mental  peculiarities.  As  to  physical  development,  the  hysterical 
patient  is  by  no  means  always  delicate ;  indeed,  some  of  the  most  stubborn 
cases  are  those  which  appear  in  blooming  health,  rosy,  well  nourished,  and 
handsome. 

There  are  also  certain  symptoms  which  are  so  characteristic  of  hysteria 
and  possessed  of  such  diagnostic  significance  that  they  have  been  called  by 
Charcot  "  hysterical  stigmata."  They  include,  especially,  modifications  of 
sensibility,  but  in  addition  to  these  are  derangements  of  motion,  the  maximum 
expression  of  which  is  the  hysterical  convulsion.  There  are  also  character- 
istic vasomotor  symptoms. 

I.  Derangements  of  Sensation. — The  symptoms  in  this  category  are, 
as  a  rule,  only  elicited  by  the  special  examination  of  the  physician,  being 
rarely  discovered  by  the  patient.  They  include,  especially,  alterations  of 
cutaneous  sensibility,  manifested  by  anesthesia  or  hyperesthesia.  Most  strik- 
ing is  insensibility  to  painful  impressions,  known  as  analgesia.  It  is  usually 
tested  by  thrusting  a  pin  deeply  into  the  flesh — an  act  which  is  often  totally 
unfelt.  Less  invariably  is  there  failure  to  appreciate  the  sharp  irritation  of 
the  electric  current.  Such  analgesia  may  be  confined  to  definite  parts  of  the 
body,  half  the  body,  or  may  be  general.  It  may  extend  to  the  mucous  sur- 
faces as  well,  and  even  to  the  deeper  tissues,  as  those  of  the  muscles  and 
joints.  While  analgesia  is  the  most  common  manifestation  of  deranged 
sensibility,  there  may  be  absence  of  the  sense  of  temperature,  of  pressure, 
and  even  of  the  muscular  sense. 

Hyperesthesia  is  almost  equally  characteristic.  The  areas  involved  may 
be  exquisitely  sensitive  or  but  slightly  so,  requiring,  sometimes,  con- 
siderable pressure  to  develop  the  tenderness,  while  at  other  times  it  is 
elicited  by  the  slightest  touch.  The  hyperesthesia  is  especially  noticeable 
when  the  attention  of  the  patient  is  directed  to  it  by  such  remarks  as,  "  This 
will  hurt  you  very  much  when  I  touch  you."  The  sensitive  areas  may  also 
be  limited  or  extended  and  anvwhere — on  the  head,  thorax,  limbs.     Inguinal 


HYSTERIA.  1 123 

tenderness  is  especially  frequent  on  the  left  side.  Even  more  characteristic 
is  the  hyperesthesia  of  the  spinal  column, — the  so-called  "  hysterical  spinal 
irritability," — which  affects  the  column  as  a  whole  or  in  segments,  not  infre- 
quently a  single  vertebra.  The  sensitiveness  may  be  so  extreme  that  the 
slightest  contact  may  cause  the  patient  to  cry  out,  while  strong  pressure  may 
be  necessary  to  cause  it.  Of  special  interest  also  are  the  hysterical  zones,  to 
be  again  referred  to. 

The  special  senses  are  variously  involved.  There  may  be  simple  dim- 
ness of  vision  or  narrowing  of  the  field,  due  to  anesthesia  of  the  peripheral 
part  of  the  retina.  There  is  often  total  amblyopia,  but  never  hemianopsia. 
Hysterical  achromatopsia  is  not  infrequent.  According  to  Charcot,  the  loss 
of  the  appreciation  of  violet  is  the  most  common,  then  of  green,  and,  lastly, 
of  blue  and  yellow.  Loss  of  hearing  is  not  infrequent,  and  still  more  fre- 
quent is  anesthesia  of  taste  and  smell,  even  bitter  substances,  like  quinin,  or 
pungent  ones  like  vinegar,  producing  no  impression  or  but  a  trifling  one. 

2.  Derangements  of  Motion. — The  most  striking  of  these  is  paralysis. 
It  commonly  comes  on  suddenly,  apparently  as  a  result  of  fright  or  other 
suddenly  acting  cause.  It  may,  however,  be  gradual,  and  take  weeks  for 
its  development.  It  is  most  frequently  hemiplegic,  but  may  be  monoplegic, 
rarely  diplegic,  while  every  form  of  organic  paralysis  may  be  simulated. 
Hemiplegia  is  more  usual  on  the  left  side — according  to  Weir  Mitchell, 
four  times  as  frequent  as  on  the  right.  The  face  is  not  usually  affected,  the 
neck  and  arms  rarely,  the  legs  oftenest.  The  patient  can  sometimes  move 
the  legs  in  bed  or  even  when  sitting  up,  while  all  attempts  at  walking  are 
unsuccessful ;  or  she  may  be  able  to  move  the  arms  when  the  eyes  are  open, 
but  not  when  they  are  shut.  It  is  a  paralysis  of  the  will.  Sometimes  one 
leg  only  is  paralyzed,  giving  rise  to  a  peculiar  gait,  the  free  leg  making  long 
strides  while  the  paralyzed  one  is  dragged  along  with  a  shuffling  noise,  and 
not  swung  outwardly  in  a  circle  as  in  true  hemiplegia.  Sometimes  there  is 
ataxia  with  paresis.  Paralysis  may  be  both  flaccid  and  spastic.  Though 
far  more  frequently  a  symptom  of  hysteria  in  women,  it  may  be  as  striking 
in  men.  Paralysis  of  the  vocal  cords  is  one  of  the  most  frequent  symptoms 
of  hysteria,  giving  rise  to  aphonia.  The  paralysis  is  easily  demonstrable  by 
laryngoscopic  examination,  because  of  anesthesia  of  the  pharynx.  It  may 
be  so  marked  that  the  vocal  cords  actually  open  with  an  attempt  at  phona- 
tion.     Anesthesia  and  motor  paralysis  are  commonly  associated. 

Contractures  and  spasms  are  a  form  of  motor  derangement;  they  may 
occur  alone  or  with  anesthesia  and  paralysis.  They  exhibit  every  variety, 
and  may  attack  any  group  of  muscles ;  they  may  be  tonic  or  clonic,  and  sud- 
den or  gradual  in  development.  The  tonic  contracture  is  most  usual  in  the 
arm,  which  is  flexed  at  the  elbow  and  wrist,  while  the  fingers  grasp  the 
thumb  in  the  palm  tightly.  In  the  feet,  also,  flexures  predominate,  the  feet 
being  inverted  and  the  toes  flexed.  In  the  larger  joints,  on  the  other  hand, 
the  extensors  are  involved,  as  a  rule.  Rarely  extensor  contractures  occur 
in  the  small  joints ;  all  disappear  with  chloroform  narcosis  unless  they  have 
persisted  a  long  time  and  shortening  of  the  muscles,  ligaments,  etc.,  has 
occurred.  The  reflexes  may  be  very  much  exaggerated  and  the  condition 
closely  resemble  spastic  paraplegia.  Extreme  emaciation  may  occur  in  con- 
nection with  these  contractures,  as  witness  a  remarkable  case  related  and 
illustrated  by  Weir  Mitchell  in  the  "'Medical  News,"  August  24,  1895. 

Even  hysterical  trismus  may  occur,  and  a  very  striking  result  of  abdom- 
inal contracture  is  the  phantom  tumor,  which  is  found  usually  just  below  and 


1 1 24  DISEASES  OF  THE  XERVOUS  SYSTEM. 

in  the  neighborhood  of  the  umbilicus,  often  simulating  a  firm  and  solid 
growth.  The  mechanism  of  its  production,  according  to  Gowers,  is  a  relaxa- 
tion of  the  recti  and  spasmodic  contraction  of  the  diaphragm,  together  with 
inflation  of  the  intestines  and  an  arching  forward  of  the  vertebral  column. 
Women  have  even  been  prepared  for  surgical  operation  on  such  tumors  when 
the  delusion  was  dissipated  by  the  anesthetic,  and  the  abdomen  has  been 
opened  for  purely  hysterical  conditions.  Such  tumor  is  not ,  infrequently 
associated  with  symptoms  of  spurious  pregnancy — pseudocyesis.  Visible 
tremor  may  be  present,  rarely  hysterical  athetosis. 

3.  \'asomotor  Deraxgemexts. — A  striking  pallor  is  often  present,  at 
other  times  hyperemia,  and  even  a  hot  skin.  Hemorrhage  from  internal 
organs,  especially  the  stomach  and  lungs,  often  alleged,  is  usually  at  least 
apocryphal.  Commonly,  the  blood  is  derived  from  the  gums,  and  its  amount 
is  never  considerable.  Yet  such  symptoms  have  been  the  basis  of  a  diagnosis 
of  pulmonary  disease  or  gastric  ulcer.  Hysterical  stigmata  or  hemorrhages 
in  the  skin  are  also  alleged,  but  are  very  rare. 

Hysterical  fever  belongs  also  to  vasomotor  symptoms.  K  temperature 
of  106°  F.  (41.1°  C),  and  even  more,  has  been  reported.  Such  tempera- 
tures are  characterized  by  their  irregular  occurrence.  Actually  they  are 
extremely  rare,  being  in  most  instances  traceable  to  deception. 

Anomalies  of  secretion  include  profuse  and  scanty  perspiration,  the  lat- 
ter resulting  in  a  peculiar  dr)-ness  of  the  skin ;  the  salivary  secretion  is  simi- 
larly influenced,  and  modifications  in  the  urinary  secretion  are  some  of  the 
most  characteristic  phenomena  of  hysteria.  They  include  ischuria,  but  espe- 
cially polyuria,  the  patient  passing  a  large  amount  of  very  light-colored  urine 
of  low  specific  gravity.  Excessive  thirst  is  also  frequent,  further  augment- 
ing the  polyuria.  The  chemical  composition  of  the  urine  is  altered  in  many 
severe  cases ;  thus,  the  phosphates  and  urates  have  been  found  diminished, 
while  the  ratio  of  earthy  to  alkaline  phosphates  may  be  changed  to  i  to  2  or 
I  to  I,  instead  of  i  to  3.  Such  changes  are  held  by  Charcot's  school  to  be 
diagnostic  of  convulsive  hysteria  as  contrasted  with  epilepsy. 

4.  Visceral  Deraxgemexts. — The  digestive  system  is  especially  dis- 
turbed by  simple  indigestion,  depraved  appetite,  flatulence,  and  gastric  pain. 
Not  infrequently  there  is  spasm  of  the  esophagus,  causing  difficulty  in  swal- 
lowing: in  some  instances  expulsion  of  food  before  it  reaches  the  stomach. 
Hysterical  vomiting  is  very^  common,  and  alleged  vomiting  of  impossible 
substances  is  one  of  the  most  characteristic  symptoms.  An  antagonism  to 
food  is  sometimes  present,  so  extreme  that  death  by  starvation  has  been 
barely  averted ;  indeed,  is  said  to  have  occurred.  Constipation  is  a  frequent 
and  troublesome  symptom.  Much  more  rare  is  the  opposite  condition  of 
diarrhea. 

Cardiovascular  and  pub.nonary  symptoms  exhibit  every  variety,  includ- 
ing irregularity  of  the  heart's  action,  tachycardia  and  bradycardia,  pre- 
cordial oppression  and  sense  of  suffocation,  with  extreme  frequency  of 
breathing  and  deranged  rhythm.  Laryngeal  spasm,  hysterical  cough,  and 
hysterical  hiccough  are  frequent  symptoms.  Hysterical  cries  with  inspira- 
tion or  expiration,  and  imitation  of  the  sounds  produced  by  various  animals 
are  described  by  the  French  neurologists. 

Joint  affections,  purely  hysterical,  were  early  studied  by  Sir  B.  Brodie, 
and  later  by  Sir  James  Paget.  They  involve  the  knee  and  hip  and  consist 
of  fixation,  tenderness,  and  even  swelling. 

The  mental  syjnptoms  are  a  prominent  feature  of  hysteria,  and  vary 


HYSTERIA.  1 125 

greatly  in  their  manifestations.  Irritability  and  capriciousness  of  temper, 
maniacal  excitement,  hallucinations,  and  even  insanity  may  occur.  The 
hysterical  trance  is  a  well-known  condition.  It  may  come  on  spontaneously, 
but  more  frequently  it  follows  one  of  the  forms  of  hysteroid  attacks  to  be 
later  described.     The  cataleptic  state  may  be  associated  with  this  symptom. 

5.  Convulsive  Seizures. — Hysterical  convulsions  are  a  recognized 
symptom,  while  in  some  they  are  the  only  manifestation  of  the  disease. 
Their  severity  varies  greatly ;  but  two  degrees  are  described,  a  milder  or 
minor,  and  a  severer  or  major. 

(a)  Minor  Form. — This  may  come  on  suddenly  or  be  preceded  by  a 
prodrome,  including  hysterical  behavior,  such  as  laughing  and  crying;  a 
sense  of  constriction  about  the  throat,  or  that  of  a  ball  rising  in  it  (the  so- 
called  globus  hystericus)  ;  a  feeling  of  anxiety  with  shortness  of  breath;  or 
pain  and  discomfort  in  the  chest  or  abdomen. 

In  the  actual  seizure  the  patient  falls,  with  this  striking  feature :  that  she 
rarely  fails  to  find  a  soft  spot,  such  as  a  sofa  or  bed,  to  receive  her.  The 
convulsion  consists  in  clonic  contractions  of  a  disordered  and  irregular  kind, 
in  which  all  four  extremities  and  even  the  trunk  may  take  part.  Though 
seemingly  unconscious,  the  patient  still  gives  to  the  careful  observer  the 
impression  of  a  certain  method  in  her  madness.  The  convulsion  lasts  usu- 
ally a  few  minutes,  when  it  passes  off  spontaneously,  or  the  patient  may  be 
aroused  by  some  powerful  impression,  such  as  the  dashing  of  cold  water  in 
the  face,  or  by  a  sharp  galvanic  shock.  She  may  remain  emotional  for  a 
time,  but  the  period  of  torpidity,  so  characteristic  of  the  epileptic  fit,  is  rare. 

{h)  Major  Form  {Hysterical  Epilepsy). — This  has  become  widely 
known,  more  particularly  from  the  graphic  descriptions  and  vivid  pictures 
furnished  by  the  French  school  of  neurology.  It  is  much  less  common  in 
this  country ;  indeed,  it  is  rare  outside  of  hospital  walls,  where  prostitutes 
are  the  usual  subjects.  The  attack  may  be  preceded  by  prpdromata  similar 
to  those  that  precede  the  milder  attacks.  The  convulsion  is  described  by 
French  writers  as  having  four  distinct  stages : 

1.  The  epileptoid  state,  closely  simulating  a  true  epileptic  attack,  with 
apparent  unconsciousness,  tonic  spasm,  even  opisthotonos,  grinding  of  the 
teeth,  livid  face,  succeeded  by  clonic  convulsions,  relaxation,  and  coma ;  last- 
ing rather  longer  than  the  true  epileptic  attack. 

2.  The  period  of  "  contortions  and  grand  movements,"  called  by  Char- 
cot "  clownism,"  characterized  by  emotional  display,  striking  contortions,  or 
cataleptic  poses. 

3.  The  period  of  plastic  positions  and  passionate  attitudes,  including 
those  of  ecstasy,  fright,  beatitude,  or  erotism. 

4.  The  return  to  consciousness  and  a  stage  characterized  especially  by 
manifestations  of  delirium  with  extraordinary  hallucinations  and  by  hyp- 
notic "  suggestibility."  In  it  visions  are  seen,  voices  heard,  and  conversa- 
tions carried  on  with  imaginary  persons.  Imaginary  events  are  related  as 
actually  true.  These  hallucinations  s6metimes  persist  even  after  recovery. 
These  periods  are  not  sharply  separated  from  one  another. 

Suggestion-  and  Hypnosis. — At  this  point  it  is  suitable  to  say  something 
of  these  conditions,  so  closely  associated  with  the  hysterical  state  and  which 
have  attracted  much  attention  of  late.  By  suggestibility  is  meant  the  sus- 
ceptibility of  a  person  to  the  production  of  a  definite  psychical  or  physical 
state  dependent  uoon  the  arousing  of  corresponding  ideas  in  the  mind.  It 
is  really  a  further  development  of  the  hysterical  mental  constitution  already 


1 1 26  DISEASES  OF  THE  NERVOUS  SYSTEM. 

referred  to,  in  which  the  patient  permits  himself  to  be  dominated  by  his 
imagination.  Suggestion  is  merely  the  artificial  fostering  of  the  psychical 
peculiarity.  It  is  most  easy  during  the  part  of  the  hysterical  attack  when 
the  patients  speak,  hear,  and  answer.  At  such  times  a  definite  direction 
may  be  given  to  the  patient's  ideas.  If  he  is  told  in  an  emphatic,  convincing 
manner  that  he  is  in  a  certain  situation,  be  it  one  of  a  pleasurable  kind  or  a 
state  of  suffering  or  danger,  he  believes  it,  and  at  once,  by  behavior  or  expres- 
sion, shows  that  he  believes  it,  and  is  actually  experiencing  the  conditions 
named.  Physical  states  may  be  similarly  suggested,  such  as  paralysis,  con- 
tractures, and  anesthesias,  while  severe  pain  may  be  inflicted  without  excit- 
ing sensibility.  After  the  attack  is  over  the  subject  is  totally  ignorant  of 
what  has  transpired,  but  during  another  attack  may  remember  the  events  of 
the  previous  one,  or,  what  is  still  more  strange,  supposed  events,  furnishing 
thus  an  instance  of  double  consciousness. 

H\ pilosis  is  closely  allied  to  suggestion.  It  is  regarded  by  many  as 
nothing  more  or  less  than  the  intentional  production  of  a  hysterical  attack, 
or  a  hysterical  psychosis  by  suggestion.  As  Striimpell  graphically  puts  it, 
"  Hypnosis  is  an  artificial  hysteria."'  This  view,  however,  is  not  held  by  all. 
The  French  school  makes  four  principal  forms  of  the  hypnotic  state  with 
many  transitions : 

1.  The  cataleptic  state,  in  which  the  limbs  retain  all  the  positions  arti- 
ficially given  them. 

2.  The  state  of  suggestion  or  artificial  hallucination,  in  which  patients 
are  induced  to  eat  tasteless  and  unnatural  food  with  a  gusto. 

3.  The  lethargic  state:  a  state  of  apparent  unconsciousness,  with  the 
eyes  closed,  the  muscles  relaxed,  yet  with  a  markedly  increased  excitability 
in  the  muscles  and  nerves,  in  which  a  light  tap  on  a  nerve  like  the  facial  is 
sufficient  to  put  all  the  muscles  supplied  by  it  into  a  tetanic  contraction  far 
outlasting  the  irritation. 

4.  A  state  of  hysterical  somnambulism,  in  which  the  patient,  w^hile  re- 
maining half  unconscious,  still  answers  automatically  questions  put  to  her, 
obeying  orders  or  giving  them,  and  sometimes  exhibiting  certain  sensory 
hyperesthesias.  It  will  be  seen  that  each  of  these  corresponds  with  one  or 
another  of  the  different  manifestations  of  the  hysterical  attack. 

Hysterogenous  Zones. — In  this  connection  some  further  reference 
should  be  made  to  the  so-called  hysterogenous  zones  already  alluded  to. 
These  are  hyperesthetic  areas  especially  studied  by  Richet,  on  which  per- 
sistent pressure  will  sometimes  excite  a  hysterical  attack.  While  the  sub- 
mammary areas,  especially  the  left,  and  the  inguinal  region  are  favorite  hys- 
terogenous zones,  the  zones  may  be  in  any  part  of  the  body :  as,  for  example, 
the  sides  of  the  trunk.  Pressure  in  such  a  zone  may  cause  an  existing 
attack  to  subside.  Hysterical  spasm  may  be  localized  or  limited  to  groups 
of  muscles. 

Diagnosis. — This  is  not  usually  difficult.  There  is  something  inde- 
scribable in  the  bearing  and  appearance  of  a  hysterical  patient  which  enables 
the  experienced  physician  often  to  recognize  the  disease  at  a  glance.  While, 
as  stated,  every  phenomenon  of  any  organic  nervous  disease  may  be  present, 
yet  the  essential  symptoms  of  organic  lesion  are  still  wanting,  and  there  are 
S3^mptoms  which  are  peculiar  to  hysteria  alone.  The  anesthesias  are 
peculiar  in  their  area  of  distribution,  and  hysterogenous  zones  are  nowhere 
else  found.  The  hysterical  convulsion  is  quite  sui  generis,  the  throat  and 
pharyngeal  symptoms  are  not  found  elsewhere,  and  the  emotional  symptoms 


HYSTERIA.  1 127 

are   tell-tale.     Cases    occasionally    occur    in    which    the    diagnosis    between 
hysteria  and  organic  disease  is  very  difficult. 

Prognosis. — This  is  very  rarely  serious,  though  the  course  and  duration 
of  the  disease  vary  greatly.  The  milder  cases  may  be  of  very  short  duration, 
while  the  more  serious  may  last  for  weeks  or  years,  often,  however,  with 
intermissions  and  changes.  Only  in  very  rare  instances  does  a  fatal  result 
occur,  and  reports  of  death  from  hysteria  demand  very  critical  examination. 

Treatment. — A  proper  prophylactic  treatment,  so  commonly  overlooked, 
would  prevent  many  cases  of  hysteria.  The  counteracting  of  all  that  is  men- 
tioned under  the  head  of  predisposition  constitutes  such  treatment.  Whole- 
some discipline  or  training  in  youth,  the  inculcation  of  self-denial  as  con- 
trasted with  overindulgence  and  the  gratification  of  fancy,  and  careful  ex- 
clusion from  the  companionship  of  hysterical  persons  make  up  the  sum  of 
these. 

The  successful  curative  treatment  of  hysteria  also  more  frequently  de- 
pends upon  the  individuality  of  the  physician  than  on  the  remedies  employed. 
Indispensable,  however,  is  the  removal  of  the  causes  which  predispose  to  the 
disease,  whether  they  be  of  the  nature  of  moral  influences  or  bodily  ailment. 
Among  the  most  difficult  to  eliminate  of  the  former  are  those  which  arise 
from  the  fondness  and  sympathy  of  relatives  who  have,  from  long  habit, 
become  almost  slaves  to  the  fancies  of  the  hysterical  subject,  and  with  whom, 
in  consequence,  firmness  has  become  impossible.  It  is  in  consequence  of 
such  difficulties  that  the  isolation  plan  of  treatment,  which  has  become  in- 
separably associated  with  the  name  of  Weir  Mitchell,  has  been  so  success- 
ful. Originated  for  neurasthenic  cases,  it  is  as  applicable  to  the  hysterical 
in  whom  neurasthenia  is  likewise  often  present,  while  hysteria  also  often 
forms  a  large  factor  in  the  neurasthenic  state.  Whenever  possible,  the 
patient  must  be  removed  from  her  previous  surroundings,  her  family,  and 
even  her  friends.  This  accomplished,  the  details  of  management  largely 
depend  upon  the  peculiarities  of  the  case,  but  in  a  general  wa})  the  Weir 
Mitchell  plan  may  be  said  to  be  as  follows : 

First,  and  indispensable,  is  the  care  of  an  intelligent  and  sensible  nurse. 
Under  her  charge  the  patient  is  put  to  bed  and  kept  in  a  condition  of  abso- 
lute rest,  even  reading  being  prohibited,  and  also  at  first  self-feeding.  Mas- 
sage is  used  daily,  at  first  for  short  periods,  which  are  gradually  lengthened, 
until  an  hour  is  thus  consumed.  With  massage  is  associated  electricity,  the 
faradic  current  with  slow  interruptions  being  usually  preferred.  Thus,  with 
a  small  electrode,  the  motor  nerve  points  can  be  picked  out,  and  the  con- 
traction of  individual  muscles  produced.  Massage  and  electricity  both  have 
for  their  purpose  the  substitution  of  exercise,  to  which  end  the  former  is  by 
far  the  more  useful  and  important.  Both  are  discontinued  during  menstrua- 
tion. The  food  at  first  is  milk,  which  has  been  usually  skimmed,  but  in  my 
own  experience  good  milk  unskimmed  and  diluted  with  one-fourth  its  bulk 
of  water,  or  aerated  water,  answers  the  purpose  better.  The  proportion  of 
casein  is  less,  and  the  oil,  which  is  so  valuable  for  the  nutrition  of  the  patient, 
is  retained  in  more  nearly  its  normal  quantity.  At  first  from  four  to  six 
ounces  of  milk  are  given  every  two  hours.  After  a  week  or  ten  days  a  chop 
or  a  few  raw  oysters  are  added  at  luncheon,  with  a  cup  of  coffee  or  tea.  and 
later  at  breakfast  an  egg,  bread  and  butter  or  biscuit  with  the  milk,  the  latter 
being  continued  at  two-hour  intervals.  The  patient  should  have  a  thorough 
sponge  bath  daily  at  the  hands  of  the  nurse.  It  is  convenient  to  make  out  a 
schedule  including  the  hours  for  nourishment,  massage,  and  electricity,  of 


1 128  DISEASES  OF  THE  XERVOUS  SYSTEM. 

which  the  last  two  should  be  separated  by  several  hours.  ^lassage  should 
be  followed  by  a  full  hour's  rest.  Under  this  forced  feeding  the  patient 
gradually  fattens,  and  concurrently  with  this  the  excitability  of  the  nervous 
system  usually  grows  less.  In  a  month  or  six  weeks  the  patient  is  allowed  to 
sit  up,  at  first  for  a  few  minutes  only,  but  each  day  a  little  longer,  until  the 
whole  day  is  thus  spent,  interruptedly  by  periods  of  rest.  Later  she  is  taken 
out  to  drive,  and  then  to  walk  for  gradually  increasing  distance,  until,  in  the 
vast  majority  of  instances,  she  is  enabled  to  perform  enormous  amounts  of 
physical  exercise  without  fatigue.  I  have  known  patients  bedridden  for 
months  and  even  years,  women  whose  relatives  had  been  worn  out  with  nurs- 
ing, who,  after  a  few  weeks  of  this  treatment,  acc|uired  the  most  vigorous 
health,  walking  many  miles  a  day  and  presenting  an  appearance  of  health 
and  strength  which  would  be  considered  absolutely  impossible  by  one 
unfamiliar  with  the  results  of  this  mode  of  treatment.  As  a  rule,  three 
months  should  be  asked  for  its  fulfillment.  As  has  already  been  said,  the 
individuality  of  the  physician  has  much  to  do  with  the  success  of  the  method. 
One  who  has  a  firm,  earnest,  yet  gentle  manner  will  do  more  with  such  cases 
than  one  who  is  vacillating  and  disposed  to  yield  to  the  caprice  of  the  patient. 
An  element  of  "  suggestion  "  must  perhaps  be  acknowledged  in  the  power 
of  the  physician  thus  constituted,  yet  the  full  application  of  this  principle  of 
treatment  by  hypnotic  suggestion  is  to  be  deprecated.  The  nurse  in  charge 
must  be  similarly  constituted,  and  it  not  infrequently  happens  that  a  nurse 
otherwise  excellent  is  totally  unadapted  for  the  management  of  a  case  of  this 
kind. 

As  to  medicines,  the  number  that  are  useful  are  few.  Iron  and  arsenic, 
in  very  moderate  doses,  are  the  only  ones  which  are  actually  curative.  The 
various  nervous  sedatives,  including  valerian,  asafetida,  the  bromids,  the 
milder  hypnotics,  such  as  phenacetin,  rarely  chloral,  may  be  used  as  occasion 
requires ;  morphin  should  never,  or  almost  never,  be  given.  A  convenient 
form  in  which  to  use  asafetida  is  the  suppository;  lo  grains  (0.66  gm.)  may 
be  put  in  a  single  one. 

The  paralysis  and  contractures  generally  require  some  time  to  overcome, 
and  in  some  cases  are  persistent  in  spite  of  all  treatment.  Cure  is  accom- 
plished mainly  by  manipulation  aided  by  electricity,  under  the  use  of  which 
the  symptoms  gradually  disappear  and  the  patient,  induced  at  first  to 
walk  for  a  few  steps,  will  slowly  acquire  full  power  of  locomotion.  Anes- 
thesia is  best  treated  by  faradization  and  the  electrical  brush.  Paralysis  of 
the  vocal  cords  is  also  best  treated  by  electricity,  suitable  electrodes  having 
been  devised  for  that  purpose. 

Allusion  should  be  made  to  metallotherapy,  a  treatment  instituted  bv  a 
French  physician  named  Burq,  who  years  ago  ascertained  that  by  laying 
plates  of  metal  upon  a  cutaneous  surface  affected  by  hysterical  anesthesia, 
sensation  is  sometimes  at  once  restored  not  only  in  the  immediate  region, 
but  also  sometimes  in  a  much  larger  area.  The  cases  so  treated  were,  for 
the  most  part,  hysterical  hemianesthesias.  Iron  is  the  metal  most  frequently 
efficient,  but  sometimes  copper,  zinc,  or  gold  are  employed.  The  process  of 
determining  the  metal  essential  to  each  individual  case  was  called  metallo- 
scopy.  and  Burq  held  that  this  metal  would  also  have  the  same  effect  if  given 
internally.  A  committee  of  the  Paris  Society  of  Biology  tested  these  state- 
ments in  1876  and  confirmed  them,  except  as  to  the  internal  administration 
of  the  metal.  A  similar  discovery  was  that  of  Charcot,  also  substantiated, 
that  the  return  of  sensation  to  an  anesthetic  area  as  the  result  of  applying  a 


N  EUR  AS  THEN  I A .  1 1 29 

metal  plate  is  accompanied  by  a  simultaneous  development  of  anesthesia  upon 
the  opposite  side  previously  normal  and  in  an  exactly  correspondmg  place. 
This  is  known  as  transfer.  Other  hysterical  symptoms  than  anesthesia  have 
been  found  to  exhibit  analogous  phenomena.  Thus,  transfer  can  sometimes 
be  observed  in  hysterical  amblyopia,  achromatopsia,  deafness,  loss  of  the 
senses  of  smell  and  taste,  contractures,  and  paralysis,  while  such  transfers 
may  be  induced  by  other  means  than  metal  plates,  known  as  esthesiogenous 
remedies.  They  include  large  magnets,  feeble  galvanic  currents,  static  elec- 
tricity, vibrating  tuning-forks,  and  sinapisms.  It  must  be  plain  to  any  think- 
ing person  that  these  phenomena  are  merely  the  result  of  suggestion  produced 
by  ideas  similar  to  those  already  described.  Their  career  will  doubtless  end 
Hke  that  of  Perkins'  tractors.  Hypnotism  has  also  been  employed  of  late 
for  the  treatment  of  hysteria,  and  has  acquired  some  popularity  in  France, 
where  it  has  been  especially  practiced  by  the  school  at  Nancy.  Wonderful 
cures  have  doubtless  thus  been  accomplished,  but  based  as  it  is  upon  mysti- 
cism and  imagery,  and  being  already  much  abused  by  charlatans,  it  is  to  be 
hoped  that  its  fate  will  be  that  of  metallotherapy  and  Perkins'  tractors. 

NEURASTHENIA. 

Synonyms. — Nervous  Exhaustion ;  Nervous  Weakness;  Encephal- 
asthenia;  the  American  Disease. 

Definition. —  A  term  originally  suggested  by  George  M.  Beard,  in 
1879,  for  a  complexus  of  symptoms  without  anatomical  basis,  in  which 
muscular  weakness,  nervous  irritability,  and  pain  are  variously  manifested. 
Beard  defined  nervousness  as  "  Deficiency  of  nerve  force,  manifested  chiefly 
by  undue  sensitiveness  to  external  impressions,"  and  neurasthenia  as  "  A 
sign  and  type  of  functional  nervous  disease  "  evolved  out  of  this  general 
nervous  sensitiveness.  The  line  of  demarcation  between  neurasthenia  and 
hysteria  is  not  always  definite.  Not  only  do  the  two  conditions  sometimes 
merge,  but  certain  cases  of  neurasthenia  are  in  no  way  distinguishable  from 
the  minor  forms  of  hysteria.  The  condition  is  called  spinal,  cerebral, 
cardiac,  or  gastric,  according  as  the  symptoms  dependent  on  one  or  the 
other  of  these  systems  predominate,  but  the  line  of  demarcation  is  not 
sharp. 

Etiology. — The  same  class  of  persons  who  are  predisposed  to  hys- 
teria are  predisposed  to  neurasthenia,  and  such  predisposition  may  be  inher- 
ited or  acquired.  So,  too,  many  of  the  exciting  causes  of  the  former  be- 
come the  exciting  causes  of  the  latter.  Among  these  are  overstrain  of 
mind  and  body,  overwork,  especially  overw^ork  associated  with  care  and 
anxiety.  It  is  distinctive  of  neurasthenia  as  contrasted  with  hysteria  that  it 
'is  more  frequent  among  men,  on  whom  business  care  and  financial  worry  fall 
more  severely.  It  is  well  known  that  men  differ  greatly  in  their  power  to 
bear  the  mental  strain  incident  to  the  struggle  for  existence  or  business  suc- 
cess. From  the  special  prevalence  of  this  disease  in  America  it  has  been 
called  "the  American  disease,"  and  is  reasonably  ascribable  to  the  fact 
that  mental  and  physical  strength  in  this  country  is  more  taxed  than  in 

any  other.  ' 

Morbid  Anatomy.— Although  Beard  took  great  pains  to  prove  that 
neurasthenia  is  a  physical  and  not  a  mental  state,  and  that  these  phenomena 
do  not  come  from  emotional  causes  or  excitability,  but  from  nervous  debility 


1 130  DISEASES  OF  THE  NERVOUS  SYSTEM. 

and  irritability,  there  has  been  found  no  distinctive  morbid  change  associated 
with  its  complexus  of  symptoms  any  more  than  with  hysteria.  It  is  barely 
possible  that  the  investigations  of  C  F.  Hodge  and  others,  demonstrating 
changes  in  nerve-cells  during  functional  activity,  may  result  in  some  further 
knowledge  in  this  direction. 

Symptoms. — It  has  already  been  said  that  the  symptoms  of  the  minor 
forms  of  hysteria  are  the  symptoms  of  many  cases  of  neurasthenia.  The 
appearance  of  the  patient  may  be  that  of  perfect  health;  less  frequently  he 
looks  worn  and  worried.  In  the  spinal  form  motor  phenomena  are  the 
most  conspicuous.  Of  this  and,  indeed,  of  all  forms,  the  most  constant 
symptom  is  muscular  zvcakncss,  as  a  result  of  which  the  patient  complains 
of  being  tired  and  weary,  even  too  weak  at  times  to  keep  out  of  bed.  Such 
weakness  may  affect  the  gait,  making  it  uncertain  and  trembling,  and  the 
acts  performed  by  the  upper  extremities  may  be  similarly  embarrassed. 
There  may  be  hyperesthesia  and  paresthesia,  and  even  the  special  senses 
may  be  affected^  especially  vision  and  hearing.  The  latter  is  more  fre- 
quently oversensitive,  and  vision  may  be  obscured  by  the  presence  of  scoto- 
mata  or  muscae  volitantes.  In  the  cerebral  form  especially  characteristic 
is  a  low-spiritedness  or  despondency,  often  painful  to  witness,  and  which  may 
alternate  with  irritahdity  or  moodiness.  Another  symptom  is  sleeplessness, 
though  many  patients  sleep  well ;  indeed,  there  is  occasionally  an  irresist- 
ible disposition  to  sleep.  A  disposition  to  seek  solitude  is  characteristic, 
Avhile  at  other  times  the  patient  fears  to  be  alone.  Again,  he  is  restless,  un- 
settled, and  impelled  to  move  about  from  place  to  place,  while  there  is 
sometimes  a  pronounced  disposition  to  suicide.  Confusion  of  mind,  and 
especially  a  difficulty  in  dealing  with  figures,  is  a  very  common  symptom, 
sometimes  an  initial  symptom,  the  simplest  arithmetical  problems  being  quite 
impossible  with  one  so  affected.    • 

The  cardiac  form  is  characterized  by  palpitation  and  frequent  irreg- 
ular action  of  the  heart  and  precordial  pain,  which  give  rise  to  the 
belief  in  the  patient's  mind  that  he  has  cardiac  disease,  arteriocapillary 
fibrosis,  or  "  hardening  of  the  blood-vessels,"  as  it  is  called  by  the  laity. 
Of  vasomotor  phenomena  there  may  be  Hashes  of  heat,  sudden  sweats,  even 
night-sweats,  and  a  relaxed  state  of  the  peripheral  blood-vessels  to  an 
extent  which  may  cause  the  "  water-hammer "  and  even  capillary  pulse, 
similar  to  that  of  aortic  regurgitation.  Epigastric  pulsation  is  often  an  an- 
noying symptom  in  women.  In  the  gastric  form  are,  especially,  gastric 
pain,  the  distinctive  symptom  of  "  nervous  dyspepsia,"  but  there  are  also 
distention  and  discomfort  aft^r  eating,  or  a  constant  noisy  motion  of  gases 
— borborygmits.  Polyuria  is  a  conspicuous  symptom.  A  slight  degree  of 
glycosuria  and  even  intermittent  albuminuria  have  been  reported.  The 
opposite  condition  of  urine — a  dark  hue  and  high  specific  gravity — is  more 
rarely  present.  Hoarseness,  aphonia,  and  very  frequent  breathing  are  re- 
garded as  symptoms  of  hysteria. 

Diagnosis. — This  is  generally  easy,  and  is  arrived  at  by  the  exclusion 
of  the  objective  symptoms  of  organic  disease  and  by  the  etiology,  for  it  will 
be  observed  that  all  of  the  symptoms  which  have  been  narrated  are  sub- 
jective in  character.  The  so-called  spinal  irritation  is  a  condition  which 
resembles  neurasthenia,  and  probably  some  of  the  cases  so  named  which  are 
not  hysteria  are  cases  of  nervous  exhaustion.  Sensitiveness  of  the  vertebrae 
is  not  apt  to  be  present  in  neurasthenia,  whereas  it  is  the  most  distinctive 
symptom  of  spinal  irritation. 


NEURASTHENIA.  1131 

Prognosis. — Recovery  from  neurasthenia  may  be  confidently  promised 
to  almost  every  patient  who  is  in  a  position  to  meet  the  indications  of  a  suc- 
cessful treatment,  which,  unfortunately,  are  apt  to  be  expensive,  though 
the  modern  hospital  affords  to  even  the  poorer  classes  an  asylum  where  the 
treatment  may  be  successfully  carried  out.  On  the  other  hand,  it  is  mostly 
the  rich  who  suffer  from  neurasthenia,  and  they  are  in  a  position  to  meet 
these  requirements. 

Treatment. — The  first  essential  condition  of  a  successful  treatment  is 
removal  of  the  causes  which  are  responsible  for  the  illness.  To  this,  in  the 
case  of  women,  and  sometimes  of  men,  the  most  successful  adjuvant  is  the 
rest  treatment  of  Weir  Mitchell,  the  technique  of  which  has  been  already 
described  under  the  treatment  of  hysteria.  After  this  and,  in  the  case  of 
men,  often  even  before  this,  remoz'al  from  the  scene  and  surroundings 
which  attended  the  development  of  the  disease  is  most  useful.  Travel 
away  from  home,  especially  in  foreign  countries,  a  sojourn  at  a  sani- 
tarium or  health  resort,  the  seaside,  the  woods,  the  mountains,  for  pro- 
longed periods,  have  always,  in  my  experience,  sooner  or  later  been  fol- 
lowed by  recovery.  For  the  poor,  the  rest-cure  as  carried  out  in  hospitals 
may  be  substituted  for  the  more  expensive  methods  of  home  treatment. 

The  treatment  of  the  insomnia  of  neurasthenia  calls  for  brief  special 
consideration,  and  what  is  said  here  may  apply  to  the  treatment  of  any 
form  of  simple  insomnia,  by  which  I  mean  insomnia  not  the  result  of 
pain.  Modern  therapeutics  has  added  to  our  resources  a  number  of  drugs 
which  are  more  or  less  efficient  to  this  end.  The  best  of  these,  considered 
from  all  standpoints,  is  sulplional.  Not  less  than  from  ten  to  fi.fteen  grains 
{0.66  to  I  gm.)  should  be  given  to  an  adult,  while  twice  as  much  may  be 
given  if  needed.  I  prefer  to  give  this  dose  and  repeat  it  in  an  hour  if  no 
effect  follows.  It  is  bulky,  soluble  with  difficulty  in  cold  water,  but  readily 
so  in  any  hot  menstruum,  and  especially  suitable  is  hot  milk.  It  should 
be  given  an  hour  or  two  before  sleep  is  desired,  but  associated  quietude  is 
necessary  to  secure  its  effect.  Nearly  the  same  may  be  said  of  trional 
in  the  same  doses.  It  is  rather  more  conveniently  administered,  and  may 
be  placed  dry  on  the  tongue  and  washed  down  with  a  mouthful  of  water. 
Paraldehyd  is  an  excellent  remedy,  but  very  disagreeable,  and  is  more 
prompt  in  its  action  than  sulphonal  or  trional,  and  should  be  given  in  dram  (4 
gm.)  doses.  Chloralamid  is  also  a  good  hypnotic;  its  dose  is  thirty  grams 
(2  gm.).  It  should  be  dissolved  in  som.e  alcoholic  menstruum  diluted  to 
1-2  ounce  (13.5  c.  c).  Phenacetin  may  be  used  in  doses  of  from  fifteen  to 
thirty  grains  (i  to  2  gm.).  Chloral,  as  a  simple  hypnotic,  is  better,  perhaps, 
than  any  of  those  named,  although  it  has  yielded  its  former  high  place  to 
those  just  mentioned  because  of  their  harmlessness.  It  has  the  further  dis- 
advantage of  sometimes  causing  drowsiness  the  next  day,  and  occasionally 
it  is  exciting.  From  ten  to  thirty  grains  (0.66  to  2  gm.)  should  be  given  at 
a  dose.  It  is  especially  useful  when  combined  with  morphin,  making  a  much 
smaller  dose  of  this  drug  efficient,  but  morphin  should  not  be  used  if  it 
is  possible  to  get  along  without  it.  Hydrobromate  of  hyoscin  may  be  used 
in  doses  of  i-ioo  grain  (0.00066  gm.)  if  the  drugs  named  fail.  Sometimes 
it  acts  like  a  charm,  at  other  times  it  produces  the  opposite  efifect — exciting- 
the  patient.     One  trial  suffices  to  settle' the  question. 

It  is  true  of  all  the  drugs  named  that  their  efifect  is  apt  to  wear  off.  and 
increasing  doses  must  be  used.  It  is,  therefore,  desirable  to  obviate  the 
necessity  of  their  use  as  early  as  possible,  and.  if  possible,  substitute  other 


1 132  DISEASES  OF  THE  NERVOUS  SYSTEM. 

measures.  Often  the  patient  simply  needs  a  start  to  put  him  in  the  way  of 
sleeping,  while  sometimes  the  simple  feeling  that  there  is  something  at  hand 
which  he  can  use  if  he  wishes  gives  him  the  needed  confidence  and  he 
goes  to  sleep  at  once.  A  warm  baih  before  retiring,  or  even  at  times  a  cool 
bath  or  cool  sponging,  and  again  a  hot  bath,  promote  sleep.  To  persons 
residing  in  cities  sleep  is  often  favored  by  a  sojourn  at  the  seaside,  many 
being  able  to  sleep  there  when  they  cannot  do  so  at  home.  The  same  is  true 
of  the  country  or  the  mountains. 

It  is  important,  too,  in  our  efforts  to  secure  sleep  for  our  patients  to 
investigate  the  various  functions,  derangement  of  any  of  which  may  keep 
a  neurasthenic  patient  awake.  Irregularities  of  digestion  and  circulation 
should  receive  attention.  An  undigested  meal  or  a  loaded  bowel  often 
keeps  one  awake,  while  an  excited  heart,  by  its  ceaseless  beating,  repels  the 
restful  sleep  without  which  life  is  wretched.  Often  a  light  meal  or  a  single 
glass  of  wine  seems  to  furnish  the  brain-cells  the  right  amount  of  stimulus 
to  enable  them — 

"  To  shut  the  banging  doors  and  windows  wide 
Of  restless  sense." 


TRAUMATIC  NEUROSES. 

Synonyms. — "Railway  Brain";  "Railway  Spine";  Traumatic  Hysteria; 

Erichsen's  Disease. 

Definition. — A  neurasthenic  or  hysterical  state,  the  result  of  shock  from 
railroad  accident  or  accident  of  similar  alarming  character. 

Historical. — The  condition  was  first  studied  by  Erichsen  in  1868  to  1875,  under 
the  designation  of  "  railway  spine."  Erichsen  regarded  it  as  an  inflammation  of  the 
spinal  meninges.  Leyden,  in  1875,  made  important  contributions  to  the  literature  of 
the  subject  in  treating  of  spinal  concussion.  Spitzka,  in  a  review  of  "  Spinal  Injuries 
as  a  Basis  of  Litigation,"  in  1883,  referred  the  symptoms  to  the  category  of  spinal 
rritations.  J.  J.  Putnam  and  G.  L.  Walton,  in  1883,  first  pointed  out  the  hysterical 
nature  of  the  affection,  a  view  which  is  commonly  accepted  to-day.  H.  W.  Page,  an 
English  railway  surgeon,  published  in  1885  a  considerable  volume  directed  against 
Erichsen's  view.  There  still  remain  a  few,  and  among  them  S.  V.  Clevenger,  in  a 
work  on  "  Spinal  Concussion,"  published  in  i88q,  and  Gowers  in  his  1892  edition,  who 
hold  that  railway  spine  is  something  more  than  a  purely  mental  condition.  W.  A. 
Hammond  suggested  the  anemic  origin. 

Etiology. — Profound  nervous  shock,  however  induced,  by  railroad  acci- 
dents, shipwreck,  boiler  explosions,  and  the  like,  even  when  the  sufferer  him- 
self is  not  a  victim,  but  is  profoundly  impressed  by  it,  is  capable  of  producing 
this  nervous  state. 

Morbid  Anatomy. — In  the  vast  majority  of  cases,  anatomical  changes 
are  not  discoverable ;  in  fact,  as  most  cases  recover,  there  is  little  oppor- 
tunity to  seek  them.  In  a  few,  however,  morbid  alterations  have  been 
found  in  the  brain  and  spinal  cord,  including  degeneration  of  the  pyramidal 
tracts  of  the  cord,  demonstrated  by  Edes  in  four  cases ;  multiple  sclerotic 
areas  in  the  white  matter,  and  arteriosclerosis  in  the  vessels  of  the  brain,  with 
scattered  areas  of  degeneration,  but  the  study  of  concussions  in  man  has 
not  led  to  very  definite  results.  The  effects  of  concussions  of  the  brain  and 
spinal  cord  have  been  studied  in  animals,  and  changes  in  the  nerve-cells  and 
nerve-fibers  have  been  foimd. 

Symptoms. — These  are  not  essentially  different  from  those  of  neuras- 


OTHER  FORMS  OF  FUNCTIONAL  PARALYSIS.         1133 

thenia  from  other  causes.  The  most  remarkable  fact  with  regard  to  them 
is  that  they  do  not  necessarily  immediately  follow  the  accident,  and  there 
may  be  some  interval  of  time  between  the  two  events — the  accident  and  its 
result.  In  some  cases  the  symptoms  appear  suddenly,  in  others  they  are 
gradual  in  their  invasion.  All  the  symptoms  detailed  under  neurasthenia 
may  be  present,  especially  spinal  tenderness  and  pain  in  various  parts  of 
the  body,  principally  in  the  back  and  head;  there  may  be  numbness  and 
tingling  in  the  extremities,  increased  muscular  irritability,  and  increased 
knee-jerk.  The  latter  varies  from  day  to  day,  and  may  be  exhausted  by 
repeated  stimulation.  Extreme  depression  of  spirits  is  another  symptom. 
Other  patients  exhibit  active  hysterical  symptoms,  including  modifications 
of  sensation  and  motion,  hemianesthesia,  anesthesia,  paresis,  and  even  paral- 
ysis. 

In  the  more  severe  cases  in  which  there  is  actual  concussion  the  symp- 
toms suggest  organic  changes,  which  are,  indeed,  actually  found  at  times  in 
the  shape  of  pachymeningitis.  Such  cases  exhibit  diminished  superficial 
reflexes,  with  exaggeration  of  the  deep  ones.  There  may  be  severe  pain, 
variously  distributed.  Other  symptoms  are  alterations  in  the  temperature 
sense  and  in  the  muscular  sense,  both  of  which  may  be  bilaterally  dis- 
tributed. There  may  also  be  modification  of  the  special  senses,  including 
those  of  smell,  taste,  and  vision,  with  inequality  of  pupils.  There  may  be 
monoplegia  with  or  without  contracture.  Symptoms  w^hich  imply  true  or- 
ganic change  are  optic  atrophy,  bladder  symptoms,  paresis,  and  exaggerated 
reflexes.     Such  cases  are  sometimes,  though  rarely,  fatal. 

Prognosis. — Most  cases  get  well.  The  effect  of  litigation  is  often  to 
delay  recovery,  while  successful  litigation  does  not  always  relieve  the  symp- 
toms, and  when  it  does,  it  is  by  no  means  always  speedily — months  and 
even  years  elapsing  before  the  cases  recover.  A  few  cases,  where  there  is 
true  organic  disease,  perish. 

Treatment.— Rest,  mental  and  physical,  is  the  first  essential  condition 
of  recovery.  It  may  be  aided  by  the  measures  useful  in  other  forms  of  neu- 
rasthenia, such  as  massage,  electricity,  and  proper  feeding.  Medicines  avail 
little,  except  for  their  moral  effect.     Narcotics  should  be  avoided. 


OTHER  FORMS  OF  FUNCTIONAL  PARALYSIS. 

Abasia-astasia. 

Definition.— Abasia  («  privative;  fiacji?,  a  step)  is  a  term  given  by 
P.  Blocq,  in  1888,  to  a  difficulty  in  starting  the  act  of  walking  from  a  state  of 
previous  rest.  Astasia  («  privative;  era- (fz?,  a  standing)  is  an  inability  to 
stand,  contrasted  with  integrity  of  sensation,  muscular  strength,  and  co- 
ordination of  other  movements  of  the  legs. 

Nature. — The  phenomena  are  thus  far  inexplicable  in  the  absence  of 
discoverable  lesions,  and  are  usually  regarded  as  hysterical.  It  is  a  condi- 
tion occurring  in  adults,  equally  frequent  in  men  and  women — as  determined 
by  Knapp's  study  of  fifty  cases,  of  whiph  half  were  in  either  sex. 

Symptoms.— These^  occur  in  connection  with  a  variety  of  morbid  states, 
and  a  large  majority  of  them  are  doubtless  hysterical. 

In  the  "  unconscious  "  variety  the  patient  is  without  any  idea  that  he 


1 134  DISEASES  OF  THE  NERVOUS  SYSTEM. 

cannot  walk  or  stand,  when  he  suddenly  finds  that  he  cannot  do  either. 
Another  variety  of  abasia-astasia  is  the  "  hypochondriacal,"  in  which  the 
patient  acts  under  "  conscious  "  erroneous  impression  that  he  cannot  walk 
or  cannot  stand.  It  is  sometimes  associated  in  the  hypochondriacal  para- 
noiac with  paresthesia,  and  in  the  neurasthenic  with  abnormally  increased 
sense  of  fatigue.  A  third  form  is  associated  with  some  suddenly  acting- 
"  shock,''  as  fright,  which  acts  inhibitorily  on  the  motions  of  the  patient. 
Finally  there  is  the  "  coercion "  variety  of  abasia-astasia,  in  which  the 
patient,  while  in  the  act  of  walking  or  standing,  is  suddenly  seized  with  the 
idea  that  he  cannot  walk  or  shall  not  walk.  This  differs  from  the  hypo- 
chondriacal form  in  that  the  patient  is  conscious  of  the  erroneousness  and 
absurdity  of  the  idea,  but  is  nevertheless  coerced  by  it. 

These  different  forms  are  not  always  sharply  defined.  Suddenness  is 
especially  characteristic  in  the  "  unconscious  "  form.  In  other  cases  the 
patient  may  walk  a  few  steps  and  then  suddenly  break  down.  Sometimes. 
he  stands  rooted  to  the  ground,  as  it  were.  At  other  times  the  development 
is  slow,  requiring  even  years  to  reach  its  acme.  Sometimes  it  is  preceded 
by  trembling  or  staggering,  as  associated  symptoms,  the  result  of  the  effort 
of  the   patient  to  stand  or   move   forward. 

Closing  the  eyes  usually  increases  the  difficulty.  On  the  other  hand^ 
sometimes,  with  the  eyes  closed  the  patient  can  walk  in  the  normal  manner,, 
when  it  is  impossible  to  do  so  with  the  eyes  open.  The  latter  is  especially 
true  of  the  hypochondriacal  variety.  In  these  cases,  too,  the  natural  gait 
is  sometimes  restored  after  attempting  an  unusual  method  of  walking,  as 
walking  backward  or  with  the  legs  crossed  or  by  leaping  or  in  military  step. 
So,  also,  abasics  can  walk  on  all-fours.  The  morbid  state  is  also  influenced 
by  certain  surroundings,  as  broad  open  surfaces  or  long  narrow  corridors 
or  standing  without  special  support.  Th.  Ziehen  refers  to  a  case  in  which 
it  came  on  when  the  patient  walked  under  a  tree,  the  moving  leaves  of 
which  produced  moving  shadows.  There  is  sometimes  associated  tachy- 
cardia ;  at  other  times  evident  hysterical  symptoms,  such  as  tender  spots, 
hemianesthesia,  and  the  like.  In  other  cases  there  is  epilepsy,  paralysis 
agitans,  or  chorea. 

Diagnosis. —  This  is  based  upon  the  retention  of  absolute  integrity  of 
sensation,  of  muscular  strength,  and  of  co-ordination  of  the  legs,  demon- 
strable in  the  recumbent  position.  From  hysterical  paraplegia  it  differs  in 
that  the  power  of  motion  is  intact  in  the  recumbent  position.  From  inter- 
mittent lameness  it  is  distinguished  by  the  fact  that  in  intermittent  lame- 
ness the  inability  to  walk  comes  on  after  the  patient  has  been  walking  a 
while,  and  the  power  of  locomotion  is  restored  after  rest.  Abasia-astasia 
has  been  observed  in  tumor  of  the  frontal  lobe  of  the  brain. 

Prognosis. — This  is  regarded  as  favorable,  though  relapses  occur. 

Treatment. — The  evident  hysterical  nature  of  the  affection,  in  the 
majority  of  cases,  suggests  the  treatment  for  such  cases.  The  rest-cure, 
massage,  gymnastics,  electricity,  gradually  increasing  practice  in  walking, 
are  measures  which  are  likely  to  be  useful.  Th.  Ziehen,  to  whose  article 
in  Eulenberg's  "  Real-Encyclopadie  "  I  am  indebted  for  much  of  the  in- 
formation in  this  section,  recommends  "  suggestion  without  hypnosis,"  espe- 
ciallv  in  the  hypochondriacal  and  hysterical  forms,  as  a  reliable  means  of 
rapid  cure;  and  in  the  cases  in  which  fear  or  terror  is  conspicuous,  small 
doses  of  opium. 


OTHER  FORMS  OF  FUNCTIONAL  PARALYSIS.         1135 


Family  Periodical  Paralysis. 

Definition. — A  rare  form  of  hereditary  or  family  paralysis  of  the 
voluntary  muscles,  usually  general,  except  the  face,  recurring-  at  intervals 
of  from  one  or  two  weeks  to  three  months,  and  confined  principally  to 
children.  It  is  attended  with  a  loss  of  reflexes  and  electrical  reaction,  but  no 
mental  or  sensory  disturbance. 

The  disease  is  rare.  It  was  first  described  by  Cavare  in  1853  and  by 
Romberg  in  1857.  Edward  Wyllis  Taylor*  collected  tvv^enty-five  cases, 
including  two  of  his  own,  up  to  September,  1898,  to  which  John  K. 
Mitchellf  added  a  twenty-sixth  in  1899. 

Etiology. — The  disease  is  hereditary  and  is  transmitted  through  the 
mother.  As  many  as  twelve  members  of  a  single  family  have  been  affected,, 
though  it  does  not  usually  affect  all  the  children.  Goldflam  suggests  that 
the  paralysis  is  due  to  autointoxication,  the  poison  acting  upon  the  nerve 
endings  in  the  muscles,  while  he  also  found  that  the  urine  secreted  during 
the  attacks  was  more  toxic  than  at  other  times.  The  view  of  autointoxica- 
tion is  not  accepted  by  all,  and  J.  J.  Putnam  has  advanced  a  theory  of  inhibi- 
tion. The  recent  studies  of  John  K.  Mitchell  on  the  case  referred  to,  for 
some  time  under  his  observation,  tend  to  confirm  Goldflam's  view,  and  also 
to  show  that  there  are  two  poisons,  one  of  which  predominates  in  one  case 
and  the  other  in  another,  and  according  as  one  or  the  other  predominates 
the  effect  is  greater  on  the  peripheral  nerves  and  muscles  or  the  spinal  cen- 
ter. It  should  not  be  omitted  that  some  clinicians,  including  C.  L.  Dana, 
consider  the  majority  of  cases  hysterical,  though  he  says  some  may  be 
cases  of  recurring  poliomyelitis. 

Symptoms. — The  disease  occurs  in  youth  and  in  the  midst  of  health,, 
even  during  sleep.  Beginning  as  a  weakness  or  weariness  in  the  arms  and 
legs,  it  is  usually  complete  in  twenty-four  hours.  It  is  rarely  confined  to  the 
legs,  and  may  also  involve  the  muscles  of  the  neck,  and  even  those  of  the 
tongue  and  pharynx,  while  those  of  the  head  and  face  remain  intact. 

Sensation  for  the  most  part  is  unaffected,  as  are  also  the  special  senses. 
The  deep  reflexes  are  diminished,  sometimes  abolished,  while  the  superficial 
reflexes  are  feeble.  Faradic  sensibility  of  nerves  and  muscles  is  greatly  les- 
sened, sometimes  absent.  There  is  no  fever,  and  sometimes  the  tempera- 
ture is  below  normal,  while  the  pulse  is  slow.  Nothing  abnormal  has  been 
found  in  the  blood  or  urine,  though  the  breath  is  heavy,  the  tongue  is 
coated,  and  the  urine  is  relatively  diminished  during  the  attack  and  increased 
after  its  termination,  as  happens  in  migraine. 

The  attack  recurs  at  intervals  of  from  one  to  two  or  more  weeks,  in 
some  instances  daily.  It  begins  to  abate  usually  in  a  few  hours  or  after  a 
day  or  two,  and  ultimately  disappears  completely,  and  the  patient  remains 
well  until  another  attack  sets  in. 

Treatment.— None  is  of  any  service,  though  some  of  the  earlier  cases 
seem  to  have  yielded  to  quinin,  though  it  is  more  than  likely  that  these 
were  in  some  way  complicated  with  malaria. 


*  "Journal  of  Nervous  and  Mental  Diseases,"  voL  xxv.,  i8q8,  p.  637.  Dr.  Taylor  alludes  to  fifty- 
three  cases,  but  does  not  include  cases  inadequately  reported:  as,  for  example,  cases  merely  men- 
tioned by  writers,  but  not  reported  in  detail. 

t"  Amer.  Jour,  of  the  Med.  Sci.,"  December,  iSgg. 


J 136  DISEASES  OF  THE  NERVOUS  SYSTEM. 


VASOMOTOR  AND  TROPHIC  DERANGEMENTS. 

Acute  Angioneurotic  Edema. 

Synonym. — Giant  Urticaria, 

Definition. — Edematous  swelling  occurring  suddenly  in  various  parts 
of  the  body,  disappearing  in  a  few  hours,  perhaps  to  recur  again. 

Historical. — Its  history  has  been  studied  by  Quincke  and  Striibing. 

Etiology. — Heredity  is  sometimes  observed,  but  any  other  cause  is  un- 
known. 

Pathology. —  The  condition  is  regarded  by  Quincke  as  a  vasomotor 
neurosis  producing  sudden  dilatation  and  increased  permeability  of  the 
vessels.  It  is,  however,  one  of  the  derangements  which  may  be  said  to 
be  of  mixed  vasomotor  and  trophic  origin. 

Symptoms. — The  face,  especially  the  eyelids  and  nose,  is  the  most 
usual  site,  but  the  swelling  may  affect  any  part  of  the  body,  as  the  hands, 
face,  or  genitalia.  Even  the  mucous  membranes  may  be  invaded,  especially 
the  lips,  mouth,  and  pharynx,  while  a  fatal  edema  of  the  larynx  has  occurred. 
The  onset  is  sudden  and  the  patient's  previous  health  may  have  been  excel- 
lent. Gastro-iniestinal  disturbances  are,  however,  sometimes  associated, 
manifesting  by  vomiting,  colic,  diarrhea,  and  gastralgia.  There  are  also  at 
times  heat,  redness,  and  itching. 

Treatment. — Remedies  calculated  to  increase  muscular  and  nervous 
tone,  such  as  strychnin,  quinin,  and  iron,  are  indicated.  In  other  respects 
the  treatment  is  symptomatic,  and  directed  to  whatever  symptoms  demand  at- 
tention. 

Raynaud's  Disease. 

Synonyms. — Lo^al  Asphyxia;  Symmetrical  Gangrene  of  the  Extremities. 

Definition. — A  vasocontractile  disease  characterized  by  three  stages, 
more   or   less   complete — viz. : 

1.  Local  syncope. 

2.  Local  asphyxia. 

3.  Local  gangrene. 

Historical. — The  disease  was  first  described  by  Maurice  Raynaud  in  1862.  Ray- 
naud's thesis,  translated  by  Barlow,  with  additional  cases  and  bibliography,  is  pub- 
lished in  volume  cxxi.,  1888,  New  Sydenham  Society's  publications. 

Symptoms. — The  disease  is  more  frequent  in  women — Raynaud's  cases 
including  twenty  women  and  five  men.  It  is  also  a  disease  of  early 
life ;  the  majority  of  Raynaud's  patients  were  between  the  ages  of  eighteen 
and  thirty,  while  five  were  between  three  and  nine.  The  first  phenomenon 
noticed  is  an  unusual  pallor  or  anemia  of  the  part,  resulting  in  marble-like 
whiteness  and  loss  of  sensation.  This  is  the  local  syncope.  Affecting,  as  it 
often  does,  the  fingers  and  toes,  these  have  been  called  dead  fingers  and 
toes.  It  follows  exposure  to  cold,  and  to  comparatively  slight  degrees  of 
cold  in  those  predisposed.  The  condition  may  disappear  under  warmth, 
and  then  only  does  pain  manifest  itself — when  the  parts  are  being  thawed 
out,  as  the  saying  is.     Local  asphyxia  follows,  consisting  in  engorgement, 


VASOMOTOR  AND  TROPHIC  DERANGEMENTS.        1137 

the  parts  previously  pale  becoming  purple  and  livid.  The  change  is  not 
.simultaneous  in  all  the  fingers,  some  being  still  white  while  the  others  are 
livid. 

The  local  asphyxia  may  succeed  the  local  syncope,  or  it  may  come  on 
independently  of  it.  The  tip  of  the  nose  and  helices  of  the  ears  are  the 
parts  prone  to  cyanosis,  but  in  addition  to  the  fingers  and  toes  the  hands, 
feet,  and  arms  and  legs  may  be  involved.  A  peculiar  and  striking  mottling 
is  the  result  on  these  large  surfaces,  produced  by  an  alternation  of  various 
.shades  of  purple  with  intervening  lighter-hued  spaces.  In  the  darkest  areas 
the  capillary  circulation  is  quite  stagnant.  There  are  also  sivelling,  result- 
ing stiffness,  and  pain,  the  latter  often  extreme  and  associated  with  an 
intense  itching.  But  in  Raynaud's  disease  there  is  perhaps  more  frequently 
anesthesia  than  pain.  These  are  the  phenomena,  too,  of  chilblains,  with 
which  so  many  suffer  in  this  climate  with  the  approach  of  cold  weather. 
In  Raynaud's  disease,  as  in  chilblains,  these  symptoms  may  pass  away  in 
time  under  the  influence  of  warmth ;  in  fact,  for  a  long  time  they  occur 
only  during  the  colder  weather.  A  reaction  takes  place,  and  the  parts 
assume  a  bright,  red  color  in  which  the  circulation  is  very  active,  and  the 
anemia  produced  by  pressure  is  rapidly  replaced  by  an  active  hyperemia. 
The  attacks  may  keep  recurring  for  years  without  further  effect,  though  in 
extreme  cases  there  may  be  slight  loss  of  substance  in  the  ear-tips  and 
fingers'  ends,  which  in  time  may  become  indurated,  uneven,  and  scarred 
from  this  cause. 

The  third  stage  of  local  or  symmetrical  gangrene  is  reached  in  a  few 
cases  only.  In  these  the  parts  affected  remain  asphyxiated,  and  the  phe- 
nomena of  dry  gangrene  make  their  appearance.  The  fingers  or  toes,  one 
or  more,  become  black,  dry,  and  cold,  while  gangrenous  blebs  appear  in 
the  parts  adjacent  to  the  sound  tissue,  a  line  of  demarcation  occurs,  and 
the  dead  part  sloughs  away  less  extensively  than  at  first  seemed  likely  to 
be  the  case.  Rarely,  and  only  in  cases  of  young  children,  does  a  fatal  ter- 
mination occur. 

The  symptoms  that  have  been  described  may  be  said  to  be  essen- 
tial, but  others  also  may  be  added  of  great  clinical  interest.  One  of  these 
is  hemoglohimiria,  which  is,  of  course,  associated  with  a  corresponding  albu- 
minuria. There  are,  at  times,  a  few  blood  discs  in  the  urine.  Hemo- 
globinuria, when  present,  generally  occurs  at  the  same  time  with  the  cyanosis, 
and  the  attack  has  frequently  been  preceded  by  a  chill.  Other  associate 
symptoms,  less  common,  are  scleroderma  and  edema,  probably  angioneu- 
rotic. 

At  other  times  cerebral  symptoms,  including  torpor  and  partial  loss  of 
consciousness,  are  present ;  at  others,  epilepsy,  mania,  delusions,  and  even 
temporary  hemiplegia.  Dimness  of  vision  is  a  symptom  easily  explained  if 
we  suppose  there  is  a  spasm  of  blood-vessels  producing  local  retinal  syncope. 
Other  associated  symptoms  are  peripheral  neuritis  with  tingling  and  formi- 
cation— neuritis  being  regarded  as  one  of  the  causes  of  the  disease ;  arthritic 
swelling ;  urticaria ;  erythema ;  also  colicky  pains,  nausea,  vomiting,  and 
diarrhea. 

Pathology. — Three  chief  theories  have  been  brought  forward  to  explain 
Raynaud's  disease :  , 

1.  That  it  is  due  to  endarteritis  obliterans. 

2.  That  it  is  caused  by  peripheral  neuritis. 

3.  That  it  is  the  result  of  vascular  spasm. 

72 


1 138  DISEASES  OF  THE  NERVOUS  SYSTEM. 

The  intermittent  nature  of  the  disease  is  quite  incompatible  with  its 
causation  by  endarteritis,  which  is  progressively  increasing  in  its  effects. 
It  is  true  that  some  of  the  results  of  peripheral  neuritis  are  similar  to  those 
of  Raynaud's  disease,  but  the  frequency  of  the  former  affection  as  contrasted 
with  the  rarity  of  the  latter  militates,  also,  against  this  view. 

The  theory  of  arteriole  spasm,  suggested  by  Raynaud  himself,  best  ex- 
plains the  symptoms.  Its  frequency  among  women  and  children,  whose 
vasomotor  system  is  so  impressible ;  its  occurrence  under  the  influence  of 
cold,  which  is  one  of  the  most  powerful  excitors  of  vasomotor  spasm ;  the 
frequent  dimness  of  vision,  which  has  been  shown  by  ophthalmoscopic 
examination  to  be  associated  with  contraction  of  the  central  artery  of  the 
retina ;  the  occasional  precedence  of  a  chill ;  and  the  phenomena  of  hemo- 
globinuria, all  go  to  show  the  probability  of  vasomotor  spasm.  Since  the 
hemoglobinuria  is  apt  to  be  associated  with  hemoglobinemia, — which  prob- 
ably arises  from  the  solution  of  hemoglobin  liberated  in  the  asphyxiated 
parts, — such  an  origin  for  the  heboglobinuria  must  be  admitted.  It  will  be 
noticed  that  the  conditions  in  Raynaud's  disease  are  in  some  respects  similar 
to  those  of  intermittent  hemoglobinuria,  and  such  similarity  affords  a  basis 
which  may  ultimately  help  to  explain  more  satisfactorily  the  phenomena  of 
both.  The  relation  of  Raynaud's  disease  to  chilblains  also  affords  an  inter- 
esting field  of  investigation — in  fact,  has  already  been  studied  by  Le- 
groux. 

Prognosis. — This  is  not  altogether  unfavorable.  Only  delicate  and 
feeble  children,  as  a  rule,  perish,  while  it  is  quite  possible,  under  favorable 
circumstances,  to  outgrow  the  tendency. 

Treatment. — Persons  subject  to  local  syncope  and  local  asphyxia 
should  be  protected  from  cold,  and  when  the  attack  comes  on,  they  should 
be  kept  warm,  if  necessary  in  bed,  the  parts  being  wrapped  in  wool  and  sub- 
jected to  artificial  heat.  Friction  may  with  advantage  be  associated.  Gal- 
vanism and  faradism  are  recommended. 

B.  B.  Gates,  of  Knoxville,  Tenn.,  has  reported  the  successful  treatment 
of  Raynaud's  disease  by  nitroglycerin  in  doses  of  i-ioo  grain  (0.00065  gni.) 
increased  to  1-50  grain  (0.0013  gm.)  three  times  a  day,  and  Harvey  Cushmg 
has  recently  reported  a  case  with  recovery  by  the  application  of  the  tour- 
niquet or  rubber  bandage  to  the  affected  limbs  for  a  few  minutes  daily. 


Progressive  Facial  Hemiatrophy. 
Synonym. — Unilateral  Progressive  Facial  Atrophy. 

Definition. —  A  gradual  progressive  wasting  of  the  bony,  muscular,  in- 
tegumental,  and  adipose  tissues  of  half  the  face. 

Etiology. — That  it  is  a  trophic  neurosis  can  scarcely  be  doubted.  In 
one  case — that  of  ^lendel's — which  came  to  autopsy  there  was  the  term- 
inal stage  of  a  neuritis  in  all  the  branches  of  the  trifacial.  In  Homen's 
case,  an  acute  one,  and  perhaps  not  strictly  to  be  regarded  as  an  instance  of 
true  facial  hemiatrophy,  a  tumor  was  found  pressing  on  the  Gasserian 
ganglion  and  trigeminal  nerve.     It  has  been  observe^  in  syringomyelia. 

The  disease  usually  begins  in  youth,  but  in  a  few  cases  it  did  not  make 
its  appearance  until  middle  age.  It  is  rather  more  common  in  the  female 
sex.     Sachs  has  collected  ninety-seven  cases. 

Symptoms. — The    atrophy    is    much   more    frequent    on   the    left    side 


VASOMOTOR  AND  TROPHIC  DERANGEMENTS.        1139 

than  on  the  right.  It  may  begin  as  a  circumscribed  spot  on  the  cheek  or 
chin,  or  diffusely,  involving  first  the  subcutaneous  tissues,  the  muscles, 
chiefly  those  of  mastication,  and  finally  the  bones,  especially  of  the  upper 
jaw.  In  the  cases  which  begin  in  early  youth  the  muscles  remain  intact. 
The  tissues  of  the  orbit  take  part  in  the  atrophy,  and  the  eye  appears 
sunken.  The  corresponding  halves  of  the  tongue  and  of  the  soft  palate  are 
sometimes  involved.  The  hair  on  the  same  side  may  fall  out  and  appears 
thin.     The  line  of  demarcation  is  sharp  in  the  median  line.     In  a  few  rare 


Fig.  133. — Left  Facial  Hemiatrophy — {Striimpell). 

instances  the  disease  is  bilateral,  and  in  a  few  cases  also  the  atrophy  involves 
the  corresponding  shoulder  and  arm.     Sensibility  is  intact. 

Diagnosis. — The  disease,  though  very  rare,  can  scarcely  be  confounded 
with  anything  else.  The  facial  asymmetry  associated  with  congenital  wry- 
neck alone  resembles  it.  Striimpell  mentions  a  case  of  facial  hemihypertro- 
phy  in  a  boy  of  ten  under  his  observation.  Hypertrophy  of  one  side  or  of 
one  limb  is  also  a  rare  condition. 

Treatment. — A  suitable  treatment  is  the  application  of  electricity  to 
the  atrophic  side,  alternated  with  massage. 


Acromegaly. 

Definition. — A  disease  characterized  by  enlargement  of  the  bones,  espe- 
cially the  bones  of  the  hands,  feet,  and  face. 

Historical.— It  was  first  described  by  Marie,  of  Paris,  in  "Revue  de  Medecine," 
1886.  It  had,  however,  been  previously  described  under  other  names,  as  "  hyperos- 
tosis of  the  entire  skeleton  "  bv  Friedreich,  as  general  hypertrophy,  or  "  makrosomie." 
by  Lombroso,  as  "giant  growth,"  by  Fritsche  and  Klebs.  Since  then  numerous  cases 
have  been  reported,  and  the  disease  was  exhaustively  described  by  Arnold,  of  Heidel- 
berg, in  Ziegler's  "  Beitrage,"  in  1S91. 

Etiology. — It  is  a  disease  of  early  adult  life,  usually  occurring  under 
thirty,  and  is,  perhaps,  slightly  more  frequent  in  women.     Heredity,  syphilis. 


II40  DISEASES  OF  THE  XERFOUS  SYSTEM. 

and  the  specific  fevers  have  preceded  the  disease,  but  no  necessary  relation 
has  been  shown. 

Morbid  Anatomy  and  Pathology. — This  consists  in  a  true  hyper- 
trophic enlargement  of  the  bones,  except  the  superior  maxillary,  which 
contributes  to  the  enlargement  of  the  face  by  a  dilatation  of  the  antrum, 
while  the  lower  jaw  is  simply  enlarged.  As  stated,,  the  enlargement  is 
uniform  and  symmetrical  instead  of  involving  only  the  shaft  as  in  osteitis 
deformans,  or  the  ends  as  in  arthritis  deformans,  and  is  quite  independent 
of  rheumatism.  Hyperplasia  of  the  pituitary  body  has  been  a  striking 
feature  in  most  cases  which  have  come  to  necrops}",  in  every  one  of  thirty- 
four  collected  by  Furnival.  ^larie  early  sought  to  make  these  changes  re- 
sponsible, as  disease  of  the  thyroid  is  for  myxedema.  Persistence  and 
enlargement  of  the  thymus  gland  have  been  found,  and  atrophy  as  well  as 
enlargement  of  the  thyroid. 

A  further  study  of  acromegaly  in  connection  with  "  giantism," 
"  dwarfism,"  and  "  cretinism,"  go  to  show  that  it  is  at  least  not  improbable 
that  all  of  these  are  the  result  of  some  deranged  function  of  the  pituitary 
gland.  It  is  well  known  that  giantism  may  degenerate  into  acromegaly, 
while  a  comparison  between  the  skeletons  of  a  dwarf  and  a  macrocephalus 
suggests  that  they  are  opposite  extremes  of  one  and  the  same  process.  Of 
further  interest  in  this  connection  is  the  embryonic  relation  between  the 
pharyngeal  tonsil — adenoids  in  the  vault  of  the  pharynx,  and  the  extraor- 
dinar}-  influence  they  have  on  nutrition — and  the  pituitary  body,  which  are 
at  one  period  of  development  in  connection  and  subsequently  separated  by 
ossifications  at  the  base  of  the  skull;  while  not  infrequently  in  early  life 
they  remain  connected  by  a  fibrous  cord  running  through  the  body  at  the 
sphenoid. 

S5miptoms. — The  most  striking  features  are  the  enlarged  bones,  espe- 
cially those  of  the  hands  and  feet,  the  appearance  of  the  former  being  well 
characterized  as  spade-like,  while  the  fingers  and  nails  are  broad.  The  legs 
and  arms,  on  the  other  hand,  are  not  elongated  early,  but  late  in  the  disease 
the  forearms  and  legs  may  increase  in  circumference ;  while  the  ends  of  long 
bones,  like  the  femurs,  are  often  prominent.  The  scapulas,  clavicles,  ster- 
num, and  the  ends  of  the  ribs  are  also  sometimes  involved.  The  proper  use  of 
the  hands  is  not  interfered  with.  The  licad  and  face  are  enlarged,  the  latter 
is  elongated,  while  the  neck  appears  short,  and  the  inferior  maxilla  may  pro- 
ject beyond  the  upper,  and  the  lower  lip  protrude  in  consequence.  The 
ears  are  unduly  prominent,  while  the  cartilages  of  the  nose,  eyelids,  and 
larynx  are  enlarged  and  thickened,  as  is  also  sometimes  the  tongue.  The 
spinal  column  may  be  involved,  and  there  may  be  kyphosis.  The  muscles, 
on  the  other  hand,  are  sometimes  atrophied,  and  the  genitalia  are  unusually 
developed.  The  skin,  though  coarse  and  exhibiting  a  tendency  to  perspire, 
is  not  thickened  as  in  myxedema. 

Among  other  symptoms  are  mental  dullness,  a  sense  of  fatigue,  and 
quite  severe  pain  in  the  head  and  extremities :  alteration  of  voice  due  to 
changes  in  the  tongue  and  larynx,  and  possibly  to  paresis  of  the  vocal 
cords ;  impairment  of  special  senses  of  taste,  smell,  and  hearing ;  blindness 
due  to  optic  atrophy:  thirst,  shortness  of  breath,  asthmatic  attacks,  palpi- 
tation, and  even  hypertrophy  of  the  heart.  In  a  number  of  cases  bitemporal 
hemianopsia  has  been  obser\-ed  and  was  due  to  pressure  on  the  chiasm  by 
the  enlarged  pituitary  body.  There  are  menstrual  derangement  and  early 
cessation  of  the  menses  in  women.     The  alterations  in  the  thyroid  have  been 


VASOMOTOR  AND  TROPHIC  DERANGEMENTS.         1141 

alluded  to,  and  an  area  of  dullness  over  the  manubrium  is  ascribed  by  Erb 
to  persistence  of  the  thymus. 

Diagnosis. — This  is  easy.  The  difference  between  acromegaly  and 
osteitis  deformans  and  arthritis  deformans  has  been  mentioned.  In  osteitis 
deformans,  too,  as  pointed  out  by  Marie,  the  face  is  triangular,  with  the  base 
upward,  while  in  acromegaly  it  is  ovoid,  with  the  large  end  downward. 
Acromegaly  has  been  mistaken  for  congenital  progressive  hypertrophy  or 
"  giant  growth,"  but  in  the  latter  only  one  limb  is  usually  involved  and  the 
shaft  of  the  bone  is  affected. 

Prognosis. — The  duration  of  the  disease  is  long  and  usually  ultimately 
fatal,  although  it  is  sometimes  arrested.  The  fatal  cases  are  probably  those 
with  tumor  of  the  pituitary  body. 

Treatment. — None  has  been  found  to  be  of  any  value.  Naturally, 
one  thinks  of  the  possible  utility  of  extract  of  the  pituitary  gland,  though  if 
the  condition  be  the  result  of  excessive  pituitary  secretion,  but  little  can  be 
expected  from  such  use.  In  fact,  such  has  been  the  result  in  the  few  cases 
in  which  it  has  been  tried. 


Scleroderma. 

Synonyms. — Cutis   tensa   chronica;    Sclerema;   Dermatosclerosis;    Glossy 

Skin. 

Definition. — A  chronic,  somewhat  diffuse,  indurated,  hide-bound,  and 
pigmented  condition  of  the  skin,  trophoneurotic  in  origin. 

Historical. — The  disease  was  first  described  by  Alibert,  in  1817.  A  recent  publi- 
cation on  the  subject  is  "  Die  Sklerodermie,"  by  Lewin  and  Heller,  1895,  in  which 
508  cases  were  collected. 

Etiology. — This  is  obscure.  It  is  more  common  in  women  than  in 
men,  and  is  most  frequent  in  early  adult  and  middle  age.  In  one  case  under 
my  observation,  that  of  a  hack-driver,  long  exposure  to  wet  and  cold  seemed 
a  likely  cause,  and  others  report  similar  experience.  Rheumatism,  especially 
of  the  joints,  and  strong  impressions  on  the  nervous  system  have  been  re- 
garded as  causes. 

Pathology. — The  identity  of  scleroderma  and  morphea  is  claimed  by 
some.  I  follow  Louis  A.  Duhring  in  separating  them,  because  both  are 
capable  of  assuming  a  variety  of  forms  which  present  entirely  different 
clinical  features  at  various  stages.  Scleroderma  is  much  rarer  than  mor- 
phea. In  the  matured  forms,  while  the  epidermis  is  unaltered,  there  is 
increase  of  pigment  in  the  lower  layers  of  the  rete,  with  a  distinct  over- 
growth of  connective  tissue  in  the  corium  and  subcutaneous  connective 
tissue.  Contrary  to  what  would  be  expected,  the  sweat  and  sebaceous  glands 
appear  to  be  normal. 

Symptoms. — The  disease  appears  first  in  the  neck,  shoulders,  back, 
chest,  arms,  and  face.  It  begins  usually  as  a  stiffening  of  the  skin  which 
passes  over  into  a  hard,  tense,  unyielding  tissue,  resisting  motion,  and  caus- 
ing fixation  and  flexion.  The  patient  is  literally  "hide-bound."  The  hand, 
with  its  smooth,  glossy  surface,  utterly  without  wrinkles,  is  striking  and 
distinctive.  .  The  change  may  involve 'the  greater  part  of  the  body  and  even 
the  whole  of  it.  When  less  general,  it  is  symmetrical.  The  condition 
passes  insensibly  into  that  of  the  surrounding  healthy  tissue.  Pigmentation 
is  usually  a  later  symptom,  but  may  be  an  early  one. 


1 142  DISEASES  OF  THE  NERVOUS  SYSTEM. 

There  is  generally  no  constitutional  disturbance  or  other  local  symptoms, 
such  as  pain,  burning,  and  tingling,  but  more  rarely  these  are  present.  The 
evolution  of  the  condition  is  generally  slow,  requiring  weeks  and  months, 
and  when  completed,  it  is  apt  to  remain  unchanged  for  months  or  years,  or 
slowly  passes  away,  leaving  the  skin  normal.  Rarely,  however,  an  atrophic 
state  may  succeed,  producing  such  a  shrinking  or  contraction  that  the  in- 
tegument is  apparently  bound  to  the  bones,  while  over  the  joints  the  skin 
may  become  so  fixed  and  immobile  that  ulcers  and  excoriations  are  easily 
produced. 

Diagnosis. — The  diagnosis  rarely  furnishes  difficulty.  In  some  stages 
it  resembles  morphea,  from  which  it  will  be  distinguished  when  that  subject 
is  considered. 

Prognosis. — This  should  always  be  guarded,  as  the  disease  is  often 
intractable,  though  recovery  sometimes  occurs. 

Treatment.— Treatment  of  a  curative  kind  is  unknown.  The  patient 
should  be  thoroughly  protected  against  cold,  as  he  is  exceedingly  sensitive. 
Friction  with  oil  is  a  rational  means  for  softening  the  skin,  and  may  give 
comfort,  but  do  not  check  the  spread  of  the  disease.  Cod-liver  oil,  iron, 
and  arsenic  are  indicated.  The  constant  electrical  current  has  been  recom- 
mended in  the  local  forms. 


Morphea. 

Synonym. — Keloid  of  Addison. 

Definition. — A  trophic,  asymmetrical  neurosis  of  the  skin,  character- 
ized by  patches  of  skin  firm  in  texture,  white,  pale  pink,  light  yellow,  or 
waxy  hued,  sometimes  elevated,  at  other  times  depressed. 

Etiology. —  More  common  than  scleroderma,  it  is  also  found  more  often 
in  women,  and  at  all  ages.  Its  etiology  is  unknown,  but  its  tropho-neurotic 
origin  is  more  than  likely. 

Symptoms. — The  patches  occur  more  frequently  about  the  breasts  and 
neck  and  sometimes  in  the  course  of  nerves,  such  as  the  intercostal  or  lum- 
bar, or  on  the  face  along  the  branches  of  the  fifth  pair.  They  range  from 
2-5  inch  (i  centimeter)  to  four  inches  (10  centimeters)  in  diameter.  There 
may  be  a  preliminary  hyperemia  with  itching  of  the  skin  and  increased  pig- 
ment deposit,  or  a  milk-white  leukodermia  from  the  beginning.  The  spots 
are  dry,  without  perspiration,  sometimes  scaly.  Ultimately  there  may  be 
anesthesia,  in  pinkish  or  purplish  hyperemic  spots  or  in  small  linear  cica- 
tricial-like  areas,  which  grow  rapidly.  In  fact,  the  rapidity  of  spread  of  the 
spots  is  one  of  the  most  interesting  clinical  features.  In  the  later  stages 
there  are  often  distinct  atrophy  and  cicatrization  with  pigmentation.  The 
spots  may  persist  for  months  or  disappear  in  a  few  weeks,  and  though  more 
frequently  persistent  for  a  long  time,  they  ultimately  disappear  spontaneously. 
The  spots  seem  to  be  the  direct  result  of  a  cutting  off  of  the  circulation  by  a 
narrowing  of  the  blood-zressels.  This  may  be  by  compression  by  an  inflam- 
matory exudate,  but  is  more  likely  to  be  a  vasomotor  constriction,  probably 
due  to  irritation  of  the  vasoconstrictor  nerves. 

Histologically  there  is  a  condensation  of  the  connective  tissue  of  the 
corium  with  a  shrinkage  of  the  papillary  layer. 

Diagnosis. — Morphea  differs  from  scleroderma  in  that  its  lesions  are 
more  circumscribed,  and  in  an  absence  of  sclerodermic  hardness.     Pigmenta- 


VASOMOTOR  AND  TROPHIC  DERANGEMENTS.        1143 

tion  and  cicatrization  usually  appear  only  in  the  later  stages  of  morphea, 
while  they  are  seen  in  the  early  stages  of  scleroderma  before  there  is  change 
in  structure.  Scleroderma  is  symmetrical  in  distribution;  morphea  is  not. 
The  atrophic  stride  seen  in  one  form  of  morphea  closely  resemble  the  linse 
albicantes  of  pregnancy  or  other  cause  of  distention. 

Treatment. — That  recommended  in  scleroderma  may  be  expected  to  be 
useful  in  morphea,  especially  arsenic,  which  is  recommended  by  Louis  A. 
Duhring.  Here,  too,  the  constant  galvanic  current  is  held  to  be  of  service, 
an  extended  trial  being,  however,  necessary. 


AiNHUM. 

Synonyms. — Amham;  Qnigila;  Suhka  Pakla,  or  Dry  Suppuration;  Pity- 
riasis cethiopius;  Scleroderma  annulare. 

Definition. — A  trophic  disease,  resulting  ultimately  in  the  amputation 
of  one  or  more  toes,  especially  the  little  toe,  confined  almost  exclusively  to 
male  negroes. 

Historical, — It  was  first  described  in  1866  by  da  Silva  Lima,  of  Brazil,  to  which 
countr\"  it  was  at  first  thought  to  be  limited,  but  since  then  cases  have  been  reported 
from  almost  every  quarter  of  the  tropical  and  semitropical  globe,  including  the  ex- 
treme southern  United  States. 

Etiology. —  It  would  seem  that  a  moist,  sandy  soil  and  warm  climate 
must  have  some  influence  in  its  etiology,  but  nothing  definite  is  known.  Its 
practical  limitation  to  the  colored  race  has  been  referred  to.  The  operation 
of  a  pathogenic  organism  has  been  suggested,  and  the  disease  as  an  ampu- 
tating leprosy.     Traumatism  has  undoubtedly  been  associated  with  it. 

Symptoms. — Ainhum  begins  as  a  furrow  or  crack  at  the  digitoplantar 
fold,  seen  first  on  the  inner  side.  In  a  few  days  the  toe  will  swell  and  be- 
come the  seat  of  a  burning,  shooting  pain,  which  may  extend  into  the  foot 
and  leg,  though  pain  is  not  constant.  The  furrow  increases  laterally  and  in 
•depth  until  finally  the  toe  is  constricted  and  the  distal  end  becomes  ovoid. 
The  swelling  subsiding,  spontaneous  amputation  ultimately  takes  place,  a  dry 
scab  forms  at  the  furrow,  and  the  case  ends.  It  is  not  always  confined  to 
one  toe,  though  it  is  as  a  rule.  Sensation  is  not  usually  destroyed,  though 
it  may  be,  and  the  nail  remains  unchanged.  There  are  no  constitutional 
symptoms. 

The  histology  of  the  process  has  been  studied  by  C.  H.  Eyles,  who  con- 
cludes that  there  is  an  ingrowth  of  epithelium  with  corresponding  depression 
of  surface,  due  to  a  hyperplasia  that  strangles  the  papillje  and  cuts  off  the 
nourishment  of  the  epithelium  and  causes  it  to  undergo  horny  change.  The 
bone  changes  are  those  of  a  rarefying  osteitis,  proceeding  from  the  perios- 
teum inward.     According  to  Collas,  it  is  an  amputating  leprosy. 

The  diagnosis  is  easy.     There  is  no  disease  which  resembles  it. 

The  prognosis  is  favorable  as  to  any  danger  to  life.  The  duration  of 
the  disease  is  from  two  to  four  years. 

Treatment  is  unnecessary. 


1 144  DISEASES  OF  THE  NERVOUS  SYSTEM. 


SYPHILIS  OF  THE  NERVOUS  SYSTEM. 

Synonym. — Syphilis  of  the  Brain  and  Spinal  Cord. 

Definition. — A  term  applied  to  the  condition  and  symptoms  resulting- 
from  invasion  of  the  nervous  system  by  syphilitic  disease. 

Etiology. — Any  one  of  the  various  lesions  which  arise  in  the  tertiary 
stage  of  acquired  syphilis  or  are  the  result  of  inherited  syphilis  may  invade 
the  nervous  system.  More  frequently  they  are  the  result  of  acquired 
syphilis,  but  a  gummy  tumor  may  develop  in  the  brain  of  the  fetus  in  utero. 
The  phenomena  of  syphilis  of  the  nervous  system  present  themselves  usually 
a  year  or  more  after  the  primary  infection.  Exceptionally  only  do  they 
present  themselves  before  the  end  of  the  first  year,  but  may  appear  a  few 
months  after  the  infection.  Occasionally  from  ten  to  thirty  years  may  elapse 
after  the  infection  before  symptoms  of  syphilis  of  the  nervous  system 
appear. 

Age  and  sex  have  a  bearing  only  as  they  influence  the  distribution  of 
the  disease.  The  same  conditions  which  predispose  to  the  development  of 
other  brain  affections  predispose  also  to  the  implantation  of  the  syphilitic 
poison.  Such  is  the  inherited  nervous  disposition,  or  vulnerability  acquired 
in  any  way,  say  through  traumatic  or  septic  agencies.  Such  predisposition 
favors  the  earlier  operation  of  the  syphilitic  poison  as  well  as  of  other  causes. 
of  nervous  disease.  For  evident  reasons  also  nervous  syphilis  is  more  fre- 
quent in  the  male  than  in  the  female  sex. 

Morbid  Anatomy. — As  stated,  any  of  the  tertiary  syphilitic  lesions 
may  be  the  cause  of  nervous  syphilis.  While  the  fundamental  process  in 
each  instance  is  the  same,  it  may  be  quite  definitely  subdivided  into  two — 

1.  Extravascular  syphilitic  new  formations. 

2.  Syphilitic  disease  of  .the  blood-vessels. 

I.  Extravascular  syphilitic  new  formations  include — 

(o)  Specialized  new  formations,  the  syphiloma  or  gumma. 
(&)  Simple  inflammatory  products. 

(a)  The  syphilitic  giimma,  or  syphiloma,  is  a  circumscribed  yellow  or 
grayish-yellow  mass  often  caseated  in  the  center.  It  may  occur  as  a  single 
focus  or  in  multiple  foci.  Its  most  frequent  seat  is  in  the  dura  mater  or  the 
subarachnoid  space,  whence  it  invades  the  brain  substance  and  adjacent  ves- 
sels and  nerves.  More  rarely  it  starts  ab  initio  in  the  substance  of  the  brain, 
when  it  sometimes  closely  resembles  the  tyroma  or  solitary  tubercle.  The 
tendency  to  degeneration,  which  results  in  the  caseation  referred  to,  is  the 
characteristic  feature  of  the  gummy  tumor,  but  it  is  associated  with  another 
property  of  extreme  importance,  a  fibroid  change  at  the  periphery,  which 
produces  the  appearance  of  a  capsule  about  the  tumor,  although  no  distinct 
capsule  exists.  Such  fibroid  change  may  also  interpenetrate  the  tumor 
itself. 

(b)  Of  even  greater  clinical  importance  is  the  simple  inflammatory  luetic 
neoplasm,  which  starts  in  the  meninges, — meningitis  gnninmtosa, — most 
frequently  at  the  base  of  the  brain,  especially  in  the  neighborhood  of  the 
optic  chiasm,  but  also  in  the  fissure  of  Svlvius  and  on  the  convexity.  In 
these  more  diffuse  areas  one  often  finds,  alongside  of  each  other,  the  differ- 
ent stages  of  young  granulation  tissue,  cheesy  foci,   and  contracting  con- 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  1145. 

nective  or  scar  tissue.     Either  of  the  two  membranes,  the  dura  mater  or  pia. 

mater,  may  be  involved. 

2.  Syphilitic   disease   of   the   blood-vessels  includes   intravascular  syphilitic 

growth. 

Starting  from  the  endothelial  cells  of  the  intima,  it  produces  a  firm 
connective  tissue  which  differs  from  atheroma  in  being  thicker  and  more 
translucent,  but  which,  after  internal  administration  of  iodid  of  potassium, 
becomes  thinner  and  more  opaque,  in  fact,  more  like  the  simple  atheroma, 
for  which  it  is,  then,  often  mistaken.  Thickening  of  the  adventitia  is  also 
sometimes  superadded.  It  is  to  be  remembered  that  this  intravascular  and 
perivascular  formation  presents  no  distinctive  histological  features,  any 
more  than  does  syphilitic  meningitis.  The  vessels  affected  are  those  of  the 
base  of  the  brain,  especially  the  middle  cerebral  artery  and  its  branches. 

The  possible  results  of  such  intravascular  growth  are  occlusion,  with 
resulting  necrotic  softening  or  induration  of  the  cortex,  especially  in  chil- 
dren; or  intracranial  aneurysms  of  the  larger  arteries.  Of  these,  Gowers 
says :  "  We  know  two  other  causes  of  such  intracranial  aneurysms :  one,  very 
rare,  is  traumatic  arteritis.  The  other  is  embolism  '  imperfectly  occluding 
the  vessels,'  probably  the  cause  of  two-thirds  of  such  aneurysms  before  the 
degenerative  period  of  life.  In  the  remainder,  in  which  there  is  no  history 
of  injury  and  no  evidence  of  embolism,  there  is  a  history  of  syphilis  in  so 
many  cases  as  to  justify  the  opinion  that  most  of  them  are  due  to  this  influ- 
ence. Often  the  history  is  imperfect,  because  the  aneurysm  has  been  unsus- 
pected until  the  final  rupture,  and  syphilis  has  not  been  inquired  for.  When 
we  consider  how  great  is  the  amount  of  new  growth  in  the  walls  of  a  dis- 
eased artery,  and  how  prone  are  the  new  elements  to  change  into  extensible 
fibroid  tissue,  the  wonder  is  that  aneurysm  is  not  a  more  frequent  occurrence. 
Probably  the  explanation  is  to  be  found  in  the  common  persistence  of  the 
elastic  layer,  which  affords  the  chief  safeguard  against  permanent  dilatation." 

A  third  effect  of  syphilitic  vascular  disease  is  hemorrhage  within  the 
substance  of  the  brain,  and  small  hemorrhages  are  not  uncommon  within  the 
brain  and  spinal  cord. 

In  the  spifiai  cord  syphilis  frequently  produces  chronic  inflammation 
of  the  dura  mater — spinal  pachymeningitis.  Its  effect  is  mainly  seen  on  the 
spinal  and  bulbar  nerve-roots,  although  the  cord  also  may  be  invaded  by 
sclerotic  fibrous  tissue.  The  pia  mater  may  be  invaded  in  association  with 
the  dura  mater,  especially  in  diffuse  inflammation,  and  sometimes  is  more 
involved  than  the  dura  mater.  The  most  common  syphilitic  manifestation 
in  the  spinal  cord,  however,  is  meningo-myelitis.  Gummata  visible  to  the 
naked  eye  are  seldom  found  in  the  spinal  cord. 

The  cranial  nerves  may  suffer  from  compression  by  tumor  or  chronic 
meningeal  inflammation,  or  may  be  invaded  by  an  inflammation  involving  the 
sheath  and  interstitial  tissue. 

Symptoms. — Of  fundamental  importance  in  studying  the  sympto- 
matology of  nervous  syphilis  is  the  fact  that  the  symptoms  due  to  syphilitic 
disease  are  in  no  way  distinctive.  They  are  essentially  the  same  as  those  of 
tumor  or  meningitis  or  occlusion  of  blood-vessels  from  other  cause.  This 
being  admitted,  it  might  seem  scarcely  necessary  to  make  a  separate  subject 
of  syphilis  of  the  nervous  system.  Jt,  however,  affords  opportunity  for  a 
somewhat  more  systematic  classification  of  the  lesions  and  a  review  of  the 
symptoms  caused  by  them. 

These  symptoms  vary  with  the  seat  of  the  lesion,  of  which  sometimes 


1 146  DISEASES  OF  THE  NERVOUS  SYSTEM. 

quite  a  close  diagnosis  can  be  made.  The  specific  nature  of  the  lesion  may- 
be inferred  to  a  degree  from  the  symptoms,  but  most  largely  from  the  his- 
tory. From  the  grouping  of  the  symptoms  ma}-  be  inferred  the  most  impor- 
tant of  the  local  processes,  as  originally  suggested  by  Huebner.  They 
are: 

1.  Basal  Brain  Syphilis  or  Basal  Guuiuiy  Meningitis. — The  symptoms 
are  to  a  certain  extent  those  of  a  tumor  in  this  section — viz.,  general  cerebral 
and  focal  syuiptonis,  due  to  the  local  effect  of  the  growth. 

General  symptoms  are  intense  headache,  often  worse  at  night,  apathy, 
loss  of  memory,  somnolence,  and  tendency  to  stupor,  all  of  which  charac- 
terize more  or  less  the  typical  tumor  of  the  brain.  Maniacal  excitement, 
ultimate  imbecility,  and  physical  w^eakness  may  supervene.  The  compres- 
sion or  focal  symptoms  due  to  basal  syphiUs  are  also  the  same  as  those  due 
to  tumor.  The  nerves  concerned  are  especially  the  optic  and  oculomotor 
(third),  and  to  a  less  degree  the  trochlear  (fourth)  and  abducent  (sixth) 
of  the  eyeball.  The  symptoms  include  narrowing  of  the  field,  hemianopsia, 
and  even  total  blindness,  alterations  in  the  pupil  and  defects  in  the  movement 
of  the  ball  and  eyelids.  In  syphilis  these  eft'ects  are  irregular  and  seldom 
bilateral.  There  may  also  be  optic  neuritis  and  even  chbked  disc,  but  the 
latter  is  less  frequent  than  in  other  varieties  of  brain  tumor.  Syphilomata 
ahvays  cause  a  rapid  and  severe  form  of  optic  neuritis,  so  that  chronicity  in 
a  neuritis  is  presumptive  evidence  against  its  syphilitic  origin.  Especially 
characteristic  of  syphilis  is  variation  in  the  severity  of  the  symptoms,  due 
to  variation  in  intracranial  pressure  the  result  of  contraction  of  the  new 
formation ;  and  especially  characteristic  is  amelioration,  the  result  of  prop- 
erly timed  specific  treatment.  Other  nerves  w^hich  suffer  are  the  auditory, 
facial,  olfactory,  and  trigeminal.  Gummata  on  the  nerve-trunks  furnish  no 
symptoms  distinct  from  those  of  inflammation. 

The  course  of  syphilitic  lesions  is  subacute  or  subchronic,  never  acute 
or  chronic.  Marked  improvement,  arrest,  and  even  cure  may  result  from 
proper  treatment.  On  the  other  hand,  involvement  of  the  blood-vessels  by 
syphilitic  disease  may  lead  to  hemiplegia,  epilepsy,  and  bulbar  symptoms,  of 
which  there  can  only  be  one  termination,  and  that  a  fatal  one. 

2.  Giimmx  Meningitis  and  Syphiloma  of  the  Cont'cxity  and  Neighbor- 
hood of  the  Fissure  of  Sylz'iiis. — In  this  more  rare  seat  of  localization  the 
same  prodromata  may  precede  the  severer  symptoms,  sometimes  for  a  con- 
siderable time.  The  latter  include,  first,  general  or  local  epileptiform  cojp- 
Tiilsions,  which  are  sudden  and  succeed  one  another  at  longer  or  shorter 
intervals.  They  are  of  great  diagnostic  value,  it  being  true  of  them,  as 
originally  said  by  Fournier,  that,  occurring  in  subjects  over  thirty,  if  not  due 
to  uremia  or  alcoholism,  in  nine  out  of  ten  cases  they  are  caused  by  syphilis. 
They  are  rarely  preceded  by  an  aura.  Other  cortical  symptoms  are  hemi- 
plegic  or  monoplegic  paresis,  cortical  derangements  of  speech,  such  as  motor 
aphasia  and  the  like,  and  imbecility.  These  cases  are  often  fatal.  The  con- 
vulsions continue,  consciousness  becomes  deranged,  coma  supervenes,  and 
death  ensues.  Even  here,  how^ever,  a  judicious  treatment  is  often  of  great 
service. 

Syphilitic  meningitis  is  more  common  at  the  base  of  the  brain  than  at 
the  convexity,  though  gummy  tumors  are  more  common  in  the  latter  situa- 
tion. In  either  place  the  symptoms  of  the  local  meningitis  are  such  as  indi- 
cate a  surface  lesion,  at  the  base  by  implication  of  the  cranial  nerves,  at  the 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  1147 

convexity  by  causing  motor  phenomena.  The  signs  always  point  to  a  super- 
ficiality of  situations  and  become  thus  of  value  in  a  topical  diagnosis,  but  they 
do  not  indicate  that  lesions  more  deeply  situated  are  absent. 

3.  Syphilitic  Disease  of  the  Walls  of  the  Arteries. — The  characteristic 
symptoms  are  those  of  a  sudden  focal  lesion,  and  are  due  to  the  sudden 
closure  of  a  vessel  by  thrombosis.  The  most  frequent  symptom  is  hemi- 
plegia. Convulsions  are  exceedingly  rare.  Hemianopsia  may  sometimes  be 
present,  indicating  disease  in  the  posterior  cerebral  artery,  while  lesions  may 
occur  in  parts  of  the  brain  in  which  there  can  be  no  focal  symptoms.  Dis- 
ease of  the  basilar  and  vertebral  arteries,  sufficient  to  cause  definite  symp- 
toms, is  seldom  survived.  In  nineteen  cases  out  of  twenty,  accord- 
ing to  Gowers,  the  Sylvian  artery  and  its  branches  are  the  vessels  in- 
vaded. 

Cerebral  embolism  causes  the  same  symptoms,  but  it  seldom  occurs 
before  forty-five,  or  the  age  of  tendency  to  degeneration,  unless  there  is  val- 
vular heart  disease  or  endocarditis.  In  the  absence  of  these,  therefore,  we 
can  infer  syphilis  with  considerable  certainty.  Except  embolism  and  injury, 
sudden  hemiplegia  occurring  between  twenty-five  and  forty-five  is  very  sel- 
dom due  to  any  other  cause  than  syphilis.  The  course  of  the  disease  and 
extent  of  the  paralysis  vary  as  greatly  as  when  caused  by  embolism.  It  may 
be  slight  and  transient,  or  severe  and  lasting.  All  of  the  symptoms  may  not 
occur  instantaneously,  some  hours  or  days  being  required  to  develop  them. 
On  the  other  hand,  the  phenomena  of  embolism  are  more  apt  to  be  suddenly 
complete.  In  thrombosis  one  stroke  may  succeed  another  at  short  intervals, 
and  this  is  rather  characteristic  of  syphilis.  So  is  the  fact  that  consciousness 
is  seldom  totally  lost.  Giddiness  and  vomiting  sometimes  precede  it,  more 
often  does  severe  headache — in  fact,  in  more  than  half  the  cases.  The  head- 
ache may  be  general  or  chiefly  on  the  side  of  subsequent  lesion.  It  may  pre- 
cede the  threatened  lesion  by  only  a  few  days,  or  a  week,  often  for  several 
weeks,  rarely  for  two  or  three  months.  There  may  be  tingling  in  the  side 
about  to  be  paralyzed.  In  severe  cases  death  takes  place  promptly,  ordinarily 
with  high  temperature. 

4.  Cases  of  Combined  Cerebral  and  Spinal  Syphilis. — Under  these  are 
included  cases  illustrating  any  one  of  the  three  forms  considered,  associated 
with  symptoms  of  a  more  widespread  syphilitic  disease.  Thus  there  may  be 
a  combination  of  the  cerebral  symptoms  described,  with  spinal  symptoms, 
the  latter  especially  often  as  the  result  of  meningitis  of  the  cervical  cord 
producing  paraplegia,  hemiplegia,  or  arm  paresis  alone,  and  pain  in  the 
course  of  the  spinal  nerves,  or  the  cerebral  symptoms  may  be  associated  with 
those  of  tabes  dorsalis  or  progressive  paralysis,  and  if  so,  there  is  scarcely  a 
limit  to  the  complex  of  nervous  symptoms  which  may  thus  arise. 

Diagnosis. — A  gumma  of  the  cortex  and  glioma  in  the  same  region 
may  produce  identical  symptoms.  So,  too,  the  symptoms  due  to  occlusion 
of  an  artery  by  syphilitic  disease  may  be  identical  with  those  due  to  embolism 
— in  fact  there  are  no  symptoms  or  combinations  of  symptoms  that  are  not 
produced  by  other  causes.  How,  then,  shall  we  know  the  syphilitic  origin? 
Having  first  made  the  topical  diagnosis,  we  notice  any  modification  of  the 
usual  symptoms  of  meningitis  or  brain  tumor  or  arterial  occlusion,  or  such 
additional  symptoms  as  may  be  due  to  syphilis.  What  are  these  ?  We  have 
seen  that  the  very  sudden  onset  of  symptoms  is  not  usual  in  syphilis  except 
from  occlusion  of  a  blood-vessel.  At  least  a  week  is  usually  necessary  for 
their  development.     On  the  other  hand,  they  are  very  seldom  chronic.     We 


1 148  DISEASES  OF  THE  NERVOUS  SYSTEM, 

have  seen  that  there  is  great  variation  in  the  severity  of  the  symptoms.  We 
have  seen  that  convulsions  occurring  after  thirty  not  due  to  uremia  or  alcohol 
are  in  nine  cases  out  of  ten  due  to  syphilis ;  that  localized  spasms,  unilateral 
or  more  limited,  ocular  palsies,  morbid  somnolence,  point  to  syphilis ;  that 
hemiplegia  in  persons  under  forty-five  years  and  not  due  to  cardiac  embolism 
is  likely  to  be  due  to  syphilis.  Persistent  headache,  worse  at  night,  either 
alone  or  associated  or  preceding  the  palsy,  is  characteristic  of  syphilis.  Of 
value  in  diagnosis  is  the  therapeutic  test, — the  effect  of  treatment, — but  it 
must  be  remembered  that  lesions  not  syphilitic — glioma,  for  example — may 
be  improved  by  antisyphilitic  treatment.  The  symptoms  are  usually  relieved 
by  specific  treatment.  Above  all,  though  not  conclusive,  is  the  knowledge  of 
the  presence  of  syphilis  learned  from  the  anamnesis,  from  ocular  discovery 
of  lesions,  from  miscarriages  in  women,  and  the  presence  of  syphilids. 
Multiple  sarcomatosis  of  the  brain  and  spinal  cord  may  cause  symptoms 
almost  exactly  like  those  of  syphilis,  but  fortunately  the  former  is  a  very 
rare  condition. 

Prognosis. — Much  benefit  may  be  obtained  by  a  timely  and  appropriate 
treatment  of  syphilis  of  the  nervous  system,  though  some  cases  do  not  re- 
spond to  treatment.  It  is  to  be  remembered,  when  there  is  actual  destruc- 
tion of  nervous  tissue,  as  in  old  cases  of  syphilis  of  the  nervous  system  or 
in  forms  of  degenerative  disease  due  to  syphilis,  no  medicines  can  be  of  much 
benefit.  It  is  only  the  syphilitic  lesion  itself  which  is  amenable  to  treatment, 
and  with  its  removal  comes  relief  to  the  pressure  and  irritation  which  cause 
so  many  of  the  symptoms  of  nervous  syphilis. 

Treatment. — It  is  evident  from  what  has  been  said  that  treatment,  to 
be  efficient,  must  be  prompt  and  early;  whence  the  importance  of  an  early 
diagnosis.  Mercury  and  the  iodid  of  potassium  are  almost  the  sole  drugs 
needed,  and  at  first  they  should  be  united.  The  most  effectual  way  to  bring 
about  the  mercurial  effect  is  by  inunction,  although  some  prefer  the  hypo- 
dermic use  of  bichlorid  of  mercury.  The  method  of  inunction,  using  from 
thirty  to  ninety  grains  (2  to  6  gm.)  daily,  and  beginning  with  the  axilla,  has 
been  described  on  page  208.  Simultaneously  the  iodid  of  potassium  should 
be  administered,  beginning  with  ten  grains  (0.66  gm.)  three  times  a  day, 
rapidly  increasing  until  some  effect  is  produced.  As  soon  as  this  effect  is 
noticed  the  dose  may  be  held  at  a  sufficient  amount,  usually  a  dram  (4  gm.) 
a  day.  It  is  well  known  that  very  large  doses  of  iodid  of  potassium  are 
borne  in  syphilis  without  producing  iodism. 

The  mercurial  inunction  should  be  kept  up  for  a  couple  of  weeks  after 
the  symptoms  have  commenced  to  yield,  or  it  may  be  substituted  by  the 
bichlorid  of  mercury  in  1-12  grain  (0.0055  g^^-)  doses  three  times  a  day, 
which  may  be  further  reduced  and  finally  omitted.  The  iodid  of  potassium 
should,  however,  be  kept  up  for  an  indefinite  time  in  such  doses  as  are  well 
borne.  Such  remedies  should  be  given  as  are  indicated  to  reUeve  special 
symptoms,  as  phenacetin,  antipyrin,  and  opium  to  relieve  pain.  A  prompt 
bleeding  is  undoubtedly  of  service  at  times  in  apoplectic  cases,  and  is  harm- 
less in  anv  case.  It  should,  therefore,  be  used  tentatively  in  all  cases  in 
which  it  is  not  contra-indicated  by  debility,  the  quantity  of  blood  drawn  being 
regulated  by  the  effect  on  the  symptoms  and  on  the  pulse. 

Should  it  happen  that  the  symptoms  are  totally  relieved  by  treatment, 
what  should  be  our  course  thereafter?  Certainly  not  to  allow  the  patient 
to  believe  he  is  permanently  cured.  For  almost  inevitably  the  symptoms 
will  return  if  such   a   course  is  pursued.     Doubtless  the   advice   given  by 


SYPHILIS  OF  THE  NERVOUS  SYSTEM.  1149 

Gowers  in  his  admirable  Lettsomian  lecture  is  good,  that  every  syphilitic 
subject,  for  at  least  five  years  after  the  date  of  his  last  symptoms,  should 
have  a  three  weeks'  course  of  treatment  twice  every  year,  taking  for  the 
time  twenty  to  thirty  grains  of  iodid  of  potassium  a  day.  But  it  is  ques- 
tionable whether  the  period  should  be  limited  to  five  years.  Better  is  it  to 
continue  the  intermittent  treatment  for  the  remainder  of  his  days.  Espe- 
cially likely  are  the  symptoms  to  return  in  the  second  half  century,  when  the 
natural  tendency  to  tissue  degeneration  sets  in. 


SECTION   X. 

DISEASES  OF  THE  MUSCULAR  SYSTEM. 

MYOSITIS. 

Rheumatic  Myositis,  Acute  axd  Chronic. 
These  have  been  treated  in  connection  with  the  subject  of  rheumatism. 

Infectious  Myositis. 

Definition. —  A  rare  form  of  acute  or  subacute  inflammation  of  striated 
muscle,  due  to  unknown  infectious  agencies. 

Morbid  Anatomy. — Several  cases  have  come,  to  necropsy.  The  con- 
ditions found  have  been  firmness,  fragility,  and  fatty  degeneration  of  the 
muscle  substance,  with  serous  infiltration  and  hyperplasia  of  the  interfas- 
cicular connective  tissues.  In  another  case  there  was  hyaline  degeneration 
in  varying  degree  without  involvement  of  the  intermuscular  tissue. 

Symptoms. — The  parts  usually  involved  are  the  extremities,  but  the 
disease  may  also  invade  the  trunk-muscles  and  heart.  There  is  swelling 
with  slight  edema,  hardness,  and  stififness,  making  motion  painful  and  diffi- 
cult. Instead  of  pain  there  is  rarely  paresthesia.  The  symptoms  resemble 
those  of  trichiniasis,  insomuch  that  it  has  been  called  pseudo-trichiniasis.  In 
addition  to  the  symptoms  named  an  erythematous  rash,  irregularly  scattered 
over  the  trunk  and  extremities,  is  regarded  by  Lowenfeld  as  characteristic. 
It  is  sometimes  followed  by  slight  pigmentation.  There  sometimes  succeeds 
an  atrophy  of  groups  of  affected  muscles,  and  Wagner  suggested  that  some 
of  the  cases  may  be  examples  of  acute  progressive  muscular  atrophy.  Such 
cases  are  hardly  fair  examples  of  infectious  myositis.  The  duration  of  the 
disease  is  from  three  months  to  three  years. 

Another  form  of  infectious  myositis  is  acute  purulent  myositis,  some- 
times associated  with  pyemia. 


Progressive  Ossifying  Myositis. 

This  is  a  rare  form  of  myositis,  in  which  the  muscles  undergo  pro- 
gressive calcification,  localized  or  extending  over  widespread  areas.  The 
disease  is  more  common  in  males,  and  usually  begins  about  puberty.  It 
occupies  many  years  in  development,  and  consists  in  a  preliminary  inflam- 
matorv  process,  followed  by  more  or  less  extensive  deposits  of  bony  plates 
throughout  the  m.uscular  system,  and  at  times  in  ossification  of  entire 
muscles,  with  fixation  of  joints  and  vertebrae. 

Treatment. — Xo  treatment  has  availed  in  any  of  these  forms  of  acute 
inflammation. 

1150 


IDIOPATHIC  MUSCULAR  ATROPHIES.  1151 

IDIOPATHIC  MUSCULAR  ATROPHIES— PRIMARY  MYOPATHIC 
FORMS  OF  MUSCULAR  ATROPHY. 

In  addition  to  the  spinal  or  myelopathic  forms  of  muscular  atrophy 
described  under  nervous  diseases,  there  are  several  varieties  of  muscular 
wasting  which  apparently  reside  in  the  muscles  themselves,  and  which  are 
therefore  strictly  idiopathic.  These  forms  occur  in  the  young,  and  follow 
decidedly  upon  hereditary  disposition.  They  are  all  probably  the  result  of 
a  congenital  tendency  to  defective  development. 

There  are  several  clinical  types  of  primary  muscular  atrophy,  of  which 
the  principal  are : 

1.  Pseudo-hypertrophy, 

2.  Erb's  form,  or  the  juvenile,  or  the  scapulo-humeral  form. 

3.  The  facio-scapulo-humeral  type  of  Landouzy  and  Dejerine. 

These  are  all  forms  of  one  disease,  called  by  Erb  progressive  muscular 
dystrophy. 

I.  Pseudohypertrophy  of  Muscles. 

Synonyms. — Pseudohypertrophic    Muscular    Paralysis;    Lipomatosis    lux- 
urians  muscularis  (Heller)  ;  Atrophia  nmsculorium  lipomatosa  (Seidel). 

Definition. — A  state  of  muscular  paresis  associated  with  an  atrophy 
of  the  muscles  involved — an  atrophy  obscured  by  interstitial  fatty  over- 
growth. 

Etiology. — This  is  especially  an  affection  of  childhood,  and  heredity  is 
an  important  causal  factor,  many  members  of  the  same  family  being  some- 
times affected  through  several  generations.  Boys  are  more  frequent  sub- 
jects than  girls,  though  the  disease  is  more  apt  to  be  transmitted  through 
the  mother,  even  though  she  may  not  herself  be  a  subject.  Heredity  is  not 
invariable.  The  disease  usually  begins  before  puberty,  though  sometimes 
as  late  as  the  twentieth  or  twenty-fifth  year  or  later.  Hysteria,  epilepsy, 
feeble-mindedness,  with  an  occasional  anomaly  of  the  skull,  have  been  ob- 
served in  the  same  families. 

Morbid  Anatomy. — The  nervous  system  is  not  involved  except  in  rare 
cases.  Minutely  examined,  the  muscles  exhibit  marked  differences  in  the 
size  of  the  muscular  fasciculi,  some  being  wider,  many  narrower  than  nor- 
mal, while  there  is  considerable  increase  in  the  adipose  and  connective  tissue 
between  the  fasciculi.     The  fibrillse  themselves  are  not  fatty. 

Symptoms. — The  disease  begins  gradually  with  paretic  symptoms,, 
without  the  hypertrophic  appearances  which  are  later  so  pronounced.  A 
child  previously  healthy  exhibits  clumsiness  in  its  movements  and  in- 
security on  its  legs,  being  especially  awkward  in  jumping  and  running" 
upstairs.  Then  close  examination  discovers  that  certain  muscles  or  groups 
of  muscles  are  enlarged,  the  calves  of  the  legs  being  especially  conspicuous. 
The  extensors  of  the  leg,  the  glutei,  the  lumbar  muscles,  the  deltoid,  triceps, 
and  infraspinales  next  become  enlarged,  while  the  hands,  arms,  and  neck  are 
rarely  involved,  in  strong  contras,t  to  the  spinal  atrophies.  Walking 
becomes  more  and  more  diificult,  until  finally  a  diagnosis  may  be  made  from 
the  gait  alone,  which  becomes  waddling,  while  the  shoulders  are  thrown 
back,  the  belly  is  thrown  forward,  the  vertebral  column  being  also  arched 


1 152  DISEASES  Of  THg  MUSCULAR  SYSTEM. 

forward  in  the  lumbar  region.  The  buttocks  stand  out,  and  the  legs  are  far 
apart.  In  walking  the  legs  are  raised  slowly,  the  toes  dropping  from  paresis 
of  the  dorsal  flexors.  Especially  characteristic  is  the  child's  method  of  ris- 
ing from  the  floor.  He  first  gets  on  all-fours,  and  raises  his  trunk  by  mov- 
ing the  arms  along  the  floor.  The  arms  are  then  drawn  toward  the  legs 
until  the  knees  can  be  reached,  when,  with  one  hand  on  the  knee,  he  pushes 
himself  up,  then  grasps  the  other  knee,  and  completes  the  act  of  raising  him- 
self to  the  erect  position.  Late  in  the  disease  the  same  paretic  condition 
may  extend  to  the  upper  extremities,  making  it  impossible  to  rise. 

The  enlargement  of  the  muscles  is  due  to  an  interstitial  deposit  of  fat, 
and  as  a  consequence  they  are  soft  and  flabby  instead  of  hard  and  firm,  as 
in  true  hypertrophy.  Thus  the  hypertrophy  is  truly  a  pseudo-hypertrophy, 
the  condition  being  really  one  of  atrophy  of  muscular  substance.  Along  with 
this  may  be  associated  a  genuine  atrophy  of  other  muscles,  with  loss  of  sub- 
stance unassociated  with  fatty  infiltration,  especially  in  the  upper  extremities. 
Very  rarelv  there  is  a  true  hypertrophy,  except  of  individual  muscle-fibers. 

Fibrillar  tz^'if citings  are  rarely  present.  Electrical  excitability  is  dimin- 
ished in  proportion  to  the  destruction  of  muscular  tissue,  but  there  is  never 
a  reaction  of  degeneration.  Sensibility  remains  normal,  and  the  sphincters 
are  intact.  The  patellar  reflex  is  sometimes  absent.  The  skin,  especially 
of  the  legs,  sometimes  presents  a  peculiar  bluish  mottling.  As  a  rule,  the 
intelligence  of  the  child  is  preserved,  though  sometimes  there  is  mental  and 
moral  obliquity. 

2.  Erb's  Form^  or  the  Juvexile  Type  of  Progressive  Muscular 

Dystrophy. 

This  type  is  also  commonly  found  before  the  age  of  twenty,  usually  be- 
tween fifteen  and  twenty,  but  its  subjects  are  not  so  young,  as  a  rule,  as  those 
of  the  pseudo-hypertrophic  form.  It  is,  like  all  the  forms  of  muscular  dys- 
trophy, hereditary  in  families  of  which  female  members  are  affected,  while 
the  boys  may  have  pseudo-hypertrophic  paralysis.  It  starts  rather  more  fre- 
quently in  the  upper  extremities,  the  upper  arms  and  shoulders,  but  may 
begin  also  in  the  back  and  legs.  The  following  are  the  muscles  involved, 
according  to  Erb :  In  the  upper  extremities  the  pectoralis  major,  latissimus 
dorsi,  and  later  the  triceps  ;  while  there  remain  normal,  at  least  for  some  time, 
the  sternomastoid.  the  levator  anguli  scapulae,  the  coracobrachialis,  the  teres 
major  and  teres  minor,  the  deltoid,  the  supraspinatus  and  infraspinatus,  and 
the  small  muscles  of  the  hand,  which,  it  will  be  remembered,  are  remarkably 
wasted  in  myelopathic  atrophy.  The  muscles  of  the  forearm,  except  the 
supinator  longus,  remain  exempt  for  a  long  time,  if  not  altogether.  In  the 
lower  extremities  the  glutei,  the  quadriceps,  the  peronei,  and  the  tibialis 
amicus  are  aft'ected,  while  the  sartorius  and  calf  muscles  are  spared  for  a 
long  time. 

\"ery  characteristic  is  the  marked  projection  of  the  scapula,  due  to  paral- 
ysis of  the  serratus.  The  gait  in  this  form  becomes  waddling  and  walking 
is  ultimately  impossible,  although,  like  its  congeners,  the  progress  of  the 
disease  is  slow,  twenty-three  to  thirty-eight  years  being  the  range  of  duration 
of  cases  described  by  Erb.  Bulbar  symptoms  are  rare,  but  the  diaphragm 
may  atrophy  and  death  be  due  to  respiratory  deficiency. 

The  muscular  changes  are  essentially  atrophic,  though  in  the  beginning 
a  few  of  the  muscular  fibers  may  be  hypertrophied.     The  interstitial  con- 


MYOTONIA  CONGENITA.  .    ii53 

nective  tissue  is  increased,  its  nuclei  proliferated,  and  there  is  no  interstitial 
fat.  The  number  of  muscle  nuclei  is  also  increased,  and  vacuoles  may  be 
seen  in  the  individual  fasciculi. 

3.  The  Facio-Scapulo-humeral  Type  of  Juvenile  Palsy. 

This  is  also  a  family  form.  Duchenne  called  attention  to  the  fact  that 
in  certain  children's  palsies  the  muscles  of  the  face  are  involved  in  the 
atrophy,  but  the  fact  was  overlooked  until  Landouzy  and  Dejerine  opened 
the  subject  anew,  and  showed  that  this  event  is  not  infrequent — indeed,  may 
be  the  first  symptom.  This  atrophy  may  begin  later  in  life — say  the  twen- 
tieth to  thirtieth  year.  In  these  cases  the  eyes  can  no  longer  be  com- 
pletely closed,  and  whistling,  laughing,  and  talking  become  difficult.  An 
appearance  characteristic,  even  diagnostic,  known  as  the  fades  myopathique, 
results,  to  which  the  half-closed  eyes,  the  sunken  cheeks,  and  the  tapir 
mouth  contribute.  The  muscles  of  mastication,  the  internal  ocular,  and 
those  of  the  forearm  and  hand  remain  normal.  Fibrillary  contractions  are 
absent,  and  there  is  no  reaction  of  degeneration.  In  other  respects  it  re- 
sembles the  juvenile  form  of  Erb's  palsy,  with  which  it  is  closely  allied. 
From  what  has  been  said  it  is  evident  that  the  three  forms  just  described 
are  modifications  of  one  variety,  a  view  strengthened  by  the  fact  that  two  or 
more  of  the  types  may  be  present  in  the  same  family. 

4.  The  Peroneal  Type  of  Progressive  Atrophy. 
Synonym. — Progressive  Neural  Muscular  Atrophy. 

This  form,  described  by  Charcot  and  Marie,  and  independently  by 
Tooth,  is  met  in  the  second  half  of  childhood,  seldom  after  twenty.  It 
occurs  also  in  families,  more  frequently  in  males.  It  begins  in  the  peroneal 
muscles,  involving  also  the  intrinsic  muscles  of  the  foot,  and  may  lead  to 
club-foot,  of  the  variety  pes  equinus  or  pes  equinovarus.  The  upper  ex- 
tremities may  be  affected  after  many  years,  and  rarely  it  begins  in  the  hands. 
It  differs  from  the  other  forms  of  juvenile  atrophy  in  the  presence  of  fibril- 
lary contraction  and  the  occasional  presence  of  the  reaction  of  degenera- 
tion, while  vasomotor  and  sensory  disturbances  may  also  be  present. 

Degeneration  of  the  peripheral  nerves  has  been  found  with  ascending 
degeneration  of  the  posterior  columns.  Both  the  symptomatology  and 
morbid  anatomy  of  this,  so  far  as  known  from  a  limited  number  of  autopsies, 
go  to  show  that  it  is  really  a  result  of  neuritis. 

Prognosis  and  Treatment. — These  are  also  essentially  identical  with 
those  of  progressive  muscular  atrophy. 

MYOTONL\  CONGENITA. 

Synonym. — Thomsen's  Disease. 

Definition. — A  hereditary  affection,  characterized  by  overdevelopment 
•of  muscles  and  by  tonic  cramp  on  attempt  at  voluntary  motion. 

Historical, — The  disease  was  described  in  1876  by  Thomsen,  a  Schleswig  phy- 
sician, in  whose  familv  it  had  been  present  for  five  generations.  Since  then  numer- 
ous cab2S  have  been  described  in  Scandinavia.  Germany,  France  and  Italy.  It  is 
rare  in  this  countrv  and  in  England.  In  1889  Hale  White  made  a  thorough  study  of 
the  subject  and  published  his  results  in  "  Guy's  Hospital  Reports  "  for  that  year. 

73 


1 1 54  DISEASES  OF  THg  MUSCULAR  SYSTEM. 

Etiology. —  The  disease  is  always  congenital,  the  symptoms  making 
their  appearance  in  early  childhood  and  in  family  groups,  more  frequently 
in  men.  Cases  of  acquired  myotonia  have  been  observed,  but  these  are 
regarded  as  somewhat  different  from  Thomsen's  disease.  A  few  isolated 
cases  presenting  the  same  symptoms  have  been  described.  It  is  to  be 
regarded  as  a  congenital  anomaly  of  the  muscular  system. 

Morbid  Anatomy. — The  muscles  are  characterized,  especially  in  the 
extremities,  bv  voluminous  development  in  strong  contrast  to  their  power. 
In  addition  to  an  obvious  macroscopic  enlargement  there  is  also  found  his- 
tologicallv  an  evident  increase  in  the  volume  of  the  muscular  fasciculi,  recog- 
nized by  Erb  and  confirmed  by  Hale  White,  together  with  intermuscular 
proliferation  of  the  muscle  nuclei  and  moderate  increase  of  the  connective 
tissue  itself.  The  heart  is  exempt,  but  the  diaphragm  may  be  involved. 
There  is  no  lesion  of  the  spinal  cord.  The  only  necropsy  in  a  case  of 
Thomsen's  disease  ever  observed  was  reported  by  Dejerine  and  Sottas.  The 
muscles  were  altered,  but  the  nervous  system  was  normal. 

Symptoms. — The  disease  manifests  itself  at  first  in  childhood  by  a 
stiffness  or  "  mild  tetanus,"  in  which  the  relaxation  which  necessarily  pre- 
cedes each  muscular  act  is  delayed.  Voluntary  contraction  takes  place 
slowly  and  with  difficulty.  The  arm  and  leg  muscles  are  involved,  and 
thus  the  child's  play  is  interfered  with.  There  is,  however,  no  paralysis, 
and  after  motion  is  started,  it  proceeds  with  facility.  Prompt,  rapid,  and 
precise  muscular  movements  are,  however,  difficult,  and  military  service, 
for  example,  becomes  impossible.  The  condition  is  aggvavatcd  by  cold  and 
emotion. 

Sensation  and  the  reflexes  are  normal.  Rarely  there  is  mental  weak- 
ness. A  peculiar  reaction  of  muscle  and  nerve  to  botli  currents  is  developed^ 
called  the  myotonic  reaction-  of  Erb.  The  motor  nerves  show  quantitatively  a 
normal  faradic  and  galvanic  excitability,  and  all  briefly  acting  stimuli  give 
short  contractions ;  but  with  continuous  irritation  by  both  currents  the  con- 
tractions attain  their  maximum  slowly  and  relax  slowly,  while  vermicular 
wave-like  contractions  pass  from  the  cathode  to  the  anode.  The  muscles 
are  also  faradically  easily  excited,  responding  to  a  fairly  strong  current 
always  with  the  above-described  prolonged  contraction.  To  galvanic  irri- 
tation of  muscle  there  is  a  slight  increase  of  excitability,  and  to  somewhat 
strong  currents  the  contractions  are  sluggish,  tonic,  and  continued.  They 
occur  only  with  current  closure  and  not  with  current  opening.  The  mechan- 
ical irritability  of  the  muscles  to  strokes  from  the  percussion  hammer  is  also 
increased. 

Dis.^nosis. — If  more  is  ^needed  than  the  peculiarity  of  the  muscular 
phenomena,  the  electrical  and  mechanical  muscular  reactions  described  are 
characteristic. 

Prognosis. — The  disease  is  incurable,  but  patients  become  accustomed 
to  the  defect  and  conceal  it  as  much  as  possible. 

Treatment. — Nothing  specific  is  known.  Friction  and  massage,  with 
muscular  gymnastics,  are  rational  measures  to  be  recommended. 


SECTION   XL 
THE  INTOXICATIONS. 

ALCOHOLISM. 

Definition. —  The  effect  on  the  human  economy  of  the  intemperate  use 
of  alcohol  in  some  one  of  the  forms  in  which  it  is  used  as  a  beverage.  Such 
effect  is  either  acute  or  chronic. 

Acute  Alcoholism, 

Definition. —  This  is  the  condition  known  as  inebriety  or  drunkenness. 
Varying  amounts  of  alcohol  are  required  to  produce  it,  very  small  quantities 
sufficing  to  intoxicate  those  unaccustomed  to  its  use,  while  the  habitual 
drinker  may  consume  large  quantities  without  effect. 

Symptoms. — The  order  of  symptoms  is  not  always  the  same.  More 
frequently  the  primary  effect  is  one  of  excitement,  associated  with  flushed 
face,  bright  eye,  and  loose  tongue.  To  this  succeeds  the  well-known  stag- 
gering gait  of  drunkenness,  which  increases  until  its  subject  is  unable  to 
walk  and  finally  falls  to  the  ground.  The  ready  speech,  at  first  coherent, 
now  wanders  at  random,  and  finally  ceases  altogether.  The  stage  of  nar- 
cosis is  reached,  and  the  drunken  man  breathes  stertorously  in  his  sleep, 
his  face  being  congested  and  his  breath  alcoholic.  He  may,  perhaps,  be 
aroused,  and  may  respond  vaguely  and  incoherently  to  a  question,  but  soon 
drops  off  to  sleep  again. 

In  another  subject  the  first  stage  is  much  more  violent,  and  he  may  cry 
out  boisterously,  and  either  spontaneously  or  upon  the  slightest  provocation 
inflict  injury  or  even  commit  murder.  In  other  subjects,  again,  there  is  no 
stage  of  excitement,  and  they  are  morose,  or  pass  gradually  and  directly  into 
stupor.  The  stage  of  inco-ordination  and  ultimate  stupor  is,  however,  inva- 
riable if  the  quantity  of  alcohol  drunk  is  enough  to  bring  it  about.  The 
effect  is  upon  the  cortical  nerve-cells  of  the  brain. 

Other  less  conspicuous  features  are  a  lowered  temperature, — 96°  F. 
(35.6°  C.)  to  90°  F.  (32.2°  C),  or  even  lower, — involuntary  evacuations 
of  the  bowels  and  bladder,  dilated  pupils,  and  muscular  twitchings. 

Diagnosis. — The  diagnosis  of  drunkenness  is  usually  easy,  yet  mis- 
takes are  not  infrequent;  it  has  been  mistaken  for  apoplexy  or  apoplexy 
with  fracture  of  the  skull.  In  the  latter  case  stupor  is  usually  deeper, 
and  the  patient  cannot  be  aroused,  while  the  breathing  is  more  stertorous. 
The  subject  should  always  have  the  benefit  of  the  doubt,  and  resident 
physicians  in  hospitals  will  often  save  themselves  and  the  institution  they 
serve  much  opprobrium  if  they  will  remember  this.  Uremic  coma  develop- 
ing with  convulsions  also  simulates  drunkenness,  and,  when  the  existence 
of  Bright's  disease  is  unsuspected,  may  cause  error.  In  such  the  odor  of 
alcohol  in  the  breath  is  wanting,  while  that  of  urine  is  sometimes  present, 
although,  of  course,  a  person  with  nephritis  might  have  an  attack  of  uremic 
coma  after  he  had  been  drinking  alcohol.     In  acute  alcoholism  the  pupil  is 

"55 


1 1 56  THE  INTOXICATIONS. 

commonly  dilated.  In  uremia  it  is  variable,  being  sometimes  dilated  and 
sometimes  contracted.  In  all  doubtful  cases  the  urine  should  be  drawn  by 
the  catheter  and  tested  for  albumin.  In  opium  poisoning,  which  may  also  be 
confounded  with  alcoholism,  the  pupil  is  contracted. 

Chronic  Alcoholism. 

Definition. — This  is  a  condition  which  supervenes  sooner  or  later  in 
individuals  who  habitually  use  alcohol  intemperately.  Dipsomania  is  a  term 
applied  to  a  condition  in  which  there  is  an  inherited  immoderate  desire  for 
alcohol  at  times,  followed  by  periods  in  which  there  is  no  suc!h  inclination. 
Intemperance  does  not  always  imply  the  consumption  of  the  same  amount 
of  alcohol,  smaller  quantities  producing  harmful  effects  in  some  persons  while 
larger  amounts  are  apparently  harmless  in  others.  The  predisposition  in 
some  persons  to  be  easily  affected  organically  by  alcohol  is  due  to  some  as  yet 
uncomprehended  constitutional  weakness.  There  is  reason  to  believe  that 
the  children  of  alcoholics  are  not  only  more  susceptible  to  the  degenerative 
effects  of  alcohol,  but  also  to  other  diseases,  such  as  gout,  rheumatism,  syph- 
ilis, and  diseases  of  the  nervous  system.  Among  the  latter  may  be  men- 
tioned, especially  epilepsy,  melancholia,  dementia,  and  insanity. 

Morbid  Anatomy. — If  we  include  under  this  the  numerous  morbid 
states  which  are  directly  or  indirectly  ascribed  to  the  long-continued  use  of 
alcohol,  such  as  cirrhosis  of  the  liver,  gastritis,  low  grades  of  meningitis, 
and  the  arterial  changes  so  frequently  ascribed  to  it,  a  large  amount  of  space 
would  be  consumed.  Fortunately,  these  conditions  have  already  been  de- 
scribed as  separate  entities,  and  their  relation  to  alcohol  as  a  cause  has  been 
discussed. 

A  few  words  may,  however,  be  devoted  to  the  consideration  of  the 
effect  of  alcohol  on  elementary  parts,  since  it  is  through  such  effect  that 
its  consequences  are  produced.  Some  time  ago  Lionel  S.  Beale  called 
attention  to  the  destructive  effect  of  alcohol  on  protoplasm.  More  recently, 
in  1894,  Obersohn,  working  in  the  laboratory  of  Gaule,  in  Ziirich,  demon- 
strated not  only  that  alcohol,  ether,  and  chloroform  destroy  cellular  proto- 
plasm, but  also  that  the  cells  which  are  the  most  complicated,  so  far  as 
function  is  concerned,  such  as  nerve-cells,  are  the  most  vulnerable.  These 
conclusions  were  confirmed  by  other  experimenters,  among  them  Wilkins,  in 
this  country,  in  1895,  and  the  whole  tendency  of  experiment  and  obser- 
vation at  the  present  day  is  to  show  the  degenerative  effect  of  alcohol  on 
elementary  histological  units. 

Chronic  alcoholism,  like^cute,  predisposes  to  other  diseases.  Its  direct 
effect,  is.  as  already  stated,  mainly  on  the  protoplasm  of  cells,  modifying 
or  impairing  their  normal  metabolism,  at  times  destroying  cells  and  substi- 
tuting them  by  fibroid  material,  at  others  inciting  to  inflammatory  action;  at 
others  still  simply  delaying  oxidation,  as  in  the  case  of  the  adipose  vesicle, 
whose  fat  remains  unoxidized  because  its  congener,  alcohol,  is  more  easily 
oxidized.  In  some  instances,  as  in  the  case  of  the  liver-cells,  fat  is  de- 
posited in  new  situations  because  it  cannot  be  sufficiently  burnt  up.  Differ- 
ent kinds  of  alcoholic  beverages  also  seem  to  act  differently,  some,  as  gin, 
producing  destruction  of  liver-cells  and  cirrhosis,  while  others,  as  malt 
liquors,  produce  fatty  livers.  It  is  also  true  that  persons  addicted  to  inter- 
mittent debauch  are  less  liable  to  inflammatory  lesions  than  constant  con- 
sumers. 


ALCOHOLISM.  1157 

As  a  consequence  of  irritation  of  the  intima  by  the  alcohol,  arise  endar- 
teritis, sclerosis,  and  thickening  followed  by  atheroma  and  fragility.  Irri- 
tation of  nervous  tissues  results  in  different  forms  of  meningitis  and  cere- 
britis  with  degeneration. 

Thirty  years  ago  Lancereaux  announced  that  alcoholic  excesses  are 
one  of  the  principal  causes  of  tuberculosis,  affecting  by  preference  the 
back  of  the  right  lung,  while  disease  of  the  left  in  front  is  the  result  of 
insufficient  aeration  or  alimentation ;  also  that  such  disease  is  characterized 
by  improvement  and  general  arrest  if  the  patient  leaves  off  his  habit,  and  by 
recurrence  if  he  relapses.  As  recently  as  1895*  this  clinician  retracted 
this  view,  while  the  observations  of  Lagneau  developed  the  remarkable  fact 
that  tuberculosis  only  became  prevalent  in  France  after  the  phylloxera  had 
ruined  the  vines  and  curtailed  the  supply  of  wine.  Then  tuberculosis,  pre- 
viously only  one-half  as  common  in  men  as  women,  reversed  its  election, 
twice  as  many  men  being  affected  as  women. 

Kidney  Changes. — The  effect  of  alcoholism  on  the  kidney  is  also  two- 
fold in  the  direction  of  contraction  and  enlargement,  the  former  due  to 
gradual  destruction  of  renal  cells  and  tubules  with  substitution  of  interstitial 
tissue,  the  latter  to  fatty  infiltration  and  hypertrophy.  I  have  often  expressed 
the  belief  that  alcohol  is  a  less  frequent  factor  in  the  production  of  inter- 
stitial nephritis  than  was  formerly  supposed,  because  of  the  facilities  for  its 
elimination  in  its  long  journey  from  the  stomach  through  the  liver  and  lungs 
before  it  reaches  the  kidney.  In  this  I  am  sustained  by  W.  Howship  Dick- 
inson and  the  enormous  experience  of  the  late  Henry  F.  Formad  as  Coro- 
ner's physician  in  Philadelphia.f  The  enlarged  kidney  of  alcoholics  was 
also  studied  by  Formad,  who  called  it  the  "  pig-back  "  kidney,  and  found  it 
a  true  hypertrophy  rather  than  a  degenerative  change. 

Symptoms. — These  may  be  classified  according  to  the  systems  they  in- 
vade.    Thus  we  have  the  effects  of  alcohol  on  the — 

Nervous  System. — The  most  constant  of  these  is  the  well-known  un- 
steadiness— especially  of  the  hands  in  the  performance  of  muscular  actions. 
It  is  also  apparent  in  an  attempt  to  protrude  the  tongue.  Gradual  mental 
deterioration  is  an  inevitable  consequence,  sooner  or  later,  of  chronic  alco- 
holism. It  is  manifested  in  sluggishness  of  intellect,  in  weakness  of  reso- 
lution, a  loss  of  moral  character,  in  irritability,  restlessness,  and  occasional 
dementia  and  insanity.  Yet  it  is  surprising  how  some  enormous  consumers 
of  alcohol  maintain  their  mental  acumen  and  ability  to  manage  large  finan- 
cial interests,  while  their  vascular  and  digestive  apparatus  is  evidently  the 
seat  of  advanced  degeneration.  When  dementia  and  insanity  are  present, 
they  are  probably  due  to  vascular  degeneration  and  consequent  secondary 
changes  in  the  brain  structure.  The  tendency  of  such  insanity  is  toward 
delusions,  including  suspicion,  distrust,  fear  of  impending  evil,  and,  more 
rarely,  delusions  of  grandeur,  as  in  general  paralysis  of  the  insane. 

Multiple  and  simple  neuritis  is  a  well-recognized  and  almost  character- 
istic symptom  of  chronic  alcoholism,  and  has  already  been  considered. 

Pachymeningitis  hjemorrhagica  is  sometimes  met.  More  frequent  are 
slight  thickening  and  turbidity  of  the  pia  arachnoid  membrane.  But  this 
is  not  peculiar  to  alcoholism,  being  the  same  as  that  found  in  the  neuroses 
ol  insanity.  ' 

*  "Effets  compares  des  boissons  alcooliques  chez  les  hommes  et  leur  influence  predisposante 

sur  la  tuberculose,"  "France  Med.,"  1805,  xliii.  et  al.  ,       ,    . 

+  "  Heart  and  Kidney  in  Brigrht's  Disease,"  "  Trans,  of  the  Assoc,  of  Ainer.  Physicians,    vol.  iv., 
1889.    Dr.  Formad's  experience  covered  as  many  as  1172  autopsies  in  a  single  year. 


1 158  THE  INTOXICATIONS. 

Digestive  Apparatus. — This  is  a  favorite  point  of  attack  in  alcoholism. 
Chronic  gastric  catarrh  is  one  of  its  most  frequent  consequences,  producing 
loss  of  appetite,  nausea,  constipation,  coated  tongue,  and  foul  breath,  symp- 
toms which  are  always  worse  in  the  morning,  and  are  temporarily  relieved 
by  the  dram  which  the  habitual  drinker  is  apt  to  seek  at  this  time  of  day. 
Autopsy  in  such  cases  may  be  negative  as  to  the  stomach,  or  reveal  the 
changes  described  under  chronic  gastric  catarrh. 

Symptoms  due  to  Liver  Changes. — From  these  arise  the  symptoms  due  to 
cirrhosis  and  contraction,  fatty  infiltration,  and  enlargement.  The  interstitial 
overgrowth  so  characteristic  of  cirrhosis  is  probably  secondary  ,to  a  primary 
poisonous  and  destructive  effect  of  the  alcohol  on  the  cells,  as  confirmed  by 
the  experiments  of  Weigert,  and  more  recently  by  those  of  Obersohn  and 
Wilkins,  previously  referred  to.  The  compression  of  the  cirrhotic  liver  on 
the  portal  vessels  produces  secondary  effects,  viz.,  hyperemia  of  the  stomach, 
causing  gastric  catarrh ;  of  the  rectum,  producing  hemorrhoids ;  and  of  the 
esophagus,  pharynx,,  and  nasal  mucous  membrane,  resulting  in  hemorrhage 
in  any  one  of  the  localities ;  in  dilatation  of  the  venulse  of  the  face  and  nose, 
and  eruptions  on  the  latter,  constituting  the  acne  rosacea  or  "  blossom,"  by 
which  the  toper  is  so  often  marked.  In  many  cases,  on  the  other  hand,  the 
livers  of  hard  drinkers  have  been  found  normal. 

From  vascular  changes  result  cardiac  and  renal  diseases,  and  their  symp- 
toms, unequal  distribution  of  the  blood  in  the  brain,  and  consequent  symp- 
toms, viz.,  dizziness,  thrombosis,  apoplexy,  softening. 

Delirium  Tremens,  or  Mania  a   Potu. 

Definition  and  Symptoms. — This  is  a  special  manifestation  of  chronic 
alcoholism,  ascribed  to  the  long-continued  action  of  alcohol  on  the  brain, 
though  its  occurrence  coincides  rather  with  the  sudden  withdrawal  of  the 
alcohol.  On  the  other  hand,  a  debauch,  however  prolonged,  by  a  person 
previously  temperate,  is  never  followed  by  mania  a  potu,  so  that  the  rela- 
tion of  the  illness  to  the  Vv^ithdrawal  of  alcohol  may  be  more  apparent  than 
real.  Purely  accidental  circumstances  may  determine  the  cessation  from 
drinking.  It  is  very  frequently  an  attack  of  acute  illness,  especially  pneu- 
monia, to  which  drunkards  are  especially  predisposed.  The  first  symp- 
tom is  usually  sleeplessness  associated  with  intense  depression,  or  there  may 
be  intense  restlessness,  during  which  the  patient,  unless  restrained,  will  go 
out  of  the  house  on  some  imaginary  business.  To  this  succeed  hallucina- 
tions of  vision,  as  the  result  o-^ which  he  imagines  he  is  pursued  by  monsters, 
serpents,  rats,  mice,  and  other  vermin.  The  intense  shivering  terror  of  the 
victim  under  these  circumstances  is  pitable,  and  the  "  horrors  " — a  term  ap- 
plied to  the  disease — is  but  a  feeble  expression  of  the  terrors  of  the  patient. 
Frequently,  in  his  attempts  to  escape  these  objects,  he  is  unmanageable,  and 
must  be  confined.  Suicide  is  not  infrequent  with  such  patients.  At  other 
times  the  eager  though  misguided  intelligence  displayed  in  watching  the  im- 
aginary objects  is  amusing.  Auditory  hallucinations  may  be  present,  and 
unusual  noises  be  complained  of.  At  the  same  time,  even  though  the 
patient  is  violent,  the  pulse  will  be  found  frequent,  feeble,  and  often  irregular. 
There  is  great  muscular  weakness,  as  evidenced  by  the  tremor  which  ac- 
companies all  muscular  acts.  There  is  slight  fever,  102°  to  103°  F. 
(38.9°  to  39.4°  C),  which  is  increased  if  there  is  intercurrent  inflammatory 
disease. 


ALCOHOLISM.  1159 

Diagnosis. — This  is  never  difficult.  The  symptoms  certainly  resemble 
those  of  meningitis,  and  meningitis  is  also  sometimes  present,  but  with  the 
history  of  the  case  and  the  general  appearance  of  the  patient  a  mistake  is 
not  likely  to  be  made.  It  is  most  important,  however,  to  examine  each  case 
thoroughly,  as  pneumonia  is  so  frequently  associated  with  delirium  tremens 
and  constitutes  its  most  serious  danger.  Again  it  is  said  a  pneumonia  of  the 
apex  is  sometimes  accompanied  by  delirium  similar  to  that  of  delirium  tre- 
mens. 

Prognosis. — If  there  is  pneumonia,  recovery  is  a  rare  event,  but  if 
delirium  is  uncomplicated,  recovery  generally  takes  place,  certainly  from  the 
first  attack,  and  generally  even  after  one  or  more  attacks  and  a  duration  of 
from  three  or  four  days  to  a  week.  If  recovery  does  not  take  place,  the 
adynamia  increases,  the  pulse  grows  increasingly  feeble,  the  tongue  dry,  the 
delirium  becomes  muttering,  and  the  patient  dies  with  the  usual  symptoms 
of  the  typhoid  state.  This  event  is,  of  course,  more  common  in  hospital 
practice. 

Treatment  of  Alcoholism. 

Acute  alcoholism  rarely  requires  any  treatment  except  restraint  from  the 
further  use  of  alcohol  and  opportunity  to  sleep  off  the  debauch.  A  full 
dose  of  chloral — from  fifteen  to  thirty  grains  (T  to  2  gm.) — may  be  neces- 
sary when  there  is  extreme  excitement.  IMorphin  is  indicated,  but  as  alco- 
holics sometimes  have  contracted  kidney,  caution  should  be  exercised  in  its 
use.  In  cases  where  the  subject  is  not  too  drunk  to  swallow,  from  half  a 
dram  to  a  dram  (1.85  to  Z-7  c.  c.)  of  aromatic  spirit  of  ammonia  often 
acts  happily ;  and  when  there  is  reason  to  believe  that  alcohol  or  undigested 
food  is  in  the  stomach,  an  emetic  of  warm  water  and  mustard — a  heaped 
dessertspoonful  of  mustard  to  half  a  pint  of  water  (250  c.  c. ) — may  be  given 
and  the  stomach  washed  out.  Should  it  be  deemed  desirable  that  an  emetic 
be  given  to  one  unconscious,  apomorphin  hypodermically  administered  is 
the  best — from  1-15  to  i-io  grain  (0.0044  to  0.0066  gm.). 

The  first  step  in  the  treatment  of  chronic  alcoholism  is  the  withdrawal 
of  the  poison.  Except  when  mania  a  potu  is  present,  this  may  be  total. 
Kothing  is  to  be  gained  by  gradual  withdrawal,  while  it  only  prolongs  the 
struggle.  No  drugs  hke  morphin  or  chloral  or  cocain  should  be  used  in 
the  treatment  of  chronic  alcoholism,  as  to  do  so  is  simply  to  substitute  one 
evil  for  another,  and  to  weaken  the  resolution  of  the  victim.  The  bromids 
may,  however,  be  availed  of,  and  trional,  chloralamid,  and  sulphonal  m.ay 
be  employed  to  procure  sleep.  Xot  less  than  fifteen  grains  (  i  gm. )  of 
any  of  these  drugs  should  be  administered  for  an  adult,  while  twice  the 
dose  mav  be  necessary.  Hydrobromate  of  hyoscin  is  often  an  admirable 
remedy  to  quiet  excitement.  It  may  be  given  in  doses  of  1-96  grain  (0.0007 
gm.).  Attempts  at  reformation  are  rarely  successful,  but  success  is  not 
impossible.  Some  means  of  restraint  is  usually  indispensable,  and  as  a  rule 
can  only  be  secured  in  an  institution.  Unfortunately,  relaxation  of  this  is 
apt  to  be  followed  by  a  relapse.  The  difficulties  increase  in  the  presence 
of  hereditary  tendency.  An  abundance  of  nutritious  food  should  be  insisted 
upon,  as  it  is  found  to  be  the  best  substitute  for  alcohol,  while  tea  and  coffee 
may  be  allowed  freely,  having  the  aJdvantage  of  being  stimulating  without 
intoxicating.  Tonics,  such  as  strychnin  1-30  grain  ('0.0022  gm.)  three  or 
four  times  a  day,  or  quinin,  should  be  administered. 

As  to  the  remainder  of  treatment,  it  must  be  mainly  symptomatic,   di- 


ii6o  THE  INTOXICATIONS. 

rected  to  the  symptoms  as  they  arise.     Neuritis,  one  of  the  most  important  o£ 
these,  has  been  elsewhere  considered. 

Still  another  drawback  is  the  intense  depression  which  succeeds  the 
exciting  effect  of  alcohol  and  often  impels  to  a  return  to  its  use.  To  cure 
this  longing,  which  he  ascribes  to  gastritis  and  a  peculiar  irritation  of  the 
gastric  nervous  supply,  Zedekauer  recommends : 

I^     Chlorated  water,  2      drams  (     8  gm.) 

Decoction  of  altliea,      .......     5^  ounces  (165  gm.) 

Cane-sugar,  .......     2      drams  (     8  gm.) 

M.     Sig. — A  tablespoonful  ever}'  two  or  three  hours. 

This,  he  says,  relieves  the  unpleasant  sensation  and  longing  for  drink  and 
restores  the  appetite. 

Various  means  have  been  at  different  times  resorted  to  with  the  object 
of  disgusting  the  victim  with  alcohol.  C.  Carter  strongly  commends  atro- 
pin,  because  of  its  physiological  antagonism  to  alcohol.  He  says  that  if 
small  doses — less  than  i-ioo  grain  (0.00066  gm.) — of  atropin  be  adminis- 
tered hypodermically  three  or  four  times  a  day  to  a  victim  of  the  alcoholic 
habit,  it  will  produce  a  great  distaste  for  alcoholic  liquor  in  from  one  to  five 
days.  Whisky  will  become  repellent  both  to  sight  and  smell,  and  will  have 
a  most  intolerable  taste,  resembling  that  of  turpentine  or  benzine.  If,  under 
these  circumstances,  drinking  is  still  attempted,  nausea  and  vomiting  follow 
without  the  addition  of  apomorphin  or  other  emetic  to  the  liquor. 

Treatment  of  Mania  a  Potu. 

The  first  indication  after  withdrawal  of  the  alcohol  is  to  secure  sleep. 
For  this  purpose  the  soporifics  previously  named  scarcely  suffice,  though  they 
may  be  tried  in  the  full  doses  specified.  Especially  may  we  hope  to  obtain 
some  result  from  the  hyoscin  in  doses  of  1-96  grain  (0.0007  gm.)  given  hypo- 
dermically. In  many  cases  of  delirium  tremens  it  is  scarcely  possible  to  do 
without  morphin,  which  may  be  given  hypodermically  in  1-4  grain  (0.0165 
gm.)  doses,  caution  being  observed  not  to  repeat  too  often.  Chloralose 
may  be  given  in  from  five-  to  ten-grain  (0.33  to  0.66  gm.)  doses,  dissolved 
in  warm  water ;  it  has  the  advantage  of  small  doses,  equal  in  effect  to  the 
largest  of  chloral,  while  it  also  diminishes  tremor  and  has  no  harmful  sec- 
ondary effects.  R.'  Bellamy  gives  twenty  grains  ( 1.32  gm.)  of  trional,  mixed 
in  water,  with  ten  minims  (0.62  c.  c.)  of  tincture  of  capsicum,  after  a  calomel 
purge.  A  ver\-  hot  bath  is  given,  of  which  the  temperature  is  gradually 
lessened.  If  in  thirty  minutes  the  delirium  shows  no  signs  of  abatement,  ten 
grains  of  trional  (0.65  gm.)  are  again  given.  In  all  cases  forced  feeding  in 
small  quantities  often  repeated  is  practiced,  the  diet  consisting  of  milk,  eggs, 
and  soups.  Paralydehyd  in  fluid  dram  (3.7  c.  c.)  doses  is  a  remedy  which  may 
be  expected  to  be  of  service.  The  fluid  extract  of  ipecac  has  recently  been 
recommended  by  W.  F.  Waugh.  of  Chicago,  to  produce  sleep,  in  from 
twenty-  to  thirty-minim  (1.23  to  1.85  c  c.)  doses  in  water,  followed  by 
dorsal  decubitus  for  at  least  five  minutes  to  avert  nausea.  A  cold  bath 
sometimes  has  a  tranquilizing  effect,  especially  if  there  is  fever,  or  spong- 
ing the  body  may  suffice.  Many  things  must  be  done  to  keep  the  patient 
occupied,  because,  after  all,  the  treatment  amounts  for  the  most  part  to  a 
conflict  between  the  patient  and  faithful  attendants  and  the  irrepressible 
and,  at  timics.  almost  maniacal  desire  of  the  patient  to  get  away.  In  pre- 
venting this  it  may  sometimes  be  necessary  to  confine  him  to  bed,  but  all 


THE  MORPHIN  HABIT.  ii6r 

gentleness  should  be  exercised  in  carrying  out  this  measure.  It  is  much 
better  to  use  a  folded  sheet  than  the  unsightly  straps  which  are  sometimes 
used  in  hospitals. 

I  have  said  that  alcohol  may  be  withdrawn  at  once.  Some  object  to 
this  because  of  fear  of  resulting  adynamia,  and  it  may  happen  that  there  is 
great  weakness,  as  indicated  by  frequent  and  feeble  pulse  demanding  alcohol. 
As  a  rule  it  is  much  better  to  stimulate  with  the  aromatic  spirit  of  am- 
monium, digitalis,  and  strychnin,  1-2  dram  (2  gm.)  doses  of  the  first,  ten 
minims  (0.62  c.  c.)  of  the  second,  and  1-30  grain  (0.0022  gm.)  of  strychnin 
being  given  every  three  hours  to  overcome  such  weakness.  Even  larger 
doses  may  be  demanded  by  emergencies.  Nourishing  food  in  easily  as- 
similable shape,  repeated  at  short  intervals,  should  be  insisted  upon  as  the 
best  substitute  for  alcohol.  With  the  first  sound  sleep  comes,  usually,  relief,, 
and  the  patient  awakes  convalescent,  unless,  as  already  said,  the  mania  is  ac- 
companied by  acute  disease,  like  pneumonia,  when  death  is  apt  to  be  the 
termination,  whatever  our  efforts. 


THE  MORPHIN  HABIT. 

Synonym. — Morphinism. 

Definition. — An  irresistible  craving  for  morphin,  which  is  commonly 
used  in  gradually  increasing  daily  doses  to  meet  the  demand.  Periodic  at- 
tacks, or  "  morphin  sprees,"  comparable  to  alcohol  sprees,  during  which 
large  quantities  are  used  for  the  time  being,  also  occur. 

Etiology. —  The  morphin  habit  is  most  frequently  acquired  as  the 
result  of  long-continued  administration  of  morphin,  by  a  physician's  order 
or  otherwise,  to  relieve  some  suffering  caused  by  a  painful  or  incurable 
malady  or  for  insomnia.  The  influence  of  heredity  in  favoring  the  forma- 
tion of  the  habit  is  acknowledged.  Neurotic  persons  are  more  apt  to  become 
its  victims.  The  victim  of  alcohol  often  becomes  a  morphin  fiend,  being 
deluded  by  earlv  experience  with  the  drug  to  believe  that  he  can  thus  over- 
come the  previous  more  disgusting,  if  not  more  terrible,  habit.  The  same 
is  true  of  cocain. 

The  quantities  consumed  are  often  enormous,  as  much  as  400  grains 
(25.92  gm.)  as  a  daily  dose  being  reported. 

Symptoms. — The  chief  symptom  is,  of  course,  the  craving  for  mor- 
phin, but  it  brings  with  it  others  which  are  more  or  less  temporarily  re- 
lieved by  a  dose  of  the  drug.  Among  these  are  irresolution  and  loss  of  self- 
control,  and  a  moral  obliquity  similar  to  that  induced  by  alcohol,  especially 
in  women,  who  are  the  most  frequent  subjects.  Untruthfulness,  especially 
with  regard  to  the  drug  and  the  quantities  used,  is  habitual.  Epigastric 
pain  or  nausea,  or  both,  are  frequently  complained  of-  toward  the  time 
when  another  dose  is  due.  though  whether  this  is  actual  or  feigned  is  not 
always  easily  determined.  Mental  depression  is  a  more  constant  and  char- 
acteristic symptom,  associated  with  intense  anxiety,  restlessness,  and  a  sense 
of  impending  evil,  both  relieved  for  a  time  by  the  dose.  All  of  these 
symptoms  are  increased  by  a  more  pfolonged  withdrawal  of  the  drug,  when 
the  mental  depression  becomes  intense,  sometimes  impelling  to  suicide.  So- 
far  from  the  usual  constipating  effect  of  morphin  being  produced  by  the 
drug  thus  used,  diarrhea  is  not  infrequent. 


ii62  THE  INTOXICATIONS. 

As  the  habit  is  prolonged  tremor,  paresis,  and  more  rarely  ataxia  are 
superadded,  while  diffuse  and  neuralgic  pain  is  complained  of.  Sleep  is 
irregular,  digestion  is  bad,  and  appetite  and  nutrition  fail,  the  pulse  becomes 
feeble  and  rapid,  vasomotor  derangements  appear,  as  shown  by  a  tendency 
to  sweating  and  by  dilatation  of  the  pupils.  Except  when  under  the  direct 
influence  of  the  drug  the  patient  grows  weak  and  becomes  a  ready  victim 
to  acute  disease. 

On  the  other  hand  the  opium  eater  sometimes  attains  old  age,  pre- 
senting a  wizened,  sallow  appearance  quite  characteristic.  The  pleasurable 
effect  so  often  ascribed  to  opium  is  rarely  realized,  though  it  is  ,not  unlikely 
that  a  certain  amplification  and  distortion  of  actual  facts  which  may  arise 
in  the  dreamy  state  may  form  the  basis  of  such  weird  and  beautiful  fancies 
as  are  pictured  by  DeQuincey. 

Diagnosis  and  Prognosis. — The  diagnosis  is  easy,  but  the  prognosis 
is  exceedingly  uncertain  because  of  the  difficulty  in  carrying  out  treat- 
ment. 

Treatment. — Successful  treatment  is  scarcely  possible  outside  of  an 
institution,  and  even  within  one  serious  difificulties  beset  the  way,  the  chief 
of  which  is  the  deception  practiced  by  the  patient.  Patients  should  be 
divested  of  their  own  clothing  and  put  to  bed  in  hospital  garb,  because  in 
this  way  alone  can  we  be  sure  that  morphin  is  not  concealed  about  the 
person.  In  the  case  of  women,  whenever  possible,  a  special  nurse  should 
be  assigned  to  each  case.  The  latest  testimony  favors  complete  and  sudden 
withdrawal  of  the  drug  as  furnishing  a  short  struggle,  though  a  severe  one. 
Such  treatment  is. usually  followed  by  diarrhea,  vomiting,  and  insomnia. 
Some  counsel  even  that  no  adjuncts  should  be  employed,  but  certainly  there 
can  be  no  harm  in  the  employment  of  general  tonic  treatment  and  remedies 
directed  to  the  irritability  of  the  stomach  and  torpor  of  the  liver.  A  calo- 
mel purge  is  useful  at  the  start.  It  is  a  well-established  fact  that,  as  in 
alcoholism,  the  patient  should  be  well  nourished,  given  such  food  as  milk, 
cream,  beef- juice,  or  beef  peptonoids,  rich  broths,  and  beef-tea.  When  there 
is  great  asthenia,  aromatic  spirit  of  ammonium,  strychnin,  and  digitalis 
may  be  given  as  directed  under  alcoholism.  If  possible,  an  occupation  of 
an  absorbing  kind  should  be  furnished.  In  most  cases  it  is  impossible  to 
secure  the  consent  of  the  patient  to  sudden  and  complete  withdrawal,  when 
the  gradual  plan  must  be  adopted.  The  success  of  either  plan  depends  on 
securing  effectual  control  of  the  patient,  and  if  this  cannot  be  obtained,  all 
efforts  fail. 

To  promote  sleep,  one  of^  the  numerous  hypnotics  in  which  the  pres- 
ent day  is  rich  should  be  given.  Chloralamid  is  probably  the  best  of 
these.  It  is  not  easy  of  administration,  because  of  its  pungent  taste  and 
difficult  solubility.  Twenty  grains  (1.32  gm.)  or  thirty  grains  (1.98  gm.) 
are  a  moderate  dose,  and  are  easily  soluble  in  a  fluid  dram  (3.7  c.  c.)  of  a 
mixture  of  two  parts  alcohol  and  one  part  glycerin.  Of  such  solution  two 
teaspoonfuls  should  be  given  in  a  glass  of  sherry  wine  or  four  tablespoon- 
fuls  of  milk  at  the  ordinary  temperature.  Trional  and  sulphonal  or  som- 
nal  may  be  given  in  from  fifteen  to  twenty-grain  (0.99  to  1.32  gm.)  doses  dis- 
solved in  hot  water.  Hyoscin  in  doses  of  1-96  grain  (0.0007  gm.)  may  also 
be  tried.  Chloral  itself  may  be  used  in  doses  of  from  ten  to  thirty  grains 
(0.66  to  1.98  gm.).  If  there  is  cardiac  weakness,  the  dose  should  not  exceed 
ten  grains  (0.66  gm.).  Chloralose  may  be  given  in  from  five  to  ten-grain 
(0.33  to  0.66  gm.)  doses  in  wafers  or  in  hot  milk 


COCAINISM.  1 163 

Too  much  carelessness  is  practiced  by  physicians  in  placing  morphin 
in  the  hands  of  patients  to  be  used  at  their  pleasure.  The  hypodermic 
syringe  has  wrought  untold  mischief,  and  should  never  be  placed  in  the 
hands  of  patients.  On  the  other  hand,  when  morphin  is  judiciously  ordered 
for  patients  suffering  extreme  pain  only,  it  is  very  rarely  the  case  that  a 
habit  is  established. 


CHLORALISM. 

Definition. — The  chloral  habit  or  the  habitual  use  of  chloral. 

This  habit  is  sometimes  acquired  when  the  drug  is  used  to  obtain  sleep 
or  prescribed  by  the  physician  for  any  purpose. 

Symptoms. — For  symptoms  and  treatment  of  acute  chloral  poisoning 
see  page  1185. 

The  presence  of  the  chloral  habit  is  characterized  by  nervousness, 
mental  weakness,  and  depression  of  spirits,  even  to  a  degree  of  melancholia. 
There  may  also  be  general  weakness,  characterized  by  muscular  tremor  and 
cardiac  palpitation.  Lowered  temperature  is  characteristic.  These  symp- 
toms are,  aggravated  by  sudden  withdrawal  of  the  drug.  There  is  some- 
times dyspnea,  aggravated  at  meals  or  after  exertion.  Mania  and  dementia 
are  reported. 

Various  skin  eruptions  or  a  tendency  toward  them  are  a  symptom. 
Though  there  may  be  no  eruption,  the  slightest  exertion  or  a  glass  of  wine 
will  produce  an  intense  erythematous  redness  on  the  face  and  elsewhere  on 
the  body.  This  erythema,  which  may  also  extend  to  the  mucous  membranes 
is  ascribed  to  vasomotor  weakness.  There  may  be  diarrhea  from  the  same 
cause. 

Treatment. — Treatment  requires  the  gradual  withdrawal  of  the  drug 
and  cardiac  stimulation  by  ammonia  and  digitalis,  the  use  of  nutritious  food, 
tonics,  massage,  and  electricity.  For  insom^nia,  if  needed,  sulphonal  or 
trional,  administered  as  previously  directed,  are  more  suitable  than  chlorali- 
mid.  In  extreme  cases  morphin  may  be  used.  It  is  not  usually  difficult  to 
master  the  habit. 

COCAINISM. 

Cocainism  has  become  a  comparatively  frequent  modern  habit.  It  is 
especially  common  among  physicians,  some  of  whom  acquire  the  habit  in 
tentative  local  applications  to  their  own  mucous  membranes  in  the  treatment 
of  patients.  I  have  known  three  successive  chiefs  of  clinic  in  throat  and 
nose  dispensary  service  to  acquire  the  habit.  Cocain  is  also  taken  as  a  sub- 
stitute for  some  other  drug,  and  its  subjects  are  very  apt  to  be  those  with 
neuropathic  tendencies. 

Symptoms. — The  effect  is  a  total  demoralization  of  the  individual,  who 
loses  all  moral  responsibility,  delaying  and  neglecting  appointments  in  the 
most  remarkable  manner.  There  is  volubility  of  tongue,  suggesting  alco- 
holism, and  the  presence  of  hallucinations,  w^hich  also  resemble  those  of  the 
alcoholic  effect.  The  eyes  are  bright,  and  the  pupils  are  dilated.  The  sub- 
ject becomes  suspicious,  charging  his  wife  with  infidelity,  and  his  best  friend 
Mrith  persecuting  him.  Hallucinations  of  hearing,  sight,  and  smell  are  some- 
limes   present,   including   tinnitus    aurium.     Mild    epileptoid    seizures,    with 


1 1 64  THE  INTOXICATIONS. 

partial  loss  of  consciousness,  may  occur,  limited  to  muscle  groups,  as  about 
the  eyes.  Nystagmus  is  also  a  symptom.  The  pulse  becomes  weak  and 
feeble.  The  symptoms  are  often  associated  with  those  of  alcoholism  and 
opium. 

A  symptom  to  which  a  certain  amount  of  diagnostic  value  has  been 
attached  is  a  sensation  of  foreign  bodies  under  the  skin.  In  one  case  ob- 
esrved  by  Rybakoft'  of  Moscow,  was  a  sensation  as  of  worms  beneath  the 
skin.     The  recognition  of  the  symptom  is  ascribed  to  M.  Magnan  of  Paris. 

Treatment. — If  uncomplicated,  treatment  is  promising.  It  mainly 
requires  withdrawal  of  the  drug,  which  should  be  total.  The  g,ssistance  of 
a  trusty  nurse  or  friend  may  be  needed,  but  it  is  not  often  necessary  to  re- 
move the  patient  to  a  sanitarium — I  am  speaking  of  uncomplicated  cases. 
Cases  complicated  with  alcoholism  or  the  opium  habit  are  more  difficult  to 
handle,  and  incarceration  in  an  institution  becomes  necessary. 

Tonics  of  the  usual  kind — strychnin,  in  full  doses,  and  quinin — should 
be  ordered.  Non-intoxicating  stimulants,  like  ammonia  and  coffee,  should 
be  given  to  counteract  the  depressing  effect,  while  good,  nourishing,  easily 
assimilable  food  is  necessary. 

THE  TOBACCO   HABIT. 

To  Cure:  Apomorphin,  1-30  grain  (0.0022  gm.),  fresh  and  pure,  every 
two  hours,  increasing  the  dose  until  slight  nausea  is  felt. 


BISULPHID  OF  CARBON  POISONING 

should  be  mentioned.  Considerable  has  been  written  on  it  in  the  German 
literature  lately.  It  occurs  in  the  vulcanization  of  rubber.  A  characteristic 
symptom  of  the  chronic  form  is  neuritis  with  resulting  paralysis  like  that  of 
lead  poisoning. 

LEAD  POISONING. 

Synonyms. — Colica   pktonum;   Plumbism;   Saturnism;   Devonshire   Colic. 

Definition. —  A  disease  of  manifold  symptoms  resulting  from  the  toxic 
effect  of  lead  on  the  system,  having  its  subjects  mainly  among  workers  in 
lead-works,  and  among  painters,  glaziers,  and  plumbers. 

Etiology. — The  lead  enters  the  system  by  inhalation,  through  the  diges- 
tive tract,  or  by  the  skin.  Almost  without  exception  the  cases  I  have  had  in 
hospital  were  from  the  lead-works  in  the  neighborhood  of  Philadelphia. 
The  Philadelphia  Hospital  is  almost  never  without  one  or  more  such  cases. 
Even  animals  in  the  neighborhood  of  lead-works  are  said  to  have  had  the 
disease ;  also  birds  which  have  been  fed  on  berries  grown  in  the  vicinity  of 
such  works.  Water  which  has  been  kept  in  lead  tanks,  or  even  painted 
tanks,  or  water  passed  through  lead  pipes,  has  produced  the  disease.  It 
must,  however,  be  very  pure  water,  such  as  rain  water,  and  it  is  the  very 
impurities  of  our  drinking-waters  which  protect  us.  Almost  all  drinking- 
waters  contain  sulphate  of  lime,  the  sulphuric  acid  of  which  combines  with 
the  superficial  layer  of  lead  and  forms  an  insoluble  coating  of  sulphate  of 
lead  which  prevents  further  solution. 


LEAD  POISONING.  1165 

Accidental  contamination  has  been  caused  by  the  use  of  cosmetics  and 
hair  dyes.  To  the  use  of  chrome  yellow  as  a  substitute  for  eggs  for  color- 
ing were  traced  a  number  of  cases  occurring  in  Philadelphia  in  a  very  inter- 
esting study  by  Dr.  D.  D.  Stewart.*  Even  the  use  of  vegetables  canned  in 
tin  vessels  is  held  to  have  produced  lead  poisoning. 

All  grades  of  what  is  known  as  tin,  which  is  really  iron  coated  with  a 
layer  of-  tin,  contain  a  small  quantity  of  lead ;  and  the  more  inferior  the  tin, 
the  larger  the  quantity  of  lead.  Certain  conditions  favor  the  solution  of  this 
lead.  Thus,  if  any  of  the  vegetable  acids,  as  acetic,  tartar,  or  citric,  be 
present,  they  may  dissolve  the  lead  and  form  soluble  salts,  which  are  readily 
absorbed.  Of  course,  such  solution  is  favored  by  prolonged  action  of  the 
acids;  hence  old  canned  vegetables  are  more  dangerous  than  those  recently 
canned,  and  it  would  be  a  wise  measure  to  insist  that  canned  foods  should  be 
stamped  with  the  date  of  the  canning.  The  solder  used  in  closing  the  cans 
may  also  be  a  cause  of  poisoning.  When  it  is  considered  how  enormous  is 
the  consumption  of  canned  foods,  and  how  few  the  cases  of  lead  poisonmg 
traceable  to  it,  it  is  evident  that  even  moderate  precautions  may  suffice  to 
remove  the  danger  altogether. 

Among  the  more  rare  cases  of  lead  poisoning  may  be  named  materials 
used  in  making  rag  carpets, f  cooking  in  badly  glazed  crockery-ware,  beer 
drawn  through  lead  pipes,  or  beer,  cider,  and  wine  from  bottles  which  have 
been  washed  with  shot  of  which  some  have  been  left  behind,  the  use  of  snufif 
packed  in  spurious  tin-foil  containing  lead,  and  from  sleeping  on  mattresses 
the  hair  in  which  was  dyed  black  by  some  lead-containing  substance ;  and 
one,  a  most  incredible  case,  mentioned  by  Naunyn,  is  that  of  a  proof-reader 
who  was  poisoned  after  many  years'  reading  of  printed  proof.  Notwith- 
standing the  solubility  of  the  acetate  of  lead  so  much  used  in  medicine,  it  is 
very  rare  that  poisoning  has  resulted  from  its  administration,  and  there  need 
be  no  fear  of  using  it  for  the  purposes  in  which  it  is  indicated  until  at  least 
two  drams  (7.4  c.  c.)  have  been  given. 

It  has  always  been  an  interesting  question  how  lead  in  the  system 
operates  to  produce  its  peculiar  effects.  That  the  lead  itself  lodges  in  the 
tissues  is  easy  of  demonstration,  and  analysts  have  gone  so  far  as  to  deter- 
rnine  the  exact  quantity  in  the  dififerent  tissues  of  animals  poisoned  by  lead ; 
which,  by  the  way,  is  surprisingly  small,  the  largest  amount  found  being  1-4 
of  one  per  cent,  in  the  bones,  while  that  in  the  muscles  was  but  2-1000  to 
3-1000  of  one  per  cent.  On  the  other  hand,  it  would  seem  that  lead  is  con- 
tained in  the  tissues  of  many  persons  who  are  healthy — according  to  J.  J. 
Putnam,  in  25  per  cent.  It  was  formerly  customary  to  ascribe  the  symptoms 
of  lead  poisoning  in  part  to  the  direct  action  of  lead  in  the  tissues ;  the 
cramps  and  the  palsy  to  the  presence  of  lead  in  the  muscular  substance ;  the 
colic  to  the  lead  in  the  unstriped  muscular  fiber-cells,  and  the  nervous  symp- 
toms to  the  lead  in  the  nerve-centers.  In  part,  too.  these  phenomena  were 
ascribed  to  anemia  of  the  tissues,  due  to  the  contraction  of  the  arterioles, 
stimulated  by  the  presence  of  lead  in  the  muscular  coat  of  the  vessel.  More 
recently,  however,  the  soundness  of  these  views  has  been  shaken  by  some 
experiments  of  Huebel.  Lead  causes  degeneration  of  nerve-cells  and  nerve- 
fibers.  The  changes  thus  induced  in  the  cell  bodies  of  the  neurons  have  been 
studied  by  Lugaro,  by  Nissl's  methQd.     In  accordance  with  these  views  the 

*  "  Philadelphia  Med.  News,"  June  i8  and  December  21,  1887. 

+  A  very  interesting- case  thus  caused  is  reported  by  Drs.  J.  Milton  Miller  and  G.  Oram  Ring  in 
the  "  Amer.  Jour,  of  the  Med.  Sciences  "  for  February,  1896,  p.  193. 


ii66  THE  INTOXICATIONS. 

symptoms  have  been  ascribed  to  altered  function  in  the  nerve  centers  thus 
affected.  The  phenomena  of  lead  poisoning  have  been  compared  to  those  of 
chronic  alcoholism,  which  are  ascribed  to  effects  upon  the  nerve-centers,  of 
circulating  blood  charged  with  alcohol. 

Some  recent  studies  by  Strauss  and  Phillipson  on  metabolic  changes  in 
lead-poisoning  found  certain  toxic  products  of  decomposition  in  the  intes- 
tines which  it  is  reasonable  to  suppose  might  produce  the  symptoms  in  lead 
cases.  Whether  the  lead  or  the  atony  of  the  bowel  produced  these  toxins 
could  not  be  proven. 

Most  cases  occur  among  adults,  usually  between  the  ages  of  thirty  and 
forty,  but  in  children  occasionally.  Women  are  said  to  be  more  j^redisposed 
than  men,  as  four  to  one,  and  to  be  more  readily  brought  under  its  influence. 

The  period  of  exposure  necessary  to  produce  lead  poisoning  varies 
greatly,  from  a  month  to  many  years. 

Morbid  Anatomy. —  This  is  not  striking.  Tissue  may  contain  a  con- 
siderable amount  of  lead  without  exhibiting  changes.  Fatty  degeneration 
and  fibrosis  are,  however,  characteristic.  Thus,  the  muscles  become  fatty 
and  fibroid.  The  kidneys  gradually  lose  their  parenchymal  cells  and  become 
fibroid,  while  nerves  exhibit  fatty  degeneration.  In  the  spinal  cord  are 
found  in  chronic  lead  poisoning  the  changes  characteristic  of  anterior  polio- 
myelitis— i.  e.,  sclerosis  of  the  anterior  cornua,  with  atrophy  of  the  cells 
and  nerve-fibers,  but  the  remainder  of  the  cord  and  nerve-roots  are  not 
altered.  Demonstrable  changes  in  the  central  nervous  system,  even  when 
there  are  symptoms  of  lead  encephalopathy,  are  not  numerous.  In  32  out  of 
71  cases  Tanquerel  found  none.  Von  Monkalow  discovered  a  high  degree 
of  atrophy,  especially  marked  over  the  frontal  region  at  the  vertex,  and  in 
the  crura  cerebri.  Small  hemorrhages  in  various  parts  of  the  brain  and 
atheroma  of  the  arteries  have  been  noticed ;  also  overgrowth  of  connective- 
tissue.     Severe  enterocolitis  has  been  found  in  acute  cases. 

Symptoms. — While  the  symptoms  which  make  known  the  presence  of 
lead  poisoning  are  at  times  rapid  in  their  development  and  at  others  slow  to 
appear,  there  seems  on  this  account  scarcely  sufficient  reason  for  dividing^ 
them  into  two  classes  of  acute  and  chronic. 

The  most  striking  of  the  symptoms,  and  often  the  first  to  which  atten- 
tion is  called,  is  colic.  Indeed,  it,  with  constipation,  next  to  be  considered, 
is  often  the  sole  manifestation  of  the  disease,  and  from  these  two  alone  a 
diagnosis  may  be  made,  after  exposure  to  lead  absorption.  The  term  lead 
colic  has  long  been  a  recognized  term  in  medical  terminology.  It  is  most 
frequent  in  the  region  of  the  umbilicus,  and  is  often  relieved  by  pressure. 
It  varies  greatly  in  degree,  being  sometimes  a  simple  grumbling  pain,  at 
others  of  extreme  severity,  the  patient  writhing  in  the  paroxysm.  This,  as 
a  rule,  does  not  last  long,  but  is  soon  followed  by  another.  On  the  other 
hand,  the  pain  may  continue  for  hours  or  until  relief  is  afforded  by  treat- 
ment. It  is  probably  due  to  powerful  contractions  of  the  muscular  wall  of 
the  intestine,  by  which  the  nerve  filaments  distributed  through  it  are  com- 
pressed. As  contrasted  with  flatulent  colic,  the  abdomen  is  not  distended, 
but  flat,  and  may  even  be  contracted,  sometimes  so  much  so  that  it  is  said 
that  the  vertebrae  may  be  discerned  through  the  abdominal  walls.  Yet  dis- 
tention of  the  abdomen  is  occasionally  present.  The  pulse  during  the  at- 
tacks of  colic  is  often  strikingly  slowed,  having  been  noticed  as  infrequent 
as  30  beats  in  a  minute. 

Groups  of  muscles  anywhere,  and  especially  the  flexor  muscles,  as  of 


LEAD  POISONING.  1167 

the  arms  and  legs,  become  involved  in  cramp,  the  latter  more  frequently. 
There  may  also  be  cramps  in  the  fingers  and  toes.  In  addition  to  these  pain- 
ful cramps,  which,  like  the  colic,  are  intermittent,  there  is  pain  in  the  neigh- 
borhood of  the  joints.  The  sum  of  these  painful  joints  and  muscles  has 
received  the  name  arthralgia  saturnina.  They  are  quite  frequent,  occurring, 
according  to  statistics  of  Tanquerel,  in  755  out  of  215 1  cases. 

Constipation  is  very  common,  even  more  commonly  present  than  the 
colic,  and  yet  it  is  not  invariable,  and  may  even  be  substituted  by  diarrhea. 

A  blue  line  on  the  patient's  gums  is  a  very  characteristic  symptom,  and 
appears  at  the  border  of  contact  of  the  gums  with  the  teeth,  or  just  above  it. 
As  a  rule,  it  is  easily  recognized  when  present.  It  is  caused  by  the  pres- 
ence of  sulphuret  of  lead,  produced  by  the  action  of  sulphureted  hydrogen 
upon  the  lead  in  the  tissue  of  the  gums.  Hence  the  line  is  more  common 
and  distinct  on  the  gums  of  those  who  take  no  care  of  the  mouth,  and  in 
whom  sulphureted  hydrogen  is  generated  in  the  decomposition  of  the  food. 
This  line  often  remains  after  all  other  symptoms  have  subsided,  and  although 
it  is  not  invariably  present,  its  disappearance  may  be  considered  as  quite  a 
certain  sign  that  the  lead  has  been  practically  eradicated. 

Anemia  is  a  very  constant  symptom  in  lead  poisoning,  and  its  higher 
degrees  are  attended  by  a  sallowness  which  early  gave  rise  to  the  term  icterus 
saturnimis,  but  which  is  in  no  way  due  to  a  deposit  of  bile  pigment.  In: 
more  serious  cases,  too,  the  impaired  nutrition  results  in  an  emaciation  which: 
is  sometimes  extreme.  Along  with  the  anemia  there  is  often  loss  of  appetite, 
and  frequently  a  szveetish  taste  and  fetid  breath. 

Comparatively  recent  studies  have  found  associated  with  lead  poisoning 
in  common  with  other  toxic  conditions  a  granular  degeneration  of  the 
erythrocytes.  The  granular  change  which  responds  to  the  basophilic 
stains  was  first  investigated  by  Geelmyden,  Hausemann,  Von  Noorden  and 
others,  but  Grawitz  was  the  first  (1889)  to  lay  particular  stress  on  the  con- 
dition as  evidence  of  a  special  form  of  degeneration.  It  would  appear  from 
the  recent  studies  of  Stengel,  White,  and  Pepper  *  that  no  poison  thus  far 
studied  is  as  regular  in  its  production  of  degeneration  or  as  prompt  in  its. 
action  as  lead. 

Another  symptom  of  great  importance  is  muscular  paralysis.  This,. 
in  contrast  with  muscular  cramp,  is  more  likely  to  involve  extensor  muscles 
than  flexors,  and  especially  those  of  the  wrist,  giving  rise  to  the  very  char- 
acteristic symptom  known  as  "  wrist-drop,"  which,  in  Tanquerel's  experience, 
occurred  in  107  out  of  215 1  cases.  Usually  it  is  not  until  the  colic  and 
arthralgia  present  themselves  that  the  wrist-drop  appears.  On  the  other 
hand,  it  has  been  the  first  symptom  observed.  It  may  last  but  a  few  days, 
or  it  may  resist  all  treatment.  It  may  affect  a  single  muscle  or  groups  of 
muscles.  It  is  further  characterized  by  the  fact  that  the  muscles  affected  are 
subject  to  rapid  and  extreme  atrophy,  so  that  they  seem  almost  to  disappear. 
Dislocations  of  the  more  movable  joints,  as  the  shoulders  and  phalanges,  may- 
occur  in  consequence.  While  sensibility  is  but  slightly  impaired,  electro- 
muscular  contractility  rapidly  disappears.  The  muscles  cease  to  respond  to 
the  faradic  current,  while  the  reaction  to  galvanism  is  unchanged  or  slightly 
increased  at  first. .    Tremor  of  the  paralyzed  muscles  is  often  observed. 

Another  set  of  symptoms  of  lead  poisoning  not  uncommon  are  those 
due  to  involvement  of  the  central  nervous  system.     Occurring  usually  only 

♦"Further  Studies  of  Granular  Degeneration  of  Erythrocytes,"   "American  Journal  of  the 
Medical  Sciences,"  May,  1902. 


ii68  THE  INTOXICATIONS. 

in  those  who  are  pecuharly  exposed,  they  come  on  in  from  eight  days  to  fifty 
years,  the  majority  showing  themselves,  according  to  Tanquerel,  within  the 
first  nine  months.  The  most  frequent  mode  of  manifestation  is  in  eclampsia 
independent  of  Bright's  disease.  True  epilepsy  may  follow  these  convul- 
sions. But  there  may  be  headache  or  amaurosis,  optic  neuritis,  apathy, 
stupor,  or  the  opposite  condition  of  maniacal  excitement  or  melancholia  and 
hallucinations.  In  a  few  cases  of  lead  poisoning  the  symptoms  are  limited 
to  the  central  nervous  system — in  /2  out  of  1390  cases  observed  by  Tan- 
querel.    Tremor  is  a  frequent  nervous  symptom  of  lead  poisoning. 

A  frequent  complication  of  lead  poisoning,  more  especially  when  it  has 
been  present  for  some  time,  is  interstitial  nephritis,  and  its  resulting  morbid 
product,  the  contracted  kidney,  as  shown  by  the  presence  of  a  small  degree 
of  albuminuria  and  hyaline  tube-casts ;  and  as  this  is  the  form  of  kidney  dis- 
ease in  which  uremic  convulsions  are  most  frequent,  it  is  evident  that  these 
must  be  distinguished  from  the  convulsions  just  referred  to  as  part  of  satur- 
nine encephalopathy.  Hence  an  examination  of  the  urine  in  every  case  of 
lead  poisoning  should  be  early  made  in  the  study  of  the  case. 

Arteriosclerosis  is  often  a  direct  result  of  lead  poisoning,  hypertrophy 
of  the  heart,  and  interstitial  nephritis. 

Gout  is  a  well-recognized  symptom  of  lead  poisoning,  but  the  relation 
between  the  two  was  sufficiently  considered  in  treating  of  that  disease. 
True,  uratic  deposits  may  occur  in  the  big  toe  joint  and  in  the  tissues,  their 
precipitation  being  favored  by  the  lead,  which  may  act  by  diminishing  the 
alkalinity  of  the  blood,  as  suggested  by  Rolfe.  I  may  repeat,  also,  that  in 
this  country  the  association  is  an  uncommon  one. 

Prognosis. — As  to  prognosis,  it  depends  largely  upon  the  degree  of 
saturation  of  the  system  with  lead.  Ordinary  lead  colic  is  commonly  fol- 
lowed by  recovery.  As  a  rule,  therefore,  persons  who  respond  most  quickly 
to  the  action  of  the  poison  are  those  who  most  promptly  recover,  provided, 
of  course,  they  are  removed  from  the  influence  of  the  lead,  for  such  persons, 
too,  being  most  susceptible,  are  in  great  danger  from  prolonged  exposure. 
\\'e  are  enabled  to  infer  something  of  the  prognosis  from  the  symptoms 
which  are  present.  If  the  attack  be  ushered  in  by  a  colic,  and  there  be  no 
other  symptoms  except  constipation,  we  may  confidently  expect  our  patient 
to  recover  completely.  If  there  be  arthralgia  and  palsy,  the  prospect  is  less 
certain,  still  less  so  if  there  be  atrophy,  and  least  of  all  if  there  be  enceph- 
alopathy, though  even  here  recovery  may  take  place.  Contracted  kidney  due 
to  lead  poisoning  is  also  usually  incurable.  Xo  favorable  prognosis  should 
be  given  when  the  patient  is  unable  to  remove  himself  from  the  cause.  It 
must  be  remembered,  too,  that" relapses  occur,  often  at  long  inter\-als,  even 
when  the  patient  is  removed  from  exposure,  and  that  the  primary  disease 
has  been  known  to  make  its  appearance  a  long  time  after  exposure. 

Treatment. — ^luch  may  be  done  to  guard  against  the  occurrence  of 
lead  poisoning  by  proper  precautions  on  the  part  of  those  exposed  to  it,  and 
those  employed  in  lead-works  may  do  much  to  protect  themselves,  or  rather 
their  employers  may  do  it  for  them.  Such  persons  should  keep  themselves 
scrupulously  clean  by  frequent  hot  baths  and  frequent  changes  of  clothing, 
which  should  never  be  allowed  to  become  saturated  with  lead.  Alehu  recom- 
mends that  hypochlorite  of  sodium  be  added  to  the  hot  baths.  It  is  made 
by  mixing  in  2  1-2  gallons  (10  liters)  of  water  13  ounces  (400  gm.)  of 
chlorinated  lime  with  11  drams  (43  gm.)  of  sodium  carbonate.  Sulphur 
baths  were  recommended  by  Todd,  it  being  thought  that  sulphur  has  the 


LEAD  POISONING.  1169 

power  of  neutralizing  lead  by  forming  insoluble  compounds  with  it.  From 
two  to  four  ounces  (62.5  to  124.5  g"^-)  of  sulphuret  of  potassium  are  mixed 
in  from  twenty  to  thirty  gallons  of  water  (75.5  to  113.4  liters).  Above  all, 
the  employees  in  lead-works  should  not  be  allowed  to  eat  mcols  in  the  lead- 
factory,  as  the  metal  is  often  introduced  with  food.  Finally,  the  ventilation 
of  the  factory  should  be  of  the  best.  Experience  has  shown  that  much  may 
be  done  to  arrest  the  dangers  of  lead-works  by  such  precautions.  The  same 
remarks  as  to  cleanliness,  bathing,  and  change  of  clothing  apply  to  painters, 
and  indeed  to  all  who  have  to  do  with  lead  in  any  shape  or  degree.  It  is 
evident  that  leadlined  and  painted  cisterns  should  never  be  used  in  houses, 
that  cosmetics  and  hair-dyes  are  dangerous,  and  that  care  should  be  taken 
in  the  selection  of  canned  foods  not  to  use  those  which  have  been  too  long 
canned. 

The  curative  measures  may  be  divided  into  those  for  the  immediate  relief 
of  urgent  symptoms  and  the  removal  of  the  lead  from  the  system.  It  is 
scarcely  necessary  to  say  that  the  patient  should  be  promptly  removed  from 
the  influence  of  the  lead.  The  extreme  pain  of  lead  colic  requires  to  be  re- 
lieved by  the  hot  bath  or  poultice,  and  an  opiate,  of  which  the  best  mode  of 
administration  is  by  the  hypodermic  syringe,  1-4  or  1-3  grain  (0.016  or  0.02 
gm.)  of  sulphate  of  morphin  being  required  for  the  purpose.  Identical 
treatment  is  required  for  the  arthralgia.  The  accompanying  constipation  is 
best  relieved  by  sulphate  of  magnesium,  the  sulphuric  acid  of  which,  on 
theoretical  grounds,  at  least,  aids  in  rendering  inoperative  the  lead  which 
has  entered  the  system  by  forming  an  insoluble  sulphate. 

These  more  urgent  symptoms  being  relieved,  measures  directed  to  the 
elUnination  of  the  lead  should  be  taken.  The  hot  baths  already  referred  to, 
may  be  used  for  this  purpose,  as  well  as  for  prophylaxis,  while  purgatives 
and  diuretics  may  aid  the  elimination.  The  iodid  of  potassium  is  the  remedy 
most  rehed  upon  to  eliminate  lead.  It  is  believed  that  after  its  absorption  the 
lead  becomes  intimately  united  with  the  albumin  of  the  tissues,  forming  an 
insoluble  compound ;  that  the  iodid  of  potassium,  after  its  absorption,  com- 
l^ines  with  the  lead  and  forms  a  soluble  iodid  of  lead,  which  is  dissolved 
out,  re-enters  the  circulation,  and  is  passed  out  with  the  urine  and  feces.  It 
is  evident  that  elimination  by  these  channels  will  be  encouraged  by  purga- 
tives and  diuretics.  It  is  even  suggested  that  acute  lead  poisoning  may  be 
produced  by  the  liberation  of  the  soluble  lead  salt  into  the  blood  in  this  way. 
Hence  caution  is  suggested  in  the  use  of  the  iodid.  Practically,  I  can 
scarcely  conceive  this  to  occur  with  such  doses  as  are  ordinarily  given,  ten 
grains  (0.66  gm.)  three  times  daily,  after  a  time  reduced  to  five  (0.33  gm.), 
but  this  dose  should  be  kept  up  indefinitely.  Iodid  of  potassium  is  more  effi- 
cient when  given  fasting  and  freely  diluted. 

For  the  paralyzed  muscles  faradic  electricity  is  indicated  and  should  be 
daily  applied,  both  to  resist  the  tendency  to  atrophy  and  to  overcome  it. 

That  restorative  and  blood-making  remedies,  in  the  shape  of  nutritious, 
easily  assimilable  food,  together  with  iron,  should  also  be  given  to  antago- 
nize the  cachexia  which  is  always  a  part  of  plumbism  is  evident.  In  view 
of  the  nervous  and  muscular  symptoms  which  enter  so  largely  into  the  dis- 
ease strychnin  may  be  expected  to  be  a  useful  adjunct  to  our  treatment,  and 
it  is  generally  so  considered.  It  shot>ld  be  given  in  full  doses,  1-30  grain 
(0.0022  gm.)  three  times  a  day,  and  increased  to  1-20  grain  (0.0033  fei^^-^' 
which  should' be  kept  up.  Ergot  is  said  to  have  been  useful  in  restoring  the 
power  of  muscles  involved  in  the  palsy, 

74 


1 170  THE  INTOXICATIONS. 


ARSENICAL  POISONING. 

Acute  Arsenical  Poisoning. — Acute  arsenical  poisoning  is  usually 
the  result  of  accidental  or  intentional  ingestion  of  Paris  green  or  "  Rough  on 
Rats,"  prepared  and  sold  for  the  destruction  of  rats,  mice,  vermin,  and 
insects.     Occasionally  it  is  taken  also  with  suicidal  intent. 

Symptoms. — These  are  intense  abdominal  pain,  at  first  gastric,  with 
vomiting;  later  intestinal,  with  diarrhea  and  tenesmus,  which  may  be  fol- 
lowed by  collapse  and  death.  The  symptoms  are  not  unlike  those  of  cholera,, 
including  rice-water  stools,  cardiac  weakness,  and  cyanosis.  Sometimes  a 
skin  eruption  makes  its  appearance,  and  sometimes  blood  and  albumin  appear 
in  the  urine.     Fatal  cases  terminate  in  one  or  two  days. 

Recovery  from  these  acute  effects  may  be  followed  by  paralysis. 

Treatment. — The  ingestion  of  a  poisonous  dose  of  arsenic  is  apt  to  be 
followed  by  free  vomiting.  But  even  in  the  event  of  emesis,  mustard  or 
sulphate  of  zinc,  from  ten  to  thirty  grains  (0.068  to  0.1944  gm.),  should  be 
administered,  and  the  stomach  well  washed  out  with  draughts  of  warm 
water.  With  the  emetic  or  before  it  the  antidote  should  be  administered. 
The  best  antidote  is  freshly  precipitated  sesquioxid  of  iron,  which  forms,, 
with  arsenic,  an  insoluble  compound.  It  must  be  freshly  prepared,  taking 
any  of  the  sesqui  solutions  of  iron,  preferably  the  chlorid,  and  neutralizing 
it  with  sodium  carbonate  or  magnesia.  The  precipitate,  being  hastily 
washed  by  emptying  on  muslin  or  a  filter,  pouring  water  on  it  and  allov»^ing 
it  to  drain,  should  be  freely  administered.  Dialyzed  iron  may  be  used,  but 
it  is  best  also  precipitated  with  ammonia  or  other  alkali  before  using.  In 
extreme  cases  the  tincture  of  the  chlorid  of  iron,  Monsel's  solution,  or 
any  of  the  sesqui  preparations  may  be  substituted  for  the  precipitated  ses- 
quixod. 

After  the  emetic  has  acted,  and  while  the  antidote  is  being  given,  castor 
oil  should  be  administered  to  carry  off  the  poison  from  the  bowels. 

Chronic  Arsenical  Poisoning. — This  is  ascribed  to  wall-papers  cov- 
ering occupied  apartments,  sometimes  to  arsenic  long  administered  as 
a  medicine,  to  artificial  flowers,  and  clothing  fabrics.  The  glazed  green  and 
red  papers  are  those  especially  dangerous.  Occasionally,  arsenic  medici- 
nally administered  may  produce  the  symptoms  of  slow  arsenical  poisoning.. 

Symptoms. — Chronic  arsenical  poisoning  may  be  suspected  in  the 
presence  of  unexplained  anemia  and  debility,  irritation  of  the  conjunctiva,, 
mouth,  pharynx,  and  lower  digestive  tract,  numbness,  tingling,  and  gas- 
tralgia;  also  nervous  symptoms  and  altered  nutrition  in  special  parts.  All 
these  symptoms  may,  however,  be  produced  by  other  causes.  Paralysis 
may  also  ensue,  resembling  that  of  lead  palsy,  but  affecting  rather  the  lower 
extremities,  especially  the  extensors  and  peroneal  group,  whence  may  arise 
the  characteristic  steppage  gait  of  peripheral  neuritis.  Deranged  electrical 
reaction  may  be  present  before  any  loss  of  power,  but  on  differential  exami- 
nation a  weakened  power  of  wrist  extension  and  feeble  power  to  spread  the 
fingers  may  be   detected. 

Treatment. — The  patient  should  be  removed  from  the  exposure  and 
the  symptoms  be  treated  as  they  arise.     The  iodid  of  potassium  may  be  used> 


PTOMAIN  AND  LEUKOMAIN  POISONING.  u/i 


PTOMAIN  AND  LEUKOMAIN  POISONING. 

Ptomain,  from  the  Greek  tit cajna,  a  cadaver,  is  a  word  suggested  by  the 
Italian  toxicologist,  F.  SeHni,  for  substances  generated  in  the  decomposition 
of  organic  matter,  which  more  recent  studies  have  shown  to  be  the  resuh 
of  bacterial  action.  Ptomains  are  basic,  uniting  with  acids  to  form  salts. 
Leukomains  are  similar  basic  substances  formed  in  the  living  body. 
Ptomains  differ  greatly  in  their  character  and  properties,  certain  ones  being 
intensely  poisonous,  others  harmless.  For  the  former  L.  Brieger  suggested 
the  name  toxins,  retaining  that  of  ptomains  for  the  non-poisonous  basic 
products;  but,  as  Victor  C.  Vaughan  suggests,  there  are  difficulties  in  the 
way  of  such  classification,  because  a  ptomain  may  be  poisonous  under  cer- 
tain conditions  and  harmless  under  others. 

Leukomains  are  more  usually  harmless,  although  they  may  also  pro- 
duce disease  under  certain  conditions. 

Among  ptomain  poisons  are  the  agencies  which  are  responsible  for 
various  forms  of  meat  poisoning,  poisoning  by  milk  products,  by  shell-fish 
and  fish. 

Meat  Poisoning. — This  succeeds  the  eating  of  various  forms  of  meat 
which  has  been  the  seat  of  a  decomposition  in  the  whole  or  some  one  of  the 
constituents  of  the  mass. 

Sausage  poisoning,  also  called  botulismus  and  allantiasis,  follows  the 
eating  of  infected  sausage.  Numerous  outbreaks  have  occurred  in  Germany, 
more  particularly  in  Wurtemberg  and  adjacent  Baden.  In  1820  Kerner 
had  collected  reports  of  76  cases,  of  which  37  were  fatal,  and  in  1822  he  had 
increased  the  number  to  155,  with  84  fatal.  The  poisonous  qualities  are  re- 
ferred to  defective  methods  of  preparation  which  permit  decomposition. 

Ham  poisoning  not  due  to  trichina  has  occurred  in  England,  Germany, 
and  Switzerland,  while  poisoning  has  also  been  traced  to  beef,  mutton,  veal, 
turkey,  and  goose-grease,  and  in  America  to  canned  meats.  Some  of  these 
must  be  ascribed  to  muriate  of  zinc  and  tin,  but  others  are  doubtless  due  to 
the  meats.  Poultry,  especially  if  kept  too  long,  and  game  birds  also  prove 
poisonous  at  times. 

Symptoms. — The  symptoms  of  various  epidemics  vary  somewhat,  but 
the  following  are  more  constant,  after  a  period  of  incubation  of  from 
one  to  forty-eight  hours :  nausea,  vomiting,  cramps,  and  diarrhea — in  a 
word,  acute  gastro-intestinal  irritation.  To  these  may  be  added  dryness 
of  the  mouth,  constriction  of  the  throat,  difdciilty  in  szuallowing,  vertigo, 
indistinctness  of  vision,  dilatation  of  pupils,  while  sometimes  constipation 
substitutes  diarrhea.  Thirst,  headache,  and  muscular  weakness  may  also  be 
present. 

The  symptoms  may  begin  at  once  without  incubation  in  a  feeling  of  lan- 
guor and  general  m.alaise,  loss  of  appetite,  nausea,  and  griping  pain  in  the  belly. 

In  fatal  cases  the  symptoms  of  cholera  are  simulated,  such  as  cramps 
in  the  legs  or  arms,  or  both,  muscular  twitchings,  stiffness  of  the  joints, 
drowsiness,  coldness  of  surface,  pinched  features,  blueness  of  fingers  and  toes 
and  around  the  sunken  eyes — in  a  word,  the  symptoms  of  collapse.  On  the 
other  hand,  the  temperature  sometirr^es  rises  to  101°  to  103°  F.  (38.3°  to 
39.4°  C.),  with  a  pulse  of  from  100  to  128. 

Poisoning  by  Milk  and  its  Products. — The  causes  of  poisoning  by 
cheese  claimed  attention  as  far  back  as   1827,  when  analyses  of  poisonous 


1 172  THE  INTOXICATIONS. 

cheeses  were  made  by  Hunnefeld.  The  older  view  that  the  poisons  are  fatty 
acids  has  been  refuted,  and  Vaughan  isolated  a  ptomain  in  1884  which  he 
has  called  tyrotoxicon  (rypoV,  cheese,  and  to^zko?',  poison).  Tyrotoxicon 
was  not,  however,  always  found  by  Vaughan  in  cheeses  of  acknowledged 
poisonous  properties.  In  1885  he  found  tyrotoxicon  in  milk  which  had 
stood  in  well-stoppered  bottles  for  about  six  months,  and  in  1886  Newton 
and  Wallace  obtained  it  from  milk  which  had  poisoned  a  number  of  persons 
in  a  hotel  at  Long  Branch,  N.  J.  Since  then  tyrotoxicon  has  been  isolated 
many  times  from  poisonous  milk.  Finally,  in  1886,  Vaughan  obtained  ty- 
rotoxicon from  ice-cream  which  had  proved  poisonous,  and  since  then  it 
has  been  frequently  found  in  such  cream.  A  number  of  cases  of  poisoning 
after  eating  "  cream  puffs  "  have  been  reported  in  Philadelphia  and  else- 
where, in  which  doubtless  the  same  ptomain  is  responsible.  A  family  un- 
der my  observation  was  poisoned  by  blanc  mange,  of  which  all  had  eaten 
freely,  and  which   had   been  made   for  several   days. 

Symptoms.— The  symptoms  of  milk  and  cheese  poisoning  are  those  of 
gastro-intestinal  irritation,  comparable  in  various  degrees  to  those  described 
as  due  to  meat  poisoning,  etc 

Poisoning  by  Shell-fish  and  Fish  (Lchthysmus) . — The  mussel  fur- 
nishes the  most  frequent  source  of  poisoning  from  this  cause,  instances 
of  which  were  reported  as  early  as  1827  by  Combe.  A  ptomain  was 
isolated  by  L.  Brieger  in  1885,  from  poisonous  mussels,  at  Wilhelms- 
haven,  where  numerous  instances  occur.  Brieger  has  called  it  mytilo- 
toxin,  from  inytilis,  a  mussel.  It  is  found  chiefly  in  the  liver  of  the  mussel, 
but  whether  in  a  special  poisonous  mussel  or  a  mussel  which  becomes 
poisonous  under  certain  circumstances  is  not  settled,  though  the  latter 
would  seem  to  be  true,  since  Schmidtmann  found  that  non-poisonous  mus- 
sels placed  in  the  waters  of  Wilhemshaven  Bay  became  poisonous,  and 
poisonous  mussels  from  the  latter  became  harmless  after  being  placed  in  the 
open  sea. 

Symptoms. — Both  cooked  and  raw  mussels  may  produce  the  poison- 
ous symptoms.     Three  sets  are  described : 

First,  those  of  gastro-intestinal  irritation,  similar  to  those  described  as 
due  to  meat  poisoning  and  which  may  terminate  fatally  within  two  days,  the 
autopsy  revealing   inflamed   stomach  and  intestines. 

In  a  second  set  of  symptoms  the  nervous  system  seems  to  bear  the 
brunt  of  the  poison,  and  these  cases  are  said  to  be  the  most  frequent.  The 
symptoms  include  a  sense  of  heat  and  itching,  usually  beginning  in  the  eye- 
lids, but  soon  extending  over  the  whole  face  and  sometimes  over  a  large 
portion  of  the  body.  An  erup^^ion,  vesicular  and  papular,  makes  its  appear- 
ance and  intensifies  the  itching.  The  eruption  is  often  followed  by  asth- 
matic breathing.  Sometimes  the  dyspnea  precedes  the  eruption,  the  face  be- 
comes livid,  the  patient  unconscious,  and  there  are  convulsive  movements 
of  the  extremities.  In  other  cases  there  are  delirium,  convulsions,  coma,  and 
death  within  three  days.  In  other  nervous  cases  there  are  numbness  and 
coldness,  frequent  pulse  but  no  fever,  the  pupils  are  dilated,  and  death  takes 
place  in  a  couple  of  hours  with  symptoms  of  collapse. 

In  a  third  set  of  cases  a  symptom  like  intoxication  by  alcohol  is  pres- 
ent, followed  by  paralysis,  coma,  and  death. 

Treatment  of  Ptomain  Poisoning. 

This  js  mainly   symptomatic — the  purgative   and   emetic  effect  of  the 


GRAIN  POISONING.  1173 

poison  general!}-  promptly  gets  rid  of  any  residue  which  may  be  in  the 
stomach  or  intestinal  canal.  But  if  there  is  any  reason  to  believe  that  these 
are  not  emptied,  purgatives  should  be  administered,  and  of  these  calomel  is 
probably  the  best  because  it  is  less  apt  to  be  rejected. 

In  addition  counterirritation  by  mustard,  hypodermic  injection  of  1-4 
grain  (0.0165  gm.)  niorphin,  repeated  if  necessary,  to  relieve  pain,  digitalis 
from  ten  to  thirty  minims  (0.66  to  2  gm.),  and  strychnin  1-30  grain  (0.0022 
gm.)  administered  in  the  same  manner  to  counteract  collapse  may  be  given. 
Stimulants  by  the  mouth  should  be  given  if  retained,  and  to  this  end  cham- 
pagne becomes  very  suitable,  or  milk  mixed  with  carbonated  water  may  be 
given  in  small  quantities. 

GRAIN  POISONING. 

For  a  century  or  more  districts  have  been  subject  to  ailments  which 
have  been  traced  to  the  use  of  certain  grains  as  food,  some  of  which  have 
been  found  to  be  spoiled  or  the  seat  of  disease.  People  in  some  parts 
of  France,  Germany,  Switzerland,  Italy,  Spain,  and  India  have  been  thus 
affected. 

I.  Ergotism. — Ergotism  is  one  of  these  ailments.  It  is  a  disease  found 
to  succeed  upon  the  use  of  meal  contaminated  with  the  sclerotmm,  an  inter- 
mediate stage  of  development  of  the  claviceps  purpura,  a  fungus  which  in- 
fests the  rye  grain.  An  ergot  is  this  sclerotium,  which  appears  at  the  base 
of  the  grain  as  a  hard,  dark-hued  "  spur,"  which,  as  it  grows,  lifts  up  the 
diseased  and  withered  mass  of  the  original  grain.  Wheat,  barley,  and  rice 
may  also  become  spurred.  The  growth  of  the  fungus  is  favored  by  wet 
seasons.  The  disease  prevailed  in  France,  Switzerland,  and  Germany  much 
more  commonly  from  the  tenth  to  the  eighteenth  century  than  at  present. 
The  cause  of  ergotism  was  discovered  in  1830  by  Thuillier. 

Two  forms  of  chronic  ergotism  are  recognized,  one  convulsive  or  spas- 
modic, the  other  gangrenous. 

Spasmodic  Ergotism. — In  this  form  there  is  a  prodromal  period  of  from 
ten  to  fourteen  days,  during  which  there  are  a  peculiar  sense  of  weariness 
and  anxiety,  a  tingling  and  sense  of  formication  in  the  skin,  especially  of 
the  fingers  and  toes,  gastro-intestinal  irritation  manifested  by  vomiting, 
purging,  and  colicky  pains,  accompanied  sometimes  with  slight  fever.  Then 
spasmodic  symptoms  set  in.  These  consist  at  first  in  involuntary  twitch- 
ings,  which  soon  pass  into  painful  continuous  contractions,  the  arms  being 
flexed  and  the  legs  and  toes  extended.  The  cramp  lasts  for  an  hour  or 
more,  followed  by  a  period  of  exhaustion,  which  may  be  succeeded  by  an- 
other painful  convulsion.  There  may  be  delirium,  melancholia,  or  de- 
mentia. The  urine  may  be  suppressed  or  violent  dysuria  may  be  present 
from  spasm  of  the  bladder.  Pustules,  boils,  whitlows,  and  other  evidence 
of  deranged  nutrition  may  appear.  Cardiac  contractions  are  slow  and 
feeble,  the  arteries  are'  constricted  and  contain  little  blood.  Death  m.ay 
occur  from  cardiac  paralysis,  and  is  often  preceded  by  convulsions  or  para- 
lytic symptoms.  The  duration  of  the  illness  is  from  four  to  eight  weeks  or 
longer. 

Sclerosis  of  the  posterior  columns  of  the  cord  was  found  in  some  of 
the  cases  which  came  to  necropsy.  Thus,  Tuczek  and  Siemens  found  it 
four  times  in  nine  autopsies,  which  represented,  also,  the  deaths  in  a  group 
of  twentv-nine  cases. 


1 1 74  THE  IKTOXICATIONS. 

Gangrenous  Ergotism. — This  form  is  ushered  in  by  the  same  prodrome 
as  that  described  for  the  spasmodic.  On  this  succeeds,  from  the  third  day 
to  the  fourth  week,  an  erysipelatous  redness  in  some  peripheral  locality,  as 
in  the  toes  and  fingers,  ears,  and  nose.  This  is  followed  usually  by  dry 
gangrene,  but  the  moist  form,  which  may  be  confined  to  a  finger  or  toe  or 
may  involve  the  whole  hand  or  foot,  may  also  appear.  The  disease  may 
not  go  beyond  the  erysipelatous  redness. 

For  acute  ergot  poisoning  see  concluding  section. 

2.  Pellagr.\. — This  is  a  disease  thought  to  be  due  to  a  fungus  which 
infests  moldy  maize  or  Indian  corn.  Lombroso  and  others  have  isolated  a 
ptomain  from  the  meal  made  of  such  corn.  The  disease  occurs  in  Lom- 
bardy,  the  South  of  France,  and  in  Spain,  especially  among  the  poorer 
classes  in  the  country  districts,  where  the  meal  of  maize  is  largely  used. 
It  begins  almost  invariably  in  an  erythema  in  the  spring  of  the  year,  which 
is  followed  by  a  scaly  and  wrinkled  condition  of  the  skin,  especially  in  the 
parts  exposed  to  the  air.  Occasionally  crusts  form,  and  beneath  these  pus 
is  found.  Along  with  these  skin  diseases  there  are  digestive  derangements, 
salivation,  dyspepsia,  and  even  dysentery.  The  disease  lasts  a  few  months, 
when  improvement  sets  in.  In  the  more  severe  and  chronic  forms  there 
may  be  headache  and  backache,  the  strength  and, mental  faculties  are  af- 
fected, sensation  is  obtunded,  and  cramps  with  convulsions  supervene,  such 
as  in  ergotism. 

The  morbid  anatomy  is  vague.  There  may  be  fatty  degeneration  and 
a  pigmentation  of  the  viscera. 

3.  Lathyrism^  or  Lupixosis. — This  is  a  condition  resulting  from  the 
use  of  meal  made  from  the  chick-pea,  or  grain  of  a  variety  of  vetches,  more 
particularly  the  lathyrus  salivus  and  lathynis  cicera.  It  is  used  in  admix- 
ture with  barley  and  wheat  in  India,  Italy,  and  Algiers.  According  to 
James  Irvine,  the  symptoms  supervene  in  India  when  the  proportion  ex- 
ceeds I- 12. 

The  symptoms  are,  first,  gastro-intestinal  irritation,  then  a  condition 
of  spastic  paralysis,  which  may  pass  on  to  complete  paraplegia.  The  arms 
are  rarely,  if  ever,  aft'ected. 

Xo  associated  morbid  change  has  been  discovered. 

Treatment  of  Grain  Poisoning. 

This  consists,  primarily,  in  the  removal  of  the  cause  and  the  substitu- 
tion of  wholesome  food ;  in  removal,  also  from  the  district,  if  possible,  and 
suitable  treatment  of  symptoms. 


SECTION  XII. 

EFFECTS  OF  EXPOSURE  TO  HfGH  THOUGH  BEARABLE  TEM- 
PERATURE. 

Such  effects  are  easily  separable  into  two  groups,  covered  by  the  terms 
heat  exhaustion  and  thermic  fever. 

HEAT  EXHAUSTION. 

Definition. —  A  condition  of  syncopal  exhaustion  with  vasomotor  paral- 
ysis and  lowering  of  body-temperature,  caused  by  exertion  under  high 
temperature.  Such  condition  may  arise  quite  independently  of  the  direct 
rays  of  the  sun.  The  heat  may  be  that  of  confined  rooms  and  may  be  arti- 
ficial heat. 

Symptoms. — The  sense  of  great  zveakness,  often  experienced  in  hot 
weather  after  some  unusual  exertion,  exhibits  the  mildest  degree  of  this  con- 
dition. In  the  more  severe  forms  a  sense  of  faintness,  associated  with 
pallor,  dissiness,  at  times  blindness,  and  the  starting  of  cold  perspiration  are 
the  first  symptoms.  Sometimes  the  victim  can  get  to  a  place  where  he  may 
sit  or  lie  down ;  at  other  time  he  faints  away  before  assistance  can  reach 
him.  Then  follows  a  condition  of  unconsciousness  or  semi-consciousness, 
whence,  under  favorable  circumstances,  he  may  respond  to  gentle  stimulus 
by  ammonia  or  wine  and  then  fall  into  a  sleep,  from  which  he  will  awake 
in  an  hour  revived. 

In  more  severe  cases  the  collapse  is  more  permanent,  the  pulse  is  ex- 
tremely feeble  and  frequent,  the  skin  continues  leaky,  while  there  may  be 
great  restlessness  and  muttering  delirium.  It  is  characteristic  of  this  form 
of  heat  affection  that  there  is  extreme  adynamia  with  lowered  body-tempera-' 
.ture.  H.  C.  Wood,  whose  name  is  inseparably  associated  with  the  subjects 
of  heat  exhaustion  and  thermic  fever,  reports  a  case  with  a  temperature  as 
low  as  95°  F.  (35°  C),  with  complete  collapse. 

Diagnosis. — Heat  exhaustion  is  characterized  by  lowered  temperature 
and  feeble  pulse,  as  contrasted  with  the  opposite  in  thermic  fever.  It  is  im- 
portant that  the  two  conditions  should  not  be  confounded,  because  of  the 
widely  different  treatment  required.  The  syncopal  attack  from  cardiac  fail- 
ure or  from  concealed  hemorrhage  much  more  closely  resembles  heat  ex- 
haustion, being  associated  also  with  feeble  pulse  and  lowered  temperature, 
but  as  the  treatment  is  identical,  the  distinction  is  less  important.  The  fall 
in  temperature  is,  however,  less  decided  in  syncope. 

Treatment. — The  patient  should  be  put  to  bed  at  once  with  his  head 
horizontal  or  slightly  raised.  When  possible,  stimulants  should  be  ad- 
ministered moderately  by  the  mouth — brandy,  whisky,  or  ammonia  with 
digitalis.  If  this  is  not  possible,  digitalis  and  strychnin  should  be  given  hy- 
podermically,  from  ten  to  thirty  minmis  (0.66  to  2  gm.)  of  the  former  and 
1-30  grain  (0.0022  gm.)  of  the  latter.  Friction  should  be  applied,  and  dry 
heat  by  hot-water  bags  or  cans. 

1175 


1176  EFFECTS  OF  EXPOSURE  TO  HIGH  TEMPERATURE. 


THER^IIC  FEVER. 

Synonyms. — Heat  Fever;  Sunstroke;  Coup  de  soleil. 

Definition. — A  state  of  high  fever  induced  by  exposure  to  heat,  natural 
or  artificial. 

Etiology  and  Pathology. — In  this  country  the  majority  of  cases  occur 
in  the  summer  season  in  those  exposed  to  the  direct  rays  of  the  sun, 
though  they  occur  also  among  those  exposed  to  high  temperature  within 
doors,  as  in  sugar  refineries,  fire-rooms  of  ocean  steamers,  laundries,  and 
the  like.  A  heated  atmosphere  charged  with  moisture,  impeding,  there- 
fore, evaporation,  produces  fever  much  more  rapidl}-  than  a  dry  heat,  which 
is  in  fact  slow  to  produce  it.  The  habitual  use  of  alcohol  is  found  to  be  a 
potent  predisposing  cause — at  least  alcoholics  succumb  verj^  much  sooner 
to  the  influence  of  overheat  than  temperate  persons. 

The  pathology  of  the  two  conditions  of  heat  exhaustion  and  thermic 
fever  is  thus  explained  by  H.  C.  Wood :  "  There  is  in  the  pons  or  higher  por- 
tion of  the  nervous  system  a  center  whose  function  it  is  to  inhibit  the  pro- 
duction of  animal  heat,  and  in  the  medulla  oblongata  a  center  (probably  the 
vasomotor  center)  which  regulates  the  dissipation  of  bodily  heat.  Fever  is 
due  to  a  disturbance  of  these  centers,  so  that  more  heat  is  produced  than  nor- 
mal and  proportionately  less  thrown  off.  Let  it  be  supposed  that  a  man  is 
placed  in  such  an  atmosphere,  that  he  is  unable  to  get  rid  of  the  heat  which 
he  is  forming.  The  temperature  of  the  body  will  slowly  rise,  and  he  may 
suffer  from  a  general  thermic  fever.  If  early  or  late  in  this  condition  the 
inhibitory  heat  center  becomes  exhausted  by  the  efifort  which  it  is  making- 
to  control  the  fomiation  of  heat,  or  becomes  paralyzed  by  the  direct  action 
of  the  excessive  temperature  already  reached,  then  suddenly  all  tissues  will 
begin  to  form  heat  with  the  utmost  rapidity,  the  bodily  temperature  rises- 
with  a  bound,  and  the  man  drops  over  with  one  of  the  forms  of  coup  de 
soleil. 

"  Heat  exhaustion,"  on  the  other  hand,  "  with  lowered  temperature,  rep- 
resents a  vasomotor  palsy — /.  e.,  a  condition  in  which  the  existence  of  the 
heat  paralyzes  the  center  in  the  medulla  oblongata,  and  the  heat  is  dissipatedl 
more  rapidly  than  it  is  produced."  It  must  be  admitted  that  the  explana- 
tion of  heat  exhaustion  is  less  satisfactory  than  that  of  thermic  fever. 

Morbid  Anatomy. —  The  high  temperature  characteristic  of  heat  fever 
remains  a  long  time  after  death.  Hence  putrefaction  sets  in  early.  Rigor 
mortis  also  occurs  promptly.  The  blood  remains  liquid.  There  is  general" 
venous  engorgement,  especially  of  the  lungs  and  cerebrum.  In  early  au- 
topsies the  left  ventricle  is  found  contracted,  the  right  dilated. 

S5miptoms. — A  sense  of  uncomfortable  burning  heat  and  feeling  of 
oppression  may  precede  the  "  stroke  "  which  fells  its  victim,  who  quickly 
becomes  unconscious  and  comatose,  perishing  sometimes  instantly,  at  other- 
times  in  a  few  hours.  In  other  cases  there  are  intense  headache,  disainess, 
oppression,  nausea,  and  vomiting,  occasionally  diarrhea.  Chrainatopsi-a,  or 
colored  vision,  may  be  present.  Sooner  or  later  unconsciousness  sets  in,  and 
may  be  associated  with  muttering  delirium  and  intense  restlessness.  In  this- 
condition  the  patient  is  commonly  admitted  to  hospital  with  face  flushed, 
eye  suffused,  skin  hot  and  dry,  temperature  from  107°  to  112°  F.  (41.6° 
to  44.4°  C),  the  breathing  labored,  sometimes  stertorous,  the  pulse  frequent- 


THERMIC  FEVER. 


1177 


and  full.  The  pupils  at  this  stage  are  usually  contracted,  though  at  first 
dilated.  The  urine  is  scanty,  sometimes  albuminous.  Usually  there  is 
relaxation  of  the  muscles,  but  at  times  there  is  a  convuJswe  tendency,  shown 


by  twitching  and  jactitation,  and  occasionally  by  epileptiform  convulsions. 
The  skin,  usually  dry,  may  become  moist  and  bathed  with  perspiration,  which 
does  not,  however,  reduce  the  temperature.  Wood  speaks  of  a  peculiar  odor 
exhaled  by  the  entire  body  as  characteristic. 


J 178  EFFECTS  OF  EXPOSURE  TO  HIGH  TEMPERATURE. 

In  fatal  cases  the  stupor  deepens,  the  pulse  becomes  more  frequent  and 
loses  even  its  seeming  strength,  then  is  irregular,  the  inspiration  is  labored 
and  irregular,  and  toward  the  last  shallow,  or  assumes  the  Cheyne-Stokes 
type  previous  to  death.  Death  does  not  usually  take  place  for  several 
hours.  In  favorable  cases  improvement  is  indicated  by  a  falling  tempera- 
ture and  a  return  to  consciousness. 

Recoverx  may  be  complete,  but  more  rarely  a  permanent  condition  re- 
sults in  which  there  may  be  more  or  less  constant  mental  weakness,  as  evi- 
denced by  incapacity  for  sustained  mental  effort,  while  exposure  to  moderate 
degrees  of  temperature  produces  great  excitement  or  headache  or  pain  in  the 
upper  cervical  region.  Epileptic  convulsions  sometimes  occur.  In  these 
cases  there  is  probably  a  certain  degree  of  meningitis. 

Attention  has  lately  been  called  by  C.  F.  Close  *  to  cardiac  dilatation  as 
a  symptom  of  thermic  fever. 

Mention  has  already  been  made,  when  treating  of  fevers,  of  the  form 
of  continued  fever  occurring  in  the  south  of  the  United  States,  where  it  is 
Icnown  as  "  Florida  fever  "  and  "  country  fever,"  and  in  India  and  the  West 
Indies  as  iievre  i)if!amiiiatoire,  for  which  John  Guiteras  proposes  the  name 
■continued  thermic  fever,  but  which  more  recently  he  is  inclined  to  ascribe  to 
a  septic  origin. 

Diagnosis. — The  diagnosis  of  heat  fever  presents  no  difficulties.  The 
distinction  between  it  and  heat  exhaustion  has  been  alluded  to. 

Prognosis. — The  prognosis  depends  partly  upon  the  severity  of  the 
■case  and  the  promptness  and  thoroughness  of  treatment.  A  few  cases  are 
almo.st  instantaneously  fatal.  If  the  cooling  treatment  can  be  applied  prop- 
erly, a  decided  majority — fully  60  per  cent. — recover.  A  temperature  of 
110°   F.    (43.3°    C),  though   indicating  gravity,   should   not    discourage. 

Treatment. — ^The  success  of  treatment  of  thermic  fever  depends  al- 
together upon  our  ability  to  lower  the  temperature.  To  this  end  the  pa- 
tient should  be  placed  in  a  hath  of  zcafer  to  which  ice  is  freely  added  to 
keep  the  temperature  down  as  low  as  it  can  be,  which  in  summer  is  not 
likely  to  be  below  60°  F.  (15.54°  C.).  The  surface  of  the  body  is  further 
vigorously  rubbed  zvith  ice.  In  the  absence  of  bathing  facilities  the  patient 
should  be  placed  on  a  mattress  covered  with  a  mackintosh  and  be  rubbed  with 
pieces  of  ice.  The  refrigerating  effect  may  be  further  increased  by  ice-water 
enemas.  This  treatment  should  be  regulated  by  the  thermometer  in  the 
rectum,  and  abated  as  the  temperature  approaches  the  nonnal,  and  renewed 
as  it  again  rises. 

After  this,  or  in  addition  to  this,  treatment  should  be  symptomatic.  For 
<!onvulsions.  chloral  or  chloroform  ;  for  heart  failure,  digitalis  and  strychnin 
Tiypodermically ;  for  asphyxia,  bleeding.  ^Nlild  cases  or  recurrent  fever  may 
be  treated  with  the  antipyretics  represented  by  antifebrin.  phenacetin,  and 
antipyrin. 

The  sequelae  referred  to  should  be  treated  symptomatically. 

*  "  Journal  of  the  Am.  Med.  Assoc,"  March  g,  1901. 


SECTION  XIIL 

ANIMAL  PARASITES  AND  THE  CONDITIONS  CAUSED  BY 

THEM. 

While  the  number  and  variety  of  parasites  which  infest  man  are  ex- 
tremely large,  the  number  of  these  which  are  directly  harmful  is  very  much 
smaller.  Representatives  of  sufficient  importance  to  deserve  consideration 
are  found  among  the — 

I.     Protozoa,    simple    cellular    organisms    representing    the    lowest 
classes  of  the  animal  kingdom  without  nervous  or  circulatory  systems. 
11.    Platyhelminthes,  or  flat  worms. 

III.  Nematodes,  or  thread  worms. 

IV.  Acanthocephali,  or  thorn-headed  worms. 
V.    Arthropoda,  or  jointed  animals. 


I.    PROTOZOA. 

I.  Psoro'Spermiasis. — The  protozoa  are  represented  by  the  psorosperms 
or  sporozoa,  and  these  by  the  coccidia.  The  latter  are  spherical  or  oval, 
nucleated  organisms,  composed  of  granular  protoplasm.  They  vary  in  size, 
the  smallest  being  from  0.012  to  0.015  mm.  (0.0005  to  0.0006  inch)  long, 
and  from  0.007  to  0.0 1  mm.  (0.003  to  0.004  inch)  wide,  and  the  largest 
from  0.04  to  0.049  mm.  (0.0016  to  0.0019  inch)  long,  and  from  0.022  to 
0.28  mm.  (0.0008  to  o.ooii  inch)  wide. 

They  lodge  within  the  epithelial  cells  of  man  and  the  lower  animals, 
one  or  more  within  a  single  cell,  whence  they  are  also  called  cytosoa.  They 
are  closely  allied  to  the  hematozoa  or  blood  parasites  which  occupy  the 
corpuscles  of  fish  and  amphibia.  Other  varieties  are  found  outside  of  cells 
in  the  submucous  tissues,  and  in  the  villi  of  the  intestinal  wall  of  dogs,  cats, 
rabbits,  man,  and  other  animals,  or  in  organs  adjacent,  such  as  the  liver  and 
kidney.  Wherever  they  lodge  they  immediately  become  encysted,  forming 
whitish,  oval  nodules,  especially  easily  studied  in  the  liver  of  the  rabbit. 
These  nodules  vary  in  size  from  that  of  a  pin's  head  to  that  of  a  split  pea, 
and  resemble  the  tubercles  of  tuberculosis.  In  most  of  the  cases  in  man  the 
liver  is  found  to  be  the  seat  of  invasion,  and  the  resulting  tumors  may  be 
felt  during  life.  They  have  thus  been  mistaken  for  echinococci.  The  spleen, 
kidneys,  omentum,  peritoneum,  and  pericardium  may  also  be  invaded.  Other 
symptoms  are  abdominal  muscular  pain,  tenderness,  sometimes  diarrhea, 
nausea,  dry  tongue,  hematuria,  and  peritonitis.  The  effect  appears  to  be 
one  of  intense  irritation,  like  that  of  general  miliary  tuberculosis  or  tri- 
chiniasis,  causing  death  in  variable  periods,  from  fourteen  days  to  several 
years.  Cases  of  internal  psorospermiasis,  as  previously  described,  have  been 
reported  in  France,  Germany,  Austria,  and  England,  but  not  in  America. 
Two  cases  of  external  or  cutaneous  psorospermiasis,  affecting  the  skin  only, 
were  reported  by  Rixford  and  Gilchrist  in  the  "  Johns  Hopkins  Hospital 
Reports,"  vol.  1.     The  affection  attacked  the  skin  of  the  face,  trunk,  and 

1179 


ii8o  ANIMAL  PARASITES. 

extremities,  producing  tubercular  nodules.  Subsequently,  internal  organs, 
including  the  lymphatic  glands  and  lungs,  were  invaded,  producing  symp- 
toms and  lesions  like  those  of  tuberculosis,  but  enormous  numbers  of 
sporozoa  were  found  in  the  caseous  masses. 

2.  Parasitic  Infus&ria. — The  protozoa  are  also  represented  by  the  in- 
fusoria, and  of  these  especially  the  subclass  flagcllata.  These  include  the 
(a)  plagioijionas  urinaria,  found  once  only  by  Kiinstter  in  the  fresh  urine  of 
a  man  who  had  suffered  from  chronic  suppuration ;  (b)  the  trichomonas 
vaginalis,  an  irregular  spindle-shaped  organism  from  0.015  to  0.025  mm. 
{0.0006  to  0.0009  inch)  long  and  from  0.016  to  0.018  mm.  ,(0.0006  to 
0.0007  inch)  wide,  found  in  the  acid  vaginal  mucus;  (c)  the  trichouionas  or 
cerconionas  honiinis,  a  pear-shaped  organism  from  0.004  to  0.007  or  0-0i5 
mm.  (^0.0002  to  0.0006  inch)  long  and  from  0.003  '--  0.004  "im.  (o.oooi  to 
0.0002  inch)  wide,  terminating  behind  in  a  pointed  projection  and  in  front  in 
four  cilia,  found  in  intestines  and  stools;  also  (d)  the  lanibiu  intestinalis,  a 
similar  shaped  organism  found  in  the  intestinal  canal.  Flagellates  have  also 
been  found  in  the  lungs  in  gangrene,  bronchiectasis,  and  pleurisy.  Of  the 
ciliated  infusoria,  halantidiuui  or  Paramecium  coli,  an  oval  body  from  0.07 
to  0.1  mm.  (0.0027  to  0.393  inch)  long  and  from  0.05  to  0.07  mm.  (0.0019 
to  0.0027  inch)  wide,  has  been  found  in  the  large  intestine  in  dysentery. 


II.    PLATYHEL^IIXTHES,  OR  FLAT  WORMS. 

The  flat  worms  include  the — 

A.  Trematodes,  or  flukes. 

B.  Cestodes,  or  tape-worms. 

A.     Trematodes^  or  Flukes. 
These  are  divided  into  liver  flukes,  blood  flukes,  and  bronchial  flukes. 

(a)  Liver  Flukes. 

These  include — 

1.  The  distonnini  Jicpaficinn,  or  fasciola  hcpatica,  from  25  to  32  mm.. 
(0.9842  to  1.2598  inches)  long  and  from  8  to  13  mm.  (0.3149  to  0.5118 
inch)  wide,  found  in  the  liver,  blood-vessels,  and  in  abscesses  in  man. 

2.  The  distomnm  buskii.  large,  from  4  to  8.5  cm.  (1.5748  to  3.3464 
inches)  long  and  from -1.4  to  2  cm.  (0.55 11  to  0.8  inch)  wide,  found  in  the 
liver  and  feces. 

3.  The  distomnm  lanceolatnm,  from  8  to  10  mm.  (0.3149  to  0.3937 
inch)  long  and  from  1.5  to  2.5  mm.  (0.059  to  0.0984  inch)  wide,  found 
in  the  intestine,  whence  it  has  been  passed  per  anum  and  even  by  the 
mouth. 

4.  The  distomnm  siiicnsc.  from  10  to  13  to  18  mm.  (0.3937  to  0.51 18 
to  0.7086  inch)  long  and  2  to  3  mm.  (0.0787  to  0.1181  inch)  broad.  This 
is  a  distoma  especially  prevalent  in  Japan,  where  it  was  described  as  disto- 
miim  endemiciim  and  distomnm  perniciosnm.  It  occurs  in  20  per  cent,  of 
the  inhabitants  of  certain  provinces,  according  to  Baelz. 

5.  The  distomnm  conjnnctum.  10  mm.  (0.3937  inch)  long  and  2.5  mm. 
(0.0984  inch)  broad,  found  in  the  liver. 


PLATYHELMINTHES,  OR  FLAT  WORMS.  1181 

6.  The  distomiim  felinenm,  from  8  to  18  mm.  (0.3149  to  0.7086  inch) 
Jong  and  1.5  to  2.5  mm.  (0.059  to  0.0984  inch)  wide,  found  in  man  and 
cats. 

All  of  these  are  known  as  liver  flukes,  being  found  in  the  bile-passages 
and  upper  part  of  the  small  intestine.  When  numerous,  they  give  rise  to 
very  serious  disturbance,  including  cholangitis  with  resulting  jaundice,  en- 
largement of  the  liver,  emaciation,  diarrhea,  and  often  ascites. 

(6)  Blood  Flukes. 

Synonyms. — Bilharzia   hmnatobia;   Schistosoma   hccniatobimn;   Dutomum 
hccmatobiuin;  Distonniiu  capcnse. 

This  distoma  was  first  described  by  Bilharz  in  1852.  The  male  is 
thread-like,  from  4  to  15  mm.  (0.1574  to  0.5905  inch)  long  and  0.6  mm. 
(0.0236  inch)  wide  in  the  widest  portion;  the  female  is  much  longer  than 
the  male, — from  15  to  20  mm.  (0.5905  to  0.7874  inch), — but  much  narrower, 
so  that  it  may  enter  the  cmvalis  gynecophorus  of  the  male. 

It  inhabits  the  venous  system,  especiall}^  the  portal  vein  and  the  veins 
of  the  spleen,  kidney,  the  venous  plexuses  of  the  bladder  and  rectum  in 
boys  of  the  lower  classes,  more  rarely  men  and  women  in  Egypt  and  Africa, 
50  per  cent,  of  the  former  being  infested,  according  to  Bilharz.  It  is 
.geographically  much  more  widely  distributed  in  Africa,  throughout  the  east 
■coast  as  far  as  Capeland,  in  numerous  districts  in  the  interior,  and  from  the 
gold  coast  to  Algiers. 

Symptoms. — The  symptoms  O'f  the  bilharzia  disease  begin  usually  with 
liematuria  and  burning  pain  in  the  urethra,  the  latter  increased  during 
micturition  and  due  to  the  irritation  of  the  worm.  In  addition  to  blood  the 
urine  contains  pus,  shreds  of  mucus,  and  the  eggs  of  the  bilharzia,  which 
are  easily  recognized  with  a  low  power  of  the  microscope.  They  are  ovoid 
and  terminate  in  a  thorn-like  end.  The  larva  may  be  seen  in  the  interior 
of  the  tgg.  The  ova  may  become  the  nucleus  of  stone  in  the  bl'adder,  a 
fact  which  is  held  responsible  for  the  large  number  of  cases  of  stone  in 
the  bladder  in  Egypt.  Hypertrophy  of  the  prostate  may  ensue.  The  large 
bowel  may  be  invaded,  causing  dysentery.  The  hemorrhage  may  lead  to 
anemia,  debility,  and  exhaustion,  terminating  fatally,  though  most  cases  re- 
cover. Attacking,  especially,  children,  the  disease  commonly  disappears  at 
puberty. 

(c)  Bronchial  Flukes. 
Synonyms. — Distomum  Westermanni;  Distomiim  pulmonalis. 

This  is  an  ovoid  fluke  from  8  to  10  mm.  (0.3149  to  0.3937  inch)  long 
and  from  4  to  6  mm.  (0.1574  to  0.2362  inch)  broad,  of  a  reddish-brown 
color.  It  is  met  in  various  parts  of  China.  Japan,  and  Formosa,  where  it 
infests  the  bronchial  tubes,  causing  cough  and  hemoptysis. 

B.    Cestodes,  or  Tape-worms. 

(a)   Intestinal  Cestodes. 

Historical, — When  mature,  these  occupj^  the  intestine  of  man.  The  larger  forms, 
at  least,  of  tape-worm  were  known  to  the  ancients  as  animal  parasites  infesting  the 
alimentary  canal.  The  correct  notion  of  the  origin  and  development  of  the  tape- 
^vorm    is,   however,   comparatively   recent,  and  for  a    long    time  the    young  worm 


ii82  AXIMAL  PARASITES. 

was  supposed  to  start  from  the  links  or  proglottides  of  the  adult  worm.  The  cysti- 
cerci  or  larval  forms  have  also  been  long  known,  but  they  were  regarded  as  simple 
cystic  tumors  until  almost  simultaneously  Redi  in  Italy,  and  Hartmann  and  Wepter 
in  Germany,  inferred  their  animal  nature,  after  which  they  were  regarded  as  worms, 
and  made  by  Zeder,  in  iSoo,  a  separate  class  of  bladder  worms. 

In  1683  Edward  Tyson  discovered  the  head  with  its  double  row  of  booklets  in  a 
large  tape-worm  in  a  dog;  in  16S4  Redi  recognized  the  head  and  the  suckers  of  several 
taeniae;  in  1700  Andrj'  recognized  the  head  of  the  icenia  sagmata,  and  in  1777  Bonnet 
and  in  1779  Gleichen-Russworm  that  of  the  bothriocephalus.  From  that  time  it  was 
believed  hy  most  authors  that  the  tape-worm  was  an  animal  which  nourished  itself 
by  fastening  its  head  into  the  intestinal  wall.  About  the  middle  of  the  last  century 
Kiichenmeister,  by  his  celebrated  feeding  experiments,  proved  that  the  cysticerci  or 
bladder  worms  represented  a  larval  stage  in  the  development  of  the  tape-worm,  the 
latter  having  for  its  habitat  the  intestine  of  man,  and  the  former,  the  muscles  and 
solid  organs  of  certain  lower  animals  and  rarely  of  man. 

Varieties  of  Tape-worm  Infesting  Man. — Of  the  several  varieties 
of  tape-worm  which  infest  man,  five  only  deserve  special  consideration — 
viz.,  the  tccnia  saginata  or  mcdiocaneUata,  the  tccnia  solium,  the  hothrio- 
cephaJiis  latus,  the  tania  flaropiinctaia,  and  tania  confusa. 

The  tania  mediocanellata  or  t<rnia  saginata  is  known  as  the  beef  tape- 
worm, because  its  embryos  or  cysticerci  are  found,  as  a  rule,  in  cattle,  pro- 
ducing the  so-called  "  measled  "  veal  and  beef ;  also  as  the  "  unarmed  "  tape- 
worm, because  the  head  is  unprovided  with  booklets.  It  has  been  found  in 
the  flesh  of  the  giraffe.  The  tccnia  solium  is  known  as  the  pork  tape-worm, 
because  met  in  the  larval  state  in  the  flesh  of  swine,  producing  "  measled  " 
pork;  and  as  the  "  armed  ''  tape-worm,  because  of  the  booklets  named.  The 
beef  tape- worm,  or  tccnia  mediocanellata,  is  the  most  common  form  of  tape- 
worm occurring  in  the  United  States,  and  I  believe  also  at  this  time  on  the 
Continent  of  Europe,  especially  in  Western  Europe.  In  the  middle  of  Ger- 
many it  is  less  unusual  to  eat  uncooked  pork,  and  although  the  laws  of  in- 
spection there  are  very  stringent,  the  tccnia  solium  has  been,  at  least  until 
recently,  the  most  common  variety  of  tape-worm  there.  But  in  Holstein 
Heller  has  met  the  tccnia  saginata  four  times  as  often  as  the  tccnia  solium. 
The  late  Professor  Leidy,  to  whom  large  numbers  of  worms  were  constantly 
being  sent  for  opinion,  informed  me  that  all  specimens  sent  to  him 
for  examination  during  a  period  of  fifteen  years  were  tccnia  medioca- 
nellata:. 

The  tccnia  mediocanellata,  or  unarmed  worm,  has  a  head  quadrate  in 
shape,  from  1.5  to  2  mm.  (0.06  to  0.0787  inch)  in  diameter,  provided  with 
four  suckers,  placed  one  toward  each  angle  of  the  head,  and  a  small  central 
rudimentary  sucker  without  rostellum  or  circlet  of  hooks.  To  this  head 
succeeds  a  slender  neck,  then  the  links.  The  tccnia  solium  has  a  smaller 
head,  spherical  in  shape,  from  0.6  to  i  mm.  ( 0.0236  to  0.0393  inch) 
in  diameter,  provided,  in  addition  to  the  four  suckers,  with  a  proboscis  or 
snout  called  a  rostellum.  on  which  are  two  rows  of  booklets,  the  inner  row 
being  the  longer.  There  are  from  12  to  14  in  each  row,  making  in  all  24  or 
28.  The  heads  of  both  worms  are  at  times  more  or  less  pigmented.  There 
is  also  a  difference  in  the  segments.  The  ripe  segments  of  the  tccnia  sagi- 
nata average  from  16  to  20  mm.  (0.63  to  0.8  inch)  in  length  and  from  four 
to  seven  mm.  (0.1574  to  0.275  inch)  in  width.  The  ripe  segments  of  the 
tccnia  solium  average  from  10  to  12  mm.  (0.4  to  0.47  inch)  long  and  from  5 
to  6  mm.  (0.2  to  0.2362  inch  )  broad. 

Tape-worm.s  are  hermaphroditic,  both  sets  of  reproductive  organs  being 
contained  in  one  segment.  Further  peculiarities  of  these  organs  will  be  con- 
sidered in  speaking  of  diagnosis.     As  to  the  length  of  the  entire  wonr.,  the 


PLATYHELMINTHES,  OR  FLAT  WORMS.  1 183. 

tcenia  mediocanellata  is  put  down  at  from  4.8  to  7.2  meters  (16  to  24  feet),, 
but  I  have  known  more  than  ten  meters  (40  feet)  to  be  passed.  The  tmvia 
solium  is  usually  much  shorter — from  1.8  to  3.6  meters  (6  to  12  feet),  but 
may  be  longer.  The  number  of  links  or  proglottides  in  the  tcenia  solium  is. 
from  800  to  900,  in  the  tcBnia  saginata  1000. 

How  do  these  tape-worms  obtain  access  to  the  intestine  of  man?  As 
already  stated,  the  larva  or  cysticercus  of  the  mediocanellata  is  found  in 
"  measly  "  beef.  The  egg  containing  the  larval  or  embryo  worm  is  in  some 
way  ingested  bv  cattle.  The  envelope  with  which  it  is  surrounded  is  di- 
gested, and  the  embryo  released.  The  latter  is  provided  with  booklets  ar- 
ranged in  three  pairs,  one  central  and  two  lateral.  The  central  pair  are 
simply  stilettos  for  boring,  the  lateral  for  tearing  and  propulsion.  By  these 
means  it  bores  its. way  through  the  intestinal  wall  and  invades  the  muscular 
tissue,  where  it  becomes  encysted,  forming  the  cysticercus  bovis.  It  is  a 
singular  fact,  however  that  the  "  measles  "  of  tcenia  saginata  very  rarely  come 
under  observation.  When  found,  the  cysticercus  of  this  worm  is  an  oval 
cyst,  scarcely  as  large  as  a  pea,  and  is  probably  often  overlooked.  Notwith- 
standing its  apparent  rarity  it  is  responsible  for  the  majority  of  tape-worms 
in  man. 

In  the  case  of  the  tcenia  solium,  the  links  of  the  worm  thrown  off  by 
man  in  the  feces  are  eaten  by  the  pig ;  during  digestion  the  shell  of  the  egg 
is  dissolved,  and  the  embryo  liberated.  The  embryo  of  the  tcenia  solium 
is  not  provided  with  the  double  row  of  booklets  possessed  by  the  mature 
worm,  but,  with  six  booklets  only,  arranged  in  pairs  like  the  booklets  of  the 
tCBnia  saginata.  It  invades  the  muscular  tissue,  like  the  tcenia  saginata,  be- 
comes encysted,  and  thus  the  cysticercus  cellulosce  telce  is  formed,  and  the 
pork  becomes  "  measled."  The  "  measle  "  of  pork  is  larger  than  that  of 
beef.  In  the  former  it  sometimes  reaches  a  length  of  nine-tenths  of  an  inch 
(22.86  mm.),  while  in  the  latter  it  is,  as  a  rule,  not  more  than  one-fourth 
of  an  inch  (6.3  mm.)  in  length. 

The  "  measles  "  of  beef  and  pork  are  rendered  inert  by  cooking,  but  it 
constantly  happens  that  imperfectly  cooked  beef  or  pork  is  eaten,  Avhen  the 
capsules  of  the  embryo  are  dissolved  ofif  in  the  stomach,  the  embryo  passes 
into  the  small  intestine,  attaches  itself,  and  grows.  From  twelve  to  six- 
teen weeks  after  the  attachment  of  the  larva  fragments  of  the  worm  may  be 
discovered  passing  per  anum. 

The  laws  demanding  the  inspection  of  pork  and  beef  are  causing  the 
tape-worm  to  become  less  common,  but  it  is  still  quite  often  met.  At  the 
present  day  we  are  much  less  in  the  habit  of  eating  uncooked  pork  than  un- 
derdone and  raw  beef.  This  is  also  the  case  in  England.  It  is  on  this  ac- 
cocnt  that  the  pork  tape-worm  is  less  common  in  America  and  England  than 
the  beef  tape-worm. 

The  third  variety  of  tape-worm,  the  hothriocephalus  latus,  is  dis- 
tinguished by  the  greater  width  of  its  segments  and  their  shortness  in  an 
anteroposterior  direction.  These  statements  refer  to  the  average,  for  the 
links  taken  from  different  parts  of  the  same  worm  vary  much  in  their 
dimensions.  The  num.ber  of  links  of  the  hothriocephalus  is  from  3000  to 
40CO.  Still  more  widely  does  the  head  of  the  bothriocephalus  latus  differ 
from  that  of  either  of  the  two  which  I  have  described.  It  has  neither 
rostellum  nor  booklets,  is  club-shaped,  1.5  mm.  (0.06  inch)  long  and  one 
mm.  (0.04  inch)  wide,  and  is  marked  by  two  lateral  depressions.  The  head, 
therefore,  is  less  formidable  than  that  of  either  of  the  two  other  worms. 


Ii84  ANIMAL  PARASITES. 

This  worm  is  not  often  met  in  this  country.  It  is  more  common  in  Switzer- 
land and  Russia,  but  is  also  found  in  Ireland,  Sweden,  and  Germany,  espe- 
cially in  Eastern  Prussia,  and  recently  in  the  neighborhood  of  the  Starn- 
berger  See  and  Munich.  It  is  called  the  Irish  tape-worm  as  well  as  the 
Russian  and  Swiss  tape-worm.  It  is  believed  that  the  cysticercus  of  this 
variety  of  tape-worm  is  found  in  certain  fish  of  the  salmon  and  trout  family, 
and  that  man  acquires  the  worm  by  eating  these  fish  uncooked.  The  length 
of  the  bothriocephalus  is  put  by  Heller  at  from  4.5  to  7.5  meters  (15  to  25 
feet),  but  if  it  be  the  longest  of  the  tape-worms,  as  is  generally  stated,  it 
must  at  times  far  exceed  this. 

There  is  still  another  form  of  tape-worm  which,  there  is  f-eason  to  be- 
lieve, is  more  common  than  is  supposed.  This  is  the  tcciiia  flarjo punctata. 
It  is  a  small  tape-worm,  not  exceeding  from  30  to  37.5  cm.  (12  to  15  inches) 
in  length.  In  the  "  American  Journal  of  the  Medical  Sciences  "  for  July, 
1884,  the  late  Dr.  Leidy  described  the  segments  of  one  of  these  worms  from 
specimens  sent  to  him.  They  were  passed  by  a  child  three  years  of  age 
after  the  administration  of  santonin.  In  fact,  all  the  specimens  of  this 
worm  as  yet  described  seem  to  have  come  from  children  from  fifteen  months 
to  three  years  of  age.  The  joints  are  proportionately  short  in  all  cases,  the 
breadth  exceeding  the  length  several  times.  They  are  transversely  linear, 
slightly  wider  back  of  the  middle,  with  the  posterior  angles  rounded  and 
the  posterior  margin  slightly,  but  irregularly  crenate.  The  anterior  im- 
mature joints  exhibit  no  distinct  traces  of  sexual  organs,  while  succeeding 
ones  have  a  more  coarsely  granular  appearance,  due  to  the  presence  of  im- 
inature  eggs.  The  pair  of  longitudinal  vessels  common  to  all  tape-worms 
are  conspicuously"  visible  in  the  segments.  At  the  posterior  part  of  the 
TDody  the  joints  in  a  ripe  condition  are  of  a  pale-brown  color,  due  to  the  con- 
tained eggs.  The  ripe  joints  are  interrupted  here  and  there  by  a  variable 
number — one  or  more — of  sterile  joints.  The  ripe  joints  are  longer, 
broader,  and  thicker.  The  eggs  distend  the  joints  and  are  diffused  through- 
out a  simple  cavity,  bounded  by  thin  parietes,  and  are  not  inclosed  in  rami- 
fied or  dendritic  uterine  pouches,  as  is  the  case  with  most  tape-worms.  In 
Dr.  Leidy's  specimens  the  mass  of  eggs  so  concealed  everything  in  these 
joints  that  the  generative  apparatus  could  not  be  determined.  But  in  the 
joints  devoid  of  eggs  there  was  to  be  seen  a  narrow,  clavate  organ,  which 
Dr.  Leidy  suspected  to  be  the  seminal  receptacle,  together  with  four  or  five 
oval  bodies,  probably  testiculae.  In  these  joints  only,  as  a  rule,  could  the 
genital  aperture  be  recognized  at  the  lateral  margin  of  the  joints,  imme- 
diately behind  the  middle. 

The  joints  of  this  tape- worm  range  in  length  from  0.2  mm.  (0.008  inch) 
in  the  neck  to  0.5  mm.  (0.02  inch),  an  inch  (2.5  cm.)  from  the  posterior  ex- 
tremity; and  in  width  from  0.63  mm.  (0.025  inch)  in  the  neck  to  2.5  mm. 
(o.i  inch),  an  inch  from  the  posterior  extremity.  The  mature  eggs  are 
raw-sienna  colored,  mostly  spherical,  and  0.07  mm.  (0.003  inch)  in  diameter. 
The  specimens  sent  to  Dr.  Leidy  were  parts  of  three  worms,  so  it  would 
seem  that  more  than  a  single  worm  may  infest  the  host,  which  is  the  case 
with  other  cestoid  worms. 

Another  instance  of  this  worm  has  been  described  by  Dr.  Weinland,  of 
Cambridge,  Mass.,  and  a  third  by  E.  Parona,  in  Italy.  It  was  named  by 
Weinland  tcrnia  flavopunctata  in  consequence  of  yellow  spots  lying  near  the 
middle  line  in  each  successive  joint,  and  representing,  according  to  Dr. 
Weinland,  a  testicle.     This  spot  had  disappeared  in  Dr.  Leidy's  specimen 


PLATYHELMINTHES,  OR  FLAT  WORMS.  1185 

as  it  had  also  in  Dr.  Weinland's  when  it  reached  Professor  Leuckhart  some 
years  afterward.  The  inclosed  embryos  are  oval  and  are  provided  with  six 
hooks  arranged  in  three  pairs.  The  intermediate  or  larval  condition  of  this 
worm  is  unknown.  I  hve  taken  some  pains  to  describe  the  tmiia  Uavo- 
punctata,  because,  as  I  have  already  said,  it  may  be  more  common  than  is 
usually  supposed,  and  it  is  desirable  that  it  should  become  so  familiar  that  it 
may  be  recognized  when  met.  The  larvae  are  developed  in  lepidoptera  and 
beetles. 

Tmiia  confiisa  is  the  name  given  by  Henry  B.  Ward  to  a  new  tape- 
worm described  by  him  in  1896.  Its  length  is  about  5  cm.  (2.0  inches)  ; 
the  terminal  proglottides  are  25  to  35  mm.  (i  to  1.3  inch),  long  and  3.5  to 
5  mm.  (0.14  to  0.20  inch)  wide,  somewhat  larger  than  the  ripe  links  of 
tcrnia  saginuta  and  tcenia  solium.  Its  scolex  has  a  diameter  of  3  mm. 
(0.066  inch)  quite  small,  provided  with  four  suckers  and  a  retracted  rostel- 
lum  with  six  or  seven  rows  of  small  hooks,*  the  largest  hooks  being  in  the 
external  row. 

Symptoms  of  Tape-worm. — Given  a  tape-worm  in  the  human  intes- 
tine, what  symptoms  does  it  produce?  It  has  often  happened  that  the 
parasite  has  been  present  without  giving  rise  to  any  symptoms,  having 
iDeen  accidentally  discovered  by  the  expulsion  of  segments. 

The  signs  occasioned  by  its  presence  may  be  put  down  in  general  terms 
as  those  of  irritation.  They  may  be  either  direct  or  reflex.  Among  the  direct 
consequences  are  vague  abdominal  pains,  nausea,  and  meteorism.  Nausea 
is  very  common,  and  both  it  and  the  pain  are  easily  accounted  for  by  the 
irritation  of  so  large  a  mass  of  living  matter  in  the  intestine.  The  reflex 
phenomena  include  a  great  variety  of  nervous  symptoms,  among  which  may 
be  named  headache,  vertigo,  dizziness,  epileptiform  convulsions,  reflex  paral- 
ysis, and  even  insanity;  loss  of  appetite,  and  other  disorders  of  digestion, 
faintness,  derangement  of  vision  and  of  hearing,  including  noises  in  the 
head.  Itching  and  dryness  of  the  nose  and  anus  and  vague  pains  through- 
out the  body  are  sometimes  noticed.  Sensations  of  weariness  and  vague 
■discomfort  may  alone  be  present.  The  only  distinctive  symptom  is,  how- 
ever, the  passage  of  links  of  the  worm.  Notwithstanding  the  presence  of 
these  symptoms,  we  are  often  compelled,  in  the  absence  of  positive  demon- 
stration,— i.  e.,  the  passage  of  pieces  of  the  worm, — to  administer  a  purge, 
in  the  action  of  which  segments  will  be  passed  if  a  worm  is  present. 

Diagnosis. — It  is  a  matter  of  no  small  importance  that  physicians 
should  be  able  to  distinguish  the  different  varieties  of  tape-worm,  for  the 
difficulties  of  treatment  vary  considerably  with  the  different  worms,  the 
tcenia  saginata  being  much  more  easily  dislodged  than  the  tcenia  solium; 
and  the  hothriocephahis  latus,  perhaps,  easiest  of  all.  In  the  first  place  the 
frequent  spontaneous  expulsion  of  segments  of  worm  may  be  taken  as  pre- 
sumptive evidence  that  they  belong  to  the  tcenia  saginata,  as  those  of  the 
tania  solium  rarely  drop  off.  Again,  the  segments  of  hothriocep'halus  latus, 
while  occasionally  expelled,  are  seldom  expelled  singly,  being  discharged  in 
pairs  or  several  joined. 

The  segments  of  the  tconia  saginata  are  stronger,  thicker,  and  less 
transparent,  and  when  expelled  spontaneously,  contain  very  few  eggs.  The 
uterus  which  contains  the  eggs,  and  ^hich  may  generally  be  demonstrated 
by  allowing  a  segment  to  dry  on  a  piece  of  glass,  or,  better,  slisfhtly  com- 
pressed between  two  glass  slides,  is  composed  of  a  central  canal  with  lateral 

*  "A  New  Human  Tape-worm,"  Henry  B.  Ward,  "  Western  Med.  Rev.'"  vol.i.,  1896. 
75 


ii86  ANIMAL  PARASITES. 

branches  which  are  more  distinct  and  less  numerous  in  the  tenia  solium — 
being  from  9  to  12 — than  in  the  tcrnia  saginata,  which  has  from  15  to  20.. 
The  genital  pores  are  lateral  in  the  case  of  the  tania  solium  and  t(xnia  sag- 
inata, but  central  in  the  bothrioccphalns,  which  has  also  a  brown,  rosette- 
shaped  uterus  very  easily  distinguished  from  that  of  the  other  two  more 
common  forms  of  teniae. 

The  tcEniO'  confusa  has  a  most  distinctive  head,  is  very  slender  com- 
pared with  the  three  other  worms  infesting  man. 

Prognosis. — This  is  favorable,  as  a  rule,  in  all  forms  of  tape-worm,  but 
the  taenia  saginata  and  hothriocephahis  latiis  are  much  more  easily  dislodged 
than  the  tcEnia  soliimi,  the  head  of  which  often  resists  removal  for  a  long 
time,  the  segments  continuing  to  reproduce  themselves  until  the  head  is  dis- 
lodged. From  eight  to  twelve  weeks  are  usually  necessary  for  the  worm  to. 
redevelop  itself  to  a  size  at  which  segments  are  again  discharged. 

Treatment. — There  is,  perhaps,  no  morbid  condition  which  has  brought 
more  opprobrium  upon  the  regular  profession  and  more  "  grist  to  the  mill  " 
for  advertisers  and  those  who  use  secret  remedies  than  tape-worm,  and  to  our 
humiliation  it  must  be  said  that  these  persons  do  seem  to  have  more  success 
in  getting  rid  of  tape-worm  promptly  than  we  do.  There  are,  I  think,  two 
reasons  why  this  is  so.  In  the  first  place,  it  is  certain  that  they  do  not  use 
different  remedies  from  those  commonly  in  use  by* the  profession,  but  they 
give  larger  doses.  In  the  second  place,  they  see  a  large  number  of  cases  and 
develop  a  sort  of  specialty  which,  like  all  specialties,  produces  greater  skill 
in  treatment.  In  order  that  a  tape-worm  may  be  successfully  removed  it  is 
necessary  that  it  shall  be  of  a  certain  size ;  so  that,  if  a  large  part  of  the  worm 
has  been  brought  away  by  medicine,  it  is  useless  to  give  anything  more  until 
the  remaining  part  increases  sufficiently  in  size. 

There  are  half  a  dozen  remedies  for  tape-worm,  and  they  are  all  good.. 
I  think  that  the  two  best  are  probably  the  ethereal  extract  of  male  fern  and 
kousso  flowers.  Some  prefer  the  first  of  these,  while  others  prefer  the 
second.  In  my  hands  kousso  has  been  decidedly  the  most  efficient — that  is, 
having  failed  with  everything  else  and  having  succeeded  with  kotisso,  it  has 
naturally  become  the  remedy  with  which  I  usually  begin  the  treatment.  It 
is  the  dried  flowers  and  immature  fruit  of  the  hrayera  anthelmintica,  a  tree 
native  to  Abyssinia. 

Patients  require  some  preparation  before  any  remedy  is  employed.  In 
all  cases  they  should  be  kept  absolutely  quiet  during  treatment.  They 
should  eat  nothing  from  breakfast  time  of  one  day  until  the  next  morning, 
during  which  the  bowels  should  be  moved  by  a  saline  cathartic,  when  one 
ounce  (30  gm.)  of  kousso  anci  eight  ounces  (240  c.  c.)  of  water  are  to  be 
taken.  A  more  pleasant  way  is  to  give  seventy-five  grains  (5  gm.)  in  a  glass 
of  white  wine  every  half  hour  until  four  doses  are  taken.  If  at  the  end  of 
six  hours  no  movement  of  the  bowels  has  taken  place,  a  promptly  acting 
aperient,  as  a  dose  of  oil,  compound  jalap  powder,  or  elaterium,  is  taken,, 
but  generally  kousso  requires  no  purgative  after  it.  The  worm  is  usually 
discharged  entire.  Of  course,  one  is  never  certain  that  this  is  the  case  unless 
the  head  is  found.  At  the  same  time,  it  does  not  follow  because  the  head 
cannot  be  found  that  it  has  not  been  passed,  for  it  is  very  small,  and  may  be 
lost  in  the  discharges.  In  the  tcenia  solium  the  head  is  about  the  size  of  a 
small  pin's  head ;  in  the  mediocanellata  it  is  a  little  larger,  and  in  the  bothrio- 
cephalus  it  is  still  larger.  If  the  head  has  not  been  removed,  it  is  certain  that 
in  from  ten  to  sixteen  weeks  the  worm  will  grow  out  again  and  begin  to 


PLATYHELMINTHES,  OR  FLAT  WORMS.  1187 

discharge  links.  Kousso  is  said  to  have  induced  miscarriage;  it  should  not, 
therefore,  be  given  to  pregnant  women.  Instead  of  kousso,  the  resin  which 
it  contains,  called  koiissin,  may  be  given,  but  I  have  had  no  experience  with 
it.  The  dose  is  from  twenty  to  forty  grains  (1.33  to  2.66  gni.),  inclosed  in 
a  wafer.  The  fluid  extract  is  also  efficient  in  dose  of  half  a  fluid  ounce 
(15  c.  c). 

The  next  remedy  in  efficiency  is  the  ethereal  extract  of  the  rhizome  of 
aspidiuin  filix  mas,  or  male  fern,  whose  active  principle — an  oleoresin — is 
extracted  by  ether.  The  preparation  of  the  patient  is  about  the  same  as 
for  kousso.  The  dose  of  the  ethereal  extract  is  from  2  to  2  1-2  drams 
(8  to  10  c.  c),  followed  in  a  couple  of  hours  by  a  purgative.  It  is  a  dark, 
thick  liquid,  bitter,  slightly  acrid,  and  nauseous.  Instead  of  the  ethereal 
extract  of  male  fern  the  oleoresin  may  be  given  in  a  gelatin  capsule.  The 
dose  is  from  i  1-2  to  2  fluid  drams  (3.  88  to  7.4  gm.).  Two  hours  later  a 
dose  of  purgative  medicine  should  be  administered.  An  important  point  to 
be  borne  in  mind  is  the  varying  quality  of  these  drugs,  and  that  they  deterio- 
rate with  age. 

The  third  remedy,  in  order  of  efficiency,  is  the  bark  of  the  root  of  the 
pomegranate.  This  has  been  given  in  the  shape  of  a  decoction,  from  two 
to  four  ounces  (60  to  120  c.  c.)  to  the  pint  (0.5  liter).  Boil  the  bark  half 
an  hour,  strain,  and  drink.  The  fluid  extract  is  more  convenient  in  the  dose 
of  from  forty-five  minims  to  two  fluid  drams  (3  to  8  c.  c).  Two  hours 
later  a  purgative  should  be  given.  An  alkaloid  is  obtained  from  pome- 
granate, named  pelletierine,  in  honor  of  the  chemist,  Pelletier.  This  is  sold 
in  a  single  dose  of  from  eight  to  twenty-five  grains  (0.5  to  1.6  gm.).  When 
first  introduced,  it  was  vaunted  as  a  "  sure  cure,"  but  the  experience  of  prac- 
titioners has  not  been  uniform,  and  success  has  been  by  no  means  invariable. 
I  have  been  successful  with  it. 

Kamala,  the  hair  of  the  rottlera  tinctoria,  is  said  to  be  very  efficient  in 
tape-worm,  but  I  have  had  no  experience  with  it.  It  is  given  in  doses  of 
from  one  to  two  drams  (4  to  8  gm.)  suspended  in  syrup,  repeated  in  from 
eight  to  ten  hours  if  it  does  not  purge.  The  fluid  extract  is  also  given  in 
doses  of  half  a  dram  to  a  dram  (2  to  4  c.  c).  It  is  purgative,  sometimes 
drastically  so.     It  may  also  cause  nausea  and  vomiting. 

Another  efficient  remedy  is  the  oil  of  turpentine.  It  is,  however,  apt 
to  produce  symptoms  so  unpleasant  that  it  should  be  the  last  used.  The 
dose  is  from  an  ounce  to  two  ounces  (30  to  60  c.  c),  mixed  with  twice  that 
amount  of  castor  oil — a  horrid  dose,  but  if  others  fail,  it  may  be  tried. 

Still  another  is  pumpkin-seed.  There  are  two  ways  in  which  it  may  be 
given.  Three  or  four  ounces  (30  to  120  gm.)  of  the  seeds  may  be  crushed 
in  a  mortar  with  water,  then  strained,  and  the  emulsion  taken  fasting,  after  a 
day's  dieting.  A  few  hours  later  a  brisk  purge  should  be  taken.  Second, 
the  seeds  may  be  made  into  an  electuary  which  is  almost  as  pleasant  as  sugar 
candy,  and  often  is  about  as  effectual.  I  should  place  these  different  rem- 
edies in  the  order  of  their  efficiency  as  follows  :  kousso,  male  fern,  pomegran- 
ate, kamala,  turpentine,  and,  lastly,  pumpkin-seed. 

Combinations  are  sometimes  very  efficient.  The  following  is  recom- 
mended by  Striimpell : 

IJ    Granati  corticis  radicis,       .        .      '.         .        .      §  iv-v  (120  to  150  gm.) 
Aquse, Oij         (1000  c.c.) 

Macerate  for  twenty-four  hours  and  boil  until  it  is  reduced  to  five 
fluid  ounces  (150  c.c  ) 

Add; 
Oleoresinte  filicis,    .        .        o gr.  Ixxv  (5  gm.). 


II 88  PLATYHELMINTHES,  OR  FLAT  IV O RMS. 

The  whole  amount  is  to  be  taken  in  three  or  four  doses  as  close  together 
as  possible. 

Thymol,  in  doses  of  ten  grains  (0.66  gm.)  three  times  a  day  in  a  wafer, 
has  been  recommended.  Another  method  is  to  give  five  grains  (0.33  gm.) 
every  hour  with  or  without  preparation.  Papain  juice  of  carica  papaya  is 
given  in  doses  of  from  one  to  ten  grains  (0.066  to  0.66  gm.). 

It  is  sometimes  useful  to  know  the  exact  course  pursued  in  a  given  suc- 
cessful case.  Thus,  in  such  a  case  the  patient  was  fasted  for  twenty-nine 
hours.  Twelve  hours  after  fasting  began  he  was  given  one  ounce  of  castor 
oil.  Twenty-four  hours  after  fasting  began  he  was  given  i,  1-2  drams 
(5-55  c.  c.)  of  oleoresin  of  male  fern.  In  five  hours  more  he  was  given 
another  ounce  of  oil.     The  \\oni:  came  away  entire  in  a  mass. 

Prophylaxis  is  of  the  greatest  importance.  Great  attention  should  be 
paid  to  the  cooking  of  meats,  especially  of  large  joints,  in  order  that  they 
may  be  thoroughly  "  done."     Rare  meats  should  not  be  eaten. 


(b)  J^isccral  Cestodcs. 

1.  Cysficercus  CcUuloscc. — It  is  not  only  as  tape-worm  that  the  system 
is  in  danger  from  these  parasites.  Human  flesh  may  also  become  "  measled," 
or  infested  with  cysticerciis  cellulosce.  Although  the  beef  measle  has  thus 
far  never  been  found  in  man,  some  sixty  or  seventy  cases  have  been  noticed 
in  which  the  pork  measle  is  said  to  have  caused  death.  As  I  have  explained, 
the  embryos  already  contained  in  the  links  of  the  worm  are  developed  into 
cattle  in  that  of  the  fcutiia  saginata.  When  cysticerci  infest  human  beings, 
the  embryos  may  have  been  introduced  with  food  or  drink ;  but  more  fre- 
quently the  links  are  regurgitated  "^^  into  the  stomach,  and  there  dissolved  by 
the  gastric  juice.  The  embryos,  thus  released,  migrate  into  the  tissues  and 
become  there  encysted — cystkerciis  celluloscE  in  human  tissue.  Situations 
in  which  cysticerci  are  found  are  the  brain,,  spinal  cord,  and  cavity  of  the 
eyeball.  In  the  former  a  train  of  symptoms  is  developed  which  sometimes 
suggests  a  diagnosis.  In  other  situations  they  seldom  give  rise  to  any  symp- 
toms. Even  in  the  brain  they  may  occupy  the  ''  silent  region "  without 
evincing  symptoms.  Seated  in  the  subcutaneous  tissue,  they  may  give  rise 
to  stififness  and  pain  on  motion. 

2.  Echinococciis  Disease. — Another  effect,  in  the  human  being,  of  tape- 
worm is  the  echinococcus  or  "  hydatid  cyst."  This  is  the  result  of  the  in- 
gestion of  the  embryo  of  a  sm^ll  tape-worm  known  as  the  tcenia  echinococcus, 
or  hydatid-forming  tape-worm.  This  small  tape-worm,  which  is  not  more 
than  1-5  inch  (4  to  5  mm.)  in  length,  is  very  common  in  dogs.  It  is  com- 
posed of  three  or  four  segmiCnts,  of  which  the  terminal  one  alone  is  mature. 
This  segment  is  about  two  mm.  (0.08  inch)  long  and  0.6  mm.  (0.025  inch) 
wide.  It  contains  about  5000  eggs.  The  head  of  the  worm  is  very  much 
like  that  of  the  tcenia  solium,  provided  with  a  rostellum,  two  rows  of  hook- 
lets,  and  four  suckers.  The  embryo  also  has  six  hooks,  arranged  in  three 
pairs,  by  which  it  burrows  through  the  intestinal  wall  and  reaches  the  peri- 
toneal cavitv  or  muscles,  or  it  may  enter  the  portal  vessels  and  be  carried  to 
the  liver.  Bv  the  systemic  vessels  it  may  reach  the  brain  and  other  distant 
parts.     Its  most  common  seat  is  the  liver.     It  may  find  entrance  with  food 


*  Portions  of  tape-worm  thus  regurgitated  may  even  pass  bj-  the  mouth. 


NEMATODES,  OR  ROUXD  WORMS.  1189 

and  drinking-water,  which  may  contain  scores  of  these  larvae  and  yet  appear 
pure ;  or  the  embryos  may  be  inhaled  with  dust. 

Geographical  Distribution  of  Echinococciis. — Except  in  Iceland,  where 
there  are  more  dogs  than  persons,  and  Australia,  where  the  mtercourse  be- 
tween man  and  dogs  is  also  very  intimate,  echinococcus  disease  is  rare  in 
human  beings.  In  Iceland  the  ratio  is  put  by  various  authorities  as  from 
I  in  6.  to  I  in  61  residents.  In  some  parts  of  Germany  it  is  not  very  rare. 
Thus,  in  Rostock,  during  a  period  of  twenty-three  years,  there  was  one  case 
of  hydatid  disease  to  1414  residents ;  in  Upper  Mecklenburg,  one  in  129,000 
persons,  and  in  Greifswald,  one  out  of  seventy-five  autopsies  disclosed  the 
disease.  It  usually  affects  persons  between  twenty  and  forty.  In  Manitoba, 
North  America,  where  there  are  settlements  by  Icelanders,  the  disease  is  not 
very  infrequent.  Thus,  A.  H.  Ferguson  reports  that  between  forty-five  and 
fifty  subjects  have  been  treated  in  Winnipeg  since  1874,  when  the  Icelandic 
immigration  occurred. 

Of  the  organs  and  tissues  invaded,  the  liver  is  the  most  frequent,  fully 
half  of  all  hydatids  being  found  in  this  organ.  After  this  the  kidneys,  blad- 
der, and  genitals  in  about  10  per  cent. ;  intestinal  canal,  9  per  cent. ;  lungs  or 
pleura,  8  per  cent. ;  brain  and  spinal  cord,  6  1-2  per  cent. ;  bones,  3  1-2  per 
cent. ;  heart  and  blood-vessels,  31-2  per  cent. :  other  oragns,  about  8  per  cent. 
Of  85  cases  collected  by  Wm.  Osier  in  Canada  and  this  country  up  to  1891, 
the  liver  was  the  seat  in  59 — considerably  over  50  per  cent. 

The  symptoms,  diagnosis,  and  treatment  of  hydatids  of  the  liver  were 
given  when  treating  diseases  of  the  liver. 

The  symptoms  of  hydatids  elsewhere  are  not  distinctive.  In  the  pleura 
and  lungs  the  discharge  of  booklets  through  a  perforation  in  the  chest-wall 
alone  justifies  a  diagnosis  of  hydatids  in  the  pleural  cavity ;  the  finding  of 
booklets  in  the  urine,  hydatid  of  the  kidney  or  urinary  passages.  The  symp- 
toms of  hydatids  of  the  brain  are  those  of  brain  tumor,  the  disease  being 
more  frequent  on  the  right  side.  The  presence  of  hydatid  disease  elsewhere 
is  presumptive  evidence  that  the  brain  symptoms  are  due  to  hydatid  disease. 

Treatment. — The  treatment  of  hydatid  disease,  so  far  as  any  is  pos- 
sible, is  given  in  connection  with  the  diseases  of  the  various  organs  in  which 
it  occurs. 

III.  NE^IATODES,  OR  ROUXD  WORMS. 

Of  these,  the  ascarides,  the  trichinae,  the  anchylostoma,  and  the  filariae 
are  the  most  important. 

A.  The  Ascarides. 

(a)  The  Ascaris  hiinhricoides. 

Description. — This,  the  ordinary  round  worm,  is  the  most  common 
human  parasite.  It  is  found  more  frequently  in  children,  but  is  not  rare  in 
adults.  The  worm  is  also  found  in  cattle  and  in  hogs.  It  is  cylindrical, 
pointed  at  both  ends,  yellowish,  striated,  and  longitudinally  marked  by  four 
bands.  The  female  is  from  15  to  25  cm.  (6  to  10  iclies)  long,  the  male 
from  10  to  20  cm.  (4  to  8  inches).  'Its  resemblance  to  the  ordinary  earth 
worm  is  so  close  that  it  is  not  easy  to  distinguish  them.  The  ova,  often 
verv  numerous  in  the  feces,  are  brownish-red  and  have  a  thick  shell.  They 
are  0.075  mm.  (0.0039  inch)  long  and  0.058  mm.  (0.0023  inch)  wide. 


1 190  ANIMAL  PARASITES. 

The  worms  are  probably  developed  from  eggs  which  are  swallowed  in 
food  and  drink.  They  inhabit  the  upper  part  of  the  small  intestine,  com- 
monly one  or  two,  but  sometimes  large  numbers.  From  this  situation  they 
may  emigrate  downward  and  pass  out  of  the  anus  or  upward  into  the 
stomach  and  esophagus,  whence  they  may  be  withdrawn  through  the  mouth 
or  nose,  or  they  may  be  vomited.  They  may  even  enter  the  trachea  and  pro- 
duce suffocation,  or  the  Eustachian  tube,  passing  out  of  the  ear  at  the  exter- 
nal meatus.  They  sometimes  invade  the  common  bile-duct  and  its  branches 
in  the  liver. 

Symptoms. — Often  there  are  none,  the  worms  being  accidentally  dis- 
covered. At  other  times  there  are  colicky  pain,  meteorism,  fretfulness  in 
children,  vertigo,  headache,  chorea,  and  even  convulsions.  Grinding  of  the 
teeth  in  sleep  by  children  is  regarded  by  the  laity  as  a  symptom  of  "  worms." 
It  is  probably  caused  by  gastro-intestinal  irritation  of  any  kind.  No  symp- 
tom is  to  be  relied  upon  which  is  not  supported  by  ocular  demonstration. 
Obstruction  of  the  bowel  has  resulted  from  the  presence  of  large  numbers 
forming  knotted  masses  or  balls.  If  a  worm  enters  the  bile-ducts,  ob- 
structive jaundice  is  almost  sure  to  be  caused  by  it. 

Treatment. — ^The  remedy  which  has  been  most  satisfactory  in  my 
hands  is  santonin  in  combination  with  calomel.  Powders  containing  san- 
tonin and  calomel,  of  each  one  or  two  grains  (0.066  to  0.132  gm.),  may  be 
prescribed  rubbed  up  with  sugar  of  milk.  Of  these,  one  is  given  night  and 
morning  until  the  bowels  are  freely  moved.  The  santonin  may  color  the 
urine  and  produce  yellow  vision,  or  xanthopsia,  but  I  have  never  seen  harm- 
ful results  in  a  large  experience,  though  poisoning,  manifested  by  convulsion, 
is  said  to  have  been  produced.  For  very  young  children  the  dose  may  be 
reduced  to  1-4  to  1-2  grain  (0.0165  to  0.033  gm.).  The  worm  tablets  exten- 
sively advertised  usually  contain  santonin  as  their  basis.  There  is  an  official 
troche,  U.  S.  P.,  containing  1-2  grain  (0.033  gm.)  of  santonin.  Santonica, 
or  Levant  wormseed,  whence  santonin  is  derived,  is  no  longer  used.  What 
is  known  as  wormseed  oil,  the  oil  of  chenopodium,  another  excellent  remedy 
for  round  worm,  is  derived  from  the  chenopodium  anthelminticuin,  or  Ameri- 
can wormseed.  The  dose  is  ten  minims  (0.65  c.  c.)  to  a  child  of  five  years, 
on  a  lump  of  sugar  or  in  emulsion — ^before  breakfast,  dinner,  and  supper  for 
two  days,  followed  by  a  purge,  of  which  none  is  more  suitable  for  children 
than  calomel,  itself  a  vermicide. 

(b)   Oxyuris  vermicularis. 

Synonyms. — Thread  Worm;  Pin  Worm. 

Description. — The  oxyuris  is  a  minute  white  worm,  well  named  thread 
worm,  the  male  being  from  three  to  five  mm.  (0.1181  to  0.1968  inch)  long, 
the  female  twenty  mm.  (0.7874  inch)  long.  Both  sexes  are  rather  blunt  at 
one  end  and  finely  pointed  at  the  other.  It  infests  the  rectum  and  colon  of 
children  and  adults,  more  frequently  the  former.  It  migrates  and  may  be 
found  in  the  bed,  and  its  ova  are  sometimes  carried  to  the  nose  under  the 
nails  used  in  scratching.  The  primary  infection  is  believed  to  be  by  uncooked 
fruit  and  vegetables  containing  the  ova,  which  may,  however,  be  trans- 
ferred from  person  to  person,  from  hand  to  hand,  or  otherwise  by  contact. 
It  has  been  suggested  that  they  may  be  transmitted  through  the  excrement 
of  flies.  The  worms  are  very  easily  detected  in  the  feces,  which  contain 
also  immense  numbers  of  the  ova.     Their  presence  produces  intense  itching, 


NEMATODES,  OR  ROUND  WORMS.  1191 

especially  at  night,  when  the  worms  migrate.  This  causes  restlessness  and 
sleeplessness,  and  may  even  cause  convulsions  in  children  and  may  weary 
and  exhaust  adults. 

Treatment, — Some  perseverance  is  sometimes  necessary  to  get  rid  of 
the  thread  worm.  I  usually  prescribe  the  same  powder  of  santonin  and 
calomel  as  for  the  round  worm, — /'.  e.,  from  one  to  two  grains  (0.066  to 
0.132  gm.)  of  each, — but  at  the  same  time  order  nightly  injections  into  the 
rectum  of  vermicides,  of  which  there  are  many — the  infusion  of  quassia, 
of  aloes,  lime-water,  vinegar,  corrosive  sublimate  (i  to  500),  salt  and  water. 
The  injection  should  be  retained  for  some  time,  and  to  this  end  the  buttocks 
should  be  raised,  or  the  child  ma}'  be  placed  on  its  hands  and  knees.  Only 
as  much  should  be  introduced — from  two  to  four  ounces  (60  to  120  c.  c.)  — 
as  can  be  conveniently  retained.     Too  large  a  quantity  is  promptly  rejected. 

B.  Trichiniasis. 

Definition. —  The  name  given  to  the  invasion  of  the  tissues  of  the  body 
by  the  embryos  of  the  trichnia  spiralis.  The  mature,  sexually  developed 
worm  has  its  habitat  in  the  small  intestine  of  man  and  other  mammalia. 

Historical. — The  history  of  the  development  of  our  knowledge  of  the  trichina  is 
very  interesting,  and  may  be  found  admirably  condensed  in  the  little  book  by  Max 
Braun,  "  Die  thierischen  Parasiten  des  Menschen,"  second  edition,  1895.  It  was 
discovered  in  human  muscle  by  Owen  in  1S35,  but  it  was  not  until  i860  that  Zenker 
showed  that  it  was  at  times  a  cause  of  death  in  man.  Since  then  three  epidemics  of 
trichiniasis  have  prevailed  in  Germany. 

Description. — The  adult  male  is  from  1.4  to  1.6  mm.  (0.055  to  0.063 
inch)  long,  0.04  mm.  (0.0015  inch)  thick,  with  a  cloacum  opening  between 
two  little  projections  in  the  hinder  end.  The  female  is  from  three  to  four 
mm.  (0.1181  to  0.1574  inch)  long,  and  0.06  mm.  (0.0023  inch)  thick.  The 
head  is  pointed  and  the  tail  is  rounded.  The  larva  or  muscle  trichina  is 
from  0.6  to  I  mm.  (0.0236  to  0.0393  inch)  long,  and  lies  coiled  in  an  ovoid 
capsule  which  is  at  first  translucent,  but  subsequently  becomes  opaque  by 
calcification.     Man,  hogs,  rats,  guinea-pigs,  and  rabbits  are  easiest  infected. 

j\Ian  commonly  acquires  trichiniasis  by  eating  infected  ham  insufficiently 
cooked.  The  capsules  are  digested  and  the  trichinae  set  free ;  they  pass  over 
into  the  small  intestine  and  there  develop  into  the  sexually  mature  worm, 
attaining  maturity  about  the  third  day.  Each  one  discharges  large  numbers 
of  embryos,  of  v/hich  the  males  die  immediately  after  birth,  while  the  females 
bore  their  way  into  the  mucous  membrane.  A  part  perforate  the  intestinal 
wall  and  find  their  way  into  the  mesentery  and  lymphatic  glands  of  the 
mesentery.  The  young  brood  is  carried  away  from  the  bowel  in  the  lymph 
stream,  and  is  distributed  partly  through  the  blood  stream  and  partly  by 
active  migration.  Before  birth  the  young  trichinae  are  from  0.09  to  o.i  m.m. 
(0.0035  to  0.0393  inch)  long,  growing  slightly  during  migration,  say 
from  0.12  to  0.16  mm.  (0.0047  to  0.0063  inch).  Their  favorite  seat  of  lodg- 
ment is  the  striated  muscular  tissue,  within  the  striped  muscular  fasciculus 
itself,  or  between  the  muscular  fasciculi  and  parallel  to  them.  In  nine  or 
ten  days  after  infection  the  first  brood  reaches  its  destination,  to  be  followed 
by  others,  since  the  intestinal  trichinae  continue  to  produce  young  throughout 
a  life  of  seven  weeks.  A  single  Worm,  it  is  said,  may  bring  forth  from 
8000  to  10,000. 

The  young  trichinae  begin  to  be  encysted  in  the  muscle  about  the  second 
or  third  week  after  infection,  by  which  time  the  parasite  has  grown  to  0.8 


1 192  ANIMAL  PARASITES. 

mm.  (0.0314  inch)  in  length.  Each  one  arranges  itself  in  a  spiral,  of  which 
the  outline  is  oval,  and  becomes  surrounded  by  a  capsule  of  corresponding 
shape,  the  worm  cyst  lying  with  the  long  axis  parallel  to  the  direction  of  the 
muscular  fibers.  The  cyst  is  transparent,  0.4  mm.  (0.0157  inch)  long,  and 
0.25  mm.  (0.0098  inch)  wide.  xA.fter  from  five  to  eight  months  calcification 
may  even  involve  the  inclosed  trichina  itself.  On  the  other  hand,  the  cap- 
sule may  undergo  fatty  degeneration,  a  pathological  change  which  takes 
place  at  times  early,  at  others  only  after  the  lapse  of  years.  The  encapsu- 
lated trichina  remains  living  and  capable  of  development  for  a  long  time — 
according  to  Damman  in  hogs  eleven  years,  while  in  man  they  have  remained 
living  twenty-five,  twenty-seven,  thirty,  and  forty  years  after  infection.  It 
has  been  shown  by  Zenker  that  the  encysting  is  not  a  necessary  condition  to 
the  mature  development  of  young  trichinae. 

Human  infection  having  been  conclusively  shown  to  be  due  to  the  eat- 
ing of  raw  pork  infested  with  trichinae,  it  is  not  at  once  evident  how  swine 
become  infected.  It  is  well  known  that  the  rats  which  infest  slaughter 
houses  are  infected  in  large  numbers,  but  it  is  plain  also  that  they  may  ac- 
quire trichinae  b\'-  eating  pork.  The  two  probably  contribute  mutually  to 
the  perpetuation  of  the  disease. 

As  to  the  distribution  of  the  trichiniasis :  most  epidemics  have  been  in 
Germany.  Even  in  America,  where  there  have  been  two  or  three  epidemics, 
it  has  been  in  German  immigrant  communities.  Apparently  it  is  rather  the 
imperfect  cooking  of  the  pork  which  is  responsible,  for  although  a  larger  per- 
centage of  American  pork  appears  to  be  infected  than  German,  yet,  as  already 
stated,  the  disease  is  much  more  infrequent  in  America  than  in  Germany.  It 
is  to  be  remem.bered  that  while  thorough  cooking  effectually  destroys  the 
parasites,  the  requisite  heat  may  fail  to  reach  the  interior  of  large  joints  con- 
taining viable  larvae. 

Symptoms. — The  immigration  of  numerous  active  parasites  in  muscular 
tissue  is  followed  by  intense  irritation,  manifested  at  first  by  fever  and  mus- 
cular pain.  The  latter  is  especially  severe  during  motion.  The  acts  of 
chewing,  swallowing,  and  breathing  are  particularly  difficult,  because  of 
the  pain  excited  by  these  acts.  In  the  early  stage  of  the  disease  diarrhea 
is  quite  common,  so  that  certain  epidemics  have  been  mistaken  for  typhoid 
fever  and  as  often  also  for  rheumatism.  In  the  very  beginning  of  the  im- 
migration into  the  muscles  edema  has  sometimes  been  observed.  The 
more  general  and  thorough  the  invasion,  the  more  intense  the  symptoms. 
\>ry  high  fever,  delirium,  infiltration  of  the  lungs,  and  fatty  degeneration 
of  the  liver  have  been  observed.  Death  may  take  place  either  from  exhaus- 
tion as  the  result  of  extreme  irrftation.  or  later  in  the  disease  from  the  same 
cause  preceded  by  anemia  and  gradual  loss  of  strength.  Usually,  however, 
improvement  sets  in  about  the  fourth  or  fifth  week,  though  convalescence  in 
bad  cases  is  slow,  and  many  weeks  elapse  before  recoverv  is  complete. 

Diagnosis. — It  is  usually  the  unexpectedness  of  the  disease  which  leads 
to  delay  in  diagnosis.  The  resemblance  of  the  symptoms  to  those  of  typhoid 
fezrr  and  muscular  rheumatism  has  been  referred  to.  vet  in  the  presence  of 
a  possible  cause — as,  for  example,  a  German  picnic  or  other  feasting  occa- 
sion where  the  favorite  ham  or  sausage  has  formed  part  of  the  feast — such 
symptoms  should  immediately  excite  suspicion.  The  discovery  by  Dr. 
Thomas  R.  Brown  in  1897*  that  eosinophilia  is  constantly  associated  with 

*  "Johns  Hopkins  Hospital  Bulletin,"  April,  18Q7. 


NEMATODES,  OR  ROUND  WORMS.  1193 

trichiniasis  is  important  and  when  present  is  confirmatory  of  the  existence 
of  the  disease.  A  differential  blood  count  should  therefore  be  made  in  sus- 
pected cases.  When  doubt  exists,  the  harpoon,  designed  for  obtaining 
samples  of  muscle  for  examination,  should  be  unhesitatingly  used,  under 
ether  or  local  anesthesia,  and  the  part  removed  carefully  examined  under 
the  microscope. 

Treatment. — Here,  as  so  often  elsewhere,  an  "  ounce  of  prevention  is 
worth  a  pound  of  cure."  Such  prevention  consists  in  thorough  official  in- 
spection of  all  pork  brought  to  market,  because  cooking  may  fail  of  its  pur- 
pose for  the  reasons  already  mentioned.  For  a  similar  reason  swine  should 
be  grain-fed,  rather  than  allowed  to  feed  on  offal.  It  is  doubtful  whether 
any  direct  measures  can  be  used  for  arresting  the  disease  after  the  muscles 
have  once  been  invaded.  It  is  a  simple  conflict  of  the  mastery  between  the 
strength  of  the  patient  and  the  life  of  the  trichinae.  In  the  majority  of 
cases  the  former  triumphs,  though  death  is  hot  infrequent  from  the  causes 
named.  If  the  disease  is  recognized  early,  the  alimentary  canal  should  be 
treated  with  vermicides  and  purgatives,  with  a  view  to  getting  rid  of  all  the 
sexually  mature  worms  which  may  happen  to  remain  there,  since  it  will  be 
remembered  that  successive  broods  develop  from  the  same  mother-worm 
while  in  the  intestinal  tract.  Glycerin,  given  in  a  tablespoonful  (30  c.  c.) 
dose  hourly,  is  said  to  destroy  the  trichinae.  Benzine,  in  one-  to  two-dram 
(4  to  8  gm.)  doses  in  capsules,  and  picric  acid  in  dose  of  from  five  to  eight 
grains  (0.3  to  0.5  gm.),  are  also  recommended,  but  are  regarded  as  less  re- 
liable. To  relieve  the  pains,  hypodermic  injections  of  morphin,  1-4  grain 
(0.0165  gm.),  or  warm  baths  may  be  used.  Restoratives  and  stimulants 
should  be  given  to  keep  up  strength. 


C.    Anchylostomiasis — Uncinariasis. 

Definition. —  A  term  applied  to  the  invasion  of  man  by  the  anchylos- 
toma  or  sclerostoma  duodenale,  also  known  as  the  unciitaria  diwdenalis, 
dochmius  anchylostommn,  strongylus  quadridentatus,  and  strongylus 
diwdenalis. 

Description. — The  male  is  from  eight  to  ten  mm.  (0.3149  to  0.3937 
inch)  long,  and  has  a  prominent  expansion  or  bursa  at  the  tail  end.  The 
female  is  from  12  to  18  mm.  (0.4724  to  0.7086  inch)  long;  both  are  provided 
with  hook-like  teeth,  by  which  they  attach  themselves  to  the  mucous  mem- 
brane. The  ova,  which  are  abundant  in  the  stools,  are  ovoid,  0.052  mm. 
(0.002  inch)  long  and  0.03  mm.  (0.0012  inch)  broad,  provided  with  a  thin, 
transparent  shell  and  deposited  in  a  state  of  segmentation.  The  habitat  of 
the  worm  is  the  duodenum  and  the  upper  jejunum  of  man  and  certain  anthro- 
pomorphous apes,  it  is  said,  throughout  the  inhabited  globe ;  but  beyond 
some  apocryphal  descriptions  by  physicians  of  the  South  American  States,  it 
is  unknown  here.  Max  Braun  also  says  it  is  sporadic  only  in  the  colder 
countries,  being  more  prevalent  in  southern  latitudes,  especially  those  of 
Italy  and  Poland ;  in  fact,  it  has  been  largely  spread  by  laborers  from  these 
countries  throughout  Germany  and  Austria-Hungary,  the  West  Indies,  and 
Brazil,  the  St.  Gothard  tunnel  being' one  of  the  localities  in  which  it  was 
first  studied.  The  larvae  are  developed  in  damp  earth  and  distributed  by 
wind  and  water.  Many  of  the  victims  are  earth-eaters.  Late  years  have 
shown  a  remarkable  increase  in  anchylostomiasis  in  this  country,  for  a  dis- 


1194  ANIMAL  PARASITES. 

semination  of  accurate  knowledge  of  which  we  are  indebted  to  Dr.  Allen 
Smith  of  the  University  of  Texas. 

Symptoms. — The  parasite  fastens  itself  to  the  mucous  membrane  by 
the  hooked  teeth  described,  and  feeds  upon  blood  drawn  therefrom.  At  first 
only  causing  gastro-intestinal  irritation,  there  gradually  results  an  anemia 
variously  known  as  Egyptian  chlorosis,  brickmaker's  anemia,  tunnel  anemia, 
and  mountain  anemia.  The  rate  of  development  of  the  anemia  varies,  being 
sometimes  very  rapid.  There  occur  also  colicky  pains,  diarrhea,  and  small 
hemorrhages.  A  consequent  symptom  is  extreme  weakness  and  indisposition 
to  effort  mental  or  physical.  Hypertrophy  and  dilatation  of  the,  heart  have 
been  found. 

Diagnosis. — The  diagnosis  is  rendered  easy  by  the  conditions  surround- 
ing the  victims  and  confirmed  by  the  discovery  of  eggs  in  the  feces.  At 
autopsy  they  may  be  found  clinging  to  the  mucous  membrane  in  the  duo- 
denum and  upper  ileum.  Anchylostomiasis,  like  trichiniasis  and  filariasis, 
is  associated  with  eosinophilia.  The  latter  condition  is  therefore  helpful  in 
diagnosis. 

Treatment. — In  treatment  prophylaxis  is  most  important.  All  water 
used  by  laborers  should  be  disinfected.  Thymol  is  said  to  be  a  specific,  and 
should  be  given  in  thirty-grain  (2  gm.)  doses  in  wafers  at  8  a.  m.  and  8 
p.  M.,  a  purge  of  castor  oil  or  magnesia  being  given  after  the  second  dose. 
Should  the  first  effort  fail,  it  may  be  repeated  in  a  week.  The  diet  should 
l>e  liquid — ^milk  and  soups. 

D.  Filariasis. 

Definition. —  A  condition  constituted  by  the  presence  of  several  species 
of  nematode  worms,  known  as  filarise. 

(a)  Filaria  sanguinis  hominis. 

A  term  applied  to  the  several  varieties  of  filaria  which  infest  the  blood 
of  man.     Of  these,  three  species  will  be  described : 

I.  Filaria  Bancrofti. — The  adult  filaria  thus  named  was  first  discovered 
T^y  Bancroft  in  Queensland  in  1876,  and  soon  thereafter  by  T.  R.  Lewis  in 
Calcutta.  Before  these  discoveries  the  larva  only  was  known,  having  been 
discovered  by  Demarquay  in  Paris  in  1863  in  the  hydrocele  fluid  of  a 
Havanese. 

The  adult  male  is  83  mm^  (3.2677  inches)  long  and  0.4  mm.  (0.0157 
inch)  in  diameter,  head  rounded,  tail  pointed,  and  spirally  rolled.  The 
female  is  about  155  mm.  (6.1023  inches)  long  and  0.7  mm.  (0.0275  inch) 
thick.  The  worm  is  about  as  thick  as  a  human  hair.  The  egg  is  0.038  mm. 
(0.0015  inch)  long  and  0.014  mm.  (0.005  inch)  wide.  The  normal  habitat 
of  the  sexually  mature  worm  is  the  lymphatic  vessel  of  different  parts  of  the 
hody  of  man,  though  it  has  been  found  also  in  the  left  ventricle  of  the  heart. 
The  female  is  viviparous,  exceptionally  oviparous,  producing  an  enormous 
number  of  young  larvae,  which  pass  from  the  lymphatic  stream  into  the  blood 
and  are  thus  distributed  over  the  body.  They  are  from  0.27  to  0.34  mm. 
(0.0106  to  0.0133  inch)  long,  0.007  to  o.oii  mm.  (0.0003  to  0.0004  inch) 
Tjroad,  rounded  anteriorly  and  pointed  behind. 

The  larvae  are  found  in  the  peripheral  circulation  after  sundown  in  a 
■drop  of  blood  taken  for  the  purpose.     The  numbers  increase  until  midnight, 


NEMATODES,  OR  ROUXD  WORMS.  1195 

Avhen  they  again  become  less  numerous.  From  midday  to  evening  there  are 
no  filarise  to  be  found.  The  cause  of  this  interesting  fact  cannot  be  ascribed 
to  the  periodic  production  of  broods,  since  ^Mackenzie  has  shown  that  the 
order  is  reversed  if  the  patient  sleeps  during  the  day  and  is  a\\'ake  during  the 
tiight,  under  which  circumstance  the  filariae  are  found  in  the  blood  in  the  day. 
This  is,  however,  not  without  exception.  It  would  seem,  as  suggested  by 
Linstow,  that  the  event  has  something  to  do  with  sleep,  and  that  during  sleep 
the  peripheral  blood-vessels  widen  and  again  contract  during  awaking;  that 
the  filariae  cannot  pass  the  contracted  capillaries  of  the  superficial  skin,  but 
rest  in  the  larger  blood-vessels  in  the  deeper  portion,  to  come  out  with  the 
widening  which  accompanies  sleep.  Their  number  in  the  blood  has  been 
variously  estimated  at  140,000  by  Carter,  and  by  ]^IcKenzie  at  from  30.000 
to  40,000. 

The  Ularia  Bancroftl  is  met  in  the  blood  in  all  tropical  countries,  espe- 
cially India,  China,  Japan,  and  Brazil.  It  has  also  been  found  in  the  Southern 
United  States  in  persons  who  have  never  been  out  of  the  country,  first  by 
Guiteras  and  later  by  others. 

2.  Filaria  Pcrstans. — This  second  variety  of  filai'ia  sanguinis  hominis 
was  also  found  by  ]\Ianson  in  a  larval  state  in  the  blood  of  a  negro  in  West 
Africa.  It  is  distinguished  from  the  other  filariee  of  man  by  its  small  size,— 
0.2  mm.  (0.0078  inch)  long, — its  active  motility  and  contractility.  INIan- 
5on  is  inclined  to  ascribe  to  this  the  sleeping  disease  of  negroes,  and  to  it 
also  the  skin  affection  known  among  negroes  as  kraii'-krazv,  which  is  a 
papillopustular  eruption,  probably  the  same  as  Xielly's  dennatose  parasi- 
taire,  the  parasite  of  which  was  called  rhahditis  XicUy  (Blanchard,  1885). 
The  posterior  extremity  is  obtuse:  the  anterior  has  a  retractile  rostellum. 

3.  Filaria  diiirna,  also  described  by  3.Ianson,  is  seen  in  the  blood  only 
in  the  larv-al  state,  agreeing  in  this  respect  with  filaria  Bancrofti,  dift'ering, 
however,  from  the  latter  in  that  it  appears  in  the  blood  only  in  the  day.  It 
was  discovered  by  Alanson  in  the  blood  of  negroes  on  the  west  coast  of 
Africa.     ]\Ianson  considers  that  filaria  loa  represents  the  adult  stage. 

Etiology. — Patrick  ^lanson  discovered  the  young  filaria,  together  with 
human  blood,  in  the  intestine  of  the  mosquito,  and  thus  secured  the  key  to  the 
problem  of  the  transmission  of  the  parasite  from  one  person  to  another.  He 
also  noticed  that  the  larvae  underwent  a  certain  degree  of  development  in  the 
intestine  of  the  mosquito,  changing  in  form  and  size.  On  the  sixth  or 
seventh  day  they  are  1.5  mm.  (0.0599  inch)  long  and  cylindrical,  and  at 
this  time  change  their  habitat  to  water  through  the  death  of  the  mosquito. 
which  takes  place  after  the  deposit  of  eggs.  Few  mosquitos,  however,  live 
long  enough  to  permit  the  development  in  their  intestine  of  the  filaria  to  the 
stage  at  which  it  is  sufficiently  mature  to  survive  in  water.  ^lanson  con- 
cludes, however,  that  man  becomes  infected  by  drinking  water  which  holds 
the  mature  filariae.  Manson's  studies  have  been  confirmed  by  Lewis,  and 
although  his  conclusions  are  not  undisputed,  they  seem  likely. 

Symptoms. — ^The  early  presence  of  filariae  in  the  blood  does  not  occa- 
sion subjective  symptoms,  and  may  last  years  without  impairment  of  health. 
Sooner  or  later,  however,  as  a  rule,  there  appear  anemia,  enlargement  of  the 
spleen,  and  fever,  with  lymphatic  tumors  in  difterent  parts  of  the  body.  A 
differential  blood  count  at  this  stage  would  be  likely  to  discover  eosino- 
philia.  Later  there  develops,  in  consequence  of  lymphatic  obstruction,  pos- 
sibly caused  by  the  parent  filaria,  possibly  by  the  ova,  elephantiasis,  espe- 
cially of  the  scrotum    (lymph   scrotum)    and  lower  extremities.     To  these 


1 196  ANIMAL  PARASITES. 

succeed  enlargement  of  the  lymphatic  glands,  chyluria,  or  hematochyluria 
already  described,  chylocele,  more  rarely  nephritis,  pyelitis,  cystitis,  and 
even  peritonitis.  Parasites  are  by  no  means  always  found  in  the  blood  in 
cases  of  elephantiasis  or  lymph  scrotum.  The  mechanism  of  these  phe- 
nomena is  thus  described  by  Manson  himself: 

"  A  parent  filaria  is  lodged  in  the  left  thoracic  duct.  In  some  way  not  yet  under- 
stood it  injures  the  walls  of  the  vessel,  causing  ulceration  or  inflammatory  thickening. 
In  time  this  lesion  leads  to  stenosis  of  the  duct.  Farz  passu  with  the  development  of 
the  stenosis  the  thoracic  duct  on  the  distal  side  of  the  stricture  dilates,  owing  to  the 
rising  lymph.  After  a  time  the  stricture  becomes  so  narrow  that  the  lymph  and  chyle 
no  longer  find  their  way  past  it  to  the  left  subclavian  vein.  They  seek;  however,  to 
reach  the  blood  by  another  route;  a  retrograde  movement  down  the  thoracic  duct  sets 
in,  and  so,  by  way  of  the  pelvic  lymphatics  in  the  walls  of  the  abdomen  and  the  anasto- 
mosis between  these  and  the  lymphatics  of  the  upper  part  of  the  body,  the  chyle  from 
the  intestines  and  the  lymph  from  the  lower  extremities  find  their  way  into  the  circula- 
tion by  the  right  thoracic  duct.  Possibly  there  are  other  routes,  as  by  the  lymphatics 
of  the  esophagus,  diaphragm,  and  back.  It  is  certain,  however,  that  a  frequent  course 
pursued  is  that  described,  which  is  much  the  same  as  that  pursued  by  the  blood  in  the 
case  of  obstructed  portal  circulation.  To  accommodate  this  diverted  chyle  and  lymph, 
the  lymphatics  by  which  they  pass  become  enlarged  and  in  many  places  varicose.  The 
tendency  to  varicosity  is  very  evident  in  such  places  as  the  scrotum,  mucous  membrane 
of  the  bladder,  or  wiierever  the  lymphatics  are  abundant  and  feebly  supported.  In 
many  instances  these  varices,  when  superficial,  can  be  seen  or  felt  and  their  nature 
readily  recognized.  If  the  ingulno-femoral  glands  are  involved,  the  varicose  groin  glands, 
so  characteristic  of  filaria  infection,  are  produced.  Sometimes  the  varix  is  apparent  on 
the  surface  of  the  abdomen  even,  as  in  a  case  related  by  Sir  William  Roberts  and  in 
another  by  Havelhing.  That  these  varices  are  really  part  of  an  anastomosis  conveying 
chyle  from  the  abdominal  viscera  to  the  blood  is  proved  by  the  nature  of  their  contents, 
which  are  usually  milky-white  or  slightly  red-tinted  chyle — not  clear  and  limpid  lymph, 
such  as  comes  from  the  legs.  As  the  lacteals  are  the  only  source  of  chyle,  these  chylous 
contents  of  the  varicose  lymphatics  must  have  come  from  that  source,  and  the  route 
followed  must  have  been  the  retrograde  one  described.  Now  if  the  lymphatics  of  the 
bladder  happen  to  be  involved  in  the  compensatory  anastomosis,  and  if  they  give  way, 
as  the  lymphatics  of  the  scrotum  so  frequently  do  in  similar  circumstances,  the  result  is 
a  leakage  of  chyle  in  the  bladder,  and  chyluria.  It  is  evident  from  this  that  the  embryo 
filariae,  although  they  are  generally  present  in  the  blood  and  the  urine  in  chyluria,  have 
nothing  whatever  to  do  with  its  production.  This  is  further  proved  by  the  fact  that  in 
some  few  cases  of  genuine  and  persistent  tropical  chyluria  no  embryo  filaria  can  be 
found  either  in  blood  or  urine.  Proper  treatment  of  chyluria  is  in  principle  the  same  as 
the  treatment  of  acquired  varix  in  any  accessible  region.  This  should  consist  of  rest, 
elevation,  lowering  of  the  tension  in  the  lymphatic  vessels  by  the  use  of  saline  purgatives, 
limited  and  appropriate  food,  and  abstinence  from  fluids  as  much  as  possible.  Certain 
drugs  have  been  vaunted  as  specifics  for  chyluria.  Temporary  recovery  from  time  to 
time  is  the  rule,  and  the  drug  which  was  being  used  at  the  time  the  urine  cleared  spon- 
taneously from  the  healing  of  the  rupture  in  the  varix  of  the  bladder  is  often  credited 
with  the  cure.  I  cannot  understand  how  a  drug  introduced  by  the  mouth  can  possibly 
cause  the  closure  of  a  gaping  varix  in  the  bladder." 

Treatment. — ^No  treatment  appears  to  be  of  any  value  in  exterminating 
the  filarise  in  the  blood.  The  symptomatic  treatment  should  consist  in  rest, 
lowering  of  the  tension  of  the  lymphatics  by  saline  purgatives,  by  appropriate 
food,  and  limitation  of  fluids  ingested.  No  drugs  have  any  influence, 
though  it  is  not  unnatural  that,  being  used  at  the  time  of  the  spontaneous 
intermission,  they  should  secure  a  reputation  for  curative  powers. 

(b)  Filaria  dracunculus. 
Synonyms. — Dracontiasis ;  Guinea-worm-  Disease. 

Description. — Dracontiasis  is  a  term  given  to  the  presence  of  the  filaria 
dracuncnhis  or  filaria  niedinensis,  or  guinea-worm. 

The  female,  until  recently  alone  known,  is  from  50  to  80  cm.  (20  to  32 
inches)   long  or  longer,  and  from  0.5  to  1.7  mm.   (0.0196  to  0.0669  inch) 


NEMATODES,  OR  ROUND  WORMS.  1197 

thick.  Quite  recently  R.  H.  Charles  found,  along  with  two  females  re- 
moved from  a  dead  body  at  Lahore,  a  much  shorter  worm,  about  four  cm. 
(1.6  inches)  long,  attached  by  its  hinder  extremity  to  one  of  the  females  at 
a  point  about  four  cm.  (1.6  inches)  from  its  head,  which  he  inferred  to  be  the 
male  attached  to  the  vagina  of  the  female,  dying  after  impregnation,  as  is 
the  case  with  some  other  parasites.  Then,  too,  the  vagina  atrophies,  as 
both  it  and  the  vulva  are  absent  in  the  mature  worm. 

As  to  the  development  of  the  worm,  the  mature  female  contains  enor- 
mous numbers  of  living  embryos,  which  are  discharged  into  the  water  of 
ponds.  After  a  few  days  they  probably  enter  the  cyclops,  a  small  crustacean, 
and  there  reach  a  certain  stage  of  development,  when  they  are  imbibed  with 
drinking-water  by  man  and  reach  their  ultimate  destination,  as  described, 
in  the  subcutaneous  and  intermuscular  connective  tissue,  especially  in  the 
lower  extremities,  about  the  foot-joint.  To  this  it  obtains  entrance  through 
the  stomach,  whence  it  penetrates  the  intestine  and  passes  to  the  subcutaneous 
connective  tissue,  where  it  attains  its  full  development,  lying  for  a  long  time 
quiescent  under  the  skin,  and  where  it  can  be  felt  like  a  cord.  Later  it  excites 
suppuration,  and  with  the  rupture  of  the  abscess  is  discharged.  It  is  also 
found  elsewhere,  as  in  the  back,  scrotum,  perineum,  the  upper  extremities, 
eyelids,  and  tongue.  L'sually  one  worm  only  is  found,  rarely  several.  It  is 
wide-spread,  occurring  in  all  races,  ages,  and  in  both  sexes.  Van  Harlingen 
described  a  case  in  a  man  who  had  always  resided  in  Philadelphia.  Accord- 
ing to  Braun,  the  fiery  serpents  described  by  ]\Ioses  were  guinea-worms. 
The  term  A  paKOvriov^vdiS  applied  by  Agatharchides  one  hundred  and  forty 
years  before  Christ,  and  Galen  called  the  disease  dracontiasis. 

Diagnosis. — The  worms  are  easily  recognized  under  the  circumstances 
named. 

Treatment. — As  to  treatment,  the  indication  is  to  remove  the  worm 
intact  after  the  abscess  is  opened,  because  of  the  irritation  excited  b}-  the 
escape  of  the  living  embryos.  The  method  of  procedure  directed  is  to  roll 
the  worm  around  a  piece  of  smooth  wood,  each  day  a  little,  in  order  to 
prevent  retraction,  until  the  whole  worm  is  withdrawn. 

It  is  said  that  the  leaves  of  the  plant  amar  pattee  are  a  specific  cure, 
Avhile  asafetida,  when  given  in  full  doses,  is  also  said  to  be  poisonous  to  the 
worm. 

(e)  Other  Filarice. 

Numerous  other  filarise,  of  less  importance,  have  been  found  from  time 
to  time  in  man.     Among  them  I  select  from  Braun : 

1.  The  filaria  immitis,  the  common  Ularia  sanguinis  of  the  dog,  found 
twice  in  man  by  Bowlby,  in  one  instance  associated  with  hematuria.  He 
found,  in  the  case  of  an  Arab,  numerous  filarise  in  the  portal  vein,  eggs  in 
the  thickened  bladder-wall,  kidney,  ureter,  and  the  lung ;  in  another  eggs 
were  found  in  a  tumor  of  the  rectum  in  a  seventeen-year-old  youth. 

2.  The  aiaria  loa,  a  delicate  worm,  from  30  to  40,  rarely  70,  mm.  (i.ii 
to  1.57  to  2.75  inches)  long,  found  between  the  conjunctiva  and  the  eyeball 
in  negroes  on  the  West  Coast  of  Africa",  whence  it  has  spread  to  South 
America  and  the  West  Indies. 

3.  The  filaria  ocnli  huinani  vel  lentis,  which  in  several  instances  was 
removed  with  lenses  the  seat  of  cataract,  of  which  it  seems  to  have  been  the 
cause. 

A.    The  filaria  labialis.  found  in  a  pustule  in  the  lips  of  a  child. 


1 198  NEMATODES,  OR  ROUND  WORMS. 

5.  The  aiaria  hoininis  oris  (Leid)-),  obtained  from  the  mouth  of  a  child. 

6.  The  aiaria  lynipliatico  vcl  hronchiaUs,  found  in  lymphatic  glands  of 
the  lungs  and  in  the  trachea  and  bronchi. 


E.    Other  Nematode  Worms. 

1.  The  tricJw€CpIiaIus  d  is  par,  an  interesting  worm  of  which  the  anterior 
portion,  equal  to  three-fifths  of  the  body,  is  very  delicate  and  hair-like,  while 
the  hinder  portion  is  much  thicker.  It  is  from  four  to  five  cm.  (1.6  to  2 
inches)  in  length,  the  male  being  somewhat  shorter.  The  hinder. end  of  the 
female  is  conical  and  pointed,  while  in  the  male  it  is  more  obtuse  and  rolled 
like  a  spring.  The  ova  are  oval,  0.05  mm.  (0.0012  inch)  long,  and  provided 
with  a  button-like  projection  like  that  on  the  end  of  a  lemon. 

Its  habitat  is  usually  the  c?ecum  of  man,  rarely  the  appendix  vermi- 
formis,  and  exceptionally  the  small  intestine.  Usually  they  are  few  in  num- 
ber and  give  rise  to  few  or  no  symptoms.  In  some  instances  large  num- 
bers are  found,  and  serious  brain  symptoms  have  been  ascribed  to  them, 
in  other  cases  anemia.  It  is  said  to  be  one  of  the  commonest  parasites 
in  man  the  world  over,  in  either  sex  and  at  any  age  except  infancy.  Beri- 
beri has  been  ascribed  to  it.  The  larvae  are  probably  developed  from  the 
eggs  in  water,  and  are  possibly  ingested  in  drinking-water.  The  ova  are 
very  resisting  to  the  destructive  agents  to  which  they  are  ordinarily  sub- 
jected.    Large  numbers  are  found  in  the  feces. 

2.  The  eustrongyhis  gigas,  or  strongylus  gigci'S,  is  an  enormous  nema- 
tode, the  male  of  which  measures  240  cm.  (2.1  feet),  and  the  female  100  cm. 
(3  feet  4  inches)  long  and  12  mm.  (0.5  inch)  thick.  It  lives  in  the  pelvis 
of  the  kidney,  more  rarely  in  the  abdominal  cavity  of  the  seal,  dog,  wolf, 
horse,  and  other  animals,  and  exceptionally  in  man. 

3.  The  strongyloides  intestinalis,  or  anguilhila  intestinalis  et  stercoralis, 
is  a  small  nematode  worm,  first  found  in  1876  in  the  stools  of  French  sol- 
diers in  Cochin  China  suffering  with  severe  diarrhea.  They  are  found  in 
all  parts  of  the  intestine  and  in  the  biliary  and  pancreatic  ducts,  producing- 
diarrhea  only  when  present  in  large  numbers. 


IV.    ACANTHOCEPHALI. 

Synonym. — Thorn-head  Worms. 

Description. — These  are  nematode-like  worms  in  the  intestinal  canal, 
which  are  provided  at  the  anterior  end  with  a  retractile  proboscis  furnished 
with  hooks,  hence  called  thorn-headed. 

Of  these  the  gigantorhynchns,  or  echiiiorhynchtis  gigas,  is  a  large  worm^ 
the  male  being  from  ten  to  fifteen  cm.  (4  to  6  inches),  "and  the  female  from 
thirty  to  fifty  cm.  (12  to  20  inches)  long,  which  attains  its  full  development 
in  the  intestine  of  the  hog,  attaching  itself  to  the  mucous  membrane  by 
its  thorn  head.  The  intermediate  host  is  the  cock-chafer  grub  in  America 
and  the  June  bug.  As  these  insects  may  be  accidentally  swallowed  by  man, 
it  is  not  impossible  that  the  parasite  may  develop  in  his  intestine. 


ARTHROPODA.  1199 


V.  ARTHROPODA. 

Of  these,  both  the  arachnides  and  insecta  contribute  to  human  para- 
sites. 

A.    Arachnoidea. 
(a)  Acarince. 

1.  Sar copies  or  acarus  scabiei — the  itch  insect.  This  is  the  most  fre- 
quently met  of  the  arachnide  parasites.  Its  oval,  nearly  circular  little  body,, 
provided  with  horns  and  bristles,  is  barely  visible  to  the  naked  eye  under 
favorable  circumstances,  the  male  being  from  0.2  to  0.3  mm.  (0.0078  to 
0.0118  inch)  by  0.145  to  0.19  mm.  (0.0057  to  0.0074  inch)  ;  the  female, 
from  0.33  to  0.45  mm.  (0.0129  to  0.0177  inch)  by  0.25  to  0.35  mm.  (0.0098 
to  0.0137  inch. 

The  female  lies  at  the  end  of  a  burrow  in  the  epidermis,  in  situations 
where  the  skin  is  most  delicate,  as  between  the  fingers,  at  the  elbows,  and 
under  the  knees,  in  the  groin,  and  on  the  penis,  very  seldom  in  the  face,  but 
in  any  delicate  part.  In  this  burrow,  some  millimeters  to  a  centimeter  long, 
the  female  deposits  her  eggs.  The  male  is  seldom  seen,  dying  after  copula- 
tion, and  the  female  after  depositing  her  eggs.  The  eggs  hatch  in  from  four 
to  eight  days,  and  in  about  fourteen  days  the  larvae  are  sufficiently  matured 
to  make  their  own  burrows.  The  disease  is  communicated  by  personal  con- 
tact or  by  clothing. 

Symptoms. — These  are  first  an  intense  itching  which  incites  to  scratch- 
ing, which,  in  turn,  causes  excoriations,  papules,  vesicles,  and  pustules. 

Diagnosis. — The  diagnostic  feature  is  the  shining  little  vesicle  readily 
recognized  by  a  moderate  magnifier  in  the  webs  of  the  fingers,  though  it 
is  often  obscured  and  obliterated  by  the  eruption  and  marks  caused  by 
scratching. 

Treatment. — This  is  very  simple.  Sulphur  ointment  is  a  prompt 
specific.  The  body  should  be  first  bathed  thoroughly  with  soft  soap,  and 
then  as  thoroughly  anointed  with  the  ointment,  which  should  be  allowed 
to  remain  until  the  next  day,  when  there  should  be  another  bath,  followed 
by  another  vigorous  application  of  the  ointment.  Three  or  four  days  of 
this  treatment  should  suffice.  An  ointment  of  naphthol,  one  dram  to  the 
ounce  (4  gm.  to  30  gm.),  is  recommended. 

2.  Demodex  folUculormn,  a  minute  parasite  from  0.3  to  0.4  mm.  (0.0118 
to  0.0157  inch)  long,  which  resides  in  the  sebaceous  follicles,  with  the 
grease  of  'vhich  it  can  sometimes  be  squeezed  out.  It  is  oftenest  met  on 
the  face  and  nose.  It  is  said  to  be  present  in  about  50  per  cent,  of  persons, 
but  this  is  probably  exaggerated.  It  usually  gives  rise  to  no  symptoms, 
but  is  said  sometimes  to  be  the  cause  of  obstruction  of  the  follicles  and  pro- 
duces thus  the  little  worm-like  accumulations  of  fat  which  may  be  squeezed 
out  of  the  follicles,  and  which  cause  inflammation  and  acne. 

Treatment. — Acne  is  well  treated  by  a  lotion  of  corrosive  sublimate,  2 
to  1000,  and  it  may  be  by  its  effect  on  tiie  demodex  that  it  is  useful. 

3.  Lepns  aiittimnalis,  or  harvest  bug,  is  a  minute  red  parasite,  from 
0.3  to  0.5  mm.  (0.0118  to  0.0196  inch)  long,  which  has  three  pairs  of  legs, 
with  rows  of  bristles  upon  its  back  and  belly.     It  prevails  in  summer  on 


I200  ANIMAL  PARASITES. 

grasses  and  plants,  attaches  itself  to  the  skin  of  man  and  animals  by  its 
hooklets,  and  gives  rise  to  irritation.. 

Treatment. — It  is  successfully  destroyed  by  sulphur  ointment  and  cor- 
rosive sublimate,  2  to  1000. 

4.  Ixodes  riciniis  is  a  minute  oval  tick,  the  male  being  1.2  to  2  mm. 
(0.0474  to  0.0787  inch)  long,  and  brownish-red  in  color,  the  female  four 
mm.  (0.1574  inch)  long,  yellowish-red,  when  distended  with  blood  bluish- 
gray,  twelve  mm.  (0.4724  inch)  long^^  six  to  seven  mm.  (0.2362  to  0.2755 
inch)  broad,  which  infests  the  skin  of  sheep,  cattle,  dogs,  horses,  and  men, 
<:ausing  irritation  and  inflammation. 

It  may  generally  be  removed  by  rubbing  or  greasing  with  any  sort  of 
oil  or  vaselin. 

{h)  Lingnafiilida',  or  Pcntastomcs. 

The  pentastomes  include  the  pentatomum  tccnioides,  or  lingitatiila  rhi- 
■naria,  and  the  pcntastoiuuui  coiistrictiim  or  porccphalus  constrictiis. 

1.  The  pentastomum  tcBnioides  is  a  lancet-shaped  worm,  already  de- 
scribed in  connection  with  parasites  of  the  liver.  The  adult  infests  the 
frontal  sinuses  and  nostrils  of  the  dog,  more  rarely  of  the  horse,  and  has 
"been  found  in  the  nostrils  of  man. 

2.  The  pentastoniiiiii  constriciuui  has  as  yet  been  met  only  in  the  larval 
state.  It  is  milk-white  in  color,  with  golden-yellow  hooklets,  13  mm. 
(0.51 18  inch)  long  and  2.2  mm.  (0.0866  inch)  wide,  provided  wath  twenty- 
three  rings.  It  has  been  found  by  Pruner  encysted  in  the  liver  of  two 
negroes  in  Cairo,  by  Bilharz  in  two  instances  encysted  in  the  liver  and 
mucosa  of  the  bowel,  and  by  Aitken  in  the  liver  and  lungs  of  an  English 
soldier  in  the  West  Indies. 


B.     Insecta. 

Of  these,  the  order  rhyncota  is  represented  by  pediculi  or  lice  and  the 
cimex  or  bed-bug,  the  diptera  by  the  pulex  or  flea. 


-  (a)  Rhyncota. 

Pediculi  (Phtheiriasis;  Pediculosis). — Of  these,  three  varieties  infest 
"human  beings  of  filthy  habits : 

I.  The  pediciilus  capitis,  or  head-louse.  The  male  is  from  i  to  1.5 
mm.  (0.0393  to  0.059  inch)  long,  the  female  from  1.8  to  2  mm.  (0.0708  to 
0.0757  inch)  long.  The  color  varies  somewhat  with  the  races.  In  the 
white  it  is  gray  with  a  dark  border,  in  the  negro  and  Chinaman  darker. 
Its  eggs  are  0.6  mm.  (0.0236  inch)  long,  of  which  the  female  lays  about 
fifty,  w^hich  mature  in  about  a  week,  and  in  eighteen  days  are  ready  to  re- 
produce. The  eggs  are  attached  to  the  hairs,  and  are  easily  visible,  being 
known  as  nits. 

The  head-louse  is  found  the  world  over,  upon  the  hairy  heads  of  men 
and  sometimes  in  other  parts  of  the  body  where  there  are  hairs.  Even 
when  they  are  quite  numerous  they  mav  produce  no  symptoms.  Gener- 
ally, however,  they  cause  itching  and  scratching,  especially  when  the  louse 
bores  deep  into  the  skin  and  produces  pustular  dermatitis,  wath  resulting 


ARTHROPODA.  1201 

crusts  and  scabs  in  which  the  hair  becomes  matted  and  tangled,  forming 
the  plica  polonica,  so  called  from  its  frequency  in  Poland. 

2.  The  pedicuhis  vestimenti,  or  body-louse,  is  considerably  larger,  bemg 
from  two  to  five  mm.  (0.1574  to  0.1968  inch)  long  and  whitish-gray  in 
color,  the  back  part  of  the  body  being  wider  than  the  thorax.  Its  eggs 
are  from  0.7  to  0.9  mm.  (0.275  to  0.0354  inch)  long,  and  about  seventy  are 
laid  by  the  female.  It  lives  on  the  clothing  in  which  it  deposits  its  eggs, 
about  the  neck,  back,  and  abdomen.  The  puncture  incident  to  sucking  is 
often  covered  by  a  hemorrhagic  point.  It,  too,  causes  itching  and  scratching, 
with  irritation  and  inflammation  of  the  skin,  and  in  old  cases  a  roughness 
and  pigmentation  causing  dark  spots  and  a  condition  known  as  morbus  er- 
rorum  or  vagabond's  disease,  which  has  been  mistaken  for  Addison's  dis- 
ease. 

3.  The  pedkulus  pubis,  phthirius  inguinalis,  or  crab-louse,  is  smaller 
than  the  head-louse,  grayish-yellow  or  grayish-white,  the  male  being  from 
0.8  to  I  mm.  (0.0314  to  0.0393  inch)  long,  the  female  1.12  mm.  (0.0441  inch) 
long.  The  eggs  are  pear-shaped,  from  0.8  to  0.9  mm.  (0.0314  to  0.0354 
inch)  long,  and  from  0.4  to  0.5  mm.  (0.0157  to  0.0196  inch)  wide.  They 
infest  the  parts  of  the  body  covered  by  shorter  hairs,  such  as  the  pubis, 
axilla,  and  eyebrows.  The  pediculus  pubis  does  not  wander  so  much  as  the 
pedicuhis  capitis  or  vestimenti,  but  adheres  more  closely  to  the  skin  and 
there  removal  is  often  with  difficulty. 

These  lice  rarely  give  rise  to  symptoms. 

Treatment. — Of  Pediculosis. — For  the  head-lice:  The  hair  should  be 
cut  short  and  burned,  the  head  thoroughly  washed  with  soap  and  water, 
and  then  anointed  with  mercurial  ointment  or  washed  with  tincture  of  coc- 
culus  indicus,  or  with  coal-oil  or  turpentine,  or  carbolic  acid,  i  to  50.  Coc- 
culus  indicus  is  to  be  preferred  because  of  its  freedom  from  odor.  The  wash- 
ing should  be  repeated  for  several  days  in  succession. 

The  treatment  for  the  crab-louse  is  the  same,  but,  as  mentioned,  it 
adheres  firmly  to  the  skin,  and  it  is  generally  necessary  to  pick  off  the  indi- 
vidual louse. 

To  get  rid  of  the  body-louse  the  clothing,  if  not  too  valuable,  should 
be  burned,  but  may  be  boiled,  or,  when  this  is  not  admissible,  treated  by 
superheated  steam. 

The"itching  promptly  disappears  with  its  cause,  but,  if  necessary,  it  may 
be  allayed  by  a  warm  bath  to  which  four  or  five  ounces  (120  to  150  gm.)  of 
sodium  bicarbonate  are  added. 

Repeated  bathing  with  soft  soap  should  be  done  until  it  is  absolutely 
certain  that  the  parasite  and  its  ova  are  removed. 

4.  The  cimex  lectularius,  or  common  bed-bug.  This  familiar  insect  is 
reddish-brown,  oval  in  shape,  from  four  to  five  mm.  (0.0574  to  0.1968  inch) 
long,  and  three  mm.  (0.1181  inch)  wide.  The  female  lays  three  or  four 
times  a  year  about  fifty  eggs,  1.12  mm.  (0.0441  inch)  long,  which  require 
about  eleven  months  for  their  perfect  development  to  the  sexually  ripe  con- 
dition. They  live  in  the  crevices  of  beds,  floors,  and  rafters,  in  furniture, 
behind  wash-boards  and  wall-paper,  in  the  habitations  of  man.  During  the 
day  they  lie  concealed;  at  night  they  wander  in  search  of  the  blood  of 
the  human  being,  which  they  draw  by  means  of  a  long  proboscis.  The 
peculiar  odor  of  the  insect  is  due  to  a  secretion  of  a  special  organ  with 
which  the  bug  is  provided. 

Human  beings  are  variously  susceptible  to  the  bite  of  the  bed-bug,  some 

76 


I202  ANIMAL  PARASITES. 

being  quite  indifferent  to  it,  others  being,  as  it  were,  special  favorites  of  the 
httle  creature. 

Treatment. — The  irritation  is  confined  to  the  moment  of  the  bite. 
The  aim  to  be  sought  is  the  extermination  of  the  insect.  This  is  often  diffi- 
cult when  a  thorough  lodgment  is  secured,  and  it  is  often  necessary  that  all 
wall-paper  should  be  removed  as  well  as  loose  woodwork.  Bedsteads 
should  be  thoroughly  scalded  and  then  treated  with  the  following:  Two 
tablespoonfuls  of  metallic  mercury  should  be  thoroughly  beaten  up  with  the 
white  of  one  egg  until  a  froth  is  attained.  Apply  freely  with  a  small  paint- 
brush, filling  in  carefully  all  cracks  and  crevices.  The  pest  is  ^ess  apt  to 
invade  iron  bedsteads,  but  even  these  must  not  be  neglected,  for  they,  too, 
in  careless  hands,  may  become  infested.  Solution  of  corrosive  sublimate,  2 
to  1000,  may  also  be  applied  in  the  same  manner. 

(b)  Dipt  era. 

1.  The  pill  ex  irritans,  or  common  flea.  Of  these  little  creatures,  the 
male  is  from  2  to  2.5  mm.  (0.0787  to  0.1181  inch)  long,  the  female  as  much 
as  four  mm.  (0.1574  inch),  red  or  dark-brown  in  color.  It  is  also  highly 
capricious  in  its  tastes,  disturbing  some  persons  not  at  all,  others  seriously. 
It  is  not  a  parasite  of  man,  and  invades  him  usuaHy  because  of  its  great 
abundance  in  certain  places  and  countries.  Though  of  world-wide  dis- 
tribution, it  is  more  troublesome  in  hot  countries  where  cleanliness  of 
household,  city,  and  person  is  a  matter  of  indifference.  The  eggs  are  not 
laid  on  human  beings,  but  in  the  cracks  of  boards,  sweepings,  and  wooden 
spit-boxes. 

Treatment. — The  essential  oils  applied  to  the  infested  parts  cause  the 
retreat  of  fleas  when  applied. 

2.  The  piilex  penetrans,  or  sand-flea  or  jigger.  The  female  buries  her- 
self in  the  skin  of  human  beings  as  well  as  of  dogs,  swine,  and  other  mam- 
mals, producing  painful  irritation,  circumscribed  swelling,  and  even  suppu- 
ration. It  especially  attacks  the  feet.  It  prevails  in  tropical  countries, 
especially  in  Central  and  South  America.     The  eggs  are  land-hatched. 

Treatment. — The  flea  may  be  picked  out  with  a  needle,  after  which 
the  essential  oils  are  rubbed  in  on  the  parts  to  keep  it  away. 

3.  Myiasis. — The  diptera  also  contribute  to  parasites  through  their 
larvae,  which  are  deposited  sometimes  in  open  sores  which  have  been 
neglected,  and  sometimes  in  the  nasal  passages  and  cavities — the  ear,  phar- 
ynx, vagina,  etc.  The  condition  is  called  myiosis,  from  the  Greek  MVia^  a 
fly. 

The  most  common  of  these  is  myiosis  vulnerum,  in  which  an  ulcer  be- 
comes filled  with  maggots,  which  are  the  larvae  of  the  blue-bottle  or  common 
flesh  fly,  sarcophaga  carnaria. 

Myiosis  nariinn,  aiiriiini,  conjimctivce,  vagims,  etc.,  are  due  to  the  lucilia 
maceUaria.  whose  larva  is  deposited  in  these  situations  usually  when  they 
are  diseased,  and  may  produce  serious  mischief,  perforating  mucous  mem- 
brane and  even  cartilage.  The  larvae  of  the  lueilia  nohilis  have  also  been 
found  in  the  auditory  passages,  producing  ringing  of  the  ears  as  a  symp- 
tom. The  larA^ae  of  sarcophuga  magniUca  have  been  found  in  ulcers  and 
other  situations,  throughout  Europe,  and  especially  in  Russia. 

Cutaneous  myiasis  is  commonly  due  to  the  larva  of  the  hypodernia  bovis 
or  bot  fly,  the   female  of  which  lays  her  eggs  on  the  skin  of  cattle  and 


ARTHROPODA.  1203 

sheep,  in  which  the  larva  bores  its  way  and  forms  the  gad  boil,  about  as 
large  as  a  pigeon's  tgg.  Rarely  in  tropical  countries  this  happens  in  the  skin 
of  man.  Cutaneous  myiosis  is  sometimes  caused  by  the  larva  of  the 
musca  vomitoria,  one  of  the  domestic  flies.  More  frequently  it  causes  in- 
ternal myiosis,  having  been  swallowed  and  again  discharged  by  vomiting. 
More  rarely  dipterous  larvae  are  found  in  the  feces,  including  those  of  the 
common  house-fly  and  the  trichomysa  fnsca,  which  has  also  been  vomited. 


SECTION  XIV. 

SUMMARY  OF  SY^IPTOMS  FOLLOWIXG  OVERDOSES  OF 

POISONS. 

{Alphabetically  Arratiged). 

To  WHICH  13  Added  a  Table  of  Minimum  Dose  which  Has  Caused   Death,  and  Maximum 
Dose   Followed  by  Reco\'Erv. 

Aconite  {Monkshood ;  Wolfsbane ;  Blue  Rocket). — All  parts  poison- 
ous. The  tincture  may  be  mistaken  for  sherry  or  whisky ;  it  has  an  ex- 
ceedingly acrid  taste. 

Symptoms. — These  appear  quickly,  and  consist  of  an  acrid  taste  m  the 
mouth,  a  feeling  of  warmth  in  the  stomach,  followed  by  a  tingling  sensation 
throughout  the  body :  muscular  weakness,  slow,  weak  pulse ;  vomiting  may 
be  present ;  collapse  follows.     The  mind  is  clear  to  the  last. 

Treatment. — Stomach-tube  or  emetics :  recumbent  posture,  with  feet 
somewhat  elevated.  Stimulants  freely,  such  as  ammonia,  ether,  digitalis, 
atropin,  and  strychnin.  Heat  to  the  extremities,  and  artificial  respiration  for 
two  hours. 

Alcohol. — Taken  in  the  form  of  spirituous  beverages.  Acute  alco- 
holic poisoning.  A  brief  period  of  excitement,  with  flushing  of  the  face, 
followed  by  unconsciousness,  stertorous  breathing,  rapid  and,  finally,  weak 
pulse,  vomiting,  a  subnormal  temperature,  delirium,  complete  muscular  re- 
laxation, at  times  convulsions ;  the  pupils  are  usually  dilated.  Recovery 
commonly  takes  place  in  a  day  or  two,  but  remissions  may  occur.  Odor  of 
alcohol  on  the  breath. 

Treatment. — Evacuation  of  stomach  by  pump ;  emetics,  like  apomor- 
phin,  i-io  grain  (0.0064  gm.)  ;  washing  out  the  stomach.  Stimulation 
by  ammonia,  coflfee,  digitalis,  strychnin,  or  even  faradic  current  to  muscles 
of  respiration. 

Delirium  Tremens. — Delirium,  with  hallucinations;  great  restlessness 
and  insomnia ;  slight  fever,  pulse  rapid  and  soft. 

Treatment. — Withdrawal  of  alcohol :  bromids  in  large  doses,  or  chloral, 
aided  by  a  cold  bath  to  produce  sleep ;  nourishing  food  and  stimulation  if 
the  condition  demands  it.  even  by  alcohol. 

Ammonia. — Taken  by  mistake  or  with  suicidal  intent  in  the  form  of 
"  household  ammonia,"  water  of  ammonia,  spirit  of  hartshorn,  and  in  lini- 
ments. 

Symptoms. — At  once,  burning  pain  in  the  mouth,  throat,  esophagus, 
and  stomach  :  the  lips  and  tongue  are  intensely  swollen  and  inflamed ;  vom- 
iting of  blood-tinged  mucus,  suffocative  cough,  with  rapidly  increasing 
dyspnea.  The  face  is  pale,  pulse  is  rapid  and  thready,  and  collapse  soon 
develops.  Death  may  follow  at  once  or  some  days  later,  from  the  violent 
gastro-enteritis  and  stricture  of  the  esophagus. 

I204 


ANTIMONY— ARSENIC— ATROPIN.  1205 

Diagnosis. — Odor  of  ammonia  on  the  breath,  vapors  of  the  corre- 
sponding salt  when  a  rod  dipped  in  hydrochloric  acid  is  held  before  the 
mouth,  together  with  the  sudden  onset  of  the  symptoms. 

Treatment. — Neutralization  with  vinegar  or  some  other  dilute  acid  at 
once,  the  acid  being  mixed  with  some  bland  oil,  if  possible.  If  the  patient 
lives,  treat  the  results  of  the  violent  inflammation.  Tracheotomy  should  be 
performed,  if  there  is  danger  of  death  from  edema  of  the  larynx. 

Antimony. — Taken  as  a  tartar  emetic,  the  tartrate  of  antimony  and 
potassium.  A  heavy,  white,  odorless,  slowly  soluble  powder  having  a  sweet- 
ish, metallic  taste ;  charring  on  heating  to  redness. 

Symptoms. — ^Metallic  taste  in  the  mouth,  burning  pain  in  esophagus, 
stomach,  and  abdom.en,  dysphagia,  violent  vomiting  and  purging  of  serous 
material,  cramps  in  the  stomach  and  muscles  of  the  arms  and  legs.  Finally, 
the  symptoms  of  collapse — cold,  clammy  skin,  great  depression,  respirations 
shallow,  pulse  weak  and  thready.  There  may  be  convulsions,  delirium,  and 
coma. 

Treatment. — If  no  vomiting,  apomorphin,  i-io  grain  (0.0064  gm.),  or 
another  emetic ;  tannic  acid  as  a  chemical  antidote,  followed  by  washing  out 
of  stomach;  external  heat,  stimulants  to  combat  the  collapse,  and  opium 
when  the  acute  symptoms  have  disappeared. 

Arsenic. — Used  in  the  form  of  arsenious  acid  in  rat-poisons,  in  fly- 
paper, and  to  preserve  stuffed  birds  and  animals.  Paris  green,  used  as  potato- 
bug  poison,  is  an  arsenite  of  copper,  hence  the  symptoms  are  similar.  Ar- 
senious acid,  or  white  arsenic,  is  an  odorless,  tasteless,  white  powder,  quite 
heavy,  and  but  slowly  soluble  in  water. 

Symptoms. — These  appear  usually  in  the  course  of  an  hour,  and  are 
those  of  violent  gastro-enteritis,  so  severe  as  to  suggest  Asiatic  cholera.  Burn- 
ing pain  in  throat  and  stomach,  persistent  vomiting  of  brown  matter  streaked 
with  blood,  though  the  vomited  matter  may  be  green  from  bile.  Purging 
of  serous  and  bloody  material,  and  finally  collapse.  Fatal  in  a  day  or  two, 
though  a  remission  sometimes  occurs  on  the  third  day.  Nervous  symptoms 
may  appear,  and  at  times  a  case  of  arsenic  poisoning  closely  simulates  acute 
yellow  atrophy  of  the  liver. 

Treatment. — Early  stage,  stomach-tube,  or  emetics.  Chemical  anti- 
dote, the  freshly  prepared  hydrated  oxid  of  iron,  made  by  precipitating  the 
solution  of  tersulphate  of  iron  by  ammonia;  the  tincture  of  chlorid  of  iron 
may  be  used  instead  of  the  solution.  Mix  and  strain,  wash,  and  administer 
the  magma.  The  best  antidote  is  the  ferri  oxidum  hydratum,  U.  S.  P.,  or 
ferri  oxidum  hydratum  cum  magnesia,  the  latter  acting  also  as  a  ourgative. 
Otherwise  treat  the  collapse. 

Atropin  {Belladonna). — The  deadly  nightshade.  Used  as  a  mydri- 
atic and  in  liniments.  The  leaves  impart  a  narcotic  odor  to  the  tincture, 
but  recognition  depends  upon  the  physiological  effect. 

Symptoms. — The  throat  is  dry.  the  pupils  are  dilated,  the  pulse  is 
rapid  and  hard ;  respirations  are  quickened  and  deepened ;  there  is  great  rest- 
lessness, occasionally  talkative  delirium.  An  erythematous  rash  is  some- 
times present.  The  urine  contains  the  alkaloid,  hence  it  will  cause  dilatation 
of  the  pupil  if  dropped  into  the  eye  of  an  animal. 

Treatment. — Tannic    acid,    followed   by  the   stomach-tube    or   emetics. 


i206         SYMPTOMS  FROM  OVERDOSES  OF  POISONS. 

Physiological  antidotes :  Morphin,  physostigrnin,  and  pilocarpin.  Artificial 
respiration  for  two  hours.  Catheterize,  as  patients  frequently  suffer  from 
retention.     Meet  collapse  by  proper  stimulation. 

Belladonna. — See  Atropin. 

Bromin. — A  dark-red,  very  heavy  liquid,  emitting  reddish  vapors  re- 
sembling chlorin. 

The  fumes,  when  inhaled,  cause  convulsive  cough,  bloody  expectora- 
tion, dyspnea,  and  spasm  of  the  glottis. 

Treatment. — Fresh,  moist  air  and  cautious  inhalations  of  ammonia. 

Bromism. — The  symptoms  of  chronic  gastro-intestinal  disturbance 
such  as  fetor  of  the  breath,  anorexia,  diarrhea ;  great  depression  of  all  the 
functions,  especially  the  sexual  function,  with  languor  and  mental  apathy. 
A  general  eruption  of  acne  is  an  early  sign. 

Treatment. — Stop  the  administration  and  aid  elimination. 

Carbolic  Acid  (and  Creasote)  is  a  colorless  or  reddish  liquid,  or 
a  crystalline  solid,  when  pure;  w^hen  impure,  the  color  varies  from  this  to 
black.     It  has  a  characteristic  odor. 

Symptoms. — These  appear  quickly.  Burning  pain  in  the  mouth  and 
stomach,  though  there  may  be  no  pain.  \'omiting  may  be  absent.  Soon 
coma  sets  in,  with  feeble  respiration,  collapse,  and  convulsions.  The  urine 
is  smoky,  but  the  most  characteristic  sign  is  the  white  eschar  on  mouth  and 
lips,  with  the  odor  of  the  acid  on  the  breath. 

Treatment. — Any  soluble,  non-poisonous  sulphate,  such  as  sulphate  of 
magnesia  or  sulphate  of  sodium,  as  a  chemical  antidote.  Stomach-tube  or 
emetics,  followed  by  washing  out  stomach  with  a  solution  of  a  sulphate. 
Oil  to  counteract  the  escharotic  effect.  Treat  the  collapse  with  heat,  stimu- 
lation, etc. 

Carbonic  Acid  Gas. — The  choke  damp  or  after-damp  of  miners.  May 
be  accidentally  inhaled  in  overcrowded  rooms,  in  fermenting  vats,  over 
lime-kilns,  or  wherever  the  products  of  complete  combustion  cannot  es- 
cape. 

Symptoms. — Headache,  dizziness,  vomiting,  and  great  drowsiness,  with 
relaxation  of  the  muscles ;  hurried  respiration,  with  violent  action  of  the 
heart.     Soon  coma  ensues. 

Treatment. —  Fresh  air,  if  need  be;  artificial  respiration, kept  up  steadily 
and  unceasingly ;  ammonia  by  inhalation ;  oxygen,  if  obtainable ;  cold  douche 
to  the  head  and  chest,  with  stimulation  as  occasion  requires. 

Carbonic  Oxid  (Carbon  Monoxid)  is  formed  during  the  incomplete 
combustion  of  carbon,  and  is  a  direct  poison,  while  carbonic  acid  gas,  the 
product  of  complete  combustion,  kills  merely  by  exclusion  of  oxygen. 

Treatment  as  for  carbonic  acid  gas. 

Caustic  Potash  or  Soda. — Taken  in  the  form  of  "  lye." 

Symptoms. — An  acrid,  burning  taste,  the  burning  extending  down  to 

the  stomach,   followed  by  vomiting,   purging,   and   collapse.     The  mucous 

membrane  of  the  mouth  shows  evidence  of  corrosion. 


CHEESE  POISONING— CONIUM.  1207 

Treatment. — Olive  oil,  to  saponify  the  alkali ;  demulcent  drinks,  dilute 
acids,  like  vinegar  and  lemon-juice,  to  neutralize.  If  the  patient  lives,  the 
resulting  stricture  of  the  esophagus  requires  dilatation. 

Cheese  Poisoning. — Decayed  cheese  owes  its  poisonous  properties  prob- 
ably to  tyrotoxicon.  Usually  there  is  severe  gastro-enteritis,  with  vom- 
iting and  purging. 

Treatment. — The  stomach-tube  may  be  used  if  vomiting  has  not  been 
very  free ;  subsequent  lavage ;  sedatives  for  the  irritation. 

Chloral. — A  popular  somnifacient  and  sedative.  Occurs  in  deli- 
quescent crystals  with  characteristic  odor  and  acrid,  burning  taste. 

Symptoms. — Profound  unconsciousness,  complete  muscular  relaxation; 
sensibility  diminished  or  lost ;  the  pulse  becomes  feeble  and  rapid,  the  respira- 
tions are  diminished  in  frequency  and  may  be  stertorous ;  the  temperature  is 
depressed  more  than  by  any  other  toxic  agent. 

Treatment. — Evacuate  the  stomach;  keep  up  the  temperature  by  ap- 
plication of  heat ;  rouse  the  patient ;  stimulate ;  use  artificial  respiration  in 
conjunction  with  the  battery. 

Chloroform. — Identified  by  its  peculiar  ethereal  odor  and  sweet,  pun- 
gent taste;  a  heavy,  volatile,  non-inflammable  liquid,  not  miscible  with 
water. 

Symptoms. — First  stage  of  narcosis,  excitement,  muscular  rigidity,  les- 
sened sensibility  to  pain.  Second  stage,  muscular  relaxation,  anesthesia  of 
conjunctiva,  insensibility  to  pain.  Third  stage,  stertorous  breathing,  dilated 
pupils  (not  responding  to  light),  abolition  of  all  reflexes,  muscles  ab- 
solutely relaxed.  Death  usually  by  failure  of  circulation.  The  symptoms 
are  the  same  if  the  chloroform  is  taken  by  the  mouth. 

Treatment. — In  case  the  chloroform  was  used  as  an  anesthetic,  lower 
the  head,  slap  a  wet  towel  on  the  patient's  chest ;  pull  out  the  tongue  to  see 
that  the  mouth  is  clear ;  artificial  respiration  at  the  rate  of  twenty  respira- 
tions a  minute,  aided  by  the  cautious  use  of  the  battery  (intierrupted  cur- 
rent). 

When  taken  internally,  stomach-tube  or  emetics ;  flicking  with  a  wet 
towel ;  stimulation  with  coffee  by  rectum ;  whisky  by  mouth,  if  possible. 

CocAiN. — Solution  used  as  a  local  anesthetic,  particularly  in  eye  sur- 
gery. 

Symptoms. — Vertigo,  headache,  paroxysmal  dyspnea,  rapid  weak  pulse, 
elevated  temperature,  mental  excitement,  blindness,  delirium,  coma,  and 
convulsions.  Some  of  these  may  be  caused  by  the  local  application  of  solu- 
tions to  mucous  membranes.  The  pupil  is  dilated,  but  the  power  of  ac- 
commodation remains  in  part. 

Treatment. — Nitrate  of  amyl,  stimulants,  atropin,  caffein,  and  ammonia. 
Death  is  unusual. 

CoNiUM  (Poison  Hemlock;  Common  or  Spotted  Hemlock). — Not  a 
native  of  this  country,  hence  cases  of  poisoning  must  be  restricted  to  the  use 
of  the  preparations.  The  plant  and  some  of  the  preparations  have  a  peculiar 
fiodor,  resembling  the  urine  of  mice. 

Symptoms. — Prominent  is  the  loss  of  muscular  power,  the  patient  stag- 


I208         SYMPTOMS  FROM  OVERDOSES  OF  POISONS. 

gering  as  if  intoxicated ;  the  arms  and  chest  are  affected  later  on,  and  death 
may  ensue  from  paralysis  of  the  muscles  of  respiration.  In  other  cases  there 
are  delirium,  stupor,  coma,  and  convulsions ;  the  pupils  are  dilated,  and 
ptosis  is  a  peculiar  symptom. 

Treatment. — Stomach-pump  or  emetics;  tannic  acid,  stimulants,  heat, 
artificial  respiration. 

Copper. — The  sulphate,  blue  stone  or  blue  vitriol,  is  used  in  the  artSv. 
Recognized  by  its  crystalline  shape,  blue  color,  and  acrid,  metallic  taste. 
Articles  of  food  are  frequently  prepared  in  imperfectly  cleansed  copper  ket- 
tles ;  a  bright  piece  of  steel,  such  as  a  knife,  will  show  a  deposit  bi  metallic 
copper  a  few  minutes  after  immersion  in  a  liquid  containing  copper.  Verdi- 
gris  (subacetate)    is  another  source. 

Symptoms. — A  metallic,  astringent  taste  in  the  mouth ;  griping  andi 
colicky  abdominal  pains ;  vomiting,  purging,  accompanied  by  tenesmus,  the 
stools  being  mucous  or  bloody.  Respiration  embarrassed,  small,  quick  pulse,, 
weakness,  great  thirst,  coma,  death. 

Treatment. — Stomach  pump  or  emetics  if  vomiting  has  not  emptied  the 
stomach ;  demulcents,  like  milk  and  eggs ;  chemical  antidotes  are  soap, 
sodium  carbonate,  and  the  yellowish  prussiate  of  potash.  Opium  should  be 
used  as  a  sedative. 

Digitalis  {Foxglove). — A  native  of  Europe.  The  tincture  has  a  dis- 
tinct odor  of  tea,  the  drug  itself  lacking  a  narcotic  odor. 

Symptoms. — Vomiting  and  purging  of  green  material;  pulse  slow, 
later  rapid  and  irregular;  headache,  occasionally  delirium  and  convulsions; 
the  skin  is  cold  and  clammy,  and  the  pupils  are  dilated.  Coma  and  death 
come  on  quite  suddenly,  though  the  mind  may  be  perfectly  clear. 

Treatment. — Stomach-pump  or  emetics  if  necessary ;  tannic  acid,  twenty 
grains  (1.33  gm.),  repeated  frequently;  strong  tea;  stimulation  with  whisky,, 
ammonia,  or  hot  coffee ;  maintain  recumbent  position  for  some  time  after  all. 
symptoms  have  subsided. 

Ergot. — Used  to  produce  abortion. 

Symptoms. — ^A  large  dose  produces  cramps  in  the  legs,  arms,  and', 
chest,  dizziness,  weakness,  pulse  small  and  pupils  dilated,  skin  cold;  there- 
may  be  vomiting  and  diarrhea. 

Chronic  ergotism,  produced  by  eating  bread  tainted  with  ergot  of  rye,, 
causes  muscular  cramps,  paresis,  delirium,  and  convulsions ;  in  other  cases; 
a  dry  gangrene.     It  occurs  in  Europe. 

Fish-poisoning. — Tainted  fish  probably  contains  ptomains,  while  sev- 
eral kinds  of  fish  are  constantly  poisonous. 

Symptoms. — Vomiting,  irritation  of  the  eyes,  great  depression,  and 
severe  nettle-rash. 

Treatment  depends  upon  the  symptoms. 

Hydrochloric  Acid. — See  Mineral  Acids. 

Hydrocyanic  Acid  (Pnissic  Acid). — The  pure  acid  is  an  exceedingly 
poisonous  gas.  In  medicine  it  is  employed  as  a  two  per  cent,  aqueous  solu- 
tion.    Contained  in  oil  of  bitter  almonds  distilled  from  the  seed;  not  fourrdi 


lODIN— MERCURY.  1209 

in  the  artificial  or  the  purified  natural  product.  Its  salt,  the  cyanid  of 
potassium,  is  employed  as  a  quickly  acting  poison  for  the  destruction  of 
animals.     Contained  also  in  cherry-laurel  water. 

Symptoms. — Patient  is  nearly  always  insensible  in  two  minutes  if  a 
fatal  dose  is  taken.  Loss  of  motor  power,  giddiness,  slow  respirations, 
pupils  insensible  to  light,  eyes  protruding,  pulse  weak ;  frothing  at  the 
mouth,  perhaps  tetanic  convulsions.  The  odor  o^  oitter  almonds  is  about  the 
patient. 

Treatment. — Stomach-tube  or  emetics,  stimulants,  hot  and  cold  douche ; 
artificial  respiration,  kept  up  steadily,  as  the  patient  is  probably  safe  if  tided 
over  the  first  half-hour.  Apply  mild  interrupted  current  to  region  of 
heart. 

loDiN. — May  be  taken  by  mistake;  the  tincture  has  the  odor  of  iodin, 
which  somewhat  resembles  chlorin. 

Symptoms. — The  symptoms  of  a  violent  gastro-enteritis,  such  as  burn- 
ing pain  in  the  throat,  stomach,  and  abdomen,  with  vomiting  and  purging. 
The  vomited  matter  may  be  yellow  from  iodin,  or  blue  if  starch  is  present  in 
the  stomach. 

Treatment. — Starch  (arrow-root)  in  any  form  as  chemical  antidote; 
stomach-tube  or  emetics ;  opium  as  sedative. 

Iodoform. — Rarely  taken  internally,  but  toxic  symptoms  may  appear 
when  used  freely  as  an  antiseptic  dressing. 

Symptoms. — Most  marked  among  these  are  great  somnolence,  slight 
nocturnal  delirium,  headache,  hurried  breathing  and  rapid  pulse.  These,, 
with  a  slight  elevation  in  temperature,  often  resemble  cerebral  meningitis^ 
A  rash  may  accompany  the  intoxication. 

Treatment. — If  taken  internally,  emetics,  etc.  Substitute  another  anti- 
septic as  a  dressing  and  aid  elimination. 

Lead. — Taken  as  sugar  of  lead  (acetate),  Goulard's  solution  (subace- 
tate),  lead  water  (subacetate),  white  lead  (carbonate). 

Symptoms. — In  acute  poisoning  there  are  the  symptoms  of  a  violent 
gastro-enteritis,  with  colicky  pains,  especially  about  the  umbilicus,  and  re- 
lieved by  pressure ;  abdominal  walls  hard ;  cramps  in  the  legs ;  convulsions. 

Treatment, — Rid  the  stomach  of  the  poison;  use  dilute  sulphuric  acid 
or  a  non-poisonous  sulphate  as  a  chemical  antidote ;  demulcents  with  opium 
for  the  pain. 

Chronic  Poisoning. — Constipation,  with  colicky  pains  centering  around 
the  navel ;  abdominal  walls  retracted  and  hard ;  pulse  apt  to  be  hard  and 
corded;  headaches;  paralysis  of  extensor  muscles  of  forearm  (bilateral 
wrist-drop)  ;  a  blue  line  on  the  gums,  due  to  a  deposit  of  sulphid  of  lead. 

Treatment. — A  thorough  course  of  potassium  iodid;  treat  the  con- 
stipation ;  avoid  further  trouble  by  cautioning  lead-workers  to  clean  their 
hands  thoroughly,  and  by  the  use  of  culphuric  acid  internally.  The  colic 
may  require  opium. 

Meat  Poisoning. — Vide  Ptomain  Poisoning. 

Mercury  (Corrosive  Siihlimate;  Bichlorid  of  Mercury;  Merciiric  Clo- 
rid,  or  the  Perchlorid). — Used  in  aqueous  solution  as  bed-bug  poison,  as  an 
insecticide,  to  preserve  specimens,  and  as  an  antiseptic  surgical  dressing. 


12 lo         SYMPTOMS  FROM  OVERDOSES  OF  POISONS. 

Symptoms. — In  concentrated  form  it  is  corrosive,  hence  mouth  and 
iips  are  swollen  and  white ;  a  metallic  taste ;  esophagus,  stomach,  and  ab- 
domen are  the  seat  of  intense  pain ;  there  are  vomiting  and  purging  of 
jnucus  and  bloody  material ;  scanty,  albuminous  urine ;  collapse. 

Treatment. — Stomach-pump  or  emetics ;  white  of  egg  as  chemical  anti- 
dote ;  demulcents ;  stimulants. 

Mineral  Acids. 

Hydrochloric  Acid  (Muriatic  Acid:  Spirit  of  Salt), 
Symptoms. — Similar  to  those  mentioned  under  sulphuric  acid,  though 
the  acid  is  not  so  powerful  and  leaves  no  distinctive  stain.  It  may  be 
recognized  by  its  odor  and  by  the  white  fumes  formed  when  the  gaseous 
acid  comes  into  contact  with  ammonia.  Medicinally  and  in  the  arts  hydro- 
chloric acid  is  used  in  aqueous  solution,  the  commercial  variety  tinted  yellow 
from  a  trace  of  iron. 

Treatment. —  Same  as  for  sulphuric  acid. 

XiTRic  Acid  {Aqua  fortis). — A  colorless,  moderately  heavy  liquid  of 
peculiar  and  characteristic  odor,  staining  organic  tissues  yellow. 

S5miptoms. — The  same  as  those  mentioned-  under  sulphuric  acid, 
though  the  characteristic  yellow  stain  may  be  found  on  the  lips. 

Treatment. — As  for  sulphuric  acid. 

Sulphuric  Acid  {Jltriol;  Oil  of  J'itriol). — A  very  heavy,  colorless, 
odorless  liquid,  having  a  very  acid  taste  and  mixing  with  water  with  the 
production  of  great  heat.  Used  largely  in  the  arts.  Turns  organic  matter 
l)lack. 

Symptoms. — Burning  pain  from  mouth  to  stomach ;  lips  and  mouth 
white,  the  vomited  matter  stained  bloody  and  black ;  dysphagia ;  unconscious- 
ness ;  collapse. 

Treatment. — Immediate  neutralization,  or  at  least  dilution,  'of  the 
poison;  soap  and  water,  chalk,  magnesia,  lime-Avater,  bicarbonate  of  sodium, 
or,  in  their  absence,  water  in  large  quantity ;  demulcents  and  opium  as  a 
sedative.  A''.  B. — Sulphuric  acid  may  kill  by  edema  of  the  glottis  or  by 
the  secondary  effects  resulting  from  esophageal  stricture  and  destruction  of 
the  gastric  mucous  membrane. 

MoRPHix  PoisoxiXG. — See  Opium  Poisoning. 

^Mushroom  Poisoxixg. — Harmless  varieties  may  prove  poisonous  to 
some  individuals.  Agaricus  muscarius  is  the  most  poisonous  variety,  con- 
training  the  active  principle  muscarin.  The  fungus  is  bright  red,  with  yel- 
low spots.  As  a  rule,  highly  colored  fungi,  with  an  astringent,  styptic 
taste  and  a  pungent  odor  should  be  avoided ;  they  frequent  especially  dark 
and  shady  places. 

Symptoms. — Excitement,  violent  colic,  vomiting,  and  diarrhea ;  breath- 
ing stertorous ;  surface  cold ;  pulse  slow ;  death  from  cardiac  failure. 

Treatment. — ^Evacuate  stomach  and  bowel ;  heat :  stimulation  ;  atropin 
as  physiological  antidote. 

NicoTix. — The    liquid,    volatile    alkaloid    of    tobacco.     An    acrid,    oily 


NITROBENZOL— PHOSPHORUS.  121 1 

liquid  of  amber  color,  smelling  of  tobacco.  A  very  deadly  and  quickly  act- 
ing poison. 

Symptoms. — Nausea,  vomiting,  faintness,  great  weakness ;  pulse  rapid 
and  feeble ;  mental  confusion ;  sight  dimmed ;  skin  cold  and  clammy. 

Treatment. — Rid  the  stomach  of  the  poison ;  administer  tannic  acid ; 
strychnin ;  heat ;  stimulants ;  place  patient  in  the  recumbent  posture. 

NiTROBENzoL  (Nitrobenzene;  Oil  of  Mirhane ;  Artificial  Oil  of  Bitter 
Almonds). — Used  in  the  preparation  of  anilin  dyes  and  in  the  arts  on  ac- 
count of  its  flavor  (soaps,  etc.).  Recognized  by  its  highly  characteristic 
odor. 

Symptoms. — Usually  not  evident  for  an  hour  or  two.  Headache,  weari- 
ness, nausea ;  the  mind  gradually  becomes  confused ;  there  is  great  anxiety 
and  cyanosis  appears,  the  latter  becoming  extreme,  until  the  whole  body  is 
blue.     Stertorous  breathing,  coma,  death  by  asphyxia  or  failure  of  heart. 

Treatment. — As  the  poison  is  slowly  soluble,  wash  out  the  stomach, 
even  if  a  long  time  has  elapsed  since  its  administration;  stimulants  (whisky, 
not  until  after  evacuation  of  stomach,  because  it  renders  the  poison  more 
soluble);  artificial  respiration;  interrupted  current. 

Opium  Poisoning  (Acute). — Taken  accidentally  or  with  suicidal  in- 
tent in  the  shape  of  morphin  or  laudanum. 

Symptoms. — Drowsiness,  stupor,  deep  breathing;  if  due  to  laudanum, 
smell  if  it  is  on  the  breath ;  contracted  pupil,  slow,  full  pulse.  For  a  time 
patient  may  be  aroused  by  shouting  into  the  ear. 

Treatment. — ^Evacuate  stomach  by  stomach-pump  or  tube,  wash  out 
thoroughly ;  administer  strong  cofifee ;  flagellation  and  electricity  to  keep 
patient  awake;  if  respiration  fails,  atropin  and  strychnin  hypodermically ; 
also  electricity  to  phrenic  nerve;  artificial  respiration. 

Oxalic  Acid. — Mistaken  for  Epsom  salt;  taken  with  suicidal  intent. 
Occurs  in  prismatic,  colorless,  odorless  crystals,  with  a  very  sour  taste. 
Volatile  without  charring  at  a  red  heat. 

Symptoms. — Those  of  a  violent,  rapidly  fatal  gastro-enteritis,  asso- 
ciated with  cramps  in  the  legs ;  the  mouth  may  be  white.  Collapse  comes 
on  quickly.     Convulsions  occur  occasionally. 

Treatment. — Carbonate  of  calcium  in  any  form ;  chalk,  whitening,  or 
marble-dust;  lime,  lime-water.  In  an  emergency  whitewash  from  a  wall. 
Follow  by  a  purgative  of  castor  oil. 

Phosphorus. — Employed  in  the  form  of  a  paste  as  a  rat  and  roach 
poison ;  matches  are  sometimes  sucked  for  suicidal  purposes.  The  paste  is 
recognized  by  its  peculiar  garlicky  odor,  and  by  the  luminous  fumes  it  emits 
in  the  dark. 

Symptoms  usually  do  not  appear  until  after  the  lapse  of  a  few  hours. 
At  first  the  ordinary  signs  of  irritant  poisoning  appear,  such  as  pain  and 
vomiting,  the  ejected  material  being  luminous  in  the  dark.  A  garlicky  taste 
in  the  mouth,  and  the  odor  of  phosphorus  may  be  perceptible  on  the  breath. 
Later  on  there  is  severe  abdominal^ pain,  also  pain  in  the  region  of  the  liver; 
this  organ  may  be  enlarged.  The  symptoms  subside,  but  from  the  third  to 
the  fifth  day  more  serious  ones  develop :  jaundice,  accompanied  by  pain  and 
vomiting;  discharges  of  blood  from,  the  bowel,  with  extravasations  beneath 


12 12  SYMPTOMS  FROM  OVERDOSES  OF  POISONS. 

the  skin.  The  urine  may  be  suppressed  or  scanty,  albuminous,  and  bile- 
stained  ;  bowels  constipated  or  loose,  the  stools  clay-colored  and  sometimes 
phosphorescent.  Death  after  grave  nervous  symptoms,  such  as  headache,, 
delirium,  convulsions,  stupor,  and  coma,  and  may  occur  very  suddenly. 
Convalescence  is  much  protracted  if  patient  recovers. 

Treatment. — Emetic  of  five  grains  (0.33  gm.)  of  sulphate  of  copper, 
which  acts  also  as  a  chemical  antidote.  Permanganate  of  potassium  in 
dilute  solution.  French  oil  of  turpentine  acts  also  as  an  oxidizing  agent, 
but  cannot  be  obtained  in  this  country.  Otherwise  the  treatment  is 
symptomatic. 

Ptomain  Poisoning. — Ptomains  are  alkaloidal  bodies,  the  products 
severe  abdominal  pain,  vomiting,  purging  of  bloodstained  material,  partial 
paralysis,  convulsions,  and  collapse. 

Treatment. — Stomach-tube  or  emetics  ;  demulcents ;  stimulants ;  heat. 

Ptomaine  Poisoning. — Ptomaines  are  alkaloidal  bodies,  the  products 
of  the  decay  of  animal  tissues.  These  are  probably  the  cause  of  the  poison- 
ous action  of  tainted  meat  and  fish,  cream-puffs,  ice-cream,  blanc  mange,. 
and  cheese. 

Poisonous  Fish. — Sickness  and  vomiting,  great  depression,  irritation 
oi  the  eyes,  severe  nettlerash.  Shell-fish  is  especially  apt  to  produce  a  rash 
in  susceptible  persons. 

Poisonous  meat  contains  ptomains,  those  produced  when  stale  meat 
is  just  beginning  to  decay  being  more  virulent  than  others  which  replace  the 
first  when  decomposition  is  well  under  way. 

Ices,  Ice-cream. — The  cheap  varieties  are  colored  with  anilin  dyes, 
which  may  not  be  free  from  arsenic.  Again,  the  highly  poisonous  alkaloid, 
tyrotoxicon,  may  have  formed  in  the  milk  used,  and  to  this  principle  most 
cases  of  poisoning  of  this  kind  are  traced. 

Symptoms  vary — dryness  of  throat,  vomiting,  and  purging  are  those 
most  commonly  observed. 

Treatment  must  be  symptomatic. 

Silver  Nitrate  (Lunar  Caustic). — Used  in  the  form  of  the  fused 
nitrate  as  a  caustic.  Otherwise  in  colorless,  rhombic  crystals,  freely  soluble, 
with  astringent  metallic  taste.  Yields  a  white  precipitate  with  chlorids  and 
stains  organic  matter  black. 

Symptoms. — Partly  gastro-intestinal  and  partly  cerebro-spinal.  Vom- 
iting of  white  material  which  rapidly  becomes  black ;  vertigo,  unconscious- 
ness, epileptiform  convulsions. 

Treatment. — Common  salt  to  be  given  immediately,  followed  by 
stomach-pump  or  emetic.     Otherwise  symptomatic. 

Strychnin. — An  alkaloid  occurring  in  nux  vomica  and  ignatia.  Ap- 
pears in  the  form  of  white,  prismatic,  odorless  crystals  which  have  an 
intensely  bitter  taste.     Used  as  a  vermin  killer. 

Symptoms. — Ordinarily  these  appear  quickly.  A  sense  of  suffocation, 
great  difficulty  in  breathing,  from  paralysis  of  the  muscles  of  respiration ; 
great  anxiety,  though  the  mind  is  perfectly  clear ;  twitching  of  the  muscles, 
finally  amounting  to  tetanic  convulsions,  with  intervals  in  which  the  patient 


SULPHURETED  HYDROGEN— ZINC.  1213 

is  exhausted  and  bathed  in  perspiration ;  opisthotonos ;  death  from  asphyxia, 
or,  between  the  attacks,  from  exhaustion. 

In  tetanus  there  is  usually  the  history  of  a  wound ;  symptoms  develop 
much  more  gradually;  the  muscles  of  the  jaw  are  early  involved,  and  trismus 
is  much  more  marked  than  spasm  of  the  respiratory  muscles,  and  the  con- 
vulsions are  tonic. 

Treatment. — Emetics  or  stomarh-tube  at  once — after  the  spasms  have 
once  set  in,  the  introduction  of  a  tube  would  excite  them ;  tannic  acid ;  nitrite 
of  amyl ;  chloroform  or  ether,  by  inhalation ;  artificial  respiration,  if  possible. 

SuLPHURETED  Hydrogex  has  the  characteristic  odor  of  rotten  eggs. 
It  forrns  the  bulk  of  the  gas  emanating  from  sewers  and  cess-pools,  some 
ammonium  sulphid  and  nitrogen  occurring  with  it.  If  dilute,  the  symptoms 
are  nausea,  diarrhea,  depression,  and  headaches.  In  more  concentrated 
form  it  produces  unconsciousness,  frequent  respiration,  rapid  pulse,  dys- 
phagia, dilated  pupils  insensible  to  light,  tonic  convulsions,  and  a  tempera- 
ture as  high  as  104°  F.  (40°  C.)  during  the  convulsions.  In  a  state  ap- 
proaching purity  sewer  gas  kills  almost  instantly ;  in  moderate  amount  it 
frequently  causes  death  in  twenty-four  hours,  all  efforts  to  restore  con- 
sciousness proving  useless. 

Treatment. — Fresh  air ;  artificial  respiration  for  many  hours ;  ammonia 
by  inhalation ;  stimulation. 

Zinc. — The  chlorid,  in  solution,  is  used  as  a  disinfectant  (Burnett's 
Disinfecting  Fluid).  A  very  heavy,  corrosive,  colorless  liquid,  of  astringent 
taste.     It  partakes  of  the  nature  of  a  corrosive  poison. 

Symptoms. — Burning  sensation  in  throat  and  stomach,  perhaps  signs 
of  local  corrosion.  Nausea,  vomiting,  purging,  dyspnea,  convulsions,  coma, 
death. 

Treatment. — Carbonate  of  potassium  or  sodium  in  water ;  milk ;  eggs ; 
tannic  acid ;  opium  as  a  sedative. 


I2I4 


SYMPTOMS  FROM  OVERDOSES  OF  POISONS. 


MINIMUM    DOSE    WHICH    HAS   CAUSED    DEATH,    AND    MAXIMUM    DOSE 
FOLLOWED   BY   RECOVERY. 


Name  OF  Poison. 


Aconite,    .    . 
Alcohol,    .    . 

Ammonia, 

Antimony,     . 

(Tartar  Emetic) 

Arsenic,    .    .    . 
Atropin,        .    . 

Belladonna,  .    . 
Carbolic  Acid, 

Chloral,     .    .    . 
Chloroform, 

Cocain,     .    .    . 


Colchicin     and 
Colchicum, 


Copper  Subace- 
tate  (Verdigris) 
Copper     Sul- 
phate,     .    .    . 


Digitalis, 

Gelsemium  and 
Gelsemin, 


Minimum  Dose  which 
HAS  Caused  Death. 


From  merely  tasting 
Fleming's  tincture  to 
f3j  (3-7  c.c.)  Flem- 
ing's tincture. 

l4  pint  gin  (236.56 
c.c),  2  bottles  of  port 
(=  II  oz.)  (29.57  c.c. 
alcohol).  In  a  boy  ot 
seven  j'ears,  f  |  iv 
(120  c.c.)  brandy. 

f  3ij  (7-4  c.c.)  'aqua 
ammonite  fortior. 

2  grains  (0.132  gm.). 
%"  grain  (0.0495  gm.) 

in  a  child. 
Less  than  i 

(0.099  gm  )• 


grams 


Maximum  Dose  with 
Recovery. 


f  3  iij      (  II. I      c.c.  ) 
Fleming's  tincture 


I  quart  gin  (946.24 
c.c);  I  quart  whisky 
(946.24  c.c);  2  bot 
ties  port ;  i}4  pints 
(236.56  c.c.)  mixed 
gin  and  brandy. 

f  1 J  (29-57  c.c.)  aqua 
ammoniae  fortior. 

!  ss  (15.84  gm.). 


3]— 313      (3.96-7.92 
gm.).  Recovery 

probable  after  i  gr. 
[  grain,  ly^  grains 
(0.066  to  o.ogg 
byi  gm.).  Child  two 
years  old,  i  grain 
(0.066  gm.),  child 
four  years  old, 
grain  (0.033  gm.) 
f  3  j  (3.7c.c.)liniment.,f  §ss  (15  c.c)  lini- 
ment;    3  iij    (11.88 


2  grains  (0.132  gm.). 

■^  grain  hypodermic- 
ally  ;     yij-    grain 
stomach. 


Usual  Fatal 
■Dose. 


Fatal  Period. 


f  3  j  (3.7  c.c). 


10  grains  (0.66  gm.); 
20  grains  (1.32  gm.); 
30  grains  (1.98  gm.). 

15  drops  (0.9  c.c.)  in- 
haled ;  30  drops  (1.8 
c.c.)  inhaled  ;  f  |  ss 
(0.15  gm.)  f§j  (0.3 
c.c.)  internally, 

)4  grain  (0.033  gm.)  in 
a  child  of  eleven  (in 
forty  seconds);  i2grs 
(0.792  gm.)  (injected 
into  urethra);  24  grs. 
(i.584gra.)  (injected 
into  rectum). 

'/^  grain  (0.022  gm.) 
(alkaloid)  f  3  iiss  (9. 25 
c.c)  wine  of  root  ; 
f  3  iiiss  (12.25  c.c)  of 
root. 

§ss,  §  j  (i6to32gm.). 

Child  sixteen  months 
old,  from  merely 
sucking  crj'stals;  fj, 
(32  gm.)  in  an  adult. 

Uncertain. 


f?jfl.  ext.  (3.7  c.c);i 
mxij  fl.ext.(in  a  child)l 


gm.)  extract. 
f3j  (3-7  c.c). 


180     grains     (11. 

gm.);     460     grains 

(30.36  gm.). 
f  §  ij  (60  c.c.)  taken 

internally  ;       f  §  iv 

(120  c.c). 


24 grains  (1.584  gm.) 
(by  stomach). 


f  §  j  wine  (29.55  C.C.); 
^  grain  alkaloid 
(0.0495  gm.). 


j   (32  gm.) 
adult. 


f  §  ij  (60  C.C.)  tinc- 
ture ;  3  j  (4  gm.) 
powdered  digitalis. 


f  §ss  (15   c.c.) 
aqua   ammo 
niae  fortior. 

3  j  (4  gm-)- 


lyz     to     2 

grains  (0.099 
too. 165  gm.). 
>^  to   3^  grain 
(0.033  to 

0.0495     gm.). 


f§ss.     (14.785 
c.c.)    of     the 

pure,  f  3  j(3-7 
c.c.)  of  the 
impure,  acid 


Usually  three 
or  fourhours. 


One-half  hour 
to  several 
'days. 


A  few  hours, 
months,  or 
even  years. 

An  hour  up  to 
several  days. 

Death  usually 
within  twen- 
ty-fourhours. 
Death  usually 
within  twen- 
ty-four hours. 


Death  usually 
within  twen- 
ty-fourhours. 

Death  usually 
within  an 
hour. 


One-half  hour 
or  less. 


Twenty-four 
hours. 


Fourto  twelve 

hours. 
Four  to  twelve 

Irours. 


About     twen- 
ty-fourhours. 

Three  to  four 
hours. 


MINIMUM  DOSE  WHICH  HAS  CAUSED  DEATH. 


1215, 


MINIMUM   DOSE    WHICH    HAS    CAUSED    DEATH,    AND    MAXIMUM    DOSE 
FOLLOWED  BY  '9JECOY^KY—{Conimued). 


Name  of  Poison. 


Hydrochloric 
Acid,  .    .    . 


Hydrocyanic 
Acid,    .    .    . 


Minimum  Dose  which 
HAS  Caused  Death. 


Maximum  Dose  with     Usual  Fatal 
Recovery.  Dose. 


(Cherry-laurel 
Water),  .  .  . 
(Oil  Bitter-Al- 
monds) (natu- 
ral unpurified), 

(Potassium  Cy- 
anid),       .    .    . 

lodin,    .... 

Iodoform,      .    . 

Lead  (Acetate), 
(Goulard's  So- 
lution), .  .  . 
(White  Lead), 

Mercury  Bi- 
chlorid,        .    . 


iff  ss  (15  CO.)  in  an 
adult ,  f  3  j  (3.7  c.c.) 
in  a  child. 

45  )fi  (2.7  c.c.)  diluted 
acid  (2  per  cent.). 
Insensibility  from 
merely  smelling  the 
strong  acid. 


ill]  (60  c.c). 
17  drops. 

(contains  about  10  to 
15  per  cent.  HCN). 

5  grains  (0.33  gm.). 

20  grains  (1.32  gm.). 


3  grains  (0.198  gm.). 


f  3  ]'  (  3-7  c.c.  ) 
Scheele's  acid  (4 
per  cent.). 


Morphin, 

Nitrobenzol(Oil 

of  Mirbane),    . 


Opium, 


Oxalic  Acid, 
Phosphorus, 


Potassium  Hy- 
droxid  (Caus. 
tic  Potash), 

Saltpeter,     .    . 

Silver    Nitrate, 
Strychnin,     .    . 


i^  grain  (0.0495  gm.); 
I  grain  (0.066  gm.). 

From  merely  tasting 
it;  8  or  9  drops (0.4  to 
0.54  c.c). 

f3ij  (7-4  c.c)  lau- 
danum ;  2^  grains' 
(0.165  gm.)  extract  ;i 
3  j  (3.96  gm.)  lauda-j 
num  ;  2  or  3  drops. 
(0.12  to  0.18  c.c)j 
laudanum  in  a  very 
young  child. 

3i]  (0.132  gm.);  3j 
(3.96  gm.)  in  a  boy 
of  sixteen. 

Lessthanigrain(o.o66 
gm.).  Childdied  from 
sucking  2  matches. 
Another  from  swal- 
lowing the  tops  of  8 
matches. 

40  grains  (2.64  gm.). 

3]  (32  gm.). 


f  3iv  (15  c.c). 


3iv  (16  gm.). 
Ij  (32  gm.). 

f  |xij  (360  c.c). 
!J  (32  gm.). 

I  j  (32  gm.). 


75  grains  (4.95  gm.); 

20     grains      (  1.32 

gm.). 
f  3  ss  (1.85   c.c). 


f  3  ij  (60  c.c.)  lauda- 
num ;  f  §  iv  to  f  §  V 
(120  to  150  c.c.) 
laudanum. 


ss  (16  gm.). 


After    sucking     300 
matches. 


ij  (64  gm.). 


f  zss  (15  c.c.) 
for  an  adult ; 
f  3j  (3-7  c.c) 
for  a  child. 

45  }n  to  f3j 
(2.7  to  3.7 
c.c). 


10  to  30  drops 

(0.6     to    1.80 

c.c). 
3  to  5  grains 

(0.198  to  0.33 

gm.). 


Fatal  Period. 


From  a  few 
hours  to 
many  weeks. 

Ten  to  fifteea 
minutes. 


Few  hours  to 
several  davs. 


3  to   5   grains  From        ten 
(0.198  to  0.33    hours      to 


gm.).    50  per 
cent,  of  cases 
fatal. 
2  to  6   grains'Seven 


eleven  days. 


to 


(0.132100.596  twelve  hours, 
gm.). 


Four    to 

hours. 


five 


30  grams.  ^  ). 

yV  grain  (0.0041  gm.)  10,  12,  40  grains 
inachildof  2^  years;!  (0.66  to  0.792  to 
Yz  grain  (0.033  gm.)  2.64  gm.) 
in  an  adult. 


4  to  5  grains  Seven  to 
(0.264  to  0.33  twelve  hours, 
gm.). 


5ss(i6gm.).  jWithin   one 

I  hour. 

A    little    lessjOne     to     five 
than  I  grain.  I  days. 


3ss  (16  gm.). 
§  j  to  §  iss  (32  A  few  hours, 
to  48  gm.). 

%  to  I  grain's  minutes  to 
(0.033  to  0.066  several  hours, 
gm.).  In  adultsdur- 

ing  or  after 
the  4th  or  5  th 
p  aroxy  sm; 
children  i-3d 
convulsion. 


APPENDIX 


TABLES    FOR    REDUCING  THE    METRIC    SYSTEM    INTO  THE  ENGLISH. 

{Troy  Weight.) 


xi?    — 


Grains  to  Grams 


0.00033 

0.00034 

0.00035 

0.000357 

0.00036 

0.000377 

0.000388 

0.0004 

0.000413 

0.000425 

0.00044 

0.000455 

0.00048 

0.00049 

0.0005 

o  000528 

0.00055 

0.000574 

0.0006 


GRAms  TO  Grams. 


Grains  to  Grams. 


0.000628 

A 

= 

0.0055 

0.00066 

A 

= 

0.0066 

0.00694 

\ 

= 

0.0082 

0.0073 

1 

= 

0.0094 

0.0077 

\ 

= 

O.OII 

0.0082 

^ 

= 

0.0132 

0.0085 

\ 

r= 

0.0165 

0.0094 

i 

:= 

0.022 

O.OOI 

1 

= 

0.033 

O.OOII 

I 

r= 

0.066 

0  0012 

2 

= 

0.132 

0.00132 

3 

= 

O.I9S 

0.00146 

4 

= 

0.264 

0.00165 

5 

= 

0.33 

0.00188 

6 

= 

0.396 

0.0022 

7 

= 

0.462 

0.00264 

8 

= 

0.528 

0.0033 

9 

= 

0.594 

0.0044 

10 

= 

0.66 

Grams  to  Grains. 


I 

=   15-43 

2 

=   30.86 

3 

=   46.29 

4 

=   61.72 

5 

=   77-15 

6 

=   92.58 

7 

=  108.01 

8 

=  123.44 

9 

=  138.87 

0 

=  154-3 

X  pound  avoirdupois  =  453.5925  gm. 
I  ounce  "  =    28.3495  gm. 

I  grain  "  =      0.0648  gm. 


Grains  to  Milligrams. 


I 

= 

64.8 

2 

= 

120.6 

3 

= 

194.4 

4 

= 

259.2 

5 

= 

324 

6 

= 

338.8 

7 

= 

453-6 

8 

= 

518.4 

9 

= 

583.2 

10 

=: 

648 

r  dram  or  60 

= 

3.89  gm. 

I  ounce  or  480 

— 

31. 1  gm. 

FLUID   MEASURES. 


I  teaspoonful  distilled  water  =  i  fluid  dram 

I  dessertspoonful  distilled  water  =  2  fluid  drams 

I  tablespoonful  distilled  water      =  4  fluid  drams 
I  wineglassful  distilled  water 
I  fluid  ounce  distilled  water 

16  fluid  ounces  distilled  water         =  i  pint 


=  2  fluid  ounces      =: 


3.7  c.  c. 
7.4  c.  c. 
14.8  c.  c. 
59.14  c.  c. 
=  29.57  c.  c.  {circa  30  c.c.*) 
=  473.11  c.  c.  {circa  480  c.c.) 


*  A  fluid  ounce  of  water  which  measures  30  c.c.  does  not.  weigh   31. i   gm.,  because  an  ounce  of 
■water  really  weighs  but  455.7  grains  Troy,  and  not  480  grams. 


1216 


APPENDIX. 


1217 


•TABLES  FOR  REDUCING   THE    METRIC    SYSTEM  INTO    THE   ENGLISH 
FLUID    MEASURES— (C^w/z/n/;^^). 


JVIiNiMS  TO  Cubic  Cen- 
timeters. 


I 

= 

0.06 

2 

=r 

0.12 

3 

^ 

0.18 

4 

= 

0.24 

5 

= 

0.31 

10 

= 

0.62 

15 

= 

0.92 

i6i 

= 

I 

20 

= 

1.23 

30 

= 

1.85 

40 

— 

2.46 

Fluie 

Ounces  to 

Cubic  Centimeters 

I 

= 

29-57 

2 

:= 

59-14 

3 

= 

88.71 

4 

= 

118.28 

5 

= 

147-75 

6 

= 

177-42 

7 

= 

206.99 

8 

= 

236.56 

9 

= 

266.13 

10 

= 

295-7 

12 

= 

354.84 

16 

= 

473-12 

Cubic 

Centimeters 

to  Minims. 

I 

= 

16.2 

2 

=: 

32-4 

3 

= 

48.6 

4 

= 

64.8 

5 

= 

81 

6 

= 

97.2 

7 

= 

II3-4 

8 

= 

129.6 

9 

■=. 

145.8 

Liters  to 
Fluid  Ounces 

1  = 

2  = 

33-8 
67.6 

3     = 

101.4 

4  = 

5  = 

6  = 

135-2 

169 

202.8 

7    = 

236.6 

C    = 

270.4 

9      =: 
10      =: 

304.2 

338 

Fluid  Drams    to 
Cubic  Centimeters. 


I 

= 

3.7 

2 

= 

7-4 

3 

= 

II. 1 

4 

=: 

14.8 

5 

= 

18.5 

6 

= 

22.2 

7 

= 

25-9 

8 

= 

29.6 

9 

= 

33-3 

10 

= 

37 

Liters  to  Pints. 


I 

=: 

2.1 

2 

= 

4-2 

3 

= 

6-3 

4 

= 

8.4 

5 

= 

10.5 

6 

= 

12.6 

7 

= 

14.7 

8 

= 

16.8 

9 

= 

18.9 

10 

= 

21 

Cubic  Centimeters 
to  Fluid  Drams. 


I 

= 

0.27 

2 

= 

0.54 

3 

= 

0.81 

4 

= 

1.08 

5 

= 

1-35 

6 

= 

1.62 

7 

= 

1.89 

8 

= 

2.16 

9 

= 

2-43 

10 

= 

2.7 

Pints  to  Liters. 


I 

= 

0.473 

2 

= 

0.946 

3 

= 

1. 419 

4 

= 

1.892 

5 

= 

2.365 

6 

= 

2.838 

7 

= 

3-3II 

8 

= 

3-784 

9 

= 

4-257 

10 

= 

4-73 

LINEAR    MEASURES. 


Centimeters  to 

Inches 

TO    Centi-     I 

Inches  to  Milli- 

Millimeters to 

Inches. 

meters. 

meters. 

Inches. 

I    =    0.3937 

I 

= 

2.54 

I     = 

25-4 

I     =   0.03937 

2    =    0.7974 

2 

= 

5.08 

2    = 

50.8 

2    =   0.07874 

3    =     1-1817 

3 

= 

7.62 

3     = 

76.2 

3    =    0.11811 

4    =    1.5784 

4 

= 

10.16 

4    = 

101.6 

4    =   0.15784 

5    =     1.9685 

5 

= 

12.7 

5     = 

127 

5     =   0.19685 

6    =     2.3622 

6 

= 

15-2 

6    = 

152.4 

6    =    0.23622 

7    =    2.7559 

7 

= 

17.78 

7    = 

177.8 

7    =    0.27559 

8     =    3.1496 

8 

= 

20.32 

8    = 

193.2 

8    =    0.31496 

9    =     3-5433 

9 

= 

22.86 

9    = 

228.6 

9    =   0.35433 

10    =     3-9370 

10 

= 

25.4 

10    = 

254 

10    =   0.3937 

Feet  to  Meters. 

Meters  1 

0  Feet. 

I    =   0.3048 

I    = 

3-28 

2   =   0.6096 

2    = 

6.56 

3    =   0.9144 

3    = 

9.84 

4   =    I. 2192 

4    = 

13.12 

5    =    1.524 

5    = 

16.4 

6    =    1.8288 

6    = 

19.68 

7    ^    2.1336 

7    = 

22.96 

8    =    2.4348 

8    = 

26.24 

g    —    2.7432 

f 

9    = 

29-52 

10    -= 

3.048 

10  =t  : 

52.8 

77 


A  micromillimeter  =  o.ooi  millimeter.     Symbol  (i. 


I2l8 


APPENDIX. 


TO   CONVERT    DEGREES   OF   FAHRENHEIT'S    THERMOMETER  TO 
CENTIGRADE,  AND    VICE   VERSA. 


Centigrade  to  Fahkenheit. 


Fahrenheit  to  Centigrade. 


I 

— 

1.8 

2 

= 

3.& 

3 

= 

5-4 

4 

= 

7-2 

5 

= 

9 

6 

= 

lo.S 

7 

= 

12.6 

8 

= 

14-4 

9 

= 

l6.2 

10 

= 

iS 

To  use  this  table,  convert  the  given  number  of 
degrees  Centigrade  into  degrees  Fahrenheit,  and 
add  32°. 


I 

= 

0-555 

2 

= 

I. II 

3 

= 

1.665 

4 

= 

2.22 

5 

= 

2.775 

6 

= 

3-33 

7 

= 

3.885 

8 

= 

4.44 

9 

:= 

4.95 

lO 

^ 

5-55 

To  use  this  table,  subtract  32°  from  the  given 
number  of  degrees  Fahrenheit  and  convert  the 
remainder  into  degrees  Centigrade. 


INDEX. 


Abasia-astasia,  1133 
Abscess,   mediastinal,   556 

of  the  brain,   1081 

of  the  heart,  612 

of  the  liver,  465 

of  the  spleen,  485 

paranephritic,   735 

perinephric,  735 

postpharyngeal,  323 
Absorption,     to     determine 

rate  of,  341 
Acanthocephali,  1198 
Acarinae,  1199 
Acidity  of  gastric  contents, 

estimation  of,  23^ 
Aconite  poisoning,   1204 
Acromegaly,   1139 
Actinomycosis,   198 

bacteriology   of,    199 

course  of,  199 

diagnosis  of,  199 

morbid  anatomy  of,  199 
of  brain,  199 
of  lungs,   199 
of  skin,   199 

symptoms  of,   199 

treatment   of,   200 
Active  congestion  of  kidney, 

693 
Acute  albuminuria,  696 
alcoholism,   1155 
angioneurotic  edema,  1 136 
anterior    poliomyelitis    of 

children,  918 
arsenical  poisoning,   1170 
articular  rheumatism,  289, 

771 
atrophic    spinal    paralysis 

of  adults,  921 
Bright's  disease,  696 
bronchial    catarrh,    517 
bulbar  palsy,  954 
catarrhal  dysentery,  104 

gastritis,  342 

nephritis,   696 
degeneration    of    internal 

organs  of  newborn,  836 
tlelirium,  1087 
desquamative        nephritis, 

696 
diarrhea,  378 
diffuse  nephritis.  696 
dyspepsia,  342 
Acute  enceohalitis  der  Kin- 
der,  1063 
febrile  jaundice,  300 
gastric  catarrh,  342 
hydrocephalus,  249 
ileocolitis,  386 


Acute  : 

intestinal  catarrh,  378 
leptomeningitis,   1040 
miliary  tuberculosis,  244 
nasal  catarrh,  497 
nephritis,  696 
parenchymatous    hepatitis, 
469 
tonsillitis,  315 
phthisis,  247 
poliomyelitis  in  adults,  921 

in  children,  918 
renal  dropsy,  696 
rheumatism,  289 
softening    of    the    brain, 

1056 
tracheobronchitis,   517 
tubal  nephritis,  696 
yellow     atrophy     of     the 
liver,  469 

diagnosis  of,  471 
etiology    of,    469 
histology  of,  470 
prognosis  of,  471 
symptoms  of,  470 
treatment  of,  471 
urine    in,    470 
Adams  -  Stokes      syndrome, 

622 
Addison's  disease,  681 
diagnosis  of,  682 
morbid  anatomy,  681 
prognosis  of,  682 
symptoms  of,  681 

coloration  of  skin,  681 
treatment  of,  682 
Adenie     and     lymphadenie, 

664 
Adipositas    universalis,    821 
Agenese  cerebrale,  1063 
Ageusia,  975 
Agraphia,  motor,  978 
Ague,  65 
Ainhum,   1143 
Akinesia  algera,  863 
Alalia,  977 

Albumin  digestion,  ^27 
examination    of    products 

of,  337 
tests   for,  686 
Albuminoid  disease,  726 

liver,  457 
Albuminous  nephritis,  696 
Albuminuric.  684 
extrarenal,  684 
general   remarks  on,  684 
physiological  or  function- 
al, 686 
renal,  685 
immediate  cause  of,  685 
Albuminuric  retinitis,  719 
Alcohol  poisoning,  1204 

I2ig 


Alcoholism,   1155 
acute,  1 155 

diagnosis  of,   1155 
symptoms  of,  1155 
chronic,   1156 

morbid  anatomy,   1156 
symptoms  of,  1157 
digestive       apparatus, 

.1158 
kidney    changes,    11 57 
liver,  1 158 
lungs,    1 1 57 
nervous  system,  1157 
vascular  changes,  1158 
treatment,   1159 
Alveolar  ectasia,  531 
Amaurosis,  689 
hysterical,  989 
toxic,  988 
uremic,  988 
Amblyopia,  989 

tobacco,  989 
American  disease,  1129 

gout,  793 
Amimia,  978 

Ammonia  poisoning,  1204 
Amnesic  aphasia,  976 
Amoeba  coli,  465 
Amusia,  976 

Amyloid  disease,  kidney,  726 
liver,  457 
diagnosis  of,  458 
etiology,   457 
morbid  anatomy,  457 
prognosis  of,  458 
treatment  of,  458 
Amyotropic  lateral  sclerosis, 

956 
Analgesic      paresis,      with 

panaritium,    943 
Analgic  panaritium,  943 
Anarthfia,  972 
Anchylostomiasis,    1193 
Anemia,  general,  644 
local,  644 
lymphatic,  664 
diagnosis  of,  666 
etiolo.g}',   664 
morbid  anatomy  of,  664 
prognosis  of,  667 
symptoms  of,  665 
treatment  of,  667 
of  the  brain,   1046 
primary   or   essential,   648 
chlorosis  tarda,  648 
diagnosis  of,  650 
etiology   of,    648 
from       pernicious 

anemia,  651 
from       secondary 
anemia,  651 
morbid  anatomy  of,  648 


1220 


INDEX. 


Anemia : 

prognosis  of,  651 
symptoms  of,  649 

murmur,  650 
treatment  oi,  bSi 
progressive     per  nicious, 
652 
diagnosis  of,  65? 
etiology  of,  652 
morbid    anatomy    of, 

656 
prognosis  of.  657 
symptoms  of,  653 
blood  changes,  654 
Eichhorst's    corpus- 
cle, 656 
treatment  of,  657 
secondary  or  symptomatic, 

645 
diagnosis  of,  647 
due     to     drain     of 

chronic  disease,  645 
due    to    hemorrhage, 

645 
from    inanition,    645 
symptoms  of,  646 

treatment  of,  647 
splenic,  668 

diagnosis  of,  669 
etiology  of,  668 
morbid  anatomy  of,  668 
prognosis   of,    669 
symptoms  of,  668 
treatment  of,  669 
toxic,  646 
Anemias   the,   644 
Aneurysm,  differential  diag- 
nosis of,  636 
from  aortic  incompet- 
ency, 637 
from        mediastinal 

tumors,  636 
from     pulsating     em- 
pyema, 637 
intracranial,  1062 
distribution,   1062 
of  the  abdominal  aorta,  635 
of  the  branches,  635 
of  the  celiac  axis,  635 
of  the  aorta,  627 
of    the    ascending    aorta, 

634 
of   the    descending    aorta, 

634 
of  the  heart.  636 

etiolog>'  of.  627 

false,  627 

dissecting,   627 
traumatic,  627 

true,   627 

varix    o  r    anastomotic. 
627 
of  the  hepatic  artery,  636 
of  the  innominate,  636 
of  the  pulmonary   artery, 

636 
of  the  renal  artery,  636 
of  the  splenic  artery,  635 
of  the  subclavian,  636 
of  the  superior  mesenteric 

artery,  636 
of  the  thoracic  aorta,  628 
physical  signs  of,  632 


Aneurysm : 

diastolic         shock, 

633 
Drummond"s   sign, 

633 
Glasgow's  sign,  633 

Perez's   sign,   633 

Scheele's  sign,  633 

points  of  election,  628 

symptoms  of,  629 

capillary   pulse,   631 

Cardarelli's        sign, 

631 
pain,  629 
pressure,  629 
tracheal     tug  ging, 

631 
voice,  630 
of  the  transverse  part  of 

aorta,  634 
physical  signs,  632 

Traube's  sign,  637 
prognosis   of,   637 
treatment  of,  638 
varieties  of,  627 
Angina   follicularis,   316 
Ludovici,   314 
maligna,    132 
membranacea,   132 
pectoris,  620 

diagnosis  of,  622 
from  hysterical  form, 

622 
■  from  intercostal  neu- 
ralgia, 622 
morbid  anatomy  of,  621 
prognosis  of,  622 
symptoms  of,  621 
numbness,  621 
oppression,  621 
pain,  621 
paroxysm,  621 
treatment,  623 
Anisocoria,  1000 
Anorexia  nervosa.   357 
Anosmia,  974 
Anthrax,   194 
bacillus,   194 
diagnosis  of,   196 
external,  195 
malignant,  edema,  195 
pustule,  195 
in  animals,  195 
incubation.  195 
intern-al,   196 

intestinal   anthrax,   196 
wool  -  sorter's     disease, 
196 
etiolog].'  of,   194 
morbid  anatomy  of,  195 
prognosis  of,  196 
symptoms  of,  195 
treatment  of,  196 
Antimony  poisoning,  1205 
Aortic   incompetency,    582 
Aortic  insufficiency,  582 
physical  signs  of,  584 
capillary  pulse,  584 
Corrigan   pulse,    582 
Duroziez's   double 
murmur,  585 
T  r  a  u  b  e  '  s      double 
sound,  585 


Aortic : 

sphygmogram,  583 
symptoms  of,  583 
stenosis,  586 

and  insufficiency,  587 
etiology  of,  583 
physical  signs,  586 
sphygmogram,  586 
symptoms  of,  586 

Aphasia,    motor    or    ataxic, 

977 
or     loss     of     faculty     of 

speech.  975 
various  forms  of,  972 
Aphemia,  977 
Aphtha,  307 

Aphthae  epizooticse,  200 
Apoplexy,  1048 

cerebral  hemorrhage,  1048 
arterial      distribution, 

1048 
diagnosis  of,  1054 
etiology   of,    1048 
morbid    anatomy     of, 

1049 
prognosis  of,  1054 
symptoms  of,  1050 
treatment  of,   1055 
embolism  and  thrombosis 
of  the  cerebral 
vessels,    1056 
diagnosis   of,    1059 
etiologj^  of,  1056 
morbid  changes   in, 

1057 
prognosis  of,  1060 
relative     frequency, 

1056 
symptoms  of,  1057 
treatment  of,   1060 
Appendicitis,  394 
bacilli,  399 
catarrhal,   397 
chronic,  404 

complications      and      se- 
quels, 404 
definition  of,  394 
diagnosis  of,  405 
differential    diagnosis    of, 

405 

etiology  of,  399 

exciting  causes,  399 

gangrenous,  402 

history,   395 

intestinal   or  parietal,   398 

morbid  anatomy  of,  397 
of  catarrhal,  397 
of   intestinal,   398 
of  ulcerative,  397 

obliterans  in,   t^qj 

pathology  and  morbid  an- 
atomy, 397 

perforation  in,  403 

predisposing  causes,  399 

prognosis  of,  407 

recurring.  404 

relapsing.  404 

symptoms  of,  400 

rigidity   of   muscle,   401 
tenderness,  400 
tumor,  401 

treatment  of,  407 
diet,  408 


INDEX. 


I22I 


Appendicitis : 

medicinal,  408 
operative,  407 
ulcerative,  397 
Apraxia,  973 
Aprosexia,  317 
Arachnoidea,  1199 
Argyll  Robertson  pupil,  999 
Arrhythmia,  616-619 
Arithmomania,   1098 
Arm-jerks,  850 
Arsenical  poisoning,  1170 
acute,   1 1 70 
chronic,  1170 
Arterial  pyemia,  573 
Arteriocapillary  fibrosis,  624 
Arteriosclerosis,  624 
etiology    of,    624 
morbid  anatomy  of,  624 
sphygmogram  in,  626 
symptoms  of,  625 
treatment  of,  626 
Arthralgia  saturnina,  1167 
Arthritis  deformans,  775 
etiology  of,  775 
morbid  anatomy  of,  776 
nature  of,  776 
symptoms  of,  776 
multiple,  777 

partial     o  r    monarthritic, 
778 
Arthritis  gonorrheal,  210 
Arthropoda,  1199 
arachnoidea,  1199 
acarinse,  1199 
linguatulidae  or  pentas- 
tomes,  1200 
insecta,  1200 
diptera,  1200 
rhyncota,  1200 
Ascarides,  1189 
Ascaris  lumbricoides,  Ii8g 
Ascites,  493 

character  of  fluid,  495 

chylosus,  495 

differential    diagnosis    of, 

494 

from  cyst  of  the  omen- 
tum, 496 

from    hydronephrosis, 

495 
from       overdistended 
bladder,  495 
etiology  of,  493 
physical  signs  of,  494 
symptoms  of,  493 
treatment  of,  496 
Aspiration  pneumonia,  228 
Associated   movements,   847 
Astereognosis,  863 
Asthma,  bronchial,  526 
cardiac,   558 
humidum,  525 
uremic,  68g 
Atactilia,  975 
Ataxia,  hereditary,  937 
Ataxia,  progressive  locomo- 
tor, 926 
Atelectasis  of  the  lung,  230 
Atheroma  of  the  blood-ves- 
sels, 624 
Athetosis,  1067,  1 119 
Athyrea,  676 


Atrophia   musculorum  lipo- 

matosa,   1151 
Atrophic    bulbar     paralysis, 

951 
spinal  paralysis,  918 
Atrophy,  1151 

acute  yellow,  of  the  liver, 
469 
diagnosis  of,  471 
etiology  of,  469 
morbid         anatomy 

of,    469 
symptoms  of,  470 
treatment  of,  471 
facio-scapulo-humeral  type 

of,  1 153 
juvenile  hereditary,  Erb's 

form  of,  1 152 
muscular,  1151 
idiopathic,  1151 
primary     myopathic, 
forms  of,  1 151 
progressive,  peroneal  type 
of.   1 153 
Atropin  poisoning,  1205 
Auditory    hyperesthesia, 
lOiS 
or    eighth    nerve,    lesions 
of,    1013 
Automatic  chorea,  iioi 
Autumnal  catarrh,  501 
fever,  17 

B 

Babinski   reflex,  849 
Bacillus  dysenterise,  106 
Bacillus  typhosis,   18 
Bacillus  X,  84 
Bacteremia,   181 
Ballismus,  1091 
Banti's  disease,  668 
Barbadoes  distemper,  83 
Barlow's  disease,  834 
Basedow's  disease,  672 
Basilar  meningitis,  249 
Bedbug,  1201 
Bednar's  aphthae,  309 
Beef  tape-worm,  1182 
Bell's  mania,  1087 

palsy,  1006 
Beri-beri,  879 
Big  jaw,  198 
Bilateral  spastic  hemiplegia, 

1066 
mental      defects      of, 

1067 
Bile-duct,  carcinoma,  451 

cicatricial  contraction, 

452 
other    affections    of, 

451. 
parasites,  452 
stenosis,  452 
Bile-passages  and  gall-blad- 
der, diseases  of,  436 
Bilharzia  hsematobia,  1181 
Biliary  cancer,  451 

colic,  445 
Bilious  fever,  65 
headache,   11 12 
remittent  fever,  83 
typhoid  fever,  300 


Birth  palsies,  1066 
Bisulphid  of  carbon  poison 

ing,   1 1 64 
Black   death,   114 
plague,    114 
vomit,  85 
Blackwater  fever,  79 
Bladder  and  rectum,  mech- 
anism of  function,  847 
Bladder,  catarrh  of,  759 
diseases  of,  759 
hemorrhoidal     veins      of, 

769 
morbid  growths  of,  769 
muscular  spasm  of,  766 
symptoms  of,  766 
treatment  of,  767 

of  incontinence,  767 
of  retention,  768 
neuroses  of,  765 
stone  in,  765 
paralysis  of,  765 
Blepharospasm,  1012 
Blood,  641 
and  blood-making  organs, 

diseases  of  the,  641 
minute  structure  of,  641 
blood  plaques,  641 
cell  forms  not  found  in 

normal,  643 
large     lymphocyte     or 
large  mononuclear 
cell,  642 
nucleated    red    corpus- 
cles, 643 
me  g  a  b  1  a  s  t  s , 

643 

microblasts,    643 

normoblasts,  643 

p  o  1  y  m  orphonuclear 

or  polynuclear  cells 

642 

basophilic  or  mast 

cells,  643 
eosinophiles,  642 
neutrophiles,   642 
red  blood  discs,  641 
sm,all  lymphocyte,  642 
transitional    1  e  u  k  o  - 
cytes,  642 
Blood-striking,  194 
Blood-vessels,    diseases    of, 

624 
Bloody  flux,  104 

murrain,  194 
Body  louse,    1201 
Bone  tumor,  198 
Bothriocephalus   latus,   1182 
Bowel,  carcinoma  of,  428 
diagnosis  of,  429 

from  chronic  inflam- 
matory thickening, 
430 

from   circumscribed 
peritoneal    exudate, 
429 
from   floating   kidney, 

429 
of  part   of  bowel   in^. 
volved,   430 
prognosis  of,  430 
symptoms  of,  428 
treatment  of,  430 


1222 


INDEX. 


Bowel : 

embolic  ulcer  of.  394 
hemorrhagic     infarct     of, 

392 
intussusception  of,  410 
invagination   of,   410 
nervous  affections  of,  424 
derangement    of    mo- 
tion, 424 
nervous       cramp, 

425 
of  sensibility.  425 
enteralgia,  425 

diagnosis  of,  425 
secretion  neurosis,  427 
treatment  of,  427 
obstruction  of,  409 
b}'  fecal  matter,  412 
by  foreign  bodies,  411 
by  morbid  growths.  412 
by  stricture,  412 
strangulation  of,  409 
syphilitic  ulcer,  394 
twists  and  knots  in.  411 
ulceration   of,   393 
Brachial  plexus.  1032 

lesions  of,  1032 
Bradycardia,  559-6i5 
explanation  of.  615 
treatment  of,  620 
Brain,  abscess  of,  1081 
affections    of    the    blood- 
vessels of.  104s 
anemia  of.  1046 
diseases  of,  963 

general   and    functional. 

1087 
of    the    membranes    of, 
1038 
hyperemia  of,  1045 
inflammation  of,  1081 
edenia  of.   1047 
sclerosis  of,  1069 
syphilis  of,   1144 
tumors  of  the.  1074 
diagnosis  of,  1079 
etiolog>'_  of.    1074 
prognosis  of.  1080 
symptoms  of.  1075 
of  basil  ganglia  or  in- 
ternal capsule,  1079 
of  base  of  the.  1079 
of    central    or    motor 

region.  1077 
of  cerebellum.  1078 
of  corpora  quadngem- 

ina,  1079 
of     corpus     callosum, 

1079 
of  crus.  X079 
of  occipital  lobe,  1078 
of  parietal  area,  1077 
of  pons   and   medulla 

oblongata.   1078 
of      prefrontal      area. 

1076 
of   temporosphenoidal 
area   on   right   side, 
1078 
treatment.  icSo 
Breakbone  fever.  90 
Breathing,  alterations  in,  m 
nervous  disease,  866 


Bright's  disease,  acute,  696 

chronic,  707 
Broadbent's  sign,  563 
Broca's  convolution.  972 
Bromin  poisoning,   1206 
Bronchial  asthma.  526 
diagnosis  of,  529 

from   cardiac   asthma, 

529 
from  hysterical  dysp- 
nea, 529 
from     spasm    of    the 
glottis,  529 
etiolog>'  of,   526 
morbid  anatomy  of,  527 
physical  signs  in,  528 
prognosis  of,  529 
S3'mptoms    of.    527 
treatment  of,  529 
tubes,  diseases  of,   517 
Bronchiectasis,   524 
diagnosis  of,  525 

from     abscess     of     the 

lung.  525 
from  circumscribed  em- 
pyema, 525 
from    phthisical    cavity. 

525 

etiology    of,    524 

morbid  anatomy  of.  524 

physical  signs  of,  525 

symptoms   of,   525 

treatment  of.  525 
Bronchitis.  517 

acute,  517 

diagnosis  of,  518 
etiology   of,   517 
morbid  anatomy  of,  517 
physical  signs  of,  518 
prognosis  of.  518 
symptoms  of,  517 
treatment  of,  518 

capillary,  228 

chronic,  519 

diagnosis  of,  52? 
etiology  of,  519 
morbid  anatomy  of.  520 
physical  signs  of,  521 
prognosis  of.  522 
symptoms  and  course  of. 
'  520 
treatment  of,  522 

foreign  resorts  in  the, 

523 
plastis.  or  fibrinous,  530 
diagnosis  nf.   531 
etiologA'   of.   530 
morbid    anatomy    of. 

530 
physical  signs  of.  531 
symptoms  of,  530 
treatment   of,    531 
Bronchocele.   670 
Bronchopneumonia.  228 

tubercular,  256 
Bronchopneumonic   phthisis, 

247 
Bronchorrhea.    520 
Brown  atrophy  of  the  heart, 

608 
Bruit  de  diable.  650 
Bubo,  oarotid.  313 
Bubonic  plague,   114 


Bubonic  plague: 
bacillus  of,   115 
diagnosis  of,  116 
etiology   of,    114 
morbid  anatomy  of,  115 
prognosis  of,   116 
symptoms  of,  115 
treatment  of,   116 

serum  therapy,  117 
varieties  of,  115 
bubonic  form,  115 
malignant        adenitis, 

pestis    minpr,    115 
pneumonic  form,  115 
siderans  or  fulmin- 
ant. 115 
septicemic  form.  115 
Buccal  psoriasis.  312 
Buhl's  disease,  836 
Bulbar  palsy,  acute,  954 
asthenic.   954 
progressive,  951 


Cachexia,  malarial,  66 

thyroidea  vel   strumipriva 
vel  thryeopriva,  676 

Cachexie        pachydermique, 
676 

Caisson  disease,  910 

Camp  fever.  55 

Cancer  in  hepatic  fissure.  484 
of  the  gall-bladder,  450 
of  the  esophagus,  325 
of  the  pancreas,  483 
of  the  pericardium.  56G 
of  the  peritoneum,  492 
of    the    transverse    colon, 

484 
Cancrum  oris,  311 
Canker,  307 

Capillary  bronchitis,  228 
Capillary  pulse.  584 
Capillar^'-     pulse    in     aneu- 
rysm of  the  aorta,  631 
Carbolic  acid  poisoning,  1206 
Carbonic  acid  gas  poisoning, 
1206 
oxid  poisoning,  1206 
Carbuncle  fever,  194 
Carcinoma  of  the  bowel,  428 
of  the  liver,  471 
massive  form.  472 
nodular  form.  472 
radiating  form,  472 
with  cirrhosis,  472 
ventTiculi.  366 
Cardarelli's  sign.  631 
Cardiac  asthma,  558 
disease,  558 
general  svmptomatology 
of.  558 
muscle,    degeneration    of, 
608 
albuminoid.   608 
amyloid,  610 
calcareous,  610 
Cardiothyroid    e  x  o  p  hthal- 

mos,  672 
Catarrh,   acute   bronchial, 
517 


INDEX. 


1223 


Catarrh : 

chronic   bronchial,   519 
nasal,  498 

of  the  bladder,  759 
Catarrhal  fever,  162 

pneumonia,  228 
Catarrhus  aestivus,  501 
Cauda    equina,    lesions    o  f, 

949 
Caudate  nucleus,  983 
Caustic  potash  or  soda,  1206 
Cavities  in  lung,  255 
Cellulitis  of  the  neck,  314 
Central  ganglia,  983 
Centrum  ovale,  982 
Cephalodynia,   y72 
Cerebellar  hereditary  ataxia, 

938 
Cerebellum,  disease  of,  984 

changes  of,  due  to  throm- 
bosis    and     embolism, 

1057 
form  o£  lesion  of,  985 
Cerebral   disease,  963 
localizations  of,  963 
summary      of       facts 
bearing  on,  986 
hemorrhage,  1048 
hyperemia,  1045 
palsies  of  children,  1062 
softening,   1056 
vessels,  a  summary  of  the 
effects   of   plugging   of, 
1058 
Cerebritis,  1081 
Cerebrospinal  fever,  167 
brain  in,  168 
complications     and     se- 
quelae, 172 
cranial  nerves  in,  169 
diagnosis  of,  172 

from   muscular   rheu- 
matism, 173 
from  tubercular  men- 
ingitis, 173 
from     typhus     fever, 

173 

■etiology  of,   168 
forms  of,  i6g 
abortive,  172 
chronic,  172 
intermittent,   172 
malignant,    171 
mild,  172 
ordinary,   169 
sporadic,   175 
incubation  period,   169 
Kernig's  sign  of,  171 
morbid  anatomy  of,  168 
predisposing   causes    of, 

168 
prognosis  of,  174 
Quincke's  lumbar  punc- 
ture  in,   173 
sequelae  of,   172 
spinal  cord  in,  168 
treatment  of,   175 
Cervical  plexus,  1031 
Cestodes,  1181 

cysticerus   cellulosae,    1188 
echinococcus   disease,  1188 
geographical    distribution, 
1 189 


Cestodes : 

intestinal,   1181 

visceral,    1188 
Charbon,  194 
Charcot's  disease,  956 
Cheese  poisoning,  1171 
Cheirospasmus,   11 15 
Cheyne-Stokes        breathing, 

866 
Chiasm  and  tract,  lesion  of, 

992 
Chicken-pox,   156 

complications  in,  157 
infantile  paralysis,   157 
varicella       gangraenosa, 

157 
eruption  in,  156 
incubation  in,  156 
Children,  reflex  convulsions 

of,   II II 
Chill,  the  congestive,  jj 
Chills  and  fever,  65 
Chloremia,  648 
Chloral  poisoning,  1207 
Chloranemia,  648 
Chlorism,   1163 
Chloroform  poisoning,   1207 
Chlorosis,  648 
Choked  disc,  989 
Choking  quinsy,  194 
Cholangitis,    chronic    catar- 
rhal, 444 
suppurative,  445 
Cholecystitis,     acute     infec- 
tious, 448 
diagnosis  of,  449 
etiology  of,  448 
morbid  anatomy  of,  449 
symptoms   of,   449 
treatment    of,    450 
Cholelithiasis,  441 
etiology  of,  441 
morbid  anatomy  of,  441 
Cholera,  91 
bacillus  of,  92 
examination  for,  103 
postmortem     test     in, 

104 
Schottelius'        culture 
method  in,  104 
of  Koch,  96 
of    Prior    and    Finkler, 
96 
collapse  in,  94 
diagnosis  of,  95 
diarrhea,  94 

differentiation  from  chol- 
era morbus,  95 
epidemics  of,  91 
etiology  of,  92 
examination  of  the  dejec- 
ta of,  96 
Koch's  views  of,  92 
medium  of  infection,  92 
morbid  anatomy  of,  92 
prognosis  of,  96 
symptoms  of,  94 
incubation,  94 
stage,  of  collapse,  94 
of    preliminary    diar- 
rhea, 94 
of  reaction,  95 
treatment  of,  97 


Cholera : 

directions  to  nurses,  99 
enteroclysis,   102 
Haffkine's  method,  98 
of  attack,  99 
protective      inoculation, 

97 
algida,  91 
Asiatica,  91 
infantum,  389 

diagnosis   of,   390 

etiology  of,   389 

prognosis  of.  390 

symptoms  of,  390 

treatment,  390 
infectiosa,  91 
maligna,  91 
morbus,   384 

diagnosis  of,  385 

etiology  of,  384 

prognosis  of,  385 

symptoms  of,  385 

treatment  of,  385 
nostras,  384 
Chorea,  acute,  1091 

diagnosis  of,  1096 

etiology  of,  1091 

morbid      anatomy      of, 
1093 

nature  of,  1093 

symptoms   of,    1094 
chronic  hereditary,  1099 

progressive,  1099 
diagnosis  of,  iioi 
morbid    anatomy    of, 

1 100 
prognosis  of,  IIOX 
treatment  of,  iioi 
electric,  1097 
hysterical,   iioi 
major,  iioi 
mild,  1091 
minor,  1091 
postchoreal   paralysis  and 

postparalytic,  1102 
procursiva,  1088 
spastica,  1067 
Choreic  movements,  846 
Choreiform   affections,    IO97 
Chronic  angina,  321 
anterior  poliomyelitis,  958 
bronchial  catarrh,  519 
catarrhal  dyspepsia,  343 

gastritis.  343 

nephritis,  707 
degeneration  of  the  motor 

nerve  nuclei,  958 
diarrhea,  382 

diffuse  meningo-encephali- 
tis,    1070 

nephritis,  707 
endocarditis,  574 
enlargement    of    the    ton- 
sils, 317 
enterocolitis,  382 
follicular  pharjnigitis,   321 
gastric  catarrh,  343 
hereditary   chorea,    1099 
interstitial  hepatitis,  458 
malaria,  79 
nasal   catarrh.  498 
nasopharyngeal      obstruc- 
tion, 317 


1224 


INDEX, 


Chronic : 

parenchymatous     nephri- 
tis, 707 
rheumatic    arthritis,    775 
rhinitis,  498 
tubal  nephritis,  707 
ulcerative  phthisis,  254 
valvular  disease,  574 

Chronically  contracted  kid- 
ney, 716 

Chvostek's  sign,   1120 

Chyluria,  752 

Cimex   lectularius,   1201 

Circumflex  nerve,  lesions  of, 

1033 
Cirrhosis    of  the    liver,   458 
atrophic,  460 
biliary,  460 
diagnosis  of,  463 

from  amyloid  liver,  463 
multilocular     hydatid, 

disease.   463 
tubercular       peritoni- 
tis, 463 
etiology,  458 
Glissonian,   469 
hypertrophic,  460 
morbid  anatomy  of,  460 
of  atrophic,   460 
of  biliary,  460 
of  hypertrophic,  460 
prognosis  of,  464 
symptoms   of,   461 
of  atrophic,  461 
of  biliary,   462 
of  hypertrophic,  462  ' 
treatment   of,    464 
Cirrhosis,   of  the   lung,   233 
Cirrhotic  kidney,  716 
Clergyman's     sore     throat, 

321 
Coagulation  necrosis,  135 
Coated  tongue,  304 
black,   304 
bright  red.  304 
dry  brown,  304 
strawberry,  304 
Cocain  poisoning,  1207 
Cocainism,    1163 
Coccygodynia,  883 
Celiac  affection  in  children, 

391 
Colica  pictonum,  11 64 
Colitis,  mucous,  382 
Colon,  dilatation  of,  422 
Color  of  tongue,  natural,  304 
Combined   lateral   and   pos- 
terior sclerosis,  939 

sclerosis,  939 
Compression  myelitis,  943 
Congenital   absence  of  kid- 
ney, 746 
Congestion     of    the     brain, 

1045 

of  the  kidney,  693 
Congestive  chill,  77 
Conium  poisoning,  1207 
Constipation,  420 

treatment  of,  421 
in   infants,   422 
Constitutional    diseases,    771 
Constriction    of    the    bowel, 

409 


Consumption   of  the   lungs, 

252 
Contagious  carbuncle,  194 
Contracted  kidney,  716 
Contracture    des    nourrices, 

1119 
Conus     meduUaris,     lesions 

of,  949 
Convulsions,      epileptiform, 
846 
reflex    in  children,   mi 
Convulsive  tic,   1012 
Copodyscinesia,  11 15 
Copper  poisoning,  1208 
Coprolalia,   ioy8 
Cord,     spinal,     diseases     of 

membranes  of,  899 
Coronary  arteries,    sclerosis 

of.  610 
Corpora    quadrigemina,    984 
Corpulence,  821 
Corrigan  pulse,  582 
Cortex,     functional    assign- 
ments of,  964 
lesion  of  the  sensory  tract 
of,  972 
irritative,  972 
motor  areas  of,  964 
sensory  areas  of,  970 
Cortical     areas     covermg 
speech,   972 
whose    function    is    un- 
known   or    uncertain, 
981 
epilepsy,  1106 
Coryza,  497 
Costiveness,  420 
Coup  de  soleil,  11 76 
Cow-pox,  152 
Crab  louse,   1201 
Cranial  nerves,  diseases  of, 

987 
Cretinism,  678 
congenital,  678 
endemic,  678 
sporadic,  678 
treatment  of,  679 
Cretinoid  idiocy,  678 

state  supervening  in  adult 
life  in  women,  676 
Crises,  tabetic,  932 
Croup,  catarrhal,  506 
false,  506 
spasmodic,   506 
treatment  of,  507 
Croupous  enteritis.  392 
nephritis.   696 
pneumonia,  212 
Crura  cerebri,  984 
Cruveilhier's  atrophy,  958 
Cryptogenetic     s  e  p  ticemia, 

298 
Curschmann's  spirals,  528 
Cutis  tensa  chronica.   it4i 
Cyanotic  induration  of  kid- 
ney, 694 
Cycloplegia,  999 
Cynanche   contagiosa,   132 
gangrenosa,   314 
tonsillaris,  315 
Cysticercus  cellulosse,  1 183 
Cystitis,   759 
bacteria  in,  759 


Cystitis : 
calculous,  760 
diagnosis  of,  760 
morbid  anatomy  of,  759 
symptoms  of,  759 
treatment  of,  761 
of  acute,  761 
of  chronic,  761 
Cysts,  echinococcus,  endoge- 
nus,  .^79 
hydatidosus,  479 
veterinorum,  479 
of  the  pancreas,  484 

D     ' 

Dandy  fever,  90 
Deafness,   nervous,    1013 
Degeneration   of   the   heart, 
amyloid,  610 
calcareous,  610 
fatty,  or  metamorphosis, 
603,  608 

circumscribed,  609 
parenchmatous     or     albu- 
minoid    (cloudy    swells 
ing),   608 
diagnosis  of.  609 
-    prognosis  of,  608 
treatment   of,  609 
Deglutition  pneumonia,  228 
Delayed  conduction  of  sen- 
sation, 861 
Delirium,  acute,  1087 
cordis,  617 
tremens,    1158 
Delusions,  865 
Dementia  paralytica,   1070 
diagnosis  of,  1073 
etiology  of,    1071 
morbid      anatomy      of, 

1071 
prognosis  of,  1073 
symptoms  of,  1071 
treatment  of,  1073 
Demodex  folliculorum,  1199^ 
Dengue,  90 

diagnosis  of,  91 
from  acute  rheumatism,. 

91 
etiology  of,  90 
prognosis  of,  91 
symptoms   of,   90 
treatment  of,  91 
Dentition,  derangements  due 

to,   304 
Depurative  disease,  726 
Derangement   of    speech   of 
irritative     origin, 
980 
prognosis  of,  981 
treatment   of,  981 
Derbyshire  neck,  670 
Dermatosclerosis,   1141 
Dettweiler's  pocket  spit-cup,. 

276 
Devonshire  colic,  1164 
Diabetes  insipidus.  817 
diagnosis  of,  819 
etiolosrv  of,  817 
morbid  anatomy  of,  817 
pathogenesis,   796 
pathology,  796 


INDEX. 


122S 


Diabetes : 

physical    and    chemical 
character  of  the  urine, 
818 
prognosis  of,  819 
symptoms  of,  817 
duration  of,  818 
treatment  of,  820 
hygienic,  821 
medicinal,  821 
mellitus,  795 
acetone  m,  80s 
beta  oxybutyric  acid  in, 

805  . 
coma  in,   801 
geographical   and   racial 

distribution,    795 
diacetic    acid    in,    805 

test  for,  808 
glucose    in.   803 

test  for,  807 
glycosuria,  803 
morbid  anatomy  of,  799 
pathogenesis    of,    796 
prognosis  of,  809 
symptoms  of,  800 
eczema,  801 
gangrene,  801 
inosite,  80S 
polyuria,  800 
thirst,  800 
uric  acid,  805 
treatment  of,  809 
diabetic  coma,  816 
dietetic,    809 
diet  table,  811 
hygienic,  813 
medicinal,  814 
of   complications,   816 
pruritus,  816 
Diagram  showing  order  of, 

teeth  eruption,  305 
Diarrhea,  alba,  391 
chronic,  382 
chylosa,  391 
nervous,  424 
Diazo  reaction,  29 
Digestive    system,    diseases 

of,  304 
Digitalis  poisoning,   1208 
Dilatation,  bronchial,  524 
of  the  colon,  422 
symptoms  of,  424 
treatment  of,  424 
of  the  heart,  600-603 
Diphtheria,  132 

complications   and    seque- 
lae, 137 
ataxic  symptoms,  137 
bronchopneumonia,     137 
capillary  bronchitis,  137 
heart,    137 
nephritis,    137 
paralysis.  137 
tendon  reflexes,  137 
toxic  neuritis,  137 
contagiousness  of,  132 
diagnosis  of,  137 

from  diphtheroid  fauci- 

tis,  137 
from  scarlet  fever,  138 
epidemic,  134 
etiology  of,  133 


Diphtheria : 
forms  of,   135 
laryngeal,  I35 
nasal,  135-136 

constitutional      infec- 
tion  in,   136 
pharyngeal,  135 
in  animals,  134 
K  1  e  b  s-Loeffler    bacillus, 

135 
morbid  anatomy  ot,  X34 
prognosis  of,   138 
symptoms   of,    i35 

laryngeal  cough,  136 

of  nasal,  136 

period     of      incubation, 

135 

seats  of  invasion,  135 

treatment  of,  140 
antitoxin,  140 

administration  of  anti- 
toxin for  immuniza- 
tion, 141 

complications     and    se- 
quelae,   144 
constitutional,   142 

prophylactic,   144 

serum  therapy,   140  .  . 
Diphtheritic     e  n  docarditis, 

570 

enteritis,    392 
Diphtheroid      sore      throat, 

132,   137 
Diplegia,  844 

facialis,  953 
Diptera,   1202 

Disseminated   nodular    scle- 
rosis,  1069 
Distomum  Buskii,  118 

capense,    1181 

conjunctum,  11 80 

endemicum,   1180 

felineum,  1181 

haematobium,    1181 

heptipaticum,  1180 

lanceolatum,  1180 

perniciosum,  1180 

pulmonalis,    1181 

sinense,    1180 

Westermanni,  1181 
Diver's  paralysis,  910 
Double  vision  in  disease  of 

motor  nerves  of  the  eye, 

1002 
Dracontiasis,   1196 
Dubini's  disease,  1098 
Duchenne-Aran's       disease, 

958 
Duchenne  s  disease,  926-951 
Duodenal  ulcer,  359 
Duodeno-cholangitis,    439 
Dysentery,    104 
Amoebic,  109 
complications,  no 
diagnosis  of,   in 
etiology  of,   100 
prognosis  of,  ill 
symptoms  of,  IIO 
treatment  of,  iii 
bacillary,  106 
complications    and    se- 
quelae, 108 
diagnosis   of,   109 


Dysentery : 

etiology  of,   106 

morbid  anatomy  of,  107 

prognosis    of,    109 

symptoms  of,  108   . 

treatment  of,   in 
serum,  112-113 
bilious,  los 
catarrhal,  104 

diagnosis  of,   106 

etiology  of,   105 

morbid  anatomy  of,  105 

symptoms  of,   105 

treatment  of,  m 
chronic,  113 

morbid  anatomy  of,  113 

treatment  of,  113 
croupous,   106 
diphtheritic,   106 

pseudomembranous,  106 

tropical,  109 

ulcerative,    106 

vaccines,  112 
Dyspepsia,  350 
atonic,  352 
flatulent,  352 
intestinal,  352 
nervous,   350 

diagnosis  of,  351 

etiology,   351 
symptoms  of,  351 

treatment  of,  3S2 


Echinococcus      or     hydatid 
disease,    1188 

Echolalia,  1098 

Echokinesis.   1098 

Eclampsia,   infantile,   nil 
uremic,   688 

Edema,  angioneurotic,   n55 
of  the  brain,  1047 

Ehrlich's   Biondi   stain,   641 

Ehrlich's  triple  stain,  641 

Eighth    nerve,    lesions    of, 
1013 

Electrical  excitation  of  mo- 
tion, 854 

Elephantiasis  grsecorum,  287 

Eleventh   nerve,   lesions  of, 
1026 

Elodes  icterodes,  83 

Embolic  pneumonia,  235 

Embolic     pneumonia, 
non-septic,  235 
septic,  237 

Embolism   of  cerebral   ves- 
sels, 1056 

Embryocardia,   617 

Emphysema    of    the    lung, 

531 
alveolar,   531 
atrophic,   532 
compensatory,  532 
interlobular  or  interstitial,. 

531.  53S 
pseudohypertrophic,    532 
senile,  532 
vesicular,  532 
diagnosis  of,  535 
etioloev  of,  532 
morbid   anatomy  of,   533 


1226 


INDEX. 


Emphysema : 

physical  signs  of,  534 
prognosis  of,  536 
symptoms  of,  534 
treatment  of,  536 
Empyema,   541 

pulsating,   545 
Encephalasthenia,  1129 
Encephalitis,    sup  purative, 
1081 
diagnosis  of,  1083 
etiology  of,  1081 
morbid      anatomy      of, 

1081 
prognosis  of,    1083 
symptoms  of,  1082 
treatment  of,  1083 
Endarteritis  chronica  defor- 
mans, 624 
Endocarditis,  acute,  mild  or 
simple  form,  567 
diagnosis   of,    569 
etiology  of,  568 
morbid  anatomy  of, 

568 
prognosis   of.   569 
symptoms  of,  569 
treatment  of,   570 
chronic,  574 

severe  or  malignant  form, 
570 
diagnosis  of,   573 
etiology  of,  570 
morbid  anatomy  of, 

571 
prognosis  of,  574 
symptoms  of,   571 
treatment  of,  574 
ulcerative,  570 
Endocardium,    diseases    of, 

567 
English  sweat,  301 
Enteralgia,  425 
Enteric  fever,  17.     See  Ty- 
phoid. 
Enteritis,  amoebic,  109 
acute    dyspeptic    of    chil- 
dren, 386 

diagnosis  of,  387 
etiology  of,  386 
prognosis  of,  387 
symptoms  of,  387 
treatment  of,  387 
chronic  catarrhal,  382 
diagnosis  of,  383 
etiology,  382 
morbid    anatomy    of, 

382 
prognosis  of,  383 
symptoms  of,  3S2 
treatment  of,  383 
croupous,  392 
diphtheritic,   392 
follicular,  388 
phlegmonous,  392 
pseudomembranous,  392 
simple  acute  catarrhal,  378 
diagnosis  of,  381 
etioloscy  of,  378 
morbid  anatomy  of 

379 
symptoms  of,  379 
treatment  of,  381 


Enterocolitis,  acute,  388 
diagnosis  of,  389 
etiology  of,  388 
morbid  anatomy  of,  388 
prognosis  of,  380 
symptoms  of,  388 
treatment  of,  389 
Enteroptosis,  376 
Eosinophiles,  642 
Ephemeral  fever,  297 
Epidemic  cerebrospinal  me- 
ningitis, 167 
cholera,   91 
erysipelas,  177 
hemoglobinuria     of     i  n- 

fants,  836 
parotitis,    161 
pneumonia,  212 
roseola,   122 
Epilepsia  acuta,  liii 

nutans,  1099 
Epilepsy,  1102 

diagnosis  of,   1107 
etiology,   1103 
morbid  anatomy  of,  1104 
prognosis  of,  1108 
symptoms  of,  1104 
of  clonic  spasm,  1105 
of   coma,    1 105 
of  grand  mal,  1104 
of  hysterical,  1107 
of  Jack  son  ian,  11 06 
of  petit  mal,  1106 
of  physical,  1106 
of  toxic  spasm,  I105 
treatment  of,  1109 
asylum,   mo 
of  convulsion,  11 10 
Equilibrium,  disturbance  of, 
associated  with  de- 
fect of  hearing, 
1013,   1017 
diagnosis  of,   1017 
etiology  of,  1017 
pathology  of,  1017 
prognosis  of,  1018 
svmptoms  of,  1017 
treatment  of,  1018 
Erb's  form  of  juvenile  he- 
reditary atrophy,  1152 
Ergot  poisoning,  1208 
Ergotism,    1173 
Erichsen's   disease,    1132 
Erroneous  projection,  looi 
Erup-tive-disease  table,  157 
Erysipelas,  177 
bacillus  of,  177 
complications  of,  179 
diagnosis  of,   180 
epidemic   of,   177 
etiology  of,  177 
facial,   178 
prognosis  of,  180 
relapses   and   recurrences 

of,  178 
sequelae   of,    179 
symptoms  of,  178 
incubation,    178 
treatment  of,  180 
Esophagismus,  324 
Esophagitis,  324 
acute,  324 
chronic,  324 


Esophagus,  323 

cancer  of,  325 

dilatation  of,  326 
diffuse  or  total,  326 

disease  of,  323 

diverticula,  327 
pressure,  327 
traction,  327 

exploration  of,  323 
Estivo-autumnal    fever,    65, 

76 
Essential  contractions,  1066 

paralysis   of  children,  918 
Eustronglyus  ,gigas,  1198 
Exophthalmic   goitre,   672 
External   popliteal   nerve, 

lesions  of,   1037 
Eyeball,   lesions   of  t  h  e 

motor  nerves  of,  998 
Eyes,  phenomena  of  paraly- 
sis   of   motor   nerves   of, 

lOOI 


Facial  hemiatrophy,  1138 
nerve,  lesions  of,  1006 
paralysis   of,    1006 
diagnosis  of,  loio 
etiology  of,  1006 
infranuclear    or    peri- 
pheral facial,  1007 
monoplegia,  1007 
nuclear,  1007 
supranuclear,   1006 
symptoms  of,  1008 
spasm,    1012 
etiology  of,  1012 
prognosis  of,  1012 
symptoms   of,    1012 

blepharospasm,  1012 
treatment  of,   1012 
Falling  fits,   1102 
False  croup,  506 

measles,    122 
Family  periodical  paralysis, 

II 35 
Famine  fever,  59 
Farcy,   197 
acute,  197 
chronic,    197 
Fssciola  hepatica,  1180 
Fatty    degeneration    of    the 
heart,  603,  608 
infiltration    of   the    heart, 
609 
of  the  liver,  456 
diagnosis  of,  456 
etiology  of,  456 
morbid    anatomy    o  f, 

456 
prognosis  of,  456 
treatment  of,  456 
metamorphosis    of    heart, 
608 
Febricula,   297 
Fehling's    test    solution    for 

sugar,  807 
Fetid  stomatitis,  308 
Fever,  estivo-autumnal,  76 
and  ague,  65 
breakbone,  go 
cerebrospinal,    167 


INDEX. 


1227 


Pever : 

ephemeral,  297 

glandular,  302 

famine,  59 

intermittent,  73 

malarial,  65 

Malta,   63 

miliary,  301 

mountain,  54 

paratyphoid,  54 

pernicious  malarial,  yj 

relapsing,   59 

remittent,  76 

scarlet,  124 

ship,  55        . 

simple  continued,  298 

typhoid,  17 

typhus,  55 

yellow,   S>2i 
Fibrillary  contractions,  846 
Fibrinous  pneumonia,  212 
Fibroid,  heart,  610 

phthisis,  265 
Fibrous  myocarditis,  610 
Fifth  nerve,  lesions  of,  1004 
paralysis  of  motor  por- 
tion, 1005 
of     sensory     portion, 
1005 
Filaria  Baricrofti,  752,   1195 

bronchialis,    1 198 

diurna,    119S 

dracunculus,    1 196 

hominis  oris,   1198 

imitis,  1 197 

labialis,   1197 

loa,   1 197 

lymphatica,    1198 

oculi    humani    vel    lentis, 
1 197 

perstans,   1195 

sanguinis,  1194 

of  the  dog,  1 197 
Filariasis,  1194 
Flat  worm,  1180 
Flea,  1202 

Flint  murmur,  580,  585 
Floating  kidney,  747 
diagnosis  of,  748 
etiology  of,  747 
symptoms  of,  748 
treatment  of,  749 
Flukes,   1 1 80 

blood,  I 181 

bronchial,  1181 

liver,    1 180 
Folic  pourquoi,   1098 
Follicular    dysentery,    388 

enteritis,  388 

stomatitis,  307 

tonsillitis,  316 
Foot  and  mouth  disease,  200 
etiology,  200 
incubation,  200 
symptoms  of,  200 
treatment  of,  201 
Fourth  nerve,  lesions  of  the, 

1000 
Friedreich's  ataxia,  937 
Functional   diseases  of  ner- 
vous system,  1087 
Functional    paralysis,    other 
forms  of,  1 133 


Gall  bladder,  cancer  of,  450 
atrophy  of,  446 
dilatation  of,  442 
Gallop  rhythm,  617 
Gall-stone,   441 

acute  impacted,  443 
diagnosis  of,  443 
etiology  of,  441 
inflammation  of,  448 
prognosis  of,  444 
symptoms  of,  443 
chronic  impacted,  444 
symptoms  of,  444 
due    to    obstruction 
of     the     common 
duct,  444 
due  to   chronic   ob- 
struction   of    the 
cystic  duct,  444 
diagnosis  of.  446 
treatment  of,  447 
preventive,  448 
Gangrene  of  the  lung,  221 

of  the  spleen,  194 
Gangrenous    stomatitis,    311 
Gastralgia,  353 
diagnosis  of,   353 
etiology  of.  353 
prognosis  of,  353 
symptoms   of,   353 
treatment  of,  353 
Gastrectasia,  373 

acute,  373 
Gastric  cancer,  366 
Gastric    contents,    chemical 
examination  of,  Zi^ 
fever,  297,   342 
neurasthenia,  350 
Gastritis,  acute  catarrhal,  342 
diagnosis  of,  343 
etiology  of,  342 
morbid    anatomy    of, 

342 
prognosis  of,  343 
symptoms   of,   342 
treatment  of,  343 
chronic  catarrhal,  343 
diagnosis  of,  345 
etiology  of,  343 
morbid    anatomy    of, 

344 
prognosis  of,  345 
symptoms  of,  344 
treatment  of,   345 
dietetic  of,  345 
diphtheritic,    350 
mycotic,   350 

phlegmonous  or   suppura- 
tive.  349 
traumatic  and  toxic,  349 
Gastrodiaphany,   332 
Gastro-enteric   fever,    17 
Gastroptosis,   376 
Gastroscopy,    332 
General  paresis.  1070 
Geographical  tongue,  312 
German  rneasles,  122 
Giant  urticaria,  1136 
Gilles  de  la  Tourette's  dis- 
ease, 1098 
Gin  liver,  458 


Girdle  pains,  931 
Glanders  and  farcy,  197 
diagnosis  of,  198 
etiology  of,  197 
incubation,  197 
morbid  anatomy  of,  197 
prognosis  of,  198 
symptoms  of,  197 
treatment  of,   198 
Glandular  fever,  302 
Glasgow's  sign,  633 
Glenard's  disease,  376 
Glissonian  cirrhosis,  469 
Globulin,  test  for,  687 
Glossitis.  311 

desiccans,  312 
parenchymatous.   311 
Glossolabiolaryngeal     paral- 
ysis, 951 
Glossopharyngeal      nerve, 

lesions  of,  1018 
Glossy  skin,  mi 
Glottis,  edema  of,  513 
Goitre,  exophthalmic,  672 
diagnosis  of,  675 
etiology  of.  672 
prognosis  of,  675 
symptoms   of.   673 
Stellwag's  sign,  673 
Moebius'  sign,  673 
von    Graefe's    sign, 

673 
treatment  of,  675 
simple,  670 
etiology,  670 
morbid  anatomy  of,  670 
symptoms  of,  671 
treatment  of,  671 
Gonorrheal  arthritis.  210 
complications  of,    211 
morbid  anatomy  of,  210 
symptoms  of,  211 
treatment  of,  212 
varieties  of,  211 
infection,  210 
Gout,  780 

etiology  of,  780 
morbid  anatomy   of,   784 
pathology  of,  781 
retrocedent  or  metastatic, 

786 
symptoms  of,  785 
of  chronic,  787 
of  irregular  or  atypical, 

786 
of  typical  acute,  785 
pharyngitis.    785 
thread  test  for  uric  acid, 

781 
treatment  of.  787 
dietetic.  787 
hygienic.  790 
medicinal,  of  acute,  790 
of  retrocedent.  793 
Gouty  kidney,  716 
Grain  poisoning,  1173 
ergotism.   11 73 
gangrenous.    1174 
spasmodic.  1173 
lathyrism    or    lupinosis, 

1 1 74 
pellagra.  1174 
treatment  of.   1174 


1228 


INDEX. 


Granular  kidney.  716 

liver,  458 

pharyngitis.  321 
Graphospasmus,  11 15 
Graves'  disease.  672 
Green  sickness,  648 
Grip,  162 

Guinea-worm  disease,  1196 
Giinzburg's  reagent,  334 

H 

Habit  chorea,  1097 

spasm,  1097 
Hallucinations.   865 
Hammond's  disease,   1119 
Hay  asthma.  501 
Hay-fever,  501 
etiology  of,  501 
symptoms  of,  502 
treatment  of.  502 
Headache,  bilious,  1112 
paroxysmal,   11 12 
sick.  1 1 12 
Head-banging,   1099 
Hearing,     modifications     of, 

in  nervous  disease,  865 
Heart,  abscess  of,  612 
aneurysm  of.  613 
atrophy  of,  608 

brown,  608 
chronic    valvular     defects 

of,  574 
congenital  defects  of,   590 
dilatation  of,   599,   603 
diagnosis  of,  605 
etiology  of,  603 
physical  signs  of,  604 
symptoms  of,  604 
treatment   of,   606 
Nauheim  baths,  606 
disease,  relation  of,  to 

kidney  disease,  753 
diseases  of,  558 
fatty  degeneration  of,  603 
fibroid     degeneration     of, 

610 
irritable,  604 
nervous  palpitation,  614 
diagnosis   of.  614 
treatment  of,  614,  619 
neuroses  of,  614 
rupture  of,  613 
Heat  exhaustion,  1175 

fever,  11 76 
Heber den's  nodosities,  777 
Heller's    test    for    albumin, 

687 
Hematorrhachis,  903 
Hematothorax.  548 
Hematuria,   idiopathic,   749 
Hemeralopia,  989 
Hemiachromatopsia,  994 
Hemianopsia,  992 
heteronymous,  992 
homonymous,  992 
lateral.  992 
nasal,  992 
temporal,  992 
Hemicrania,   1112  _ 
Hemiplegia    spastica     cere- 
bralis,   1063 
infantile,   1063 


Hemoglobinuria,  79,  750 
paroxysmal,   751 
toxic,  751 
Hemopericardium,   566 
Hemophilia,  837 
etiology  of,  837 
morbid  anatomy  of,  837 
prognosis  of.  838 
symptoms  of,  838 
treatment  of,  838 
Hemorrhagic  infarct  of  the 
bowel.  392 
lung,  235  _ 
Hemorrhagic  nephritis,  696 
Hemorrhoids.  431 
diagnosis  of,  433 
etiolog\%  431 
symptoms  of,  432 
external,   432 
internal,    432 
treatment  of.  433 
Hepatic  arterj-  and  vein,  dis- 
eases of,  455 
intermittent   fever,   445 
Hepatitis,   suppurative,  465 
diagnosis  of,  467 
etiology  of,  465 
prognosis  of,  467 
symptoms  of,  466 
treatment  of,  467 
Hereditary    ataxic    para- 
plegia,   937 
diagnosis  of,  938 
etiology  of,  937 
morbid     anatomy    of, 

937 
prognosis  of,  938 
symptoms  of,  937 
treatment  of,  938 
Hobnail  liver,  458 
Hodgkin's  disease,  664 
Holy  rollers,  iioi 
Hooping-cough,  157 
Huntington's  chorea,  1099 
Hutchinson's  teeth,  207 
Hj'brid  measles,  122 

scarlet  fever,  122 
Hydrocephalus.  1084  , 
internal,   1084 
congenital.   1084 
diagnosis,   1085 
etiologv'.   1084 
morbid  anatomy,  1085 
prognosis.  1085 
symptoms.  1085 
treatment.  1086 
acquired.  1085 
diagnosis,  1086 
etiology.    1085 
morbid     anatomy, 

1085 
prognosis.  1086 
SA-mptoms.   1085 
treatment.  1086 
Hydrochloric    acid    poison- 
ing, 1210 
Hydrochloric  acid,  test  for, 

334 
Hvdrocvanic  acid  poisoning. 

1208 
Hydronephrosis,   745 
Hydropericardium,  566 


Hydroperitoneum,  493 
Hydrophobia,  184 
diagnosis  of,  187 
etiology  of.  184 
incubation,  184 
morbid  anatom}'  of,  185 
Pasteur  Institute,  188 
prognosis  of,  187 
symptoms  of,  185 
treatment  of,  188 
Hydropneumothorax,   549 
Hydrorrachis,  950 
Hydrothorax,  548 
Hyperemia    of  brain,  1045 
etiology  of,  '1045 
morbid  anatomy  of,  1045 
symptoms,  1045 
treatment  of,   1046 
of  the  liver,  452 
active,  454 

treatment,  454 
passive,  452 

etiology,  452 
morbid  anatomy  of, 

452 
symptoms  of,  453 
treatment  of,  453 
Hyperchlorhydria,   354 
-     diagnosis  of,  355 
etiology  of,  354 
prognosis  of.  355 
symptoms  of,  354 
treatment  of,  355 
diet,  356 
Hyperpepsia,  354 
Hypertrophic     cirrhosis     of 
the  liver,  460 
symptoms  of,  462 
Hypertrophy  of  heart,   599, 
600 
diagnosis  of,  602 
etiology  of,  600 
morbid  anatomy  of,  601 
prognosis  of,  603 
symptoms  of,  601 
treatment  of,  603 
Hypnosis     and     suggestion, 

1 125 
Hypoglossal    nerve,    lesions 
of,  1030 

diagnosis  of,  1031 
etiology  of,  1030 
prognosis  of,  1031 
S3'mptoms  of,  1030 
treatment  of,  103 1 
Hysteria,  1121 

diagnosis  of.  1 126 
etiology  of,  1121 
prognosis  of,   1127 
symptoms  of,  1122 
treatment  of,  1127 
Hysterical  epilepsy,  1125 

fever,  1124 
Hysterical,    stigmata,    1122- 

1124 
Hysterogenous  zones,  1126 

I 

Ichthyosis  lingualis,  312 
Icterus,  436 

gravis,  469 

neonatorum,  439 
Idiopathic  anemia,  653 


INDEX. 


1229 


Ileus    paralyticus    vel    ner- 
vosus,  412 

Illusions,  865 

Impacted  gall-stone,  443,  444 

Infantile  convulsions,   liil 
diagnosis  of,  iiii 
etiology  of,  mi 
prognosis  of,  11 12 
symptoms  of,  iiii 
treatment  of,  11 12 
palsy,  918 
scurvy,  834 

treatment  of,  834 

Infectious  diseases  of  doubt- 
ful nature,  297 

Inflammatory     rheumatism, 
289 

Influenza,  162 

complications  of,   165 
diagnosis  of,  165 
etiology  of,  163 
incubation  of,  164 
morbid  anatomy  of,  164 
prognosis  of,  166 
symptoms  of,  164 
treatment  of,  166 
varieties  of,  164 

Inhalation   tuberculosis,   2S'Z 

Insular  sclerosis,  1069 

Interglobular      emphysema, 
531 

Intermittent  fever,  Jt, 
diagnosis  of,  75 
incubation  of,  y^ 
prognosis  of,  76 
symptoms  of,  72 
treatment  of.  80 

Internal  capsule,  lesions  of, 

983 
Interstitial    suppurative    ne- 
phritis, 730 
Interstitial     nephritis, 

chronic,  716 
Intestinal    obstruction,    409 
acute  and  chronic,  409 
diagnosis  of,  415 
etiology  of,  410,  411,  413 
prognosis  of,  418 
symptoms  of,  413 
treatment  of,  418 
Intestines,  diseases  of,  378 

obstruction  of,  409 
Intoxications,  iiSS 
Intracranial  aneurysm,  1062 

tumors,  1074 
Intrathoracic  tumors,   553 
Intussusception,  410 
treatment  of,  418 
Invagination,  intestinal,  410 
lodin  poisoning,   1209 
Iodoform  poisoning,  1209 
Iridoplegia,  999 

accommodative,  999 
reflex,  or  Argyll  Robert- 
son pupil,  999 
skin,  999 
Irritation  of  auditory  nerve, 

1016 
Irritative  fever,  297 

J 
Jacksonian  epilepsy,  1106 
Jail  fever,  55 


Jaundice,  436 
obstructive,  437 

diagnosis  of,  440 

symptoms,  437 

treatment,  439 
of  the  new-born,  439 
simple  catarrhal,  439' 

diagnosis  of,  440 

etiology  of,  439 

morbid  anatomy  of,  439 

prognosis  of,  440 

symptoms  of,  439 

treatment  of,  440 
Jerkers,  iioi 
Jumpers,  iioi 

K 

Keloid  of  Addison,  1142 
Kendall's  fever,  83 
Keratosis  mucosae  oris,  312 
Kernig's  sign,  171 
Kidney,  abscess  of,  735 
amyloid,  726 

diagnosis  of,  729 
duration  of,  728 
etiology  of,  726 
morbid  anatomy  of,  726 
prognosis  of,  729 
symptoms  of,  728 
treatment  of,  729 
anomalies  of  form  and  po- 
sition, 746 
congenital     absence 

of,  746 
floating,  747 
horseshoe,  747 
lobulated,  747 
cirrhotic,  716 
congestion  of,  693 
active,  693 

passive,  or  cyanotic  in- 
duration, 694 
diagnosis  of,  695 
morbid    anatomy    of, 

694 
prognosis  of,  695 
symptoms  of,  695 
treatment  of,  695 
contracted,  716 
cysts  of,  744 
congenital,   744 
dermoid,  745 
differential  diagnosis  of, 

745 
echinococcus  or  hydatid, 

746 
hydronephrosis,  745 
retention  or  obstruction, 

744 
treatment  of,  746 

derangement    of    circula- 
tion, 693 

diseases  of,  693 

fatty  and  contracting,  709 

gouty,  716 

granular,  716 

lardaceous,  726 

large  white,  707 

movable,  747 

relation  of  disease  of,  to 
heart  disease,  753 

small  white,  709 


Kidney : 

stone  in,  736 
tuberculosis  of,  283 
tumors  of,  742 
diagnosis  of,  743 
symptoms  of,  742 
treatment  of,  744 
waxy,  726 
Kinepox,  152 
Knee-jerk,  849 
Koplik's  sign,  120 
Krouomania,  1099 


Labyrinthine    vertigo,    1017 
Lacunar  tonsillitis,  316 
La  Grippe,  162 
Lagophthalmos,  1008 
Landry's  paralysis,  SiJJ,  922 
Lardaceous    disease    of    the 
kidney,  709,  726 
liver,  457 
Large  white  kidney,  707 
Laryngeal     muscles,     paral- 
ysis of,  514 
treatment  of,  517 
Laryngitis,    acute   catarrhal, 

S05 
chronic  catarrhal,  508 
etiology  of,  508 
morbid  anatomy  of,  508 
prognosis  of,  508 
symptoms  of,  508 
treatment  of,  508 
syphiHtic,  513 
tubercular,  511 
diagnosis  of,  512 
etiology  of,  511 
morbid  anatomy  of,  51I 
prognosis  of,  512 
symptoms  of,  511 
treatment  of,  512 
Laryngoplegia,  515 
Larynx,  503 
bilateral    abductor    paral- 
ysis of,  1021 
diseases  of,  503 
examination  of,  503 
spasm  of,  1023 
tensor  paralysis  of,  1022 
total  paralysis  of,  1021 
unilateral  abductor  paral- 
ysis of,  1022 
Lata,  IIOI 

Lateral    sclerosis,   amyo- 
trophic, 9S6 
Lathyrism,  1174 
Lead  poisoning,  1164 
etiology  of,  1164 
morbid  anatomy  of,  I166 
prognosis  of,  1168 
symptoms  of,   1166 

blue  line,  1167 
treatment  of,  1168 
Leprosy,  287 

anesthetic  form  of,  288 
diagnosis  of,  2S8 
etiology.  287 
morbid  anatomy  of,  288 
prognosis  of.  289 
symptoms  of,  288 
treatment  of.  289 


1230 


INDEX. 


Leprous  neuritis,  88o 
Leptomeningitis,  acute,  1040 

diagnosis  of,  1042 

etiology  of,  1040 

morbid      anatomy      o£ 
1041 

prognosis  of,  1043 

symptoms  of,   1041 

treatment  of,  1043 
cerebral,  1040 
chronic,  1043 
spinal,  901 

acute,  901 

chronic,  902 
Leukemia,  658 

diagnosis  of,  662 

etiology  of,  659 

morbid  anatomy  of,  659 

prognosis  of,  664 

symptoms  of,  660 
blood  changes,  661 

treatment  of,  664 
Leukocytosis,  663 
Lithemia,  793 

diagnosis  of,  794 

etiology  of,  793 

prognosis  of.  794 

symptoms  of,  793 

treatment  of,  794 
Little's  disease,  1066 
Liver,  abnormalities  of  posi- 
tion of,  435 
abscess  of,  465 
active  h3'peremia  of,  454 
acute  yellow   atrophy   of, 

469 
altered  shape  of,  435 
amyloid,  457 
atrophic  cirrhosis  of,  460 

diagnosis   of,  463 

etiology,  458 

morbid  anatomy  of,  460 

symptoms  of,  461 
biliary  cirrhosis  of,  460 
carcinoma  of,  471 
changes   in  hepatic  artery 

and  vein,  455 
cirrhosis  of,  458 
diseases  of,  435 

blood-vessels  of,  452 
dislocation  of,  435 
echinococcus    disease    of, 

477 
fatty.  455 

infiltration  of,  456 

metamorphosis  of,  457 
floating,   435 
hydatid  cyst  of.  452 
hyperemia  of,  452 
hypertrophic   cirrhosis   of, 

460 

diagnosis  of,  463 

etiology  of.  458 

morbid  anatomy  of,  460 

prognosis.  464 

symptoms  of,  461 

treatment.  464 
lardaceous.  457 
morbid  growths  of,  471 
parasites  of,  477 
passive  hyperemia  of,  452 
red  atrophy  of,  452 
sarcoma  of,  472 


Liver : 

syphilis   of,   475 
Lobar  pneumonia,  212 
Lobular  pneumonia,  228 
Local   asphyxia,    1136 
Localization  of  cerebral  dis- 
ease, 963 
Lockjaw,  190 
Long  thoracic  nerve,  lesions 

of,  1032 
Ludwig's  angina,  314 
Lues  venerea,  202 
Lumbago,  772 
Lumbar  plexus,   lesions  of, 

1036 
Lung,  abscess  of,  221 

cavities  in,  256 

cirrhosis  of,  221 

diseases  of,  531 

emphysema  of,  531 

fibroid  induration  of  221 

gangrene  of,  221 

hemorrhagic     infarct     of, 
235 

metastatic  abscess  ol,  237 

tuberculosis  of,  238 

tumors  of,  537 
carcinoma,   537 

diagnosis  of,  538 
peribronchial  cancer,  537 
physical   signs,   538 
Lupinosis,  1174 
Lymphadenitis,  simple,  557 

tuberculous,  557 
Lj^mphadenoma,  664 
Lymphadenosis,   664 
Lymphatic  glands,  tubercu- 
losis of,  279 
Lymphatism,  667 
Lyssa,   184 

M 

Maladie  de  la  tic  convulsif, 
1098 

Malaria,  chronic,  79 
Plasmodium   of,   80 

Malarial  cachexia,  79 
fever,  65 
algid  form,  78 
blood  changes,  72 
in  chronic,  J2 
cachexia,  79 
chronic  form,  72 
clinical  varieties,  72) 
comatose  form,  77 
estivo-autumnal,  65,  76 
favoring  causes,  71 
geographical       distribu- 
tion, 71 
hematuria,  79 
incubation  of,  72, 
intermittent  form  of,  72, 
irregular  forms  of,  78 
latent  form  of,  78 
morbid  anatomy  of,  72 
Plasmodium,   66 
prophylaxis   against,  80 
quartan,   65 
quotidian.  65 
remittent  form,  76 
seasons  favoring,  71 
tertian,  65 


Malignant  jaundice,  469 
lymphoma,  664 
pustule,   194 
Malleus  humidus,  197 
Malta  fever,  63 

distribution  of,  63 
etiology  of,  63 
morbid  anatomy  of,  65 
symptoms  of,  63 
treatment  of,  65 
Mania-a-potu,   1158 

treatment  of,  1160 
Marsh  fever,  65 
Mastication,  spasm  of  mus- 
cles of,   1005 ' 
Measles,   118 
complications  and  sequelae 

of,    121 
contagiousness  of,  118 
diagnosis  of,   121 
morbid  anatomy  of,  119 
pneumonia  in,  121 
prognosis  of,  121 
recurrent  attacks  of,  119 
symptoms  of,  119 
bronchitis,    119 
incubation,   iig 
Koplik's  sign,  120 
■  treatment  of,   122 
Meat  poisoning,  1171 
Median  nerve,  lesions  of, 1035 
Mediastinal  abscess,  556 
disease,  551 
tumors,  553 
diagnosis  of,  556 
morbid  anatomy  of,  555 
pathology  of,  553 
symptoms  of,  554 
treatment  of,  556 
Mediterranean  fever,  63 
Megrim.    11 12 
Membranes    of    the    brain, 

diseases  of,  1038 
Membranous  croup,  132 
Meniere's  disease,  1017 
Meningeal  apoplexy,  903 
Meningocele,  950 
Mercury  poisoning,  1209 
Merycismus,  352 
Metastatic  abscess  of  lung, 

237 
Miasmatic  fever,  65 
Migraine,  11 12 
diagnosis  of,  11 13 
etiology  of,  11 12 
morbid  anatomy  of,  III3 
prognosis  of.  11 14 
symptoms  of,  11 13 
treatment  of,  114 
preventive,  11 14 
Migran,   1112 
Miguet,   307 
Mild  chorea,  logi 
Miliary  fever,  301 
diagnosis  of,  301 
duration  of,  301 
etiology  of,  301 
morbid  anatomy  of,  301 
prognosis  of,  301 
symptoms  of,  301 
treatment  of,  302 
Milk  sickness,  201 
Miltzbrand,  194 


INDEX. 


1231 


Mimetic  facial  paralysis, 
1006 
spasm,  1012 
Miosis,  999 
Miryachit,   iioi 
Mitral  insufficiency,  576 
etiolog>-  of,  576 
mechanism  of,  576 
murmur.  578 
physical  signs,  577 
symptoms  of,  576 
treatment  of,  593 
stenosis,  578 
etiology  of,  579 
mechanism  of.  578 
murmur  in.  579 
physical  signs  of,  579 
symptoms  of,  579 
treatment  of,  593 
Mogigraphia,   1115 
Monoplegia  facialis,  1006 
Morbilli,   118 
Morbus  maculosus,  835 
neonatorum,  836 
Werlhofi.  835 
virgineus,  648 
Morphin  habit,   1161 

poisoning,  1210 
Morphinism,  1161 
Morphea,  1142 
Morvan's  disease,  943 
Motor  agraphia,  978 
aphasia,  977 

function   of   the    stomach, 
to  test,   341 
Mountain  fever,  54 

sickness,  55 
Mouth-breathing,  317 
Mouth,  diseases  of,  304 
Mucous  colitis.  382 
Multiple    arthritis    deform- 
ans, 7jy 
neuritis,  872 

sclerosis     of     brain     and 
cord,  1069 
Mumps,  161 

complications  of,  161 
diagnosis  of,   162 
etiology  of,  161 
morbid  anatomy  of,  161 
prognosis  of,   162 
symptoms  of,  161 
incubation,  ibi 
treatment  of,  162 
Muscle- jerk,  849.  850 
Muscular    system,    diseases 

of,  1150 
Musculospiral  nerve,  lesions 

of,  1033 
Mushroom  poisoning,  1210 
Myalgia,   771 
Mycotic  endocarditis,  560 
Mydriasis,   999 
Myelitis,  diffuse,  acute  and 
chronic,  911 
diagnosis   of,   916 
etiology  of.  911 
morbid  anatomy  of,  gi2 
prognosis  of.  gi6 
symptoms  of.  913 
treatment  of.  917 
acute  anterior  polyomyeli- 
tis  of  children,  918 


Myelitis : 

diagnosis  of,  920 
etiology  of,  918 
morbid      anatomy      of, 

918 
prognosis  of,  920 
symptoms  of,  919 
treatment  of,  920 
Myelocele,  950 
Myocarditis,   610 

acute   suppurative,  612 
diagnosis  of,  612 
etiology  of,  610 
physical  signs,  611 
prognosis  of,  612 
sj^mptoms  of,  611 
treatment  of,  612 
Myocardium,     diseases     of, 

599 
INIyoclonia,    1098 
Myodegeneration,  610 
Myositis,    1 1 50 

acute,   1150 

chronic,    1150 

infectious,  1150 

progressive  ossifying,  1150 

rheumatic,  11 50 
Myotonia  congenita,  1153 
Myxedema,   676 

diagnosis  of,  679 

etiology  of,  677 

morbid  anatomy  of,  677 

prognosis  of,  679 

symptoms  of,  677 

treatment   of,   679 


N 

Neapolitan  fever,  63 
Nematodes,      or      round 

worms,  1 189 
Neoplasmata   cerebri,    1074 
Nephritis,    acute    parenchy- 
matous, 696 
complications  of,  701 
pneumonia,  701 
diagnosis  of,  701 
etiology  of,  696 
morbid  anatomy  of,  697 
glomerular  chan- 
ges, 698 
interstitial     chan- 
ges, 698 
tubal  changes,  698 
prognosis  of,  702 
symptoms  of.  699 

urine,  699 
treatment  of,  703 
chronic  interstitial,   7t6 
complications   of,   722 
diagnosis   of,   722 
etiology  of,  716 
morbid    anatomy    of, 

718 
prognosis  of,  722, 
symptoms  of,  719 
cardiac,  719 
dimness    of    vision, 

721 
hypertrophy  of  the 
left  ventricle,  720 
urine,  720 


Nephritis : 

treatment  of,  723 
chronic    parenchymatous, 

707 
complications  of,  711 
diagnosis   of,   711 
morbid    anatomy    of,. 

707 
prognosis  of,  712 
symptoms  of,  709 

duration  of,  711 

urine,  710 
treatment  of,  712 

diet,  713 

hygienic    measures, 

713 
septic  and  pyemic,  730 
suppurative  interstitial,  73a 
diagnosis  of,   733 
etiology  of,  730 
morbid    anatomy    of, 

prognosis  of,  740 
symptoms  of,  722 

urine.  732 
treatment  of,  734 
Nephrolithiasis,  736 
diagnosis  of,  739 
X-ray  in,  740 
etiology  of,  727 
morbid   anatomy   of,   736 
prognosis  of,  734 
symptoms  of,  738 
treatment  of,  740 
Nephroptosis,  747 
Nerve,     phrenic,     affections 
of,  1 03 1 
circumflex,  1033 
median,  1035 
musculospiral,    1033 
suprascapular,   1033 
treatment  of  lesions  of, 
1036 
tumors  of,  886 
ulnar,  1035 
Nervous  deafness,  1013 
etiology  of,   1013 
symptoms  of,  1014 
treatment  of,  1015 
diseases,      alterations      in 
breathing  and  pulse 
866 
in  vision  and  hearing, 
865 
mental    phenomena    in, 

865 
sensory  motor  phenom- 
ena, 863 
aftersensation     i  n, 

861 
delayed    conduction 
of     sensory     im- 
pressions,  861 
muscular  sense.  862 
sense     of     locality, 
861 

of  pain.  861 
o  f     temperature, 
861 
tactile       sensibility, 
860 
vasomotor    and   trophic 
phenomena,  863 


1232 


INDEX. 


Nervous : 
exhaustion,    1129 
fever,    17 

hypersecretion    of   hydro- 
chloric acid,  354 
system,  diseases  of,  840 
bladder    and    rectum, 

control   in,   847 
general   symtomatolo- 

gy  of,  843 
histology  of,  840 
phenomena  of  motion 
in,  843 
athetosis,  846 
cataleptic      rigidity, 

847 

choreic  movements, 
846 

constant  or  co-ordi- 
nate spasm,  847 

co-ordination,  845 

epileptiform  c  o  n  - 
vulsion,  846 

fibrillary  c  o  n  t  rac- 
tion,  846 

motor    i  rritation, 

845 
nystagmus,   847 
rhythmical  contrac- 
tions, 846 
single    contractions, 

846 
tremor  or  trembling 
motions,   846 
Neuralgia,  880 
diagnosis  of,  884 
etiology  of,  880 
prognosis  of.  884 
symptoms  of.  881 
treatment  of,  8S4 
varieties     of,      depending 
upon    nerves    in- 
volved, 881 
brachial,   882 
c  e  r  vicobrachial, 

882 
cervico  -  occipital, 

882 
of  the  feet,  883 
of  the  fifth  pair, 

881 
of     the      phrenic- 
nerve,  882 
of  the  spinal  col- 
umn, 883 
dorso-intercos- 
tal.  882 
lumbo-abdomi- 
nal,  883 
Neurasthenia,  1129 
diagnosis  of,    11 30 
etiology  of,   1129 
morbid  anatomy,  1123 
prognosis  of,  1131 
symptoms  of,  1130 
treatment  of,  1131 
Neuritis,  endemic.  878 
Neuritis,  localized.  867 
diagnosis  of,  86g 
etiology,  867 
morbid  anatomy  of,  867 
prognosis  of.  869 
symptoms  of,  868 


Neuritis : 

treatment  of,  869 
multiple,  872 

diagnosis  of,  876 
etiology  of,  872 
morbid      anatomy      o  f, 

prognosis  of.  877 
symptoms  of,  873 
treatment  of,  878 
progressive  interstitial  hy- 
pertrophic of  infants, 
939 
Neuroses,  1087 
Newborn,    acute    degenera- 
tion of  internal  organs  of, 

836 
hemorrhagic    diseases    of. 

836  _  _ 
syphilitic  diseases  of.  836 
Nicotin  poisoning,   1210 
Ninth  nerve,  lesions  of,  1018 
Nitric  acid  poisoning.  1210 
Nitrobenzol  poisoning,   121 1 
Noma,  311 

Nose,  diseases  of,  497 
Nutmeg  liver.  452 
Nystagmus,  998 

O 

Obesity,  821 

symptoms  of,  822 

treatment  of,  822 
Obstruction  of  bowel,  405 
Occupation  neuroses,  11 15 
Ocular  pals3^  1003 

treatment  of,  1003 
Olfactory  nerve.  987 
Oliver's  sign,  631 
Onomatomania.  1098 
Ophthalmoplegia.   1002 
Opium  poisoning,  121 1 
Opplar-Boas  bacillus.  368 
Optic  atrophy,  991 

gray,  992 
nerve,  affections,  989 

and  tract,  987 
neuritis,  989 

etiolog>'  of,  990 

morbid  anatomy  of,  989 

symptoms  of,  991 
Organic    acids    of    stomach, 

determination  of,  336 
Oriental  plague,  114 
Osteo-arthritis,  775 
Osteomalacia,  829 

diagnosis  of.  830 

etiology  of,  829 

morbid  anatomy  of,  830 

pathogeny,  830 

prognosis  of.  831 

symptoms  of.  830 

treatment  of.  831 
Oxalic  acid  poisoning,  121 1 
Oxyuris  vermicularis,  1190 
Ozena,  498 


Pachymeningitis.       cerebral 
1038 
external,  1038 
hemorrhagic,   1038 


Pachymeningitis  : 
internal,  1038 
pseudomem  b  r  a  n  o  u  s, 

1038 
purulent,  1038 
spinal,  900 
cervical       hypertrophic, 

900 
external,  900 
hemorrhagic,  900 
internal.  900 
Painless  whitlows,  943 
Palpable  kidney,  747 
Palsies,  cerebral,  of  children, 

1062 
Paludal  fever,  65 
Pancreas,  cancer  of,  483 
diagnosis  of,  484 
morbid  anatomy  of,  483 
symptoms  of,  483 
cysts  of,  484 
diseases  of,  481 
Pancreatitis,  acute,  482 
diagnosis  of,  483 
etiology  of,  482 
morbid  anatomy  of,  482 
prognosis  of.  483 
symptoms  of.  482 
treatment  of,  483 
chronic,  483 
Pandemic  chorea,  iioi 
Papillitis.  989 
Paradoxical    c  o  n  t  ractions, 

853 
Paresthesia,  978 
Paralysie    generale    spinale 

anterieure     sub-acute     of 

Duchenne,  921 
Paralysis,    acute    ascending, 
spinal,  922 
diagnosis  of,  923 
etiology  of,  922 
prognosis  of,  923 
symptoms  of,  922 
treatment  of,  923 

agitans,  1088 

diagnosis  of,  1090 
etiology  of,  1088 
morbid  anatomy  of, 

1088 
prognosis  of,  1090 
symptoms  of,  1089 
treatment  of,  1090 

combined,  of  the  interary- 
tenoid  and  thyro-aryte- 
noid  muscles,   516 

o  f  t  h  e  abductors  o  f  t  h  e 
glottis,    51S 

of  the  cricothyroid  mus- 
cle, 51S 

of  the  arvtenoid  muscles, 
516 

of  the  laryngeal  muscles, 

514 
of  the  thyro-epiglottidean 

and    aryteno-epiglottid- 

ean  muscles.  515 
of      the      thyro-arytenoid 

muscle,  516 
of    the    tongue,    the    soft 

palate,  and  lips,  951 
Paramimia,  978 


INDEX. 


1233 


P  a  r  a  m  yoclonus,  multiple, 

1091 
Paranephritis,  735 

diagnosis  of.  736 
etiology  of,  735 
morbid  anatomy  of,  736 
symptoms  of,  736 
treatment  of,  736 
Paraphasia.  97S 
Paraplegia,  ataxic,  939 
diagnosis  of,  940 
etiology  of,  939 
morbid  anatomy  of,  939 
prognosis  of,  940 
symptoms  of,  939 
treatment  of,  940 
cerebralis  spastica,   1067 
spastic,  1067 
Parasites,  animal,  1179 

of  the  liver,  477 
Parasitic  stomatitis,  307 
Paratyphlitis,  394 
Paretic  dementia,  1070 
Parkinson's  disease,  1088 
Parotid  bubo,  313 
Parotitis,  acute,  313 
chronic,  314 
epidemic,  161 
secondary,  162 
Paroxysmal  headache,  11 12 
Parry's  disease,  672 
Pasteur's   treatment   of   hy- 
drophobia   by    attenuated 
virus,  188 
Pythogenic  fever,  17 
Peduncles,    cerebellar,    dis- 
ease of,  985 
Peliosis.  831 

rheumatica,  831 
Pellagra,  11 74 
Pentastomes,  1200 
Peptic  ulcer,  359 
Perez's  sign,  633 
Pericarditis,  559 
acute,  559 

diagnosis  of,  564 
etiology  of,  559 
morbid  anatomy  of,  560 
physical   signs,  562 
Bamberger's  sign,  561 
Broadbent's  sign,  563 
Ewart's  sign,  562 
Friedreich's  sign,  563 
of    chronic    adhesive, 

563  .      ^  . 

pleuropericardial  fric- 
tion sound,  564 
Retch's  sign.  565 
prognosis  of.  565 
symptoms  of,  561 
treatment  of,  565 
Pericardium,  cancer  of,  566 

diseases  of,  559 
Perihepatitis,  468 

diagnosis  of,  468 
etiologj'  of.  468 
morbid  anatomy  of, 

468 

prognosis  of,  469 

symptoms  of,  468 

treatment  of,  469 

Perinephric  abscess,  735 

78 


Periodical    oculomotor    pa- 
ralysis,  1003 
Periosteal  cachexia,  834 
Peripheral     nerves,     affec- 
tions of,  867 
neuritis,  872 
Perisplenitis,  485 
Peritoneum,  cancer  of,  492 
diseases  of,  487 
tuberculosis  of,  282 
Peritonitis,  acute,  487 
diagnosis  of,  490 
etiology  of,  487 
morbid      anatomy      o  f, 

488 
physical  signs,  489 
prognosis  of,  490 
symptoms  of,  488 
treatment  of,  490 
of  acute  general,  488 
chronic,  491 
circumscribed,  491 
hysterical,  490 
in   typhoid    fever,   47 
Perityphlitis,  394 
Pernicious  anemia,  652 
malarial  fever,  77 
algid  type,  78 
asthmatic  tj'pe,  77 
bilious  type,  77 
comatose  type.  77 
hematuric  type,  79 
temperature,  77 
treatment  of,  80 
Pertussis,  157 
Pestilential  or  putrid  fever, 

55 
Petechial  fever,  55,  167 

Petit  mal,  1106 
Pharyngitis,  acute  catarrhal, 

chronic  catarrhal,  321 

phlegmonous,  322 

ulcerative,  322 
Pharynx,      circulatory      de- 
rangement of,  320 

diseases  of,  315 

hypertrophy     of     adenoid 
tissue  of,  317 

spasm  of,  1020 
Phlegmonous  tonsillitis,  315 
Phosphorus  poisoning,  121 1 
Phrenic  nerve,  affections  of, 

1031 
Phthisis,  acute,  247 

bronchopneumonic,  247 

chronic  ulcerative,  254 

fibroid,  265 

florida,  247 

pneumonic  form  of,  248 

pulmonalis,  252 
Piles,  431 
Pin  worm.  1190 
Pityriasis  ethiopius.  1143 
Plague,  bubonic,   114 
Platyhelminthes,  1180 

cestodes,  1181 
intestinal.  I181 

diagnosis'  of,   1185 

prognosis  of,  1186 

symptoms  of,  1185 

treatment  of,  1186 


Platyhelminthes : 

prophylaxis,   1188 
trematodes,  1180 
blood  fluke,  1181 
bronchial  fluke,  1181 
liver  fluke,  1180 
Pleura,  diseases  of,  539 
hydatid  disease,  551 
morbid  growths  of,  551 
carcinoma,  551 
chondroma    and     lip- 
oma, 551 
sarcorna,  551 
tuberculosis  of,  544 
Pleurisy,  539 
acute,  539 

diagnosis  of,   544 
etiology  of,  539 
morbid  anatomy  of,  540 
physical  signs  of,  542 
Skoda' s  r  e  s  o  n  ance, 

543 
prognosis  of,  545 
pus-formation  in,  541 
resolution  in,  540 
serous  accumulation  in, 

540 
symptoms  of,  541 
treatment  of,  546 
blood-letting,  546 
lapping,  547 
chronic,  547 

treatment  of,  548 
diaphragmatic,  544 
encysted  or  circumscribed, 

544 
exudative,  547 
hemorrhagic,  544 
interlobular,  544 
latent,  547 
plastic,  547 
pulsating,  547 
suppurative,  544 
tubercular,  544 
Pleurodynia,  883 
Plumbism,  1164 
Pneumogastric  nerve,lesions 
of,  1019 
cardiac  branches  of  the, 
1024 

diagnosis  of,  1023 
etiology  of,  1020 
gastric   and    esophageal 
branches  of  the,  1024 
involving     the     nucleus 

and  trunk,  1019 
laryngeal     branches    of 
the,  1020 

etiology  of,  1020 
symptoms  of,  1021 
pharyngeal  branches  of 
the,  1020 

etiology  of,   1020 
symptoms  of,    1020 
pulmonary   branches   of 

the,  1024 
treatment  of,  1025 
Pneumonia,     aspiration     or 
deglutition,   228 
broncho-,  228 
diagnosis  of.  231 
etiology  of,  228 


1234 


INDEX. 


Pneumonia : 

morbid  anatomy  of,  229 
physical    signs,    231 
prognosis  of,  231 
symptoms  of,  230 
treatment  of,  232 
chronic  interstitial,  233 
diagnosis  of,  235 
etiology  of,  233 
morbid      anatomy      of, 

233 
physical  signs  of,  234 
prognosis  of,  235 
symptoms  of,  234 
treatment  of,  235 
•croupous,  212 
bacillus  of,  213 
complications  of,  222 
diagnosis  of,  222 
duration    of    stages    of, 

216 
etiology  of,  213 
in  children,  223 
incubation,  216 
in  the  aged,  223 
larval,  212 
migratory,  212 
morbid  anatomy  of,  214 
stage    of    congestion, 
214 
of     gray     hepatiza- 
tion, 214 
of  red  hepatization, 

214 
of  yellow  hepatiza- 
tion, 215 
mortality  in,  223 
nature  of,  214 
physical  signs  of,  216 
first  stage,  216 
second  stage,  217 
Skoda's    resonance, 

218 
third  stage,  218 
prognosis  of,  223 
symptoms  of,  216 
delayed        resolution, 

220 
herpes,  220 

phlegmasia    alba    do- 
lens,  220 
prune-juice     expecto- 
ration, 219 
ermination,  220 
by  abscess  of  lung,  221 
by  fibroid  induration  or 

cirrhosis,  221 
by    gangrene    of    lung, 

221 
by  resolution,  220 
by    tubercular    phthisis, 

222 
treatment,  223 
serum,  227 
embolic,  235 
non-septic,  235 
septic,  237 
streptococcus,  220 
Pneumonic  phthisis,  247 
Pneumonitis,  212 
Pneumopericardium,    566 
Pneumothorax,  549 


Pneumothorax : 
diagnosis  of,  550 
etiology  of,  549 
physical  signs  of,  549 
Hippocratic    succussion, 

550 
metallic   tinkling,    550 
symptoms  of,  549 
treatment  of,  550 
Podagra,  780 

Poisons,  overdoses  of,  1204 
Polioencephalitis       inferior 

chronica,  951 
Poliomyelitis,  acute,  918 
in  adults,  921 
diagnosis  of,  921 
treatment  of,  921 
in  children,  918 
diagnosis  of,  920 
etiology  of,  918 
morbid  anatomy  of,  918 
prognosis  of,  920 
symptoms  of,  919 
treatment  of,  920 
subacute      and      chronic, 

921 
superior,  1003 
Pollen  catarrh,  501 
Polyneuritis,  872 
Polysarcia  adiposa,  821 
Popliteal   nerve,   lesions   of, 

1037 

external,  1037 
internal,  1037 
Porencephalia,  1063 
Postchoreal     paralysis     and 

postparalytic  chorea,  1102 
Post  erior  spinal  sclerosis, 

926 
Posthemiplegic        mobile 

spasm,  1 102 
Postpharyngeal  abscess,  323 
Pressure    paralysis    of    the 

spinal  cord,  943 
Presystolic  murmur,  580 
Primary     lateral     sclerosis, 

924 
Professional  spasm,  11 15 
Progressive  bulbar  palsy, 

951 

diagnosis  of,  953 

etiology  of,  951 

morbid  anatomy  of,  951 

prognosis  of,  953 

symptoms  of,  952 

treatment  of,  953 
facial  hemiatrophy,  1138 
general    paralysis    of    the 

insane,  1070 
muscular     atrophy,      type 

Duchenne-Aran,   958 
neural   muscular   atrophy, 

1153 
pernicious  anemia,  652 
spastic  paraplegia,  939 
spinal    muscular    atrophy, 
958 
diagnosis  of,  961 
etiology  of,  958 
morbid  anatomy  of,  959 
prognosis  of,  962 
symptoms  of,  960 


Progressive  bulbar  palsy: 

treatment  of,  962 
Prosopalgia,  881 
Proteolysis,  337 
Protozoa,  11 79 
parasitic  infusoria,  1180 
psorospermiasis,   II79 
Protracted  simple  continued 
fever,  298 
diagnosis  of,  299 
etiology  of,  298 
prognosis  of,  299 
symptoms  of,  299 
treatment  of,  .299 
Prune-juice      expectoration, 

219 
Pseudo-angina  622 
Pseudohypertrophic  emphy- 
sema, 532 
Pseudohypertrophy  of  mus- 
cles, 1151 
Pseudoleukemia,  664,  668 
Pseudomembranous    croup, 

136 
Pseudomembranous    enter- 
itis, 392 
Psychical  epilepsy,  1106 
Ptomain  poisonmg,   1212 

treatment  of,  1212 
Ptosis,  998 
Ptyalism,  313 
Puking  fever,  201 
Pulmonary        consumption, 
252 

insuflficiency,  589 
stenosis,  590 
Pulmonohepatic  angle,  331 
Pulse,  irregular,  616 
anacrotic,  618 
delirium  cordis,  617 
dicrotic,  618 
embryocardial,  618 
explanation  of,  616 
gallop  rhythm,  617 
peculiarities  of,  616 
varieties  of,  616 
Pulsus  bigeminus,  617 
bisferiens,  618 
paradoxus,  617 
trigeminus,  617 
Purpura,  831 
arthritic,  834 

treatment  of,  836 
hemorrhagica,  835 

treatment  of,  836 
Henoch's,  835 
scorbutic,  832 
simple  arthritic,  834 
symptomatic,  831 
Putrid  sore  mouth,  308 
Pyemia,  181 
arterial,  573 
diagnosis  of,  183 
etiology  of,  181 
prognosis  of,  183 
symptoms  of,  182 
treatment  of,  183 
Pyelonephritis,  730 
Pylephlebitis,  455 
Pyiethrombosis,  454 
Pyopneumothorax,  549 
Pythogenic  fever,  17 


INDEX. 


1235 


Q 

Quigila,  1 143 

Quincke's  lumbar  puncture, 

174 
Quinsy.  315 

etiology  of,  315 

morbid  anatomy  of,  315 

symptoms  of,  315 

treatment  of,  316 

R 

Rabies,  184 

Rachitis,  ^^24 

Railway  brain,  1132 
spine,  1132 

Raynaud's  disease,  1136 
pathology  of,  1137 
prognosis  of,  11 38 
symptoms  of,  11 36 
treatment  of,  11 38 

Reaction     of     degeneration, 

partial,  yOi 
significance  of,  857 
Rectum,  cancer  of,  430 
mechanism  of  control  of, 

847 
neuralgia  of,  426 
Red  atrophy  of  the  liver,  452 

granular  kidney,  716 
Reflexes,  1065 
ankle,  849 
cutaneous,  848 
deep-seated,  1036 
patellar,  1033 
periosteal,  850 
segments  of  cord  presid- 
ing over,  853 
tendon  or  deep,  853 
their  significance,  852 
Reichmann's  disease,  354 
Relapsing  fever,  59 
diagnosis  of,  62 
etiology  of,  59 
incubation  in,  60 
morbid  anatomy  of,  60 
prognosis  of,  62 
relapse  in,  62 
spleen  in,  60 
symptoms  of,  60 
treatment  of,  62 
Relation  of  locality  to  symp- 
toms in  cerebral   disease, 
963 
Remittent  fever,  65,  76 
chill  in,  70 
diagnosis  of,  76 
prodromal  symptoms  of, 

76 
treatment  of,  80 
Renal  cirrhosis,  716 
associated   witn  hypertro- 
phy of  the  left  ventricle 
without     valvular     dis- 
ease, 753 
relation   of,   to   heart   dis- 
ease. 753 
dropsy,  687 
infarct,  758 
sclerosis,  716 
Ren  mobilis,  747 


Rennet,  action  of,  340 
Respiration  and  deglutition, 
muscles  of,  affections   of, 
1021-1024 
Respiratory  system,  diseases 

of,  497 
Retina,  affections  of.  987 
functional  disturbances  of, 

988 
hemorrhage  into,  988 
hyperesthesia  of,  989 
organic  disease  of,  987 
Retinitis,  988 
albuminuric.  988 
syphilitic,  988 
Revaccination,  154 
Rheumatic  fever,  289 

complications  of,  293 
diagnosis  of,  294 
etiology'  of,  289 
morbid  anatomy  of,  291 
prognosis  of,  294 
symptoms  of,  291 
prodrome,  291 
recurrence,  292 
subcutaneous      nodules, 

292 
treatment  of,  294 
joint,  77-, 
myositis,  771 
purpura,  831 
Rheumatism,  771 
acute    articular,    289,    771 
See    Infectious    Dis- 
eases, 
chronic  articular,  773 
morbid  anatomy  of,  772, 
symptoms  of,  774 
treatment  of,  774 
muscular,  771 
diagnosis  of,  772 
etiology  of,  771 
symptoms  of,  771 
cephalodynia,  772 
lumbago,  772 
pleurodynia,  772 
stift'  neck  or  torticol- 
lis, 772 
treatment  of,  772 
Rheumatoid  arthritis,   775 
Rhinitis,  acute,  497 
chronic,  498 
atrophic.  499 
hyperatrophic,  499 
symptoms  of,  499 
treatment  of,  499 
sj-philitic,  207 
Rhyncota,   1200 
Rhvthmical        contractions, 
846 
or  hysterical  chorea,  iioi 
Rickets,  824 
complications,  828 
diagnosis  of,  828 
etiologv'  of,  824 
morbid  anatomy  of,  826 
shape  of  chest,  827 
progn6sis  of,  828 
symptoms  of,  827 
treatment  of,  828 
Riga's  disease,  307 
Rock  fever,  63 


Rocky  Mountain  fever,  54 
Rose  cold,  501 
Rotch's  sign,  563 
Rotheln,  122 
Rubella,  122 

diagnosis  of,  123 

etiology  of,  123 

incubation  of,  123 

prognosis  of,  124 

symptoms  of,  123 

treatment  of,  124 
Rubeola,  118,  122 

notha,  122 


Sacral  plexus,  lesion  of,  1036 

treatment  of,  1037 
Salivary  glands,  diseases  of, 

inflammation  of,  2)^:^ 
Salt  solution,  normal,  com- 
position of,  102 
Sarcoma  of  the  liver,  472 
diagnosis  of,  474 
symptoms  of,  473 
Saturnism,  1164 
Scarlatina,  1^4 

simplex,    126    (See  also 

Scarlet  Fever) 
scarlatina  anginosa,  128 
maligna,  128 
miliaris,   12& 
Scarlet  fever,  124 

Loeffler's  bacillus,  128 
complications     and     se- 
quelae, 128 
diagnosis  of,  130 
etiology  of,  1.24 
epidemics  of,  128 
hemorrhagic,   128 
morbid  anatomy  of,  125 
prognosis  of,  130 
symptoms  of,  125 

raspberry  tongue,  126 
strawberry  tongue, 
126 
treatment  of,  131 
Scheeles  sign,  633 
Schistosoma      haematobium, 

1181 
Sciatica,  870 

diagnosis  of,  871 
etiology  of,  870 
symptoms  of,  870 
treatment  of,  871 
Sciatic     nerve,     lesions    of, 

1036 
Sclerema,  1141 
Scleroderma,  1141 
Sclerose  cerebrale,  1063 

en  plaques,  1069 
Sclerosis,    amyotrophic    lat- 
eral, 956 
diagnosis  of,  950 
etiolog}'  of,  956 
morbid  anatomy  of,  956 
symptoms  of,  956 
treatment  of,  958 
of  brain  and  spinal  cord, 
io6g 
diagnosis  of,  1070 
etiology  of,  1069 


1236 


INDEX. 


Sclerosis : 

morbid  anatomyofj 

1069 
symptoms  of,  1069 
treatment,  1070 
of  the  coronary   arteries, 

610 
toxic.  939 
Scotoma,  996 
Scrivener's  palsy,  1 1 15 
Scrofula,  279 
Scurvy.  832 

diagnosis  of,  833 
etiology  of,  832 
morbid  anatomy  of,  833 
prognosis  of.  833 
symptoms  of,  833 
treatment  of,  833 
infantile,  834 
deviation  of  vision,  lOOl 
Senile  tremor,  1091 
Septicemia,   167 
and  pyemia,  181 
bacilli,  181 
diagnosis  of,   183 
etiology,   181 
prognosis  of,  183 
symptoms  of.  182 
treatment  of,  183 
Serratus  palsy,  1032 
Seven-day  fever,  59 
Seventh    nerve,    lesions    of, 

1006 
Shaking  palsy,  1088 
Ship  fever,  5S 
Sick  headache,  11 12 
Silver      nitrate      poisoning, 

1212 
Simple  angina,  320 
continued  fever,  298 
or  round  ulcer,  359 
Sixth  nerve,  lesions  of,  af- 
fecting the  eyeball,  lOOi 
Skodaic  sign,  536 
Slow  consumption,  254 

nervous  fever,  17 
Slows,  201 
Smallpox,  145 

complications  of,  149 
contagium,   146 
diagnosis  of,  150 
forms  of,  149 
confluent,  149 
discrete.  149 
hemorrhagic,  149 

purpura  variolosa,  149 
variola       hemorrhagica 

pustulosa,  149 
variolse  sine  variolis, 
:  149 
varioloid,  149 
morbid   anatomy   of,   147 
prognosis  of.  150 
symptoms  of,  148 
incubation,   148 
muscular  pain,  148 
initial   rashes,    148 

diffuse      scarlatinous, 

148 
measly.    148 
treatment  of,  150 
special  modes,  131 


Small  sciatic  nerve,  lesions 

of,  1037 
Smoker's  tongue,  312 
Soor,  307 
Sore  throat,  320 
Spasm,  constant  or  co-ordi- 
nate. 847 
of  muscles  of  mastication, 

1005 
tonic  and  clonic,  845 
Spasmodic  tabes  dorsalis, 

924 
Spasms   of  the   muscles   of 
respiration    and     degluti- 
tion,  1099 
Spastic  diplegia,  1066 
paralysis  of  children.  1066 
paraplegia,  1067 
diagnosis  of,  1068 
etiology,  1067 
morbid      anatomy      of, 

1067 
symptoms  of,  1067 
treatment   of,    io58 
Spastic  infantile  hemiplegia, 

1063 
Spastic  rigidity  of  the  new- 
born,  1066 
spinal  paralysis,  924 
diagnosis  of.  925 
etiolog}',  924 
morbid    anatomical 

conditions,   924 
prognosis  of,  925 
symptoms  of,  924 
treatment  of,  925 
Speech    areas   in   cortex   of 
brain,  964 
derangements       o  f, 
irritative      origin 
of,  980 
to      test      derange- 
ments of,  980 
S  p  h  y  g  m  ograms,  578,  580, 

583,  586,  618,  619,  626 
Spina  bifida,  950 
Spinal   accessory  nerve,  le- 
sions of.    1026 
symptoms  of,  1026 
spasm  of,   1026 
symptoms  of,  1027 
cord,   acute   affections  of, 
908    • 
anemia.  908 
congestion,  908 
embolism.  908 
thrombosis.  908 
affections  of,  888 

the  membranes  of.  899 

the  substance  of,  904 

chronic     affections     of, 

924 
compression   of.   943 
diagnosis  of,  945 
etiology.  943 
morbid    anatomy    of, 

943 
prognosis  of.  945 
symptoms  of,  943 
treatment  of.  945 
hemorrhage     into     the 
substance  of,  908 


Spinal : 

cord,  localization,  892 
secondary  systemic  de- 
generations      of, 

905 
after  cerebral  le- 
sions, 906 
after    injuries    of 
the  Cauda  equi- 
na, 907 
after  t  r  a  nsverse 
lesions    of    the 
cord,  906 
membranes,  hemorrhage 
into,  903 
extrameningeal.  003 
intrameningeal.  903 
medullary,    903 
nerves  and  branches,  dis- 
eases of,  1031 
paralysis  of  children,  918 
Splanchnoptosis,  376 
Spleen,  abscess  of,  485 
amyloid.  486 
atrophy  of,  486 
diseases  of,  485 
echinococcus,  486 
hemorrhagic  infarct,  486 
in  anthrax,  195 
in  cirrhosis  of  the    liver, 

462 
in  leukemia,  659 
in  malaria,  72 
in  typhoid  fever,  22 
in  typhus  fever,  56 
neoplasm  of,  486 
rupture  of,  485 
wandering.  486 
Splenic  apoplexy,  194 

fever,  194 
Splenitis,    485 
Split  spine,  950 
Sporadic    cerebrospinal    fe- 
ver.  175 
cholera,  384 
Spotted  fever,   167 
St.   Anthony's   fire,    177 
Starch  and  sugar,  digestion 

of,  340 
Status  epilepticus,  1105 

lymphaticus,  667 
Stenocardia,  620 
Steppage  gait,  874 
Stereognosis,  863 
Stigmata,     hysterical,     1122, 

1 124 
Stomacace,   308 
Stomach,    action    of,    rennet 
in,  340 

cancer  of,  366 
bacillus  of.  368 
diagnosis  of,  370 
etiology  of.  366 
morbid  anatomy  of,  367 
prognosis  of,  372 
secondary,  367 
symptoms  of.  368 
treatment  of,  372 
chemical       examination 

of  contents  of.  332 
determination     of    acid 
salts  in,  334 


INDEX. 


123/ 


Stomach : 

determination  of  loosely 
combined     HCl     i  n, 

335 
of    organic    acids    in, 
336 
examination    of    prod- 
ucts   of    albumin    di- 
gestion in,  337 
reaction  of,  333 
determination   of    rate   o^ 

absorption  from,  341 
digestion    of    starch    and 

sugar  in,  340 
dilatation  of  the,  373 
diagnosis  of,   375 
physical  signs  of,  373 
morbid  anatomy,  373 
prognosis  of,  375 
symptoms  of,  373 
treatment  of,  375 
dietetic,    376 
diseases  of,  329 
d  i  a  g  nostic     technique 
for,  329      .       .  , 

external    examination    of, 

329 

auscultation,  332 
palpation,   330 
percussion,  330 
Stomatitis,  acute  catarrhal, 
306 
aphthous,    307 
mercurial.  309 
mycotic,  307 
syphilitic,  309 
.    ulcerative,  308 
treat  ment    of    different 

forms  of,  310 
prophylaxis  against,   310 
Struma      exophthalmica, 
672 
simple,  670 
Strychnin  poisoning,  1212 
St.  Vitus'  dance,  iioi 
Sudor  anglicus,  301 
Suffocative  catarrh,  228 
Sugar  and  starch,  digestion 

of,  340 
Suggestion     and     hypnosis, 

1125 
Sulphureted    hydrogen    poi- 
soning, 1213 
Sulphuric     acid     poisoning, 

1210 
Sunstroke,  1176 
Suprarenal  capsule,  diseases 

of,   681 
Suprascapular  nerve,  lesions 

of,   1033 
Surgical   kidney,   730 
Swamp  fever,  65 
Sweating  disease  of  Picar- 

dy,  301 
Swelled  head,  198 
Sydenham's  chorea,    1901 
Syphilis,  202 

acquired,  203 

initial  sore,  202 

primary,  202 

secondary,  202 

tertiary,  202 


Syphilis  : 
congenital,  203 
contagiousness  of,  202 
diagnosis  of,  207 
hereditary,  203 
germ  inheritance,  203 
sperm  inheritance,  203 
transmission,  203 
morbid  anatomy  of,  203 
fibroid      induration, 

204 
gumma,  205 
mucous    patch,    204 
papular       eruption, 

204 
pustular      eruption, 

204 
syphilides,  204 
macular,   204 
squamous,  204 
venereal  wart,  204 
Hutchinson's   teeth, 
207 
of  brain  and  spinal  cord, 

1 144 
of  the  liver.  475 
diagnosis   of,   476 
symptoms   of,   476 
treatment   of,   477 
of    the    nervous    system, 
1 144 
diagnosis  of,  1147 
etiology  of,  1144 
morbid    anatomy    of, 

1144 
prognosis  of,  1148 
symptoms  of,  1145 
treatment  of,  1148 
Syphilitic    ulcer    of    bowel, 

394 
Syringomyelia,  941 
diagnosis  of,  942 
etiology  of,  941 
symptoms  of,  941 
treatment  of,  942 


Tabes   dorsalis,   926 
course  of,  934 
differential  diagnosis  of. 

934 
etiolosfv  of,  926 
morbid  anatomy  of,  927 
prognosis  of,  934 
symptoms  of,  929 

arthropathies,   933 

cerebral,  933 

gait,  931  . 

girdle   pains,   931 

inco-ordination,    931 

motor      phenomena 
930 

reflex,   932 

Romberg's  sign.  930 

sensory,  931 

vasomotor  and  troph- 
ic phenomena,  933 

visceral  pain,  932 
treatment  of,  935 
mesenterica,  282^ 
Tabetic  crises,  932 


Tables    for    conversion    of 
metric   into    English   sys- 
tem, 1216 
Tachycardia,  615 
explanation  of,  615 
paroxysmal,  615 
treatment  of,  619 
Tachycardia   strumosa,   672 
Tactile    sensibility    in    ner- 
vous diseases,  860 
Tape-worm,  1181 
intestinal,  1181 
visceral,    1188 
Temperature,       effects       of 

high,   1 175 
Tendon  reflexes,  852 
Tenth  nerve,  lesions  of,  1019 
Test  breakfast,  2i2>2 
dinner,  22>2> 
for  free  HCl,  334 
Boas"  test,  334 
for     lactic     acid,     UfJel- 
mann's,  337 
Tests  for  albumin,  686 

contact  method  with  ni- 
tric acid,  or  Heller's, 
687 
heat  and  acid,  686 
picric  acid,  687 
for  globulin,  687 
Tetanilla,  11 19 
Tetanoid    pseudoparaplegia, 

1067 
Tetanus,  190 
bacillus  of,  190 
diagnosis  of,   192 
etiology  of,  190 
morbid  anatomy  of,  191 
predisposing     causes     of, 

191 
prognosis  of,  193 
symptoms  of,  191 
treatment  of,  193 
varieties  of,  190 
idiopathic,   191 
neonatorum,  191 
traumatic,  191 
Tetany,'  11 19 
The  pox,  202 
The  rose,  177 

Theories   of  cardiac  hyper- 
trophy   in    renal    disease, 

753 
Thermic  fever,  1176 

treatment    of,    1178 
Thick  neck,  670 
Third  nerve,  lesions  of,  998 
Thomsen's  disease,   1153 
Thornhead  worms,  1198 
Thread  worms,  1190 
Thrombosis    and    embolism, 

454 
of    cerebral    sinuses    and 
veins,  1056-1061 

primary,  1061 
secondary,  1061 
Thrush,  307 
Thyrocele.  670 
Thyroid  gland,  enlargement 
of,  673 
neoplasms  of,  680 
glands,  diseases  of,  670 


1238 


INDEX. 


Tic,   complex    co-ordinated, 
1099 
douloureux,  88 
simple,    1097 
generalized,  1097 
localized,  1097 
with  explosive  utterances, 
1098 
Tinnitus  aurium,  1016 
etiology  of.   1016 
treatment  of,  1016 
Tobacco  habit,   1164 
Tongue,     inflammation     of, 

psoriasis  of,  312 
Tonic    contraction    of    ex- 
tremities,   1066 
Tonsillar  abscess,  315 
Tonsillitis,  315 
acute  parenchymatous,  315 
chronic,  317 
diagnosis  of,  319 
etiology  of,  317 
morbid  anatomy  of,  3^7 
prognosis  of,  319 
symptoms  of,  317 
treatment  of,  319 
follicular,    316 
Tonsils,  diseases  of,  315 
Tooth  rash,  305 
Tropical  diagnosis  of  cere- 
bral lesions,  963 
Torticollis,      or      wry-neck, 
1027 
congenital,  1027 

pathology  of,  1029 
spasmodic,  1028 
treatment    of,    1029 
Trachea,  diseases  of,  517 
Tracheobronchitis,   a  c  u  t  e  j 

517 
Tracts  within  the  bram,  982 
Transverse  myelitis,  911 
Traube's    half-moon    space, 

331 
Traumatic  hvsteria,  1132 

neuroses,  1132 
Trembles,  201 
Tremor,  hereditary,  1091 
hysterical,  1091 
other  forms  of,  1091 
asthenic,  1091 
senile,  1091 
simple,  1091 
toxic,  1091 
Trichiniasis,    1191 
Tricuspid         incompetency, 
588 

physical  signs  of,  589 
jugular  pulse,   588 
stenosis,  589 

physical  signs  of,  589 
Trifacial   nerve,   lesions   of, 
1004 
diagnosis  of,   1005 
symptoms  of,  1005 
paralysis     of     motor 
portion  of  the,  1005 
of  sensorv  portion  of 

the,    1005 
treatment  of,  1006 
Trigeminus,  lesions  of,  1004 


Trophic  derangements  due 

to  nervous  diseases,  864 
Tube-casts,  690 
blood,  6go 
cylindroid,  692 
epithelial,  690 
granular,  692 
hyaline,   691 
mucous,  692 
oily  or  fatty,  692 
pus,  690 
waxy,  691 
Tubercle,  242 

anatomy  and  histology  of, 

242 
calcareous   infiltration   of, 

244 
caseation  of,  243 
degeneration  of,  243 
fibroid  change  in,  244 
histogenesis  of,  243 
retroactive     inflammation, 

caused  by,  244 
softening  of,  243 
solitary,  243 
Tubercular        consumption, 
252 
peritonitis,  282 
ulcer  of  bowel,  393 
Tuberculin    test    for    tuber- 
culosis, 264 
Tuberculosis,  238 
bacillus  of,  238 

to  stain,  238 
etiology  of,  238 
age,  240 
climate,  240 
defective  food,  240 
Fleck's  studies,  239 
heredity,  239 
locality,   240 
race,  240 

shape  of  chest,  241 
traumatism,  241 
acute,    clinical     varieties, 
245 
general   miliary   or   ty- 
phoid  form,   245 
miliary    meningeal 
form,  249 
diagnosis  of,  251 
etiology  of,  249 
morbid    anatomy    of, 
V    249 

prognosis  of,  251 
symptoms  of,  250  * 
treatment  of,  251 
miliary  pulmonary  form 
succeeding       b  r  o  n- 
chitis,  chronic  tuber- 
culosis,       whooping- 
cough,     or     measles, 
247 
pneumonic  phthisis,  247 
chronic  fibroid.  265 

physical   signs,   265 
prognosis  of,  266 
symptoms  of,  265 
treatment      (see     o  f 
ulcerative) 
chronic  ulcerative,  254 
diagnosis  of,  263 


Tuberculosis: 

morbid    anatomy    of, 

252-254 
physical   signs,  257 
prognosis  of,  265 
symptoms  of,  257 
treatment  of,  266 
climatic,  266 

hygiene     and     die- 
tetic, 268 

medicinal,  269 

special      symptoms, 

273 
pneumptherapy,  272- 
prophylactic,   275 
serum-,  271 
of    the    heart    and    blood 

vessels,  286 
of  the  kidney,  283 
miliary  granulations  in,. 

283 
morbid  anatomy  of,  283; 
primary  foci  in,  283 
symptoms  of,  283 
treatment  of,  284 
of   the   lymphatic   glands, 
279 
diagnosis  of,  280 
etiology  of,  279 
prognosis  of,  280 
symptoms  of,  279 
tabes     mesenterica,, 
280 
treatment  of,  281 
of  the  mammary  glands,. 

286 
of  the   ovaries,   Fallopiaa 

tubes,  and  uterus,  285 
of  the  pelvis  of  the  kid- 
ney, ureters,  and  blad- 
der, 284 
of  the  peritoneum,  282 
of  the  pleura,  281 
of  the  serous  membranes, 

281 
of     the     testes,     prostate 
gland,  and  seminal  ves- 
icles, 285 
Tuberculous     leptomeningi- 
tis, 249 
lymphadenitis,  279 
Tumors  of  the  spinal  cord 
and        membranes^ 

946 
diagnosis  of,  947 
prognosis  of,  949 
symptoms  of,  947 
treatment  of,  949 
varieties  of,  946 
Twelfth    nerve,    lesions    of,, 

1030 
Typhlitis,  394 
Typhoid    fever,    17 

abortive    form   of,   32 
albuminuria  in,  28 
antiseptic  treatment  of,, 

50 
atypical  forms  of,  31 
bacteriology   of,    18 
bed-sores  in,  47 
blood   changes   in,   30 
boils  in,  3^ 


INDEX. 


1239 


Typhoid : 

bone  lesions  in,  34 
Brand    bath    treatment 

of,  41 
cardiac       comphcations 

in,   34 
chills  in,  31 
cholecystitis  in,  35 
circulatory  system  in,  22 
complications  in,   32 
constipation  in,  46 
contagiousness  of,  19 
cystitis  in,  48 
delirium  in,  28 
diagnosis,  36 
diazo-reaction   of   urine 

in,   29 
diet  in,  41 
disinfection  of  stools  in, 

52 
Ehrlich's  reaction  in,  29 
eliminative  and  antisep- 
tic treatment  of,  50 
etiology,   17 
expectant     symptomatic 

treatment  of,  45 
hemorrhage  in,  46 
hemorrhagic    form    of, 

32 
herpes  in.  24 
in  children,  23,  40 
incubation  of,  23 
indications    for    alcohol 

in,  45 
influence  of  age  on,  20 
influence  of  seasons  on, 

20 
management   of   conva- 
lescence in,  48 
meteorism  in,  26 
methods     of     reducing 

temperature  in,  44 
milk  leg  in,  z^ 
mode  of  conveyance  of, 

20 
morbid  anatomy  of,  21 
nervous    or    meningeal 

form  of,  Z2 
parotitis  in,  23i 
perforation  in,  28-47 
peritonitis  in,  47 
Peyer's  patches   in,   21 
predisposing   causes  of, 

20 
prodromal       symptoms, 

prophylaxis  in,  52 
pulmonary  form,  32 
relapses  in,  35 
renal  form,  28 
rose-colored  spots  in,  23 
sequelae  of,  32 
serum-therapy  in,  51 
skin  rashes  in,  22, 
splenic   enlargement  in, 

21-24 
temperature  in,  23 
thrombosis  in,  32 
tonsillar  form  of,  32 
treatment  of,  41 

by  cultures  of  serum, 
51 


Typhoid : 

treatment   by    diet    and 
rest,  41 

expectant      symptom- 
atic, 45 
of  convalescence,  48 
of   special    symptoms, 

46 
tube  rcular  phthisis  in, 

34 
tympanitic  distention  in, 

46 
typhoid  spine  in,  34 
unusual  form  of  onset, 

31 

urine  in,  23 

walking  form  of,  23 

Widal  reaction,  2>7 
Typhus  abdominalis,  17 
exanthematicus,  55 
fever,  55 

etiology, 

contagiousness,  55 

diagnosis  of,  36 

eruption  of,  56 

incubation  of,  56 

morbid  anatomy,  56 

prognosis  of,  58 

symptoms  of,  56 

treatment  of,  58 
icterodes,  59,  83 
tropicus,   83 

U 

Uffelmann's   test    for   lactic 

acid,  337  , 

Ulcer,  gastric  and  duodenal, 

359  .       . 

course  and  termination 

of,  362 
diagnosis  of,  362 

from  cancer,  363 
etiology  of,  359 
morbid  anatomy  of,  360 
prognosis  of,  364 
symptoms  of,  360 
hemorrhage,  361 
treatment  of,  364 
operative,  366 
Ulceration  of  the  bowel,  393 
Ulcerative  colitis,  382 
Ulcerative  endocarditis,  570 
Ulcus    ventriculi    pepticum, 

359 
Ulnar  nerve,  lesions  of,  1035 
Uncinariasis,  1193 
Undulant  fever,  63 
Unilateral  progressive  facial 

atrophy,  11 38 
Uremia,  688 

symptoms  of,  688 

treatment  of,  705 
Uric  acid,  thread  test,  781 
Uricacidemia,  793 
Uricemia,  793 
Urinary  organs,  diseases  of, 

684 

V 

Vaccina,  152 
Vaccine  disease,  152 
bacteriology  of,  I53 


Vaccine : 

disease,   humanized 

lymph  in,  153 
operation  in,  153 
phenomena  of,  I53 
rashes,  154 
Vaccinia,  152 

hemorrhagica,  154 
nature  of,  152 
Vaccinosyphilis,  155 
Vagus     nerve,     lesions     of, 

1019 
Valvular    (cardiac)    defects, 

574 
congenital,  575 
morbid  anatomy  of,  575 
relative     frequency     of, 

591 
disease,      chronic,      prog- 
nosis of,  592 
treatment  of,  593 
of  dropsy,  598 
of  dyspnea,  597 
of     irregularities     of 
heart     action     and 
palpitation,  599 
lesions,  associated  or  com- 
bined, 592 
Valvulitis,  567 
Varicella,   156 
Variola,  145 

Variolae  sine  variolis,  149 
Vasomotor  and  trophic  de- 
rangements,   1 136 
Vesical  catarrh,  759  , 
Vesicular  emphysema,  532 
Vesicular  or  herpetic  stoma- 
titis, 307 
Visceroptosis,  376 
tiology  of,  376 
symptoms  of,  377 
treatment  of,  378 
Vision,  modifications  of,  in. 

nervous  disease,  865 
Vocal    cords,    paralysis    of, 
516 

W 

Warty   or   verrucose   endo- 
carditis, 568 

Wasting  palsy,  958 

Water  cancer,  311 

Waxy  kidney,  726 
liver,  457 

Weil's  disease,  300 

Wernicke's  scheme,  974 

Whooping-cough,  157 
complications  and  sequelae 

of,  159 
diagnosis  of,  159 
morbid  anatomy  of,  158 
prognosis  of,   160 
shape  of  chest  in,  158 
symptoms  of,  158 
treatment  of,  160 

Winckel's  disease,  836 

Woolsorter's  disease,  196 

Word-blindness,  976 

Word-deafness,  976 

Word-image,  972 

Writer's  cramp,  1115 
etiology  of,  11 15 


1240  INDEX. 

Writer's  cramp:  Y  Yellow  fever: 

diagnosis  of,  1117  jaundice  in,  86 

treatment  of,  1117              Yellow  atrophy  of  the  heart,  morbid  anatomy  of,  85 

Wry-neck,   1027                                    610  prognosis  of,  88 

of  the  liver,  acute,  469  prophylaxis  of,  ^ 

^                              fever,  83  slow  pulse  of,  87 

X                                  albuminuria  in,  86  symptoms  of,  86 

bacillus  icterodes  of,  84  treatment  of,  88 

Xerostomia,  313                               diagnosis  of,  87  by  serum,  89 


